Sigmoid volvulus in the Middle East

Mid-ileal Volvulus Treated With Urgent Small Bowel Resection: A Case Report

Volvulus is a rare condition characterized by intestinal twisting that requires immediate medical intervention due to its potentially life-threatening complications such as bowel obstruction, ischemia, and perforation. The majority of volvulus cases occur in the colon, while those in the small intestine are exceedingly rare. We present the case of a 77-year-old patient with a complex medical history who presented with abdominal pain and signs of intestinal obstruction due to an ileal volvulus. This case highlights the importance of considering this unusual entity in the differential diagnosis of acute abdominal discomfort.

Metachronous volvulus of the descending colon after resection of the sigmoid volvulus; a case report

INTRODUCTION AND IMPORTANCE

Volvulus of the large bowel is a pathological condition characterized by the twisting of the colon around itself, resulting in obstruction and potentially severe complications such as bowel ischemia and necrosis. The objective of this case report is to highlight the importance of considering volvulus as a differential diagnosis in patients with a history of colonic surgeries, particularly when presenting with symptoms indicative of bowel obstruction.

CASE PRESENTATION

The case was a 55 years old male patient who underwent Hartman procedure three years back for an indication of gangrenous sigmoid volvulus. Three months later the colostomy was reversed and descending colo-rectal end-to-end anastomosis was performed. He currently presented to the emergency department with a one day history of abdominal distension which was progressive and associated with colicky persistent abdominal pain. Exploratory laparotomy was done which showed the descending colon was massively dilated and twisted 360 degree in the counterclockwise direction. The patient was discharged from the ward after one week stay.

CLINICAL DISCUSSION

Despite of the fact that volvulus is the third most common cause of bowel obstruction, consecutive bowel obstruction secondary to volvulus at a separate time and site is an extremely rare phenomenon.

CONCLUSION

A metachronous colonic volvulus is an extremely rare clinical entity. In a patient who presents with bowel obstruction with a history of prior sigmoid colectomy. it is important to consider metachronous volvulus as differential diagnosis specially in patients with significant risk factors or residing in a geographic area known with high rates of volvulus.

A Twist on Adolescent Abdominal Pain in the Emergency Department

Abdominal pain is a common complaint in pediatric patients in the emergency department (ED). Evolutions in clinical practice have shifted away from computed tomography (CT) to ultrasound (US) in assessing abdominal pain. However, ultrasound may not reliably rule out critical diagnoses. We present a 15-year-old male with intermittent suprapubic abdominal pain. Subsequent CT imaging showed swirling mesenteric vessels with a dilated sigmoid colon. In adolescent abdominal pain, sigmoid volvulus (SV), although rare, should be considered. Clinicians should avoid anchoring bias by maintaining a broad differential. Definitive care is surgical with resection to prevent recurrence.

Sigmoidectomy following sigmoid volvulus: who is at risk of anastomotic failure?

BACKGROUND

Anastomotic leak following elective sigmoidectomy performed due to sigmoid volvulus (SV) is a devastating complication. The aim of this study was to identify the incidence and risk factors associated with leak in this specific group of patients.

METHODS

A retrospective study was performed at two university-affiliated tertiary centres in Israel. All consecutive patients between January 2014 and April 2020 treated for SV with elective sigmoidectomy and primary anastomosis were reviewed and those suffering from anastomotic leak identified. Factors associated with this complication were assessed using univariate analysis and odds ratios subsequently calculated.

RESULTS

Of the 99 patients initially identified, 58 were included in the study group [45 males and 13 females (77.6% versus 22.4% respectively) mean age 67.4 years, range 13-97]. There were 10 anastomotic leaks identified (17.2%). On univariate analysis recurrent decompression (OR 8.28, p = 0.027), age > 80-years (OR 6.88, p = 0.027), open rather than laparoscopic surgery (OR = 5.83, p = 0.005) and ASA grade 3/4 (OR 0.132, p = 0.023) were significantly associated with anastomotic leak. Male sex approached but not reach statistical significance.

