Review of sigmoid volvulus. Clinical patterns and pathogenesis

Relationship Between Sigmoid Volvulus Subtypes, Clinical Course, and Imaging Findings

Background: Recent studies indicate that the organo-axial subtype of a sigmoid volvulus is more prevalent than the conventional mesentero-axial subtype. Our study aimed to assess the clinical and radiological findings that differentiate between these two subtypes, as well as to ascertain treatment outcomes and prognostic characteristics. Methods: A retrospective review included 54 patients, during which abdominal plain radiographs and computed tomography images were analyzed by two radiologists, and data on recurrence, mortality, and treatment outcomes were documented. Results: The mesentero-axial subtype comprised 40 cases (74%). No distinct radiographic findings were observed to differentiate between the two groups. In computed tomography, the sole significant parameter for differentiation was the number of transition zones. The diameter of the segment exhibiting a volvulus was greater in instances of the mesentero-axial subtype. The endoscopic detorsion treatment proved ineffective in five patients within the mesentero-axial sigmoid volvulus cohort. Conclusions: Identifying these two types of SV on CT images is essential because of their distinct prognoses and therapeutic results.

Epidemiology and age-related trends in surgical outcomes for sigmoid volvulus: a 17-year analysis

BACKGROUND

Sigmoid volvulus, a gastrointestinal disorder characterized by twisted bowel, often requires medical intervention, either through endoscopic or surgical means, to avoid potentially severe outcomes. This study examined the challenges elderly patients face in undergoing surgical treatment, encompassing both mortality and morbidity. Furthermore, it aimed to determine how medical practices and outcomes have changed over a period of 17 years.

METHODS

We utilized data from the National Surgical Quality Improvement Project, which covers the period from 2005 to 2021, to identify patients who underwent left hemicolectomy for colonic volvulus. The patients were categorized into three age groups: < 60 years, 60-75 years, and > 75 years. We performed a meticulous logistic regression analysis, carefully adjusted for risk factors, to compare mortality, morbidity, and types of surgical treatment administered among the different age groups.

RESULTS

Our study included 6775 patients. The breakdown of the patient population was as follows: 2067 patients were < 60 years of age, 2239 were between 60 and 75 years of age, and 2469 were > 75 years of age. The elderly cohort, those aged above 75 years, were predominantly male, had lower BMIs, underwent fewer laparoscopic surgeries, required more diverting stomas and end-ostomies, and had longer hospital stays. Notably, the elderly population faced a mortality risk that was 5.67 times (95% CI 3.64, 9.20) greater than that of their youngest counterparts, with this risk increasing by 10% (95% CI 1.06, 1.14) for each additional year of age. Furthermore, the odds of mortality associated with emergency surgery were 1.63 times (95% CI 1.21, 2.22) higher than those associated with elective surgery. The postoperative morbidity odds were also elevated for emergency surgeries, 1.30 times (95% CI 1.08, 1.58) greater than that for elective cases. Over the 17-year period, we observed a decline in mortality rates, an increase in the utilization of laparoscopic procedures, and overall stability of morbidity rates.

CONCLUSION

Our findings highlight the increased vulnerability of patients over 75 years of age, who are not only at an elevated risk of mortality compared to their younger counterparts, but also a continuously increasing risk with age. By focusing on elective surgeries for younger patients and minimizing emergency surgeries for the elderly, it may be possible to reduce the mortality risk associated with surgical interventions in this population.

Recurrent Sigmoid Volvulus in Children-Our Experience and Systematic Review of the Current Literature

Sigmoid volvulus (SV) occurs rarely in children. After encountering two cases of recurrent SV, we reviewed the literature to define the recurrence risk, identify outcome predictors and to give treatment recommendations. We found 256 cases reported in children (mean age 10.2 years, gender ratio (m:f) 2.3:1). Associations exist with Hirschsprung disease (HD) in 10%, neurodevelopmental disorders in 10.9% and chronic constipation in 10.2%. Common symptoms and clinical signs were abdominal pain (85%), distension (85%), tenderness (54%) and vomiting (59%). Signs of peritonitis were present in 14% and indicated a gangrenous sigmoid (X2 = 45.33; p < 0.001). A total of 183 had abdominal radiographs, and 65% showed a positive 'coffee-bean-sign'. Contrast enemas were positive in 90%. A total of 124 patients underwent laparotomy; in 41 cases, the sigmoid was gangrenous and associated with more complications (X2 = 15.68; p < 0.001). Non-operative treatment (NOT) like endoscopic, fluoroscopic or rectal tube decompression was performed in 135 patients and successful in 79% with a 38-57% recurrence rate. A total of 73 patients subjected to elective surgery: 50 underwent sigmoid resection; 17 had surgery for HD. Clinicians should consider SV in all children with abdominal pain, distension and vomiting. Gangrene carries a higher morbidity. After successful NOT we recommend counselling about the recurrence risk and definitive surgery should be advised. HD is frequent in newborns but sometimes found in older children.

