Volvulus in very-low-birth-weight preterm infants enrolled in the German Neonatal Network: Prevalence, mortality, and outcome

Volvulus in very-low-birth-weight preterm infants enrolled in the German Neonatal Network: Prevalence, mortality, and outcome | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Volvulus in very-low-birth-weight preterm infants enrolled in the German Neonatal Network: Prevalence, mortality, and outcome Bastian Siller, Mats Ingmar Fortmann, Martina Kohl-Sobiana, Kianusch Tafazzoli-Lari, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7956838/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Mar, 2026 Read the published version in BMC Pediatrics → Version 1 posted 14 You are reading this latest preprint version Abstract Background: Volvulus is an emergency condition, but data on its prevalence and outcome in preterm infants are scarce. Methods: We analyseddata from the German Neonatal Network and conducted a PubMed literature search on the primary hospital stay of very-low-birth-weight infants who underwent surgery for volvulus. Infants who underwent surgery for focal intestinal perforation and/or necrotising enterocolitis served as a comparison group. Results: Nine relevant publications involving 102 preterm infants with volvulus were identified, revealinga wide range of postnatal onset and a mortality rate of 10.7%. The prevalence of volvulus was 123/23,652 (0.5%) according to the German Neonatal Network,which was significantly lower than the prevalence of necrotisingenterocolitis and/or focal intestinal perforation. The volvulus group had a significantly higher proportion of female premature infants than the groups with necrotising enterocolitis or focal intestinal perforation. Most operations for volvulus were performed after the 20th day of life. Preterm infants who underwent surgeryfor volvulus had significantly less intraventricular haemorrhage and faster feeding than did those with necrotising enterocolitis and/or focal intestinal perforation. Notably, however, perioperative mortality was highest in the volvulus group. Furthermore, mortality until discharge was significantly greaterin the necrotising enterocolitis group (24%) than in the volvulus group (15%). Conclusion: Volvulus occurs in five out of 1,000 very-low-birth-weight infants, particularly in those requiring immediate surgery after 20 days of age. volvulus very low birth weight infants period of occurrence prevalence outcome Figures Figure 1 Figure 2 Figure 3 Introduction In very small premature infants, most surgical abdominal interventions are performed due to focal intestinal perforation (FIP) or necrotising enterocolitis (NEC). Small bowel volvulus, on the other hand, is a rare but very serious differential diagnosis that requires immediate surgery. There are few data on volvulus at this age. An etiology due to malrotation is considered rare. 1 Although cases of gastric and sigmoideal volvulus have been reported, volvulus without any signs of malrotation is found more frequently, with an estimated incidence of 1.3 per 1,000 very low birth weight infants. (VLBWI). 2 Several risk factors for the development of volvulus without an underlying malformation have been identified in the context of preterm birth. These include a gestational age of ≤ 28 weeks, 3,4,5,6 intestinal immaturity with prolonged transit time, 5,7,8 gaseous distention due to CPAP support, 5,7,8 intrauterine growth restriction, and female sex. 5 , 9 Early diagnosis is crucial for preventing extensive intestinal damage resulting from large-scale irreversible ischemia. 5 , 10 Clinical signs of volvulus include common signs of acute abdomen, such as tenderness and pain, as well as recurrent bilious vomiting, lactic acidosis and rapid deterioration of the infant's condition. 2 , 4 , 10 In VLBWI, a volvulus may be misdiagnosed as a more prevalent condition, such as sepsis, FIP, or NEC. This may lead to delayed diagnosis and therapy. 4 The prognosis of volvulus depends on early diagnosis and treatment. Delayed diagnosis, particularly in cases of midgut volvulus, can have catastrophic consequences, including haemorrhage, lifelong dependence on parenteral nutrition, and associated complications. 9 , 11 To better understand the circumstances surrounding the important differential diagnosis of volvulus in VLBWIs, we conducted a literature search via the PubMed database. We also analysed the incidence, risk profile and treatment outcomes at the time of discharge after initial hospitalisation in the large database of the German Neonatal Network (GNN), which has been maintained since 2009 and contains more than 20,000 data records. We then compared these outcomes to those of infants with FIP or NEC. Methods Literature search We searched the PubMed database using only the terms 'volvulus' and 'preterm infant'. Our aim was to summarise demographic data on primary postnatal hospitalisations, time of onset and mortality from case series in single centres or regions. To this end, we first read all the abstracts. Case reports, comments, editorials and articles focusing on other topics were excluded. From the remaining manuscripts, we extracted the following data: the number of cases collected, the gestational age at birth, the age at onset of volvulus, and the number of deaths. Patients and study design The GNN is a national population-based observational multicentre cohort study. Currently, 71 out of 162 level 3 neonatal intensive care units in Germany are participating. Between January 2009 and December 2016, VLBWIs with birth weights of less than 1500 g and a gestational age of less than 37 + 0 weeks were enrolled. Between January 2017 and December 2019, the inclusion criteria were a birth weight of less than 1000 g or a gestational age of 28 + 6 weeks or less. Between January 2020 and December 2021, infants with a gestational age of 26 + 6 weeks or less were included. Beginning in January 2022, VLBWIs with a gestational age of 28 + 6 weeks 28 + 6 days or less were enrolled. For the present study, a subset of the GNN was selected according to the following criteria: enrolment between January 2009 and December 2023; discharge or death by 31 December 2023; and the presence of surgically treated NEC, FIP or volvulus. Infants were enrolled after written informed consent was obtained from their parents. Predefined data on general neonatal characteristics, antenatal and postnatal treatment and outcomes were recorded by the participating centers. After discharge from primary hospitalisation, case report forms were sent to the study centre at the University of Lübeck. Data quality was evaluated by a physician or a study nurse trained in neonatology via annual onsite monitoring. The data were subsequently coded and curated for analysis. All parts of the study were approved by the ethics committees of the University of Lübeck, vote numbers 08–022 and 2023 − 812, and the participating centres. Definitions The need for surgery for NEC and/or FIP was recorded by ticking a box on the case report form. As surgery for volvulus is less common, it was recorded by ticking the box ‘other surgery’ plus free text. We defined all infants who underwent surgery for volvulus as cases and infants who underwent surgery for NEC or FIP as the comparison cohort. In the event of multiple operations, only the most serious one was counted. For this purpose, surgery due to a volvulus was considered more serious than surgery for NEC, while a FIP operation was considered less serious. On the basis of national data, infants were classified ‘small for gestational age’ if their sex-specific birth weight was below the 10th percentile. 12 Bronchopulmonary dysplasia was classified if the infant received CPAP and/or oxygen for 28 days and met the criteria according to the Walsh physiological definition at gestational age 35 + 0 to 36 + 6 weeks or died of respiratory failure before that. 13 Intraventricular haemorrhages, defined by the criteria of Papile, were included at all levels of severity. 