CONCLUSIONS

Recurrent endoscopic decompression, age > 80 years, open surgery and ASA grade 3/4 are associated with anastomotic leak and these patients should be considered for formation of a colostomy instead. If an anastomosis is performed, patients should be appropriately counselled and monitored in the perioperative period.

Acute Colonic Pseudo-obstruction and Volvulus: Pathophysiology, Evaluation, and Treatment

Acute colonic pseudo-obstruction (ACPO) and volvulus are two disease processes that affect the colon causing abdominal distension and may necessitate operation intervention. ACPO may be associated with multiple comorbidities, infectious diseases, and cardiac dysfunction. It may be treated with conservative management including endoscopic decompression or neostigmine. If the distension is not addressed, high mortality may result if peritonitis develops. Volvulus most commonly occurs in the sigmoid colon or cecum. If left-sided, endoscopic decompression may resolve the obstruction if detorsion is successful, although sigmoid colectomy should be performed during the admission. If cecal volvulus is identified, right hemicolectomy should be performed.

Management of acute sigmoid volvulus: A tunisian experience

BACKGROUND/OBJECTIVE

Sigmoid volvulus is the most common type of volvulus. Its epidemiological features, as well as its management, differ between developed and developing countries. This work aims to analyze the epidemiological features thus allowing to compare them to the rest of the "volvulus belt'' and assess the surgical management of sigmoid volvulus in Tunisia.

METHOD

This is a retrospective review of 64 patients with sigmoid volvulus treated in the General Surgery department of Jendouba Hospital. January 2005-December 2019.

RESULTS

64 patients were treated for acute sigmoid volvulus. The sex ratio male to female ratio was 5.4/1 with male predominance. 5.4:1 (54 males to 10 females). The mean age was 62 years. The classic triad of intestinal occlusion was reported in 56 patients. The mean duration of symptoms was 4.2 days. An accurate preoperative diagnosis was made in 58 cases. Forty patients had a viable bowel obstruction, and all of them had a resection and primary anastomosis. Sixteen patients had a gangrenous bowel obstruction, of which 6 patients had resection-primary anastomosis, and 10 had Hartmann's procedure. Out of the total five deaths reported, there were only two among patients who had resection-primary anastomosis for gangrenous bowel obstruction. The most common postoperative complication was wound infections in 5 cases. The median length of hospital stay following surgery was 8 days. No recurrences of volvulus after a median follow-up of 11 months.

CONCLUSIONS

Although Tunisia belongs to the volvulus belt, the epidemiologic features of sigmoid volvulus tend rather be similar to those of developed countries. The use of primary surgery, if no endoscopy is performed, is a good alternative. For patients who have contraindications for endoscopic treatment, surgical treatment is the only option.

Clinical outcomes of sigmoid volvulus and risk factors for its recurrence: a multicenter study in Korea

PURPOSE

Sigmoid volvulus is one of the leading causes of colonic obstruction. The aims of this study were to review the treatment characteristics and clinical outcomes of patients diagnosed with sigmoid volvulus over 10 years at five university-affiliated hospitals in Korea, and to identify possible risk factors for its recurrence.

METHODS

Retrospective review was performed for medical records of patients who were diagnosed with sigmoid volvulus and managed surgically or conservatively at the five Hallym University-affiliated hospitals between January 2005 and July 2018.

RESULTS

A total of 69 patients were diagnosed, of whom 11 patients underwent emergency surgery and 58 patients were conservatively managed. Non-operative management was successful in 53 of 58 patients (91.4%) at initial admission. Of the non-operative managed patients, six patients required emergency surgery due to unsuccessful decompression or recurrence whereas 23 patients underwent regular surgery for definitive treatment. And overall recurrence rate and mortality rate were 25.8% (15/58) and 1.7% (1/58), respectively. A total of 40 patients underwent surgery; 23 underwent regular surgery and 17 underwent emergency surgery. Restoration of bowel continuity was more frequently performed in the regular surgery group than in the emergency surgery group (87.0% vs 52.9%, P = 0.03). In multivariable analysis, only non-operative management at the initial admission (P = 0.029) was independently associated with recurrence.