WSES consensus guidelines on sigmoid volvulus management

Sigmoid volvulus is a common surgical emergency, especially in elderly patients. Patients can present with a wide range of clinical states: from asymptomatic, to frank peritonitis secondary to colonic perforation. These patients generally need urgent treatment, be it endoscopic decompression of the colon or an upfront colectomy. The World Society of Emergency Surgery united a worldwide group of international experts to review the current evidence and propose a consensus guidelines on the management of sigmoid volvulus.

A Seven-Year Etiological Study of Adult Bowel Obstruction in Shiraz, Iran

BACKGROUND

Bowel obstruction is a disorder in the passage of bowel contents, the etiology of which varies depending on temporal and geographical conditions. This study investigated the etiology of bowel obstruction in a large number of patients at an adult surgery referral center in southern Iran.

METHODS

In this cross-sectional study, we reviewed the medical records of all patients admitted to Shahid Faghihi hospital (Shiraz, Iran) between 2014 and 2020 with a diagnosis of small or large bowel obstruction. Patients with missing or obscure data on etiology were excluded. Data was collected on the patients' age, gender, history of relevant surgeries, comorbidities, cause of obstruction, site/type of obstruction, treatment, intensive care unit (ICU) admission, length of hospital stay, and outcome. Statistical analyses were made using SPSS v. 25.0.

RESULTS

A total of 2781 bowel obstruction patients (61.4% males, 38.6% females) with a median age of 58 (IQR 43-71) years were studied. Most responded to non-surgical treatment (61.3%). While the obstruction was mostly partial (65.5%), 94.4% of patients with complete obstruction required surgery. Small bowel obstruction (SBO) was almost three times more prevalent than large bowel obstruction (LBO). Adhesion bands were the leading cause of SBO (66.77%), while LBO was primarily due to colorectal tumors (33.9%).

CONCLUSION

The predominant etiology of LBO was colorectal cancer, suggesting that policymakers should improve surveillance programs to detect the condition earlier. Regarding SBO, the leading cause was adhesion bands, indicating the necessity of further efforts to reduce the rate of adhesions following intra-abdominal operations.

Sigmoid volvulus: definitive surgery is safe and should be considered in all instances

Background

Acute sigmoid volvulus (ASV) represents a small but significant portion of cases of large bowel obstruction, especially in the elderly and co-morbid. Given the characteristics of the patient cohort most commonly affected, a non-operative/conservative approach is often undertaken but is associated with a high rate of recurrence.

Objective

We sought to evaluate outcomes for those patients who underwent non-operative management, emergency surgery or staged, semi-elective surgery following decompression for ASV at our institution.

Methods

Hospital in-patient enquiry (HIPE) data were used to identify all patients who presented with sigmoid volvulus between January 2005 and June 2020 inclusive. Patient notes were interrogated, including surgical and endoscopic procedures performed. Patient demographics and co-morbidities were recorded.

Results

Thirty-nine patients were treated over a 15-year period with a mean age of 73 years at first presentation (range 36–93). Twenty-two patients (56%) had just a single admission for ASV with three deaths in this group.

Seventeen patients (44%) had more than one admission with volvulus due to recurrence after a decompression-only strategy on the index admission. Of these, three succumbed to complications of their subsequent episodes of volvulus.

Twenty-five patients underwent surgical intervention (fifteen on, or shortly following, their first admission and ten following at least two admissions for ASV). The overall mortality in the operative group was 2/25 (8%) with both deaths in those undergoing emergency surgeries. Five patients were treated successfully with endoscopic measures alone and had required no further interventions at the time of compiling data.

Conclusion

There is a high recurrence rate following non-operative management of acute sigmoid volvulus and consequently, a cumulative increase in the attendant significant morbidity and mortality with subsequent episodes. Given the relatively low complication rate of definitive surgery, even in those patients perceived to be high risk, we contend that all patients should be considered for early surgery to prevent the likely recurrence of sigmoid volvulus.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

Different clinicopathological features of non-elderly sigmoid volvulus patients

PURPOSE

Sigmoid volvulus is frequently seen in male patients over 60 years old. Here, we aimed to investigate the causes of sigmoid volvulus developing in patients under 60 years of age.

METHODS

Patients diagnosed with sigmoid volvulus between 2009 and 2018 were retrospectively analyzed. The patients were divided into two as under 60 years old and above. The co-morbidity, mortality, morbidity, complications, age, and gender data were analyzed.

RESULTS

A total of 134 patients were included. The median age was 70 (19-92), ≤ 59 age patients constituted 24% of all patients. Eighty-one percent (109/134) of the patients were male, and male/female ratio was lower in ≤ 59 age patients (2.0 vs 6.2, p = 0.01). Diseases that caused and underlying colon dilatation (mental retardation with hypomotility, pregnancy-puerperium, Hirschsprung's disease, etc.) were more common in ≤ 59 age patients, but no observed at 60≤ age patients (15.2% vs 0%, p = 0.0007). While there was no difference between the two groups in terms of mortality, it was proportionally higher in the 60≤ age group (3.0% vs. 13.9%, p = 0.12).