14 Endpoints Using the primary hospitalisation data, we compared mortality, days in hospital, weight gain and the incidence of adverse events such as intraventricular haemorrhage, blood culture-positive sepsis, bronchopulmonary dysplasia and retinopathy between the case and control groups. The daily weight gain [g/d] was calculated as (weight at discharge [g] – birth weight [g]) ÷ days in the hospital. Statistics The present study compared infants who underwent surgery for volvulus cases with a control group of infants who underwent surgery for NEC or FIP. The data were compared via the Mann‒Whitney U test for continuous variables and Fisher’s exact test for other variables. The endpoints included mortality until discharge, the duration of hospital stay until discharge, and weight gain during the hospital stay. The type I error level was set to 0.05, and the p values given were two-sided. Data analyses were performed using SPSS 29.0 (Munich, Germany). Results The literature search yielded 115 results. Single case reports (n = 43) and manuscripts focusing on locations other than the midgut, such as the stomach or sigmoid colon, or on topics unrelated to preterm infants were excluded (n = 21). We also excluded manuscripts that focused on topics related to volvulus that were not directly relevant to our study, such as long-term outcomes and surgical or imaging techniques (n = 14). Additionally, manuscripts focusing on topics such as necrotising enterocolitis or animal experiments were excluded (n = 16). Studies with no available abstracts or manuscripts or those written in languages other than English or German were also excluded (n = 9). Articles such as comments or editorial letters were also excluded (n = 2). Finally, nine manuscripts were selected for data extraction and summary (Table 1 ). These included a total of 102 cases of volvulus (median: seven; range: two–36), with a minimum gestational age of 23 weeks. The age at the onset of volvulus ranged from a median of four to 45 days, with an absolute minimum of zero to a maximum of 149 days. Six publications provided data on mortality, resulting in a rate of 12.2%. Table 1 Literature search Author/ Year Cases (N) GA (weeks) [unit] age @ volvulus (days) [unit] Died (N) comment Boulton 1989 17 15 34.5 ± 3.2 M (n.s.) 5 (1–35) n.s. (R) n.s. - Drewett 2009 5 4 32 (28–38) M (R) 4 (1–4) M (R) 0 Early VWM 6 27 (25–33) M (R) 45 (22–57) M (R) 0 Late VWM Grosfeld 1996 18 8 29.6 ± 4.3 M (n.s.) n.s. n.s. case series on GI perforation Kargl 2015 19 15 26 (24–33) M (R) 20 (2–99) M (R) 2 VWM Maas 2014 6 5 24.4 (23.6–25.4) M (R) 44 (37–52) M (R) 3 - Horsch 2016 20 12 31 (24–36) M (R) 4 (1–75) M (R) 1 later presentation (d28-75), exclu-sively in 5 preterms Mishra 2021 15 6 26.4 (24.6–27.4) M (R) 32 (25–137) M (R) 1 - Yarkin 2019 2 26 25.9 (23–32) M (R) 27 (0–149) M (R) 2 VWM, n = 6 incomplete questionaires Moser 2021 21 2 < 32 + 6 n.a. 31 (23–39) M (R) n.s. - Summary of the publications selected from a PubMed search that yielded 115 hits when the terms “volvulus” AND “preterm infant” were used. We selected those presenting neonatal volvulus case series with demographic and outcome data at the end of primary hospitalisation period. Abbreviations: GA: gestational age; VWM: volvulus without malrotation; VLBW: very low birthweight infant, born with less than 1500g; n.s. not stated Between January 2009 and December 2023, 33,518 preterm infants were eligible for enrollment in the GNN (Fig. 1 ). Among the 23,652 enrolled infants, the frequency of surgery for volvulus was 123 (0.5%), which was much lower than the frequency of surgery for NEC (642, 2.7%) or FIP (645, 2.7%). The infants with volvulus were slightly more mature than those in the comparison cohort were (Table 2 ). Compared with the NEC/FIP cohort, the volvulus cohort presented a significantly greater percentage of females. When we compared volvulus cases with the comparison cohort, we found no differences in birth weight, multiple births, the use of antenatal steroids, or the prevalence of small for gestational age. Table 2 Clinical characteristics Surgery for Volvulus (n = 123) FIP (n = 645) NEC (n = 642) NEC or FIP (n = 1287) Gestational age (weeks) 25.6 (24.9–26.9) 24.7 (24.0–26.1)† 25.4 (24.3–26.9)ns 25.1 (24.1–26.4)† Birth weight (g) 715 (610–870) 670 (540–820)** 705 (580–884)ns 685 (560–850)ns Female sex 65, 53% 256, 40%** 270, 42%* 526, 41%* Multiple birth 36, 29% 247, 38%, ns 210, 33%, ns 457, 36%, ns Antenatal steroids 111, 90% 586, 91%, ns 570, 89%, ns 1156, 90%, ns Small for gestational age 21, 17% 147, 23%, ns 134, 21%, ns 281, 22%, ns Day of surgery§ 29.5 (23–51) 7 (5–12) † 17 (9–28) † 10 (6–20) † Table 2 shows the summary of the clinical demographic characteristics of all cases that received surgery for volvulus, necrotising enterocolitis (NEC) and/or focal intestinal perforation (FIP) from the database of the German Neonatal Network. Categorical variables are given as n, percentage, continuous variables as median (inter quartile range). Small for gestational age was defined as less than the 10th percentile; §: Data concerning the day of surgery were available in 62 infants with surgery for volvulus and 985 infants with surgery for NEC or FIP. P-values were derived from Fisher’s exact test and Mann-Whitney-U test. *:p<0.05, **:p<0.01 and †: p<0.001 vs. volvulus; ns: not significant. The most significant discrepancy was observed in relation to the day of surgery. The majority of cases of volvulus occurred after 20 days of age, whereas the majority of cases of NEC or FIP surgery were necessary within the first three weeks of life (Fig. 2 ). Owing to the much higher rate of surgery for NEC or FIP, this condition was more common at any time during the hospital stay. However, the relative risk of volvulus in children who needed surgery increased over time (Fig. 3 ), from less than 5% within the first 20 days of life to 13–30% after that time. Although a shorter median interval until completion of postnatal nutrition was recorded for volvulus cases than for FIP or NEC cases, interestingly, no differences were recorded in this context with respect to the cumulative total number of days with IV access (Table 3 ). Probiotics were used significantly less frequently in the NEC group (68%; p = 0.020) than in the volvulus group (80%). No differences were found in the prescription of carbapenems between the groups. Notably, the rate of blood culture-positive sepsis cases was significantly greater (10%) in the NEC group than in the volvulus group. However, there were no differences in the outcomes of periventricular leukomalacia, BPD or ROP. In contrast, intraventricular haemorrhages were significantly more prevalent in the NEC (40%; p < 0.05) and FIP (44%; p < 0.001) groups than in the volvulus group (27%). There were no significant differences in length of hospitalisation or average weight gain until discharge, although the pathological associations were different. The NEC group had the highest mortality rate (24%), which was significantly greater than that of the volvulus group (15%). However, no differences were found between the FIP group or the combined FIP/NEC group and the volvulus group. Coincidentally, perioperative mortality was significantly greater in the volvulus group (24%) than in the FIP group (9%, p = 0.002), the NEC group (19%, ns) and the combined FIP/NEC group (11%, p = 0.037). Table 3 Short-term Outcome Surgery for Volvulus FIP NEC NEC or FIP Data until discharge N = 123 N = 645 N = 642 N = 1283 Intraventricular haemorrhage 33, 27% 286, 44%,† 253, 40%,* 539, 42%,† Periventricular leukomalacia 10, 8% 52, 8%, ns 74, 12%, ns 123, 10%,ns Sepsis 39, 32% 203, 32%,ns 267, 42%,* 470, 37%,ns Bronchopulmonary dysplasia 59, 48% 317, 49%,ns 324, 51%,ns 641, 50%,ns Retinopathy of prematurity 14, 12% 100, 16%,ns 119, 19%,ns 219, 18%,ns Days with i.v. access 58 (33–103) 44 (28–73),ns 62 (33–104), ns 51 (30–87), ns Days until complete food tolerance 15 (11–26) 28 (20–41),* 23 (14–42),** 26 (17–41),† Use of probiotics 83; 80% 430, 75%,ns 396, 68%.* 826, 72%,ns Use of carbapenem 83, 78% 469, 82%,ns 487, 83%, ns 956, 83%,ns Days in hospital 116 (79–140) 114 (88–140),ns 116 (72–150),ns 115 (84–144),ns Weight gain (g/d) 18.0 (14.2–21.7) 17.9 (14.6–21.2),ns 17.4 (14.5–20.6),ns 17.7 (14.6–20.9),ns Perioperative mortality* 15; 24% 46, 9%,** 89, 19%,ns 135; 11%,* Mortality until discharge 19, 15% 80, 12%,ns 154, 24%,* 234, 18%,ns Table 3 demonstrates the frequency of typical general and possible abdominal surgery-specific outcomes of very low birth weight preterm infants. In addition, the length of hospitalisation, and the weight gain during hospitalisation are shown. Categorical variables are given as n, percentage, continuous variables as median (inter quartile range). All other variables are given as median (inter quartile range). *Data concerning the perioperative mortality, defined within 30 days after first surgery, were available in 62 infants with surgery for volvulus and 985 infants with surgery for necrotising enterocolitis (NEC) or focal intestinal perforation (FIP). p-values were derived from Fisher’s exact test and Mann-Whitney-U test. ns: not significant; *:p<0.05, **:p<0.01 and †: p<0.001 vs. volvulus. Discussion To our knowledge, the results presented here regarding volvulus in premature infants are based on the largest dataset to date. They confirm that in VLBWI, volvulus typically manifests at a later postnatal age than NEC or FIP requiring surgery. The median age at surgery was 29.5 days, which is consistent with previous studies. 2 , 15 Our finding that volvulus is five times more common in VLBWIs requiring surgery after the 20th day of life than NEC or FIP is highly important for current neonatal practice. Few large-scale studies have reported the incidence and outcome of volvulus in preterm infants. Mishra and Stringer retrospectively analysed a 10-year period in a single center study. They reported that 7/514 (1.4%) preterm infants with a gestational age of less than 28 weeks underwent surgery for volvulus. The prevalence was much higher than the 0.2% prevalence of volvulus surgery in 7,382 preterm infants at ≥ 28 weeks gestation. 