CONCLUSION

Although non-operative treatment can be initially attempted, surgery is required for preventing recurrence. Regular surgery should be considered to restore continuity of the bowel.

Characteristics of Intestinal Volvulus and Risk of Mortality in Malawi

BACKGROUND

Intestinal volvulus is a common cause of mechanical intestinal obstruction (MIO) in Africa. Sigmoid volvulus has been well characterized in both high-income and low-income countries, but there is also a predilection for small bowel volvulus in sub-Saharan Africa.

METHODS

An analysis was performed of the Kamuzu Central Hospital Acute Care Surgery Registry from 2013 to 2019 on patients presenting with intestinal volvulus. Bivariate analysis was performed for covariates based on the intestinal volvulus type. Multivariate Poisson regression models estimated the relative risk of volvulus and mortality.

RESULTS

A total of 4352 patients were captured in the registry. Overall, 1037 patients (23.8%) were diagnosed with MIO. Intestinal volvulus accounted for 499 (48.1%) of patients with MIO. Sigmoid volvulus, midgut volvulus, ileosigmoid knotting, and cecal volvulus accounted for 57.7% (n = 288), 19.8% (n = 99), 20.8% (n = 104), and 1.6% (n = 8), respectively. Mean age was 46.8 years (SD 17.2) with a male preponderance (n = 429, 86.0%) and 14.8% (n = 74) mortality. Overall, the most common operations performed were large bowel (n = 326, 74.4%) and small bowel (n = 76, 16.7%) resections with 18.0% (n = 90) ostomy formation. Upon regression modeling, the relative risk for volvulus was 2.7 times higher in men than women after controlling for season and age. There was no statistically significant difference in the relative risk of mortality based on the type of volvulus.

CONCLUSION

Volvulus is a significant cause of primary bowel obstruction in sub-Saharan Africa. Type of intestinal volvulus is not associated increased risk of mortality. Reasons for increases in the incidence of small bowel volvulus are still largely undetermined.

Retrospective study on pattern and outcome of management of sigmoid volvulus at district hospital in Ethiopia

Background

Sigmoid volvulus is the commonest cause of large bowel obstruction in many regions of the world. Its prevalence varies greatly geographically. In Ethiopia, the disease is the commonest cause of emergency admissions due to intestinal obstruction. However, few studies have been conducted discussing the management outcome in Ethiopia and Africa. This research was conducted to assess the pattern & management outcome of acute sigmoid volvulus at a district hospital in South-west Ethiopia.

Methods

A facility based retrospective cross-sectional review of surgical records was done to identify patients who had acute sigmoid volvulus. Data was collected using structured questionnaire by three pre trained data collectors. The collected data was checked for its completeness, and then entered, edited, cleaned and analyzed using Statistical Package for the Social Sciences (SPSS) version 22.0. For all statistical significance tests the cut-off value set was P < 0.05.

Result

A total of 131 patients were managed for acute sigmoid volvulus. 108 (82.4%) were men with a male to female ratio of 4.7:1. The hospital prevalence of acute sigmoid volvulus was 27.9%. Majority (42%) of the patients were in the 6th decades of life. Abdominal pain, abdominal distention & inability to pass feces & flatus were the predominant presenting compliant while abdominal distention was the dominant physical finding in all of the patients. Ninety-seven patients (74%) had viable bowel obstruction of which 29 patients had successful rectal tube deflation. The remaining 68 patients were managed operatively by either primary resection & anastomosis (62 patients) or derotation alone (6 patients). Thirty-four patients had gangrenous bowel obstruction and