CONCLUSION

By decreasing age, male dominance disappears progressively, and it is likely to have an underlying colonic hypomotility in young sigmoid volvulus patients.

Colonoscopy-assisted percutaneous sigmoidopexy: a novel, simple, safe, and efficient treatment for inoperable sigmoid volvulus (with videos)

BACKGROUND AND AIMS

Many patients with sigmoid volvulus are old with co-morbidities, making elective surgery prohibitive. Colonoscopic management is often successful but volvulus often recurs. We devised a method of colonoscopy-assisted percutaneous sigmoidopexy as an alternative method to prevent recurrence of sigmoid volvulus. This study aimed to assess its safety and effectiveness.

METHODS

Patients with sigmoid volvulus American Society of Anesthesiologists physical status classification ≥3 or Barthel index <30 were included. We excluded patients with intestinal necrosis and those who were unable to be repositioned but who could undergo intestinal resection. Colonoscopy-assisted sigmoidopexy was performed under radiographic observation. First, a colonoscope was inserted to the fixation site. A site for percutaneous puncture of the colon was identified by transmitted illumination and finger pressure. An exploratory puncture through the abdominal wall was made with a 23-gauge cattelan needle with the patient under local anesthesia, followed by a skin incision. Sigmoid fixation was then performed using a 2-shot anchor device that allows the sigmoid colon to be sutured to the abdominal wall. Fixation was repeated at 5 to 10 sites (average 8.8). The primary outcome measurement was sigmoid volvulus recurrence within 12 months. The secondary outcome measurement was adverse events.

RESULTS

Eight patients received colonoscopy-assisted sigmoidopexy, and no sigmoid volvulus recurred during the 12-month follow-up period. One case of postoperative subcutaneous emphysema was successfully managed with conservative therapy.

CONCLUSION

Colonoscopy-assisted sigmoidopexy was an effective, safe alternative method to prevent the recurrence of sigmoid volvulus.

Contemporary Management of Sigmoid Volvulus

BACKGROUND

Sigmoid volvulus is an uncommon cause of bowel obstruction that is historically associated with high morbidity and mortality. The objective of this study was to evaluate contemporary management of sigmoid volvulus and the safety of primary anastomosis in patients with sigmoid volvulus.

METHODS

The National Surgical Quality Improvement Project from 2012 to 2015 was queried for patients with colonic volvulus who underwent left-sided colonic resection. A propensity score-matched analysis was performed to compare patients with sigmoid volvulus undergoing colectomy with primary anastomosis without proximal diversion to colectomy with end colostomy.

RESULTS

Two thousand five hundred thirty-eight patients with sigmoid volvulus were included for analysis. Patients had a median age of 68 years (interquartile range, 55-80) and 79% were fully independent preoperatively. Fifty-one percent of operations were performed emergently. One thousand eight hundred thirteen (71%) patients underwent colectomy with anastomosis, 240 (10%) colectomy with anastomosis and proximal diversion, and 485 (19%) colectomy with end colostomy. Overall, 30-day mortality and morbidity were 5 and 40%, respectively. After propensity score matching, mortality, overall morbidity, and serious morbidity were similar between groups.

CONCLUSIONS

Sigmoid volvulus occurs in elderly and debilitated patients with significant morbidity, mortality, and lifestyle implications. In selected patients, anastomosis without proximal diversion in patients with sigmoid volvulus results in similar outcomes to colectomy with end colostomy.

Usability of elective laparoscopic sigmoidectomy and feasibility of single-incision laparoscopic surgery for sigmoid volvulus: report of three cases

A therapeutic guideline for sigmoid volvulus (SV) has not been established, and the most recommended surgical procedure for SV has not been determined. Our objective is to assess the usability of elective laparoscopic sigmoidectomy and the feasibility of single-incision laparoscopic surgery for SV following endoscopic reduction. SV typically affects the elderly and accounts for 1% to 7% of intestinal obstructions in Western countries. We report on 3 patients with SV who underwent elective laparoscopic sigmoidectomy following endoscopic reduction, and we first describe single-port surgery for SV. We discuss the 3 patients (a 79-year-old male, an 88-year-old female, and a 67-year-old female) with SV who underwent elective laparoscopic sigmoidectomy following endoscopic reduction. All 3 patients underwent laparoscopic sigmoidectomy, and 2 patients underwent single-port laparoscopic surgery without complications. Recurrence of volvulus was not seen during the course of 12 to 24 months. In experienced hands, elective laparoscopic sigmoidectomy after colonoscopic detorsion is a valuable alternative, and single-port surgery is also feasible.