15 Yarkin et al. conducted an epidemiological study including more than 20,000 VLBWIs. They reported a prevalence of 0.13%, which was higher than previous estimates based on case series. 2 , 16 In our cohort, the prevalence of 0.5% for individuals with volvulus treated with surgery was within the reported range. According to our findings, girls are more likely to develop volvulus, which has been previously reported. 2 , 6 In cases of extreme prematurity, the relatively early complication of FIP or NEC is associated with a 13–17% higher risk of IVH than volvulus, whereas volvulus is a relatively late event in prematurity with a high perioperative mortality risk. This means that one in four premature infants dies perioperatively, whereas only one in nine dies from FIP or NEC. However, over the period until discharge, the mortality rate for NEC appears to have reached a similarly high level as the perioperative rate for volvulus. We did not find any differences with regard to growth or weight gain compared with the comparison cohort requiring surgery for NEC or FIP. Our study has several limitations. Detailed data on malrotation, localisation and extent of volvulus are not recorded in the GNN dataset. In addition, data on clinical symptoms preceding volvulus, such as bilious vomiting, lactic acidosis and severe abdominal pain, were not collected. Furthermore, we cannot provide outcome data such as the need for parenteral nutrition at discharge or surgical outcome data such as transplantation, enteral autonomy, the presence of an iliocaecal valve or postoperative bowel length. We report here that in preterm infants with a birth weight less than 1500 g, surgery for volvulus is needed for 5 out of every 1000 babies. Compared with infants who need surgery for NEC or FIP, volvulus is more common in girls and occurs at a later postnatal age, usually after day 20. Abbreviations FIP Focal intestinal perforation GNN German Neonatal Network IVH Intraventricular haemorrhage NEC Necrotising enterocolitis VLBWI Very low birth weight infant Declarations Ethics approval and consent to participate All aspects of the study comply with the Declaration of Helsinki and have been approved by the Ethics Committee at the University of Lübeck in Germany (vote numbers 08-022 and 2023-812) and at the participating centres. Only VLBWI whose parents or legal guardians had given formal written consent, having received detailed information about the study, were included in the GNN study. Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare that there are no financial or non-financial competing interests. Funding The German Neonatal Network is funded by the German Ministry of Research and Education (BMBF-grant-No: 01ER0805 and 01ER1501) and the Deutsche Forschungsgemeinschaft (SFB 1665--515637292, Sexdiversity). IF is supported by the Section of Medicine, University of Lübeck in the Advanced Clinician Scientist Program LACS02-2024. Clinical Trial Number Not applicable Authors' contributions BS conducted the initial investigation, wrote the original draft, conducted the formal analysis. GS and WG reviewed the initial draft, conceptualised and supervised the project, reviewed the data curation, data analysis, and visualisation of the results and wrote the final submission. MIF contributed to the initial draft. Together with MKS and KTL he supported editing and reviewing. All authors reviewed the final draft. References Costner BJ, Carter BS, Wentz SC, Wills ML. Intestinal malrotation in an extremely preterm very low birthweight infant. BMJ Case Rep. 2011; doi:10.1136/bcr.06.2010.3073. Yarkin Y, Maas C, Franz AR, Kirschner HJ, Poets CF. Epidemiological study on intestinal volvulus without malrotation in VLBW infants. Arch Dis Child Fetal Neonatal Ed. 2019; 104:F415-18. Millar AJ, Rode H, Cywes S. Malrotation and volvulus in infancy and childhood. Semin Pediatr Surg. 2003;12:229-36. Kimura K, Loening-Baucke V. Bilious vomiting in the newborn: rapid diagnosis of intestinal obstruction. Am Fam Physician. 2000;61:2791-8. Drewett M, Burge DM. Late-onset volvulus without malrotation in preterm infants. J Pediatr Surg. 2009;44:358-61. Maas C, Hammer S, Kirschner HJ, Yarkin Y, Poets CF, Franz AR. Late-onset volvulus without malrotation in extremely preterm infants--a case-control-study. BMC Pediatr. 2014;14:287. Kitano Y, Hashizume K, Ohkura M. Segmental small-bowel volvulus not associated with malrotation in childhood. Pediatr Surg Int. 1995;10:335-8. Mihatsch WA, Franz AR, Högel J, Pohlandt F. Hydrolyzed protein accelerates feeding advancement in very low birth weight infants. Pediatrics. 2002;110:1199-1203. Berger M, von Schweinitz D. Malrotationsfehlbildungen des Dünndarms. In : von Schweinitz D, Ure B, editors. Kinderchirurgie. Springer Reference Medizin. Berlin, Heidelberg; 2019. p.405-16. Vinocur DN, Lee EY, Eisenberg RL Neonatal intestinal obstruction. Am J Roentgenol. 2012;198:W1-10. Göpel W, Lüders C, Heinze K, Rausch TK, Fortmann I, Szymczak S, König IR, Herting E, Hanke K. The Effect of Parental Weight and Genetics on the BMI of Very Low Birth Weight Infants as They Reach School Age. Dtsch Arztebl Int. 2025;122:65-70. Voigt M, Rochow N, Guthmann F, Hesse V, Schneider KT, Schnabel D. Birth weight percentile values for girls and boys under consideration of maternal height. Z Geburtshilfe Neonatol. 2012;216:212-9. Walsh MC, Yao Q, Gettner P, Hale E, Collins M, Hensman A, Everette R, Peters N, Miller N, Muran G, Auten K, Newman N, Rowan G, Grisby C, Arnell K, Miller L, Ball B, McDavid G; National Institute of Child Health and Human Development Neonatal Research Network. Impact of a physiologic definition on bronchopulmonary dysplasia rates. Pediatrics. 2004;114:1305-11. Papile LA, Burstein J, Burstein R, Koffler H. Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm. J Pediatr. 1978;92:529-34. Mishra PR, Stringer MD. Intestinal malrotation in extremely premature infants: a potential trap. Pediatr Surg Int. 2021;37:1607-12. Durell J, Hall NJ, Drewett M, Paramanantham K, Burge D. Emergency laparotomy in infants born at <26 weeks gestation: a neonatal network-based cohort study of frequency, surgical pathology and outcomes. Arch Dis Child Fetal Neonatal Ed. 2017;102:F504-7. Boulton JE, Ein SH, Reilly BJ, Smith BT, Pape KE. Necrotizing enterocolitis and volvulus in the premature neonate. J Pediatr Surg. 1989;24:901-5. Grosfeld JL, Molinari F, Chaet M, Engum SA, West KW, Rescorla FJ, Scherer LR 3rd. Gastrointestinal perforation and peritonitis in infants and children: experience with 179 cases over ten years. Surgery. 1996;120:650-6. Kargl S, Wagner O, Pumberger W. Volvulus without malposition--a single-center experience. J Surg Res. 2015;193:295-9. Horsch S, Albayrak B, Tröbs RB, Roll C. Volvulus in term and preterm infants - clinical presentation and outcome. Acta Paediatr. 2016;105:623-7. Moser MF, Müller IJ, Schalamon J, Resch B. Neurodevelopmental outcome of very preterm infants with gastrointestinal tract perforations does not differ compared to controls. Wien Klin Wochenschr. 2021;133:680-6. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 12 Mar, 2026 Read the published version in BMC Pediatrics → Version 1 posted Editorial decision: Revision requested 16 Dec, 2025 Reviews received at journal 15 Dec, 2025 Reviews received at journal 27 Nov, 2025 Reviews received at journal 25 Nov, 2025 Reviews received at journal 23 Nov, 2025 Reviewers agreed at journal 20 Nov, 2025 Reviewers agreed at journal 20 Nov, 2025 Reviewers agreed at journal 20 Nov, 2025 Reviewers agreed at journal 19 Nov, 2025 Reviewers invited by journal 09 Nov, 2025 Editor invited by journal 04 Nov, 2025 Editor assigned by journal 31 Oct, 2025 Submission checks completed at journal 31 Oct, 2025 First submitted to journal 25 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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11:55:41","extension":"xml","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":79941,"visible":true,"origin":"","legend":"","description":"","filename":"ba7e3fab984d453f86de3fa1d0a026261structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7956838/v1/a22b43e99400a587e708a8d4.xml"},{"id":96284988,"identity":"eb3513af-2263-4328-9a82-99343746071d","added_by":"auto","created_at":"2025-11-19 11:55:41","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":85911,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7956838/v1/ae611b671e66e9875ab7d92d.html"},{"id":96284987,"identity":"96b86e1a-16e2-4918-9aed-14a5d4fc6a23","added_by":"auto","created_at":"2025-11-19 11:55:41","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":236709,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart of patient selection. Abbreviations: NEC: necrotisingenterocolitis; FIP: focal intestinal perforation.