Volvulus of the colon--a continuing surgical problem

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.

Nonresective alternative for the cure of nongangrenous sigmoid volvulus

PURPOSE

Recurrence in sigmoid colon volvulus is a very vexing problem, because it occurs after all types of treatment including a resection of the sigmoid. A nonresective procedure that prevents recurrence in the long term has been devised and tried during the period 1968 to 1992.

METHODS

The procedure involves extraperitonealization of the whole sigmoid colon via a left paracolic gutter incision in a manner akin to an extraperitonealized colostomy and placing it in the left half of the infraumbilical abdominal wall. This article presents a study of 84 patients who underwent this operation and who were followed-up. Some very useful practical points for ensuring the success of the procedure are also presented.

RESULTS

The subjects comprised 58 male and 26 female patients, aged 10 to 81 (median, 60) years. The operating time ranged from 40 to 70 (median, 50) min. The operative mortality (9 percent) and morbidity of the procedure including cardiopulmonary complications (7 percent), incidence of small-bowel obstruction (1 percent), and incisional hernia formation (2.3 percent), were reasonably low. The incidence of wound-healing problems was significantly (P < 0.02) reduced in the 1980s and 1990s. Seventy-six patients were available for follow-up ranging from 0.5 to 25 (mean+/-standard error, 6.671+/-0.573; median, 6) years. Forty-eight patients were followed-up for five or more years. No patients developed recurrence of volvulus during the entire follow-up period.

CONCLUSIONS

This nonresective, recurrence-free procedure provides a cure for nongangrenous sigmoid volvulus. It may be performed safely, even in relatively poor-risk patients, with acceptably low morbidity and mortality rates.

Volvulus of the splenic flexure: report of a case and review of the literature

This is the first case report of gangrenous colon from volvulus of the splenic flexure. It is also the first reported treatment of splenic flexure volvulus by exteriorization of the splenic flexure as a loop colostomy. Splenic flexure volvulus has veen a rare cause of mechanical obstruction, producing 1 per cent of colonic volvuluses. Fourteen detailed case reports of splenic flexure volvulus were reviewed. Patients averaged 53.2 years old. Eight of 14 were women. Previous abdominal surgery, anomalies of fixation, and constipation played important roles in the pathogenesis. Diagnosis was made before surgery in two-thirds of the patients. Treatment varied. One patient died without treatment. In two, the volvulus reduced spontaneously. Eleven required emergency surgery. Three underwent operative detorsion, one exteriorization of the splenic flexure as a loop colostomy (the present report), and six partial colectomy. All treated patients survived without recurrence of volvulus. Thus, there was only one death in 14 cases, a seven per cent mortality rate. This low mortality rate was attributed to the rarity of gangrenous colon from splenic flexure volvulus.

Sigmoid volvulus: high mortality in county hospital patients

Between 1970 and 1980, 12 patients were admitted 16 times to San Bernardino County Medical Center for sigmoid volvulus. The seven men and five women averaged 68.5 years old. Sixty-seven per cent recounted histories of neuropsychiatric disorders. Fifty per cent had been institutionalized. Forty-two per cent had endured previous episodes of sigmoid volvulus. Fourteen of 24 nonoperative attempts at reduction were successful but were followed by nine recurrences. Ten of 12 patients eventually underwent surgery. Eight procedures were electively scheduled following spontaneous or nonoperative reductions. Two emergency procedures for gangrenous colons were required. Both of these patients died. Mortality following elective surgery was 25 per cent. Twenty-nine major complications followed the ten procedures. All ten patients underwent sigmoid resections. Follow-up disclosed only two living patients. Only five had survived one year following initial hospitalization and only two for two years. The high mortality of this and other American series was attributed to the frail nature of the elderly, debilitated, institutionalized patients with neuropsychiatric and multiple medical disorders, who develop sigmoid volvulus in the United States. [Key words: Volvulus, sigmoid, Sigmoid, surgical treatment].

Recurrence of volvulus after sigmoidectomy

Three patients had recurrences of left-sided colonic volvulus after allegedly total resections of redundant sigmoid loops. All three patients had chronic, acquired megacolon. Other instances of late recurrence of volvulus after sigmoidectomy are documented in the literature. Sigmoidectomy may be an inadequate operation for sigmoid volvulus in younger patients and/or in patients with severe chronic megacolon. The decision to perform an interval operation and the selection of the type of operation must take this into account.

Intermittent sigmoid volvulus in the younger age groups

Sigmoid volvulus is a well-recognized clinical entity, occurring more commonly in the male in middle or old age. In younger age groups the diagnosis is therefore often delayed. We report here 11 patients of an average age of 31 years (range 12-57 years), with a preponderance of females (7 : 4), who have presented to us in the past 2 years with intermittent sigmoid volvulus. The average age at onset of initial symptoms was 26 years. All had the diagnosis confirmed radiologically by colonoscopy or at operation. The diagnostic features of the condition are described.