The morphology of the foetal sigmoid colon in the African population: a possible predisposition to sigmoid volvulus

AIM

This study aimed to determine the morphological types of the foetal sigmoid colon and establish if the anatomical predisposition to sigmoid volvulus is present in Black African foetuses. Sigmoid volvulus affects Black Africans in our province more frequently than other ethnic groups, and males more than females. Its aetiology remains speculative, with factors being proposed that do not suggest the pathogenetic mechanisms or the gender bias. Previous anatomical studies have suggested that Black Africans have a predisposition to sigmoid volvulus due to an elongated sigmoid colon. We investigated whether this phenomenon occurred during foetal development.

METHOD

Foetuses were donated from local hospitals. Population groups were defined as Black African and non-African. After dissection, the anatomy of the sigmoid colon was described according to level of origin, classic or elongated type and shape (broad or narrow).

RESULTS

A total of 296 Black African foetuses and 37 non-African foetuses were donated. The sigmoid colon in the majority of foetuses in all gestational age groups had a low level of origin. An elongated colon was seen in 68% of Black African and 17% of non-African foetuses (P < 0.0001). Among Black Africans there was a higher proportion of elongated sigmoid colon among male (73%) than female foetuses (62%) (P = 0.044). In foetuses with an elongated sigmoid colon the broad shape was more common in females than males and the long-narrow shape was more common in males (P = 0.038).

CONCLUSION

The elongated sigmoid colon seen in Black Africans is present in utero and occurs more frequently in Black African males. A narrow shape is more common in male foetuses and the broad shape is more common in female foetuses. These anatomical features may be the cause of the predisposition to sigmoid volvulus in Black African adults.

Bowel obstruction and hernia

Bowel obstruction and abdominal hernia are commonly observed in patients seeking emergency care for abdominal pain. This article discusses bowel obstruction, adynamic ileus, acute colonic pseudo-obstruction, and abdominal hernias, with particular emphasis on the management of patients in the emergency department (ED). Although the diagnostic approach to bowel obstruction often requires imaging, abdominal hernia may be identified in most circumstances by history and physical examination alone. Urgent surgical consultation is indicated when there is a concern for bowel ischemia, strangulation, or complete obstruction. This article reviews an ED-based approach to the patient presenting with symptoms of bowel obstruction or hernia.

Tube sigmoidostomy: a valuable alternative to sigmoidopexy for sigmoid volvulus

OBJECTIVE

To compare the effectiveness of tube sigmoidostomy and sigmoidopexy as effective treatment options for patients with acute uncomplicated sigmoid volvulus.

METHODS

The records of 72 patients with acute uncomplicated sigmoid volvulus with obstruction who were treated by tube sigmoidostomy (Group I: n=32) and sigmoidopexy (Group II: n=40) were reviewed retrospectively. Follow-up period was 22 months (range: 6-51 months).

RESULTS

Results show significant improvement in postoperative tachycardia, respiratory distress and urine output in Group I patients as compared to those in Group II. Most of the clinical parameters of Group I patients normalized by day 3, while it took up to 7 days in Group II patients. Intraabdominal hypertension caused by persistent colonic dilatation after sigmoidopexy was found to be an important determinant of postoperative morbidity. As compared to tube sigmoidostomy, the sigmoidopexy group had delayed recovery, more chances of abdominal fascial dehiscence, and longer hospital stay, as well as more prolonged abdominal discomfort, constipation, and recurrent volvulus rates during follow-up.

CONCLUSION

Tube sigmoidostomy provides both fixation and decompression of the redundant sigmoid colon in the postoperative period while allowing time to recover from massive dilatation and edema caused by prolonged volvulus. Compared with sigmoidopexy for the treatment of uncomplicated sigmoid volvulus, tube sigmoidostomy leads to lesser rates of morbidity and recurrence. Thus, it can be considered as a definitive alternative treatment option for uncomplicated sigmoid volvulus.

Sigmoid colon morphology in the population groups of Durban, South Africa, with special reference to sigmoid volvulus

Sigmoid volvulus demonstrates geographical, racial, and gender variation. This autopsy study was undertaken to establish morphological differences of the sigmoid colon and its mesocolon in which the length and other characteristics were assessed. A total of 590 cadavers were examined (403 African, 91 Indian, and 96 White). Length and height of the sigmoid colon and mesocolon were significantly longer in Africans, and mesocolon root was significantly narrower in Africans. Mesocolic ratio for Africans, Indians, and Whites was 1.1 ± 0.8, 1.8 ± 0.7, and 1.9 ± 1.0, respectively. Africans had a significantly high incidence of redundant sigmoid colon with the long-narrow type and suprapelvic position predominating (P = 0.003); the opposite applied to the classic type. There was no difference in sigmoid colon length, mesocolon height, and width between males and females in all population groups. Among Africans, the long-narrow type was more common in males, and the classic and long-broad types were more common in females. Splaying of teniae coli and thickening of the mesentery were more common in Africans. Tethering of the sigmoid colon to the posterior abdominal wall was less common in Africans compared with other population groups. In conclusion, the sigmoid colon was longer, and the sigmoid mesocolon root was narrower in Africans compared with the other population groups, and the sigmoid colon had a suprapelvic disposition among Africans. In Africans, the sigmoid colon was longer in males with a long-narrow shape. These differences may explain geographical and racial differences in sigmoid volvulus.

