Malrotation in patients with duodenal atresia: a true association or an expected finding on postoperative upper gastrointestinal barium study?

We retrospectively reviewed the imaging and surgical findings in 17 patients with duodenal atresia to determine (a) the frequency of coexistent malrotation in patients with duodenal atresia and (b) the reliability of the upper gastrointestinal barium study (UGI) in differentiating malrotation from postoperative deformity of the duodenal sweep after repair of duodenal atresia. Postoperatively, 9 (53%) of the 17 patients had UGI findings consistent with malrotation. Of these nine, only two had malrotation coexistent with duodenal atresia, while the other seven had normal midgut rotation demonstrated intraoperatively. The radiographic appearance of malrotation was simulated in two patients in whom the ligament of Treitz had been surgically divided, in three in whom the ligament had not been taken down, and in two in whom the status of the ligament was not specified in the surgical report. Although there is an association between duodenal atresia and malrotation, this cannot be accurately documented on postoperative UGI examination. Malrotation cannot be detected preoperatively because contrast material cannot pass beyond the level of the atresia. Postoperatively, surgical deformity of the duodenal sweep cannot be reliably distinguished from malrotation.