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7956838/v1/6683b59c166553ff4a85f0f5.png"},{"id":96284978,"identity":"c05071ef-eba7-421f-9405-348d8fffe334","added_by":"auto","created_at":"2025-11-19 11:55:41","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":32123,"visible":true,"origin":"","legend":"\u003cp\u003eAbsolute number of patientsrequiring surgery for volvulus or necrotising enterocolitis (NEC)/focal intestinal perforation(FIP). During the first 20 days of life, more than 95% of all surgical cases were attributed to NEC or FIP. After day 21, the proportion of surgeries due to volvulus increased markedly.\u003c/p\u003e\n\u003cp\u003eData on the timing of surgery were available for 62 infants with volvulus and 985 infants who underwent surgery for NEC or FIP, resulting in a total of 1,047 cases.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7956838/v1/0105a078f5078894763ebea1.png"},{"id":96364760,"identity":"e1871e52-d63d-4c02-87a2-ee68a5f01111","added_by":"auto","created_at":"2025-11-20 10:09:36","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":111104,"visible":true,"origin":"","legend":"\u003cp\u003eThe relative frequency of infants with very low birth weightsrequiring surgery due to volvulus (n = 62) or focal intestinal perforation(FIP)/necrotising enterocolitis (NEC) (n =985) is given as a fraction of the total number of cases and is shown graphically in 10-day sections up to 100 days after birth.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7956838/v1/4821853ec9bd2df692868529.png"},{"id":104739648,"identity":"2cd9c66d-696d-48ee-9670-ca6301a9cb77","added_by":"auto","created_at":"2026-03-16 16:11:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":983018,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7956838/v1/78c498d2-9797-47bd-b33e-03d653323da1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Volvulus in very-low-birth-weight preterm infants enrolled in the German Neonatal Network: Prevalence, mortality, and outcome","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn very small premature infants, most surgical abdominal interventions are performed due to focal intestinal perforation (FIP) or necrotising enterocolitis (NEC). Small bowel volvulus, on the other hand, is a rare but very serious differential diagnosis that requires immediate surgery. There are few data on volvulus at this age. An etiology due to malrotation is considered rare.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Although cases of gastric and sigmoideal volvulus have been reported, volvulus without any signs of malrotation is found more frequently, with an estimated incidence of 1.3 per 1,000 very low birth weight infants. (VLBWI).\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Several risk factors for the development of volvulus without an underlying malformation have been identified in the context of preterm birth. These include a gestational age of \u0026le;\u0026thinsp;28 weeks,\u003csup\u003e3,4,5,6\u003c/sup\u003e intestinal immaturity with prolonged transit time,\u003csup\u003e5,7,8\u003c/sup\u003e gaseous distention due to CPAP support,\u003csup\u003e5,7,8\u003c/sup\u003e intrauterine growth restriction, and female sex.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eEarly diagnosis is crucial for preventing extensive intestinal damage resulting from large-scale irreversible ischemia.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Clinical signs of volvulus include common signs of acute abdomen, such as tenderness and pain, as well as recurrent bilious vomiting, lactic acidosis and rapid deterioration of the infant's condition.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e In VLBWI, a volvulus may be misdiagnosed as a more prevalent condition, such as sepsis, FIP, or NEC. This may lead to delayed diagnosis and therapy.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe prognosis of volvulus depends on early diagnosis and treatment. Delayed diagnosis, particularly in cases of midgut volvulus, can have catastrophic consequences, including haemorrhage, lifelong dependence on parenteral nutrition, and associated complications.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eTo better understand the circumstances surrounding the important differential diagnosis of volvulus in VLBWIs, we conducted a literature search via the PubMed database. We also analysed the incidence, risk profile and treatment outcomes at the time of discharge after initial hospitalisation in the large database of the German Neonatal Network (GNN), which has been maintained since 2009 and contains more than 20,000 data records. We then compared these outcomes to those of infants with FIP or NEC.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eLiterature search\u003c/p\u003e\u003cp\u003eWe searched the PubMed database using only the terms 'volvulus' and 'preterm infant'. Our aim was to summarise demographic data on primary postnatal hospitalisations, time of onset and mortality from case series in single centres or regions. To this end, we first read all the abstracts. Case reports, comments, editorials and articles focusing on other topics were excluded. From the remaining manuscripts, we extracted the following data: the number of cases collected, the gestational age at birth, the age at onset of volvulus, and the number of deaths.\u003c/p\u003e\u003cp\u003ePatients and study design\u003c/p\u003e\u003cp\u003eThe GNN is a national population-based observational multicentre cohort study. Currently, 71 out of 162 level 3 neonatal intensive care units in Germany are participating. Between January 2009 and December 2016, VLBWIs with birth weights of less than 1500 g and a gestational age of less than 37\u0026thinsp;+\u0026thinsp;0 weeks were enrolled. Between January 2017 and December 2019, the inclusion criteria were a birth weight of less than 1000 g or a gestational age of 28\u0026thinsp;+\u0026thinsp;6 weeks or less. Between January 2020 and December 2021, infants with a gestational age of 26\u0026thinsp;+\u0026thinsp;6 weeks or less were included. Beginning in January 2022, VLBWIs with a gestational age of 28\u0026thinsp;+\u0026thinsp;6 weeks 28\u0026thinsp;+\u0026thinsp;6 days or less were enrolled. For the present study, a subset of the GNN was selected according to the following criteria: enrolment between January 2009 and December 2023; discharge or death by 31 December 2023; and the presence of surgically treated NEC, FIP or volvulus.\u003c/p\u003e\u003cp\u003e Infants were enrolled after written informed consent was obtained from their parents. Predefined data on general neonatal characteristics, antenatal and postnatal treatment and outcomes were recorded by the participating centers. After discharge from primary hospitalisation, case report forms were sent to the study centre at the University of L\u0026uuml;beck. Data quality was evaluated by a physician or a study nurse trained in neonatology via annual onsite monitoring. The data were subsequently coded and curated for analysis. All parts of the study were approved by the ethics committees of the University of L\u0026uuml;beck, vote numbers 08\u0026ndash;022 and 2023\u0026thinsp;\u0026minus;\u0026thinsp;812, and the participating centres.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eDefinitions\u003c/strong\u003e\u003cp\u003eThe need for surgery for NEC and/or FIP was recorded by ticking a box on the case report form. As surgery for volvulus is less common, it was recorded by ticking the box \u0026lsquo;other surgery\u0026rsquo; plus free text. We defined all infants who underwent surgery for volvulus as cases and infants who underwent surgery for NEC or FIP as the comparison cohort. In the event of multiple operations, only the most serious one was counted. For this purpose, surgery due to a volvulus was considered more serious than surgery for NEC, while a FIP operation was considered less serious. On the basis of national data, infants were classified \u0026lsquo;small for gestational age\u0026rsquo; if their sex-specific birth weight was below the 10th percentile.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Bronchopulmonary dysplasia was classified if the infant received CPAP and/or oxygen for 28 days and met the criteria according to the Walsh physiological definition at gestational age 35\u0026thinsp;+\u0026thinsp;0 to 36\u0026thinsp;+\u0026thinsp;6 weeks or died of respiratory failure before that.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Intraventricular haemorrhages, defined by the criteria of Papile, were included at all levels of severity.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/p\u003e\u003cp\u003eEndpoints\u003c/p\u003e\u003cp\u003eUsing the primary hospitalisation data, we compared mortality, days in hospital, weight gain and the incidence of adverse events such as intraventricular haemorrhage, blood culture-positive sepsis, bronchopulmonary dysplasia and retinopathy between the case and control groups. The daily weight gain [g/d] was calculated as (weight at discharge [g] \u0026ndash; birth weight [g])\u0026thinsp;\u0026divide;\u0026thinsp;days in the hospital.