Resection and primary anastomosis with or without modified blow-hole colostomy for sigmoid volvulus

AIM: To evaluate the efficacy of resection and primary anastomosis (RPA) and RPA with modified blow-hole colostomy for sigmoid volvulus.

METHODS: From March 2000 to September 2007, 77 patients with acute sigmoid volvulus were treated. A total of 47 patients underwent RPA or RPA with modified blow-hole colostomy. Twenty-five patients received RPA (Group A), and the remaining 22 patients had RPA with modified blow-hole colostomy (Group B). The clinical course and postoperative complications of the two groups were compared.

RESULTS: The mean hospital stay, wound infection and mortality did not differ significantly between the groups. Superficial wound infection rate was higher in group A (32% vs 9.1%). Anastomotic leakage was observed only in group A, with a rate of 6.3%. The difference was numerically impressive but was statistically not significant.

CONCLUSION: RPA with modified blow-hole colostomy provides satisfactory results. It is easy to perform and may become a method of choice in patients with sigmoid volvulus. Further studies are required to further establish its role in the treatment of sigmoid volvulus.

Mechanical obstruction of the small bowel and colon

Mechanical obstruction of the small bowel and colon is moderately common, accounting for several hundred thousand admissions per year in the United States. Patients generally present with abdominal pain, nausea and emesis, abdominal distention, and progressive obstipation. Clinical findings of high fever, localized severe abdominal tenderness, rebound tenderness, severe leukocytosis, or metabolic acidosis suggest possible complications of bowel necrosis, bowel perforation, or generalized peritonitis. Differentiation of total mechanical obstruction from partial mechanical obstruction and pseudo-obstruction is important because total mechanical obstruction is generally treated surgically,whereas the other two entities are usually treated medically. Mechanical obstruction is usually suggested by plain abdominal radiographs, and confirmed by small bowel follow through,abdominal CT, or CT enteroclysis.

Cecal volvulus in cerebral palsy: report of a case

A rare case of cecal volvulus in cerebral palsy that was preoperatively diagnosed and surgically treated without complications is herein reported. A 45-year old man, who had been treated for cerebral palsy as a result of a neonatal cerebral hemorrhage, was admitted to our hospital because of abdominal pain and vomiting. A plain abdominal X-ray film showed evidence of a huge quantity of gas in the left abdomen. Using a gastrographin enema from the colonoscope, an obstruction of the ascending colon was revealed with tapering of the lumen. A computed tomography scan showed a grossly dilated air-distended bowel in the left abdomen and soft tissue with internal architecture containing swirling strands of soft tissue and fat attenuation. An emergency laparotomy was performed. During the laparotomy the ileocecal region, which was unfixed at the retroperitoneum, was found to be twisted counterclockwise by 360 degrees around the mesentery with the terminal ileum, thus resulting in a diagnosis of cecal volvulus. We therefore conducted an ileocecal resection. Cecal volvulus is an uncommon form of intestinal obstruction with a high mortality rate and may present considerable difficulty in diagnosis. Although cecal volvulus is rare as a cause of intestinal obstruction, it should be included in the differential diagnosis of bowel obstruction in cerebral palsy.

Sigmoid volvulus: diagnostic twists and turns

OBJECTIVE

The purpose of this study was to describe the clinical profile of patients with sigmoid volvulus and highlight the diagnostic difficulties and pitfalls.

METHODS

This was a retrospective descriptive study of patients with sigmoid volvulus seen at a community hospital over a 5-year period from July 1999 to July 2004.

RESULTS

Twenty-eight cases of sigmoid volvulus were identified, of which 16 were male and 12 female. The median age was 74 years. Twenty-seven were Chinese and one was Malay. Seven out of 28 patients were from nursing institutes while the rest came from their own homes. Eleven were bedridden and chronic constipation was a problem for 17 patients. Co-existing medical illnesses, including neuropsychiatric conditions, were common. Abdominal distension and pain were the most frequent presentations (26 and 21 patients, respectively). Twelve patients had constipation and 11 had diarrhoea. Only nine had the complete typical triad of abdominal distension, pain and constipation. The classical coffee-bean sign was identified in nine out of 26 initial plain abdominal radiographs done at the emergency department and a further 11 were diagnosed after review by the surgical team in the ward. Another four were identified only after computed tomography scan of the abdomen and pelvis. The remaining two patients were diagnosed intra-operatively after they underwent emergency laparotomy.

CONCLUSIONS

As our aged population continues to grow, sigmoid volvulus may be more commonly encountered. Emergency physicians should maintain a high index of suspicion and avoid the pitfalls so as to prevent delay in diagnosis and treatment.

