Volvulus of the sigmoid colon in Delhi, India

Sigmoid volvulus an update

Sigmoid volvulus is the third most common cause of colonic obstruction in the United States after cancer and diverticulitis. Etiologic factors include anatomic variation, chronic constipation, neurologic disease, and megacolon. Management of sigmoid volvulus involves relief of obstruction and the prevention of recurrent attacks; the outcome depends on the population and selection of patients. Although volvulus is uncommon, it may be encountered during pregnancy and is a condition that poses significant risk to both mother and fetus requiring a management strategy that varies with each trimester.

Gangrenous sigmoid volvulus: a clinical study of 76 patients

BACKGROUND AND AIMS

This study investigated the clinical picture of gangrenous sigmoid volvulus presented by Indian patients to describe the various patterns of gangrene and to identify the risk factors leading to the very high mortality from this disease.

PATIENTS AND METHODS

A structured protocol including nine parameters was used to study risk factors in 76 patients treated at two major teaching hospitals in India. The clinical picture of patients at the two hospitals did not differ significantly.

RESULTS

Contrary to expectations, we found gangrene in 26% of cases extending beyond the area of constriction into the rectum/descending colon. This extension was sometimes patchy and had an ill defined line of demarcation, which may lead to an error in judgment and cause a failure of anastomosis, which can be fatal. Risk factors were age over 60 years, the presence of shock on admission and a history of previous episodes of volvulus.

CONCLUSION

This study identified three risks for survival. It is suggested that all patients with nongangrenous sigmoid volvulus undergo a recurrence-prevention procedure immediately or electively. We also found that extension of gangrene beyond the confines of the constriction is not uncommon, calling for caution on the part of the treating surgeon.

Volvulus of the colon--a continuing surgical problem

Twenty-six cases of colonic volvulus from the University of Kentucky Medical Center and the Lexington Veterans Administration Hospital, covering a ten-year period, are presented. Overall mortality was 19 per cent (5 of 26 patients). Cecal volvulus carried the greatest mortality, 30 per cent (3 of 10 patients), whereas sigmoidal volvulus had relatively low mortality rate of 7 per cent (1 or 15). A single patient who had volvulus of the transverse colon died. The most significant factor leading to death was not necrotic bowel but the necessity for emergency operation in these generally debilitated patients. A plan of management with the major aim to convert emergency situations into elective or urgent ones is presented with the expectation that the mortality rate can be improved.

Extraperitonealization for sigmoid volvulus: a reappraisal

A prospective study was carried out in a university hospital to evaluate the results of extraperitonealization of the sigmoid colon in non-gangrenous sigmoid volvulus. Eighty-eight patients with non-gangrenous sigmoid volvulus were operated upon using the technique of extraperitonealization of the sigmoid colon. There was no recurrence of the volvulus at 1 to 6 years follow up but 8 patients (9.1%) had constipation and 2 patients (2.2%) had distension of the lower abdomen. Extraperitonealization of the sigmoid colon is a reasonable non-resection alternative for non-gangrenous sigmoid volvulus and has minimal morbidity, mortality and no recurrence in our series.

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.

Sigmoidal volvulus in childhood: report of two cases

Volvulus of the sigmoid colon is a very uncommon cause of acute obstruction in children. Although common in adults in India, it was found to account for only 0.8 per cent of all acute obstructions in infants and children in this institution. It causes a proximal torsional obstruction of the colon with an acute onset of symptoms. The onset of volvulus is characterized by colicky pain over the left lower quadrant, vomiting, tenderness, and rigidity in te left lower quadrant. A scout film of the abdomen may be inconclusive, but a barium-enema examination is diagnostic. The number of cases reported is too small to allow conclusions about the best treatment for children who have sigmoidal volvulus.

Volvulus of the sigmoid colon: a ten-year study

A ten-year study of volvulus of the sigmoid colon is presented. Although the results of treatment of volvulus of the sigmoid colon are generally improving, the challenge for further improvement remains.

Volvulus of the sigmoid colon in Brazil: a report of 230 cases

Etiologic and physiopathologic aspects of volvulus of the sigmoid colon in Brazil are presented. It is believed that sigmoidal volvulus in Brazil is a frequent complication of megacolon caused by Chagas' disease, differing in some characteristics from volvulus found in other countries. A review of 230 cases treated between 1938 and 1974 in the Surgical Department of Hospital das Clinicas, University of Sao Paulo School of Medicine, is presented. The successive variations used to treat this disease occurred parallel to those introduced in the surgical treatment of uncomplicated megacolon. From the results, the following treatment is recommended: endoscopic emptying in cases without clinical, roentgenographic or endoscopic signs of intestinal ischemia. Laparotomy should be performed when a complicated volvulus is suspected or when it is not possible to empty the loop. When a simple volvulus is found, the loop should be untwisted and the gaseous contents siphoned off by menas of a rectal catheter. When there is necrosis of the colon, the Hartmann operation is recommended. It is important to submit patients to a definitive treatment of the megacolon soon after endoscopic emptying or surgical detorsion of the volvulus, since recurrences following these measures are frequent.