Income Disparities in Nationwide Outcomes of Malrotation with Midgut Volvulus

Background: Malrotation with midgut volvulus is a surgical emergency commonly encountered in pediatric surgical practice. Outcomes are excellent when diagnosis and treatment are achieved in timely fashion, but the development of bowel ischemia is associated with many negative consequences. The purpose of the present study is to investigate outcomes of midgut volvulus at a national level.

Methods: The Nationwide Readmissions Database was used to identify patients 0-18 years (excluding newborns) with malrotation and midgut volvulus from 2010-2014. Demographics, procedures, and complications were compared by income group (highest quartile vs lowest quartile) using standard statistical tests. Results were weighted for national estimates.

Results: Emergency surgery for midgut volvulus was performed in 572 patients. The majority (86%) underwent Ladd’s procedure whereas only14% required bowel resection and/or ostomy. Temporary abdominal closure and second look surgery was performed in 8% of those undergoing bowel resections versus 0% in those undergoing isolated Ladd’s (p < 0.001). Patients in the lowest income quartile were more likely to require bowel resection (18% vs 8%, p=0.03) or ostomy (9% vs. 2%, p=0.015) compared to those in the highest income quartile. Low-income patients were more likely to experience prolonged lengths of stay, higher hospital costs, and complications including infections, respiratory dysfunction, endotracheal intubation, blood transfusions, and use of parenteral nutrition (Table 1). The overall readmission rate was 20% and was lower in those with lowest income (13% vs. 29%, p=0.003). Index mortality was similar between groups (Table 1).

Conclusion: Income disparity represents a major factor in surgical outcomes in children with midgut volvulus. A broad spectrum of clinical outcomes following surgery for midgut volvulus exists, and those patients with lower income are at significantly higher risk for numerous complications, negative outcomes, and higher resource utilization. These findings support additional investigation of practices to mitigate risk for low-income patients.