Gastrointestinal surgery and pregnancy

Gastrointestinal disorders during pregnancy that require surgery often mimic the symptoms and signs of conditions that do not require surgery. Anatomic and physiologic changes of pregnancy can alter the usual clinical presentation of gastrointestinal disorders that require surgery. These alterations can be a challenge to diagnosis. Prompt treatment is critical to successful management. Most elective and urgent operations can be performed during pregnancy with minimal maternal and fetal risk. The condition of the mother should always take priority because proper treatment of the mother usually benefits the fetus as well.

Colonic pseudo-obstruction in sickle cell disease

A young Arab woman with sickle cell-beta0-thalassemia disease developed acute colonic pseudo-obstruction that became chronic but showed some response to hydroxyurea. There was no evidence of microvascular or macrovascular occlusion. We also report the case of an Arab man with sickle cell anemia who presented with acute colonic pseudo-obstruction from which he recovered completely within a few days. Although the development of pseudo-obstruction in these two cases seems to have been a complication of sickle cell disease, its pathogenesis remains unclear. There are several reports of ischemic and inflammatory disorders of the colon complicating sickle cell disease; however, these two cases represent the first descriptions of large-bowel pseudo-obstruction in this hemoglobinopathy [corrected].

Intra-abdominal Sepsis in Elderly Persons

Elderly patients represent a greater percentage of the population now than ever before, with 12.4% of North Americans being >65 years of age. Intra-abdominal illnesses in this population often have different etiologies than those seen in younger populations. Because of a variety of physiologic changes that occur as people age, elderly persons have different sites of infection, may present with vague symptoms and longer histories, are more gravely ill, and, overall, have worse prognoses. The major causes of intra-abdominal sepsis in elderly persons are reviewed, explanations for the differences in presentation and prognosis are offered, and the treatments of each cause are reviewed.

Percutaneous endoscopic sigmoidopexy in sigmoid volvulus with T-fasteners: report of two cases

PURPOSE

We report two cases of percutaneous endoscopic sigmoidopexy in patients with sigmoid volvulus.

METHODS

Two patients with recurrent sigmoid volvulus were considered unfit for resective surgery or general anesthesia (American Society of Anesthesiologists physical status III-IV). Fixation of the sigmoid colon to the abdominal wall was performed percutaneously under sedation in the endoscopy suite. Fixation was obtained using three T-fasteners in a triangular disposition in the bowel. The T-fasteners were cut at the skin after 28 days.

RESULTS

Both procedures were successfully performed in approximately 20 minutes and were well tolerated. Feeding commenced the same day. One patient died after seven months of follow-up, without recurrence, of causes not related to volvulus. The other patient had no recurrence after 18 months of follow-up.

CONCLUSION

The authors purpose was to show a new technique for colonic fixation performed in patients with recurrent sigmoid volvulus who otherwise had contraindication for elective surgery. Future studies will be required to verify the effectiveness and safety of this novel technique.

Sigmoid volvulus in Department of Veterans Affairs Medical Centers

PURPOSE

Sigmoid volvulus is the third leading cause of large-bowel obstruction. The optimal management strategy remains controversial. This study was undertaken to evaluate the care of patients with sigmoid volvulus recently treated at Department of Veterans Affairs hospitals.

METHODS

All patients with the International Classification of Diseases, Ninth Revision, Clinical Modification, Third Edition code for colonic volvulus during the period 1991 to 1995 were identified in the computerized national Department of Veterans Affairs database. Data on patient demographics, clinical course, and outcomes were analyzed.

RESULTS

Two hundred twenty-eight patients had volvulus of the sigmoid colon and sufficient clinical data for evaluation. The mean age was 70; all were males. Endoscopic decompression was attempted in 189 of 228 (83 percent) patients and was successful in 154 of 189 (81 percent). Management included celiotomy in 178 of 228 (78 percent) patients. There were no intraoperative deaths. Twenty-five of 178 (14 percent) patients died within 30 days of surgery. The mortality rate was 24 percent for emergency operations (19/79), and 6 percent for elective procedures (6/99). Mortality was correlated with emergent surgery (P < 0.01) and necrotic colon (P < 0.05). Among those 50 patients managed by decompression alone, six (12 percent) died during the index admission. Ten of the remaining 44 (23 percent) patients eventually developed recurrent volvulus requiring further treatment, and 2 of 10 (20 percent) patients died.

CONCLUSIONS

In this cohort sigmoid volvulus often presents as a surgical emergency. Initial endoscopic decompression resolves the acute obstruction in the majority of cases. Surgical intervention carries a substantial risk of mortality, particularly in the setting of emergent surgery or in the presence of necrotic colon.