\u003c/p\u003e\u003cp\u003eStatistics\u003c/p\u003e\u003cp\u003eThe present study compared infants who underwent surgery for volvulus cases with a control group of infants who underwent surgery for NEC or FIP. The data were compared via the Mann‒Whitney U test for continuous variables and Fisher\u0026rsquo;s exact test for other variables. The endpoints included mortality until discharge, the duration of hospital stay until discharge, and weight gain during the hospital stay. The type I error level was set to 0.05, and the p values given were two-sided. Data analyses were performed using SPSS 29.0 (Munich, Germany).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe literature search yielded 115 results. Single case reports (n\u0026thinsp;=\u0026thinsp;43) and manuscripts focusing on locations other than the midgut, such as the stomach or sigmoid colon, or on topics unrelated to preterm infants were excluded (n\u0026thinsp;=\u0026thinsp;21). We also excluded manuscripts that focused on topics related to volvulus that were not directly relevant to our study, such as long-term outcomes and surgical or imaging techniques (n\u0026thinsp;=\u0026thinsp;14). Additionally, manuscripts focusing on topics such as necrotising enterocolitis or animal experiments were excluded (n\u0026thinsp;=\u0026thinsp;16). Studies with no available abstracts or manuscripts or those written in languages other than English or German were also excluded (n\u0026thinsp;=\u0026thinsp;9). Articles such as comments or editorial letters were also excluded (n\u0026thinsp;=\u0026thinsp;2). Finally, nine manuscripts were selected for data extraction and summary (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). These included a total of 102 cases of volvulus (median: seven; range: two\u0026ndash;36), with a minimum gestational age of 23 weeks. The age at the onset of volvulus ranged from a median of four to 45 days, with an absolute minimum of zero to a maximum of 149 days. Six publications provided data on mortality, resulting in a rate of 12.2%.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eLiterature search\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAuthor/ Year\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCases (N)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGA\u003c/p\u003e\n \u003cp\u003e(weeks)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e[unit]\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eage @ volvulus (days)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e[unit]\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDied (N)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ecomment\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBoulton\u003c/p\u003e\n \u003cp\u003e1989\u003csup\u003e17\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003cp\u003e(n.s.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e(1\u0026ndash;35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003en.s.\u003c/p\u003e\n \u003cp\u003e(R)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003en.s.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrewett\u003c/p\u003e\n \u003cp\u003e2009\u003csup\u003e5\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003cp\u003e(28\u0026ndash;38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003cp\u003e(R)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e(1\u0026ndash;4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003cp\u003e(R)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEarly VWM\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003cp\u003e(25\u0026ndash;33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003cp\u003e(R)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003cp\u003e(22\u0026ndash;57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003cp\u003e(R)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLate VWM\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGrosfeld\u003c/p\u003e\n \u003cp\u003e1996\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eM (n.s.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003en.s.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003en.s.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ecase series on GI perforation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKargl\u003c/p\u003e\n \u003cp\u003e2015\u003csup\u003e19\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003cp\u003e(24\u0026ndash;33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003cp\u003e(R)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003cp\u003e(2\u0026ndash;99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003cp\u003e(R)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVWM\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMaas\u003c/p\u003e\n \u003cp\u003e2014\u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.4\u003c/p\u003e\n \u003cp\u003e(23.6\u0026ndash;25.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003cp\u003e(R)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003cp\u003e(37\u0026ndash;52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003cp\u003e(R)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHorsch\u003c/p\u003e\n \u003cp\u003e2016\u003csup\u003e20\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003cp\u003e(24\u0026ndash;36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003cp\u003e(R)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e(1\u0026ndash;75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003cp\u003e(R)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003elater presentation (d28-75), exclu-sively in 5 preterms\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMishra\u003c/p\u003e\n \u003cp\u003e2021\u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26.4\u003c/p\u003e\n \u003cp\u003e(24.6\u0026ndash;27.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003cp\u003e(R)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003cp\u003e(25\u0026ndash;137)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003cp\u003e(R)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYarkin\u003c/p\u003e\n \u003cp\u003e2019\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.9\u003c/p\u003e\n \u003cp\u003e(23\u0026ndash;32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003cp\u003e(R)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003cp\u003e(0\u0026ndash;149)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003cp\u003e(R)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVWM, n\u0026thinsp;=\u0026thinsp;6 incomplete questionaires\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMoser\u003c/p\u003e\n \u003cp\u003e2021\u003csup\u003e21\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;32\u0026thinsp;+\u0026thinsp;6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003en.a.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003cp\u003e(23\u0026ndash;39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003cp\u003e(R)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003en.s.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\"\u003eSummary of the publications selected from a PubMed search that yielded 115 hits when the terms \u0026ldquo;volvulus\u0026rdquo; AND \u0026ldquo;preterm infant\u0026rdquo; were used. We selected those presenting neonatal volvulus case series with demographic and outcome data at the end of primary hospitalisation period. Abbreviations: GA: gestational age; VWM: volvulus without malrotation; VLBW: very low birthweight infant, born with less than 1500g; n.s. not stated\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eBetween January 2009 and December 2023, 33,518 preterm infants were eligible for enrollment in the GNN (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Among the 23,652 enrolled infants, the frequency of surgery for volvulus was 123 (0.5%), which was much lower than the frequency of surgery for NEC (642, 2.7%) or FIP (645, 2.7%). The infants with volvulus were slightly more mature than those in the comparison cohort were (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Compared with the NEC/FIP cohort, the volvulus cohort presented a significantly greater percentage of females. When we compared volvulus cases with the comparison cohort, we found no differences in birth weight, multiple births, the use of antenatal steroids, or the prevalence of small for gestational age.