Discordant intestinal malrotation in adult monozygotic twins discovered incidentally during laparoscopic gastric bypass: A case report and review of the literature

INTRODUCTION AND IMPORTANCE: Intestinal Malrotation is an uncommon entity in the adult population; more so in monozygotic twins, where concordance is expected. In literature, discordant intestinal Malrotation has only been discovered when one twin became symptomatic, and the other was screened. To the best of our knowledge, this is the first documented case of discordant adult type intestinal Malrotation in otherwise asymptomatic monozygotic twins discovered incidentally during Laparoscopic Roux-en-Y Gastric bypass (LRYGB). CASE PRESENTATION: Twins A and B met the NIH criteria for bariatric surgery, neither having symptoms of acute or chronic volvulus or history of intraabdominal surgery. Twin A had a LRYGB performed by a trained bariatric surgeon, noting no anatomic anomalies. 5 months later, Twin B had LRYGB and intestinal Malrotation was diagnosed incidentally. CLINICAL DISCUSSION: Diagnosis of Intestinal Malrotation is rare in adults, usually discovered after becoming symptomatic or during abdominal imaging for another indication. Two cases of discordant intestinal Malrotation in monozygotic twins have been documented, both discovered when one twin became symptomatic due to acute volvulus, suggesting epigenetic phenomena. When discovered incidentally during surgery, patients can safely undergo their intended procedure, but literature suggests prophylactic division of Ladd's bands, while appendectomy is left to the discretion of the surgeon. CONCLUSIONS: Intestinal Malrotation appears to be associated with epigenetic phenomena and if discovered incidentally during surgery, the proposed procedure can be carried out by an experienced surgeon, in addition to division of Ladd's bands and appendectomy.