Management and causes of acute large-bowel obstruction

Acute LBO has many possible causes. In the United States, the most common cause is colorectal carcinoma. Mechanical obstruction should be differentiated from pseudo-obstruction by contrast enema or colonoscopy because the treatments differ. The high postoperative mortality and morbidity of LBO compared with elective resection are explained by the multiple associated pathophysiologic changes of obstruction. Management of this condition requires careful assessment, awareness, and expertise in the current modalities of treatment. Gangrene and perforation should be avoided because they limit treatment options and are associated with an increase in mortality. We prefer, in most instances, to perform a single-stage procedure, which has the advantages of reduced hospital stay (and cost) and avoidance of a stoma. However, the appropriate treatment needs to be tailored to the individual situation. Recent developments in nonoperative decompressing procedures may demonstrate advantages in the future.

Use of trephine stoma in sigmoid volvulus

INTRODUCTION

Sigmoid volvulus is a disease of the elderly who often have severe comorbid conditions that increase their operative risk and limit treatment options. Conservative treatment with decompression via sigmoidoscopy with rectal tube placement has high success and recurrence rates. Surgical resection with primary anastomosis is the treatment of choice when decompression fails or if the volvulus recurs. Unfortunately, perioperative complications are frequent. Moreover, many patients with sigmoid volvulus are bedridden or incontinent of stool and do not benefit from extensive resection and maintenance of bowel continuity.

METHODS

Twelve debilitated patients with sigmoid volvulus determined preoperatively to be poor candidates for laparotomy and reanastomosis were treated with a trephine stoma. Initially, each patient had decompression via rigid sigmoidoscopy and rectal tube placement. Surgical intervention consisted of formation of a small hole (trephine) in the left lower quadrant. Through this hole, a sigmoid resection and end colostomy were performed. No midline laparotomy was required.

RESULTS

Operative times and analgesia requirements were significantly decreased (P = 0.05) compared with patients who underwent formal laparotomy. Length of hospital stay, complication rates, and length of bowel resected were similar using either surgical technique.

CONCLUSIONS

The trephine stoma procedure offers significantly shorter operative times, with decreased perioperative morbidity. For high operative risk or debilitated patients with sigmoid volvulus, resection with end colostomy using the trephine stoma technique is the procedure of choice.

Colonic volvulus in the spinal cord injured patient

At the Prince Henry Hospital between 1970 and 1987, 8 cases of colonic volvulus were diagnosed in spinal cord injured (SCI) patients. This represents an incidence of 2.6% of SCI patients being treated at the hospital. The aetiology of volvulus is multifactorial and in these patients may be related to: neurological deficit; constipation as a result of immobility; and medications used for controlling muscle spasm, bladder and bowel function. Symptoms and signs are modified by the neurological deficit and awareness of the altered presentation will prevent delay and missed diagnoses. The effect of spinal cord injury and drugs on colonic motility needs further evaluation.

Sigmoid volvulus in west Africa: a prospective study on surgical treatments

To evaluate the efficacy of different types of surgery, we performed a prospective, randomized trial in 31 consecutively hospitalized patients with sigmoid volvulus. These patients represented 8 percent of 377 cases of emergency surgery. At the time of surgery, the patients were divided into two groups according to the absence (Group A) or presence (Group B) of bowel gangrene. At random, each group was assigned two surgical treatments. Seventeen patients entered Group A and underwent mesosigmoidopexy (seven patients) or resection and primary anastomosis (10 patients). Fourteen patients entered Group B and underwent Hartmann's procedure (eight patients) or resection and primary anastomosis (six patients). Overall mortality was four patients among 31 (13 percent), with a significant prevalence in the group with gangrene (21.4 percent vs. 5.8 percent). In Group A, the rate of success in patients treated with resection-anastomosis was higher than that in patients undergoing mesosigmoidopexy (90 percent vs. 71.5 percent). In Group B, a meaningful difference was observed between the rate of success of patients undergoing Hartmann's procedure and that of those undergoing resection and primary anastomosis (87.5 percent vs. 50 percent). The mortality rates were 12.5 percent and 33.3 percent, respectively. The results of our study show that the therapeutic approach to sigmoid volvulus should be diversified according to the absence or presence of gangrenous colon. The treatment of choice seems to be resection with primary anastomosis in patients with viable colon and Hartmann's procedure in patients with gangrenous colon.

Sigmoid volvulus in the high altitude of the Andes. Review of 230 cases

Sigmoid volvulus (SV) is uncommon in the United States. Little has been published in the English literature about the high incidence of SV among rural areas of the Bolivian and Peruvian Andes at 13,000 feet above sea level. A review of 230 cases of SV in a Bolivian hospital is presented. SV accounted for 79 percent of all intestinal obstructions. Nonoperative reduction was attempted in all patients except those with peritonitis. Nonoperative reduction alone was performed in 31 percent of the patients, and 69 percent underwent surgical intervention, 66 percent as an emergency and 3 percent electively. Surgical treatment consisted of sigmoidectomy and primary anastomosis (50 percent), Hartmann's procedure (12 percent), and operative detorsion with sigmoid plication (38 percent). Overall mortality was 13.5 percent. Fifty-seven of the surgically treated patients developed significant complications. The etiology of SV is unclear. High altitude, along with other etiologic factors, may play an important role in SV. To our knowledge, this series represents the highest incidence of SV in bowel obstruction.