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eClinical characteristics\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSurgery for\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVolvulus\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;123)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFIP\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;645)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNEC\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;642)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNEC or FIP\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;1287)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGestational age (weeks)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.6\u003c/p\u003e\n \u003cp\u003e(24.9\u0026ndash;26.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.7\u003c/p\u003e\n \u003cp\u003e(24.0\u0026ndash;26.1)\u0026dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.4\u003c/p\u003e\n \u003cp\u003e(24.3\u0026ndash;26.9)ns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.1\u003c/p\u003e\n \u003cp\u003e(24.1\u0026ndash;26.4)\u0026dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBirth weight (g)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e715\u003c/p\u003e\n \u003cp\u003e(610\u0026ndash;870)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e670\u003c/p\u003e\n \u003cp\u003e(540\u0026ndash;820)**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e705\u003c/p\u003e\n \u003cp\u003e(580\u0026ndash;884)ns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e685\u003c/p\u003e\n \u003cp\u003e(560\u0026ndash;850)ns\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale sex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65, 53%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e256, 40%**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e270, 42%*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e526, 41%*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMultiple birth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36, 29%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e247, 38%, ns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e210, 33%, ns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e457, 36%, ns\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAntenatal steroids\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e111, 90%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e586, 91%, ns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e570, 89%, ns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1156, 90%, ns\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSmall for gestational age\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21, 17%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e147, 23%, ns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e134, 21%, ns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e281, 22%, ns\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDay of surgery\u0026sect;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29.5\u003c/p\u003e\n \u003cp\u003e(23\u0026ndash;51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e(5\u0026ndash;12) \u0026dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003cp\u003e(9\u0026ndash;28) \u0026dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e(6\u0026ndash;20) \u0026dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eTable 2 shows the summary of the clinical demographic characteristics of all cases that received surgery for volvulus, necrotising enterocolitis (NEC) and/or focal intestinal perforation (FIP) from the database of the German Neonatal Network. Categorical variables are given as n, percentage, continuous variables as median (inter quartile range). Small for gestational age was defined as less than the 10th percentile; \u0026sect;: Data concerning the day of surgery were available in 62 infants with surgery for volvulus and 985 infants with surgery for NEC or FIP. P-values were derived from Fisher\u0026rsquo;s exact test and Mann-Whitney-U test. *:p\u0026lt;0.05, **:p\u0026lt;0.01 and \u0026dagger;: p\u0026lt;0.001 vs. volvulus; ns: not significant.\u003c/p\u003e\n\u003cp\u003eThe most significant discrepancy was observed in relation to the day of surgery. The majority of cases of volvulus occurred after 20 days of age, whereas the majority of cases of NEC or FIP surgery were necessary within the first three weeks of life (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Owing to the much higher rate of surgery for NEC or FIP, this condition was more common at any time during the hospital stay. However, the relative risk of volvulus in children who needed surgery increased over time (Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e), from less than 5% within the first 20 days of life to 13\u0026ndash;30% after that time.\u003c/p\u003e\n\u003cp\u003eAlthough a shorter median interval until completion of postnatal nutrition was recorded for volvulus cases than for FIP or NEC cases, interestingly, no differences were recorded in this context with respect to the cumulative total number of days with IV access (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). Probiotics were used significantly less frequently in the NEC group (68%; p\u0026thinsp;=\u0026thinsp;0.020) than in the volvulus group (80%). No differences were found in the prescription of carbapenems between the groups. Notably, the rate of blood culture-positive sepsis cases was significantly greater (10%) in the NEC group than in the volvulus group. However, there were no differences in the outcomes of periventricular leukomalacia, BPD or ROP. In contrast, intraventricular haemorrhages were significantly more prevalent in the NEC (40%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and FIP (44%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) groups than in the volvulus group (27%). There were no significant differences in length of hospitalisation or average weight gain until discharge, although the pathological associations were different. The NEC group had the highest mortality rate (24%), which was significantly greater than that of the volvulus group (15%). However, no differences were found between the FIP group or the combined FIP/NEC group and the volvulus group. Coincidentally, perioperative mortality was significantly greater in the volvulus group (24%) than in the FIP group (9%, p\u0026thinsp;=\u0026thinsp;0.002), the NEC group (19%, ns) and the combined FIP/NEC group (11%, p\u0026thinsp;=\u0026thinsp;0.037).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eShort-term Outcome\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSurgery for\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVolvulus\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFIP\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNEC\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNEC or FIP\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eData until discharge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;123\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;645\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;642\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1283\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIntraventricular haemorrhage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33, 27%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e286, 44%,\u0026dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e253, 40%,*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e539, 42%,\u0026dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePeriventricular leukomalacia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10, 8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52, 8%, ns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e74, 12%, ns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e123, 10%,ns\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSepsis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39, 32%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e203, 32%,ns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e267, 42%,*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e470, 37%,ns\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBronchopulmonary dysplasia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59, 48%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e317, 49%,ns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e324, 51%,ns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e641, 50%,ns\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRetinopathy of prematurity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14, 12%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100, 16%,ns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e119, 19%,ns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e219, 18%,ns\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDays with i.v. access\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58 (33\u0026ndash;103)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44 (28\u0026ndash;73),ns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62 (33\u0026ndash;104), ns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51 (30\u0026ndash;87), ns\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDays until complete food tolerance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (11\u0026ndash;26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 (20\u0026ndash;41),*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23 (14\u0026ndash;42),**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26 (17\u0026ndash;41),\u0026dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUse of probiotics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e83; 80%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e430, 75%,ns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e396, 68%.