Volvulus of the sigmoid colon in Jordan

This report discusses 27 patients with sigmoid volvulus treated at Jordan University Hospital (JUH) during a 15-year period. These patients represented 4.7 percent of adult patients treated for intestinal obstruction in the same period. The average age was 54.5 years, and none of the patients was institutionalized. Twenty-five patients presented with acute symptoms, and two had chronic symptoms. Sigmoidoscopic detorsion was achieved in 15 patients. Emergency resection was required in two of these patients: for the development of gangrene a few hours after detorsion in one patient and for recurrence within 24 hours in the other despite the presence of a rectal tube. Early recurrence occurred in two other patients and was managed endoscopically. Emergency surgery was performed in 10 other patients: for a failed endoscopic detorsion in three patients, for ulcerated and bleeding mucosa forecasting gangrene in another, and as a primary treatment in six patients who were either misdiagnosed or suspected to have gangrenous bowel. Elective resection was performed in 13 patients. The mortality rate was 15 percent (4/27) for the whole series and 33.3 percent (1/3) for those with gangrenous bowel.

True and false large bowel obstruction

Acute large bowel obstruction can be the result of mechanical causes (such as colorectal cancer) or motility disturbances, the latter being termed colonic pseudo-obstruction. Whatever the aetiology, the pathophysiology of large bowel obstruction has clinical significance. Changes in motility augmented by increased colonic blood flow may play a role in dissemination of tumour cells and/or bacteria. Intravascular fluid depletion, especially shortly after intestinal decompression, has important haemodynamic implications. The diagnosis is often confirmed on plain abdominal X-ray, but water-soluble contrast studies are important in distinguishing a mechanical obstruction (which almost always requires an operation) from a pseudo-obstruction (which can usually be managed without surgery). Mortality and morbidity may be reduced by optimization of the patient's condition both before and after the operation using intensive care facilities and by careful timing of surgery. The surgical management of malignant large bowel obstruction is best directed by a senior surgeon. For tumours up to and including the splenic flexure, an extended right hemicolectomy is advisable since it offers adequate removal of the tumour and allows an immediate safe ileocolic anastomosis. More distal tumours should be resected if possible, and there is much to recommend on-table irrigation and immediate anastomosis, although a colostomy with a mucous fistula or Hartmann's procedure still have a place. Endoscopic diagnosis and decompression enables definitive surgery to be undertaken electively and several techniques are being evaluated. Non-operative reduction of sigmoid volvulus by rigid or flexible endoscopy is achieved with high success rates, but is not recommended for caecal volvulus. Resection is usually necessary in both to prevent recurrence. Mortality of colonic volvulus is closely related to bowel viability. Uncomplicated colonic pseudo-obstruction may be managed medically or by endoscopic decompression. It often occurs in association with systemic medical conditions, which need to be treated vigorously. Surgery is indicated if there are signs of impending or frank perforation, or if non-operative measures fail.

Sigmoid volvulus in Kaduna, Nigeria

Worldwide regional variations exist in the incidence of sigmoid volvulus. This article describes the experience with sigmoid volvulus at the Ahmadu Bello University Teaching Hospital in Kaduna, Nigeria. Sixty of 121 patients who had large-bowel obstruction over a 15-year period had sigmoid volvulus. Fifty-seven (95 percent) had gangrenous bowel. The mortality rate was 16.7 percent. The clinical presentation and the treatment modalities offered are discussed.

Experience with colonic volvulus

Fifty-eight cases of colonic volvulus were reviewed including 30 cases of sigmoid volvulus, 27 cases of cecal volvulus, and 1 of transverse colon volvulus. Decompression procedures were attempted in 31 instances of sigmoid volvulus in 27 patients and were successful 25 times (81 percent). Seven patients with sigmoid volvulus did not undergo surgery and of those, two died of unrelated causes, one was lost to follow-up, one was well, and three had recurrent volvulus. Twenty-four operations were performed on 23 patients and there were three deaths (13 percent mortality). There was one recurrence in two patients who underwent simple detorsion. Chronic large-bowel motility disturbances were a persistent problem in 9 of 20 (45 percent) surgical survivors. Among 27 instances of cecal volvulus, one was reduced by contrast enema and ten endoscopic attempts at decompression were unsuccessful. Twenty-six operations were done and there were four operative deaths (15 percent mortality). There were no recurrences. Large-bowel motility disorders were noted in follow-up in 3 of 22 patients (14 percent). Overall there were 10 deaths in 58 patients for a 17 percent mortality rate. These data support the importance of endoscopic decompression for sigmoid volvulus but not for cecal volvulus. Definitive treatment of both forms of volvulus should include assessment of colonic motility.