*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e826, 72%,ns\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUse of carbapenem\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e83, 78%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e469, 82%,ns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e487, 83%, ns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e956, 83%,ns\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDays in hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e116\u003c/p\u003e\n \u003cp\u003e(79\u0026ndash;140)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e114\u003c/p\u003e\n \u003cp\u003e(88\u0026ndash;140),ns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e116\u003c/p\u003e\n \u003cp\u003e(72\u0026ndash;150),ns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e115\u003c/p\u003e\n \u003cp\u003e(84\u0026ndash;144),ns\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWeight gain (g/d)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.0\u003c/p\u003e\n \u003cp\u003e(14.2\u0026ndash;21.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.9\u003c/p\u003e\n \u003cp\u003e(14.6\u0026ndash;21.2),ns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.4\u003c/p\u003e\n \u003cp\u003e(14.5\u0026ndash;20.6),ns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.7\u003c/p\u003e\n \u003cp\u003e(14.6\u0026ndash;20.9),ns\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePerioperative mortality*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15; 24%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46, 9%,**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e89, 19%,ns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e135; 11%,*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMortality until discharge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19, 15%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80, 12%,ns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e154, 24%,*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e234, 18%,ns\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eTable 3 demonstrates the frequency of typical general and possible abdominal surgery-specific outcomes of very low birth weight preterm infants. In addition, the length of hospitalisation, and the weight gain during hospitalisation are shown. Categorical variables are given as n, percentage, continuous variables as median (inter quartile range). All other variables are given as median (inter quartile range). *Data concerning the perioperative mortality, defined within 30 days after first surgery, were available in 62 infants with surgery for volvulus and 985 infants with surgery for necrotising enterocolitis (NEC) or focal intestinal perforation (FIP). p-values were derived from Fisher\u0026rsquo;s exact test and Mann-Whitney-U test. ns: not significant; *:p\u0026lt;0.05, **:p\u0026lt;0.01 and \u0026dagger;: p\u0026lt;0.001 vs. volvulus.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo our knowledge, the results presented here regarding volvulus in premature infants are based on the largest dataset to date. They confirm that in VLBWI, volvulus typically manifests at a later postnatal age than NEC or FIP requiring surgery. The median age at surgery was 29.5 days, which is consistent with previous studies.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Our finding that volvulus is five times more common in VLBWIs requiring surgery after the 20th day of life than NEC or FIP is highly important for current neonatal practice.\u003c/p\u003e\u003cp\u003eFew large-scale studies have reported the incidence and outcome of volvulus in preterm infants. Mishra and Stringer retrospectively analysed a 10-year period in a single center study. They reported that 7/514 (1.4%) preterm infants with a gestational age of less than 28 weeks underwent surgery for volvulus. The prevalence was much higher than the 0.2% prevalence of volvulus surgery in 7,382 preterm infants at \u0026ge;\u0026thinsp;28 weeks gestation.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Yarkin et al. conducted an epidemiological study including more than 20,000 VLBWIs. They reported a prevalence of 0.13%, which was higher than previous estimates based on case series.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e In our cohort, the prevalence of 0.5% for individuals with volvulus treated with surgery was within the reported range. According to our findings, girls are more likely to develop volvulus, which has been previously reported.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn cases of extreme prematurity, the relatively early complication of FIP or NEC is associated with a 13\u0026ndash;17% higher risk of IVH than volvulus, whereas volvulus is a relatively late event in prematurity with a high perioperative mortality risk. This means that one in four premature infants dies perioperatively, whereas only one in nine dies from FIP or NEC. However, over the period until discharge, the mortality rate for NEC appears to have reached a similarly high level as the perioperative rate for volvulus. We did not find any differences with regard to growth or weight gain compared with the comparison cohort requiring surgery for NEC or FIP.\u003c/p\u003e\u003cp\u003eOur study has several limitations. Detailed data on malrotation, localisation and extent of volvulus are not recorded in the GNN dataset. In addition, data on clinical symptoms preceding volvulus, such as bilious vomiting, lactic acidosis and severe abdominal pain, were not collected. Furthermore, we cannot provide outcome data such as the need for parenteral nutrition at discharge or surgical outcome data such as transplantation, enteral autonomy, the presence of an iliocaecal valve or postoperative bowel length.\u003c/p\u003e\u003cp\u003eWe report here that in preterm infants with a birth weight less than 1500 g, surgery for volvulus is needed for 5 out of every 1000 babies. Compared with infants who need surgery for NEC or FIP, volvulus is more common in girls and occurs at a later postnatal age, usually after day 20.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eFIP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eFocal intestinal perforation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGNN\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGerman Neonatal Network\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIVH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntraventricular haemorrhage\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNEC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNecrotising enterocolitis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eVLBWI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eVery low birth weight infant\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003ch3\u003eEthics approval and consent to participate\u003c/h3\u003e\n\u003cp\u003eAll aspects of the study comply with the Declaration of Helsinki and have been approved by the Ethics Committee at the University of Lübeck in Germany (vote numbers 08-022 and 2023-812) and at the participating centres.\u0026nbsp;Only VLBWI whose parents or legal guardians had given formal written consent, having received detailed information about the study, were included in the GNN study.\u003c/p\u003e\n\u003ch3\u003eConsent for publication\u003c/h3\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch3\u003eAvailability of data and materials\u003c/h3\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003ch3\u003eCompeting interests\u003c/h3\u003e\n\u003cp\u003eThe authors declare that there are no financial or non-financial competing interests.\u003c/p\u003e\n\u003ch3\u003eFunding\u003c/h3\u003e\n\u003cp\u003eThe German Neonatal Network is funded by the German Ministry of Research and Education (BMBF-grant-No: 01ER0805 and 01ER1501) and the Deutsche Forschungsgemeinschaft (SFB 1665--515637292, Sexdiversity). IF is supported by the Section of Medicine, University of Lübeck in the Advanced Clinician Scientist Program LACS02-2024.\u003c/p\u003e\n\u003ch3\u003eClinical Trial Number\u003c/h3\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch3\u003eAuthors' contributions\u003c/h3\u003e\n\u003cp\u003eBS conducted the initial investigation, wrote the original draft, conducted the formal analysis. GS and WG reviewed the initial draft, conceptualised and supervised the project, reviewed the data curation, data analysis, and visualisation of the results and wrote the final submission. MIF contributed to the initial draft. Together with MKS and KTL he supported editing and reviewing. All authors reviewed the final draft.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCostner BJ, Carter BS, Wentz SC, Wills ML. Intestinal malrotation in an extremely preterm very low birthweight infant. BMJ Case Rep. 2011; doi:10.1136/bcr.06.2010.3073.\u003c/li\u003e\n\u003cli\u003eYarkin Y, Maas C, Franz AR, Kirschner HJ, Poets CF. Epidemiological study on intestinal volvulus without malrotation in VLBW infants. Arch Dis Child Fetal Neonatal Ed. 2019; 104:F415-18.\u003c/li\u003e\n\u003cli\u003eMillar AJ, Rode H, Cywes S. Malrotation and volvulus in infancy and childhood. Semin Pediatr Surg. 2003;12:229-36.\u003c/li\u003e\n\u003cli\u003eKimura K, Loening-Baucke V. Bilious vomiting in the newborn: rapid diagnosis of intestinal obstruction. Am Fam Physician. 2000;61:2791-8.\u003c/li\u003e\n\u003cli\u003eDrewett M, Burge DM. Late-onset volvulus without malrotation in preterm infants. J Pediatr Surg. 2009;44:358-61.\u003c/li\u003e\n\u003cli\u003eMaas C, Hammer S, Kirschner HJ, Yarkin Y, Poets CF, Franz AR. Late-onset volvulus without malrotation in extremely preterm infants--a case-control-study. BMC Pediatr. 2014;14:287.\u003c/li\u003e\n\u003cli\u003eKitano Y, Hashizume K, Ohkura M. Segmental small-bowel volvulus not associated with malrotation in childhood. Pediatr Surg Int. 1995;10:335-8.\u003c/li\u003e\n\u003cli\u003eMihatsch WA, Franz AR, H\u0026ouml;gel J, Pohlandt F. Hydrolyzed protein accelerates feeding advancement in very low birth weight infants. Pediatrics. 2002;110:1199-1203.\u003c/li\u003e\n\u003cli\u003eBerger M, von Schweinitz D. Malrotationsfehlbildungen des D\u0026uuml;nndarms. In\u003cem\u003e: \u003c/em\u003evon Schweinitz D, Ure B, editors.\u003cem\u003e Kinderchirurgie.\u003c/em\u003e Springer Reference Medizin. Berlin, Heidelberg; 2019. p.405-16.\u003c/li\u003e\n\u003cli\u003eVinocur DN, Lee EY, Eisenberg RL Neonatal intestinal obstruction. Am J Roentgenol. 2012;198:W1-10. \u003c/li\u003e\n\u003cli\u003eG\u0026ouml;pel W, L\u0026uuml;ders C, Heinze K, Rausch TK, Fortmann I, Szymczak S, K\u0026ouml;nig IR, Herting E, Hanke K. The Effect of Parental Weight and Genetics on the BMI of Very Low Birth Weight Infants as They Reach School Age. Dtsch Arztebl Int. 2025;122:65-70.\u003c/li\u003e\n\u003cli\u003eVoigt M, Rochow N, Guthmann F, Hesse V, Schneider KT, Schnabel D. Birth weight percentile values for girls and boys under consideration of maternal height. Z Geburtshilfe Neonatol. 2012;216:212-9.\u003c/li\u003e\n\u003cli\u003eWalsh MC, Yao Q, Gettner P, Hale E, Collins M, Hensman A, Everette R, Peters N, Miller N, Muran G, Auten K, Newman N, Rowan G, Grisby C, Arnell K, Miller L, Ball B, McDavid G; National Institute of Child Health and Human Development Neonatal Research Network. Impact of a physiologic definition on bronchopulmonary dysplasia rates. Pediatrics. 2004;114:1305-11.\u003c/li\u003e\n\u003cli\u003ePapile LA, Burstein J, Burstein R, Koffler H. Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm. J Pediatr. 1978;92:529-34.\u003c/li\u003e\n\u003cli\u003eMishra PR, Stringer MD. Intestinal malrotation in extremely premature infants: a potential trap. Pediatr Surg Int. 2021;37:1607-12.\u003c/li\u003e\n\u003cli\u003eDurell J, Hall NJ, Drewett M, Paramanantham K, Burge D. Emergency laparotomy in infants born at \u0026lt;26 weeks gestation: a neonatal network-based cohort study of frequency, surgical pathology and outcomes. Arch Dis Child Fetal Neonatal Ed. 2017;102:F504-7.\u003c/li\u003e\n\u003cli\u003eBoulton JE, Ein SH, Reilly BJ, Smith BT, Pape KE. Necrotizing enterocolitis and volvulus in the premature neonate. J Pediatr Surg. 1989;24:901-5.\u003c/li\u003e\n\u003cli\u003eGrosfeld JL, Molinari F, Chaet M, Engum SA, West KW, Rescorla FJ, Scherer LR 3rd. Gastrointestinal perforation and peritonitis in infants and children: experience with 179 cases over ten years. Surgery. 1996;120:650-6.\u003c/li\u003e\n\u003cli\u003eKargl S, Wagner O, Pumberger W. Volvulus without malposition--a single-center experience. J Surg Res. 2015;193:295-9. \u003c/li\u003e\n\u003cli\u003eHorsch S, Albayrak B, Tr\u0026ouml;bs RB, Roll C. Volvulus in term and preterm infants - clinical presentation and outcome. Acta Paediatr. 2016;105:623-7.\u003c/li\u003e\n\u003cli\u003eMoser MF, M\u0026uuml;ller IJ, Schalamon J, Resch B. Neurodevelopmental outcome of very preterm infants with gastrointestinal tract perforations does not differ compared to controls. Wien Klin Wochenschr. 2021;133:680-6.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"volvulus, very low birth weight infants, period of occurrence, prevalence, outcome","lastPublishedDoi":"10.21203/rs.3.rs-7956838/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7956838/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eVolvulus is an emergency condition, but data on its prevalence and outcome in preterm infants are scarce.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e We analyseddata from the German Neonatal Network and conducted a PubMed literature search on the primary hospital stay of very-low-birth-weight infants who underwent surgery for volvulus. Infants who underwent surgery for focal intestinal perforation and/or necrotising enterocolitis served as a comparison group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Nine relevant publications involving 102 preterm infants with volvulus were identified, revealinga wide range of postnatal onset and a mortality rate of 10.7%. The prevalence of volvulus was 123/23,652 (0.5%) according to the German Neonatal Network,which was significantly lower than the prevalence of necrotisingenterocolitis and/or focal intestinal perforation. The volvulus group had a significantly higher proportion of female premature infants than the groups with necrotising enterocolitis or focal intestinal perforation. Most operations for volvulus were performed after the 20th day of life. Preterm infants who underwent surgeryfor volvulus had significantly less intraventricular haemorrhage and faster feeding than did those with necrotising enterocolitis and/or focal intestinal perforation. Notably, however, perioperative mortality was highest in the volvulus group. Furthermore, mortality until discharge was significantly greaterin the necrotising enterocolitis group (24%) than in the volvulus group (15%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eVolvulus occurs in five out of 1,000 very-low-birth-weight infants, particularly in those requiring immediate surgery after 20 days of age.\u003c/p\u003e","manuscriptTitle":"Volvulus in very-low-birth-weight preterm infants enrolled in the German Neonatal Network: Prevalence, mortality, and outcome","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-19 11:55:36","doi":"10.21203/rs.3.rs-7956838/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-16T08:44:22+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-15T20:35:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-28T01:33:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-25T23:18:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-23T13:52:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"285315622061039206445122561246048910383","date":"2025-11-20T08:45:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"213400540642814973220676656435782811030","date":"2025-11-20T08:41:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"284370162272059628065654615255363471825","date":"2025-11-20T07:38:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"215059417749742480891792077369175385628","date":"2025-11-20T00:54:23+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-09T23:38:44+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-04T05:04:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-31T12:27:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-31T12:25:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2025-10-25T19:26:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a6edf423-5f8e-46d2-89d4-478eab8b9314","owner":[],"postedDate":"November 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-16T16:08:13+00:00","versionOfRecord":{"articleIdentity":"rs-7956838","link":"https://doi.org/10.1186/s12887-026-06638-4","journal":{"identity":"bmc-pediatrics","isVorOnly":false,"title":"BMC Pediatrics"},"publishedOn":"2026-03-12 16:00:22","publishedOnDateReadable":"March 12th, 2026"},"versionCreatedAt":"2025-11-19 11:55:36","video":"","vorDoi":"10.1186/s12887-026-06638-4","vorDoiUrl":"https://doi.org/10.1186/s12887-026-06638-4","workflowStages":[]},"version":"v1","identity":"rs-7956838","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7956838","identity":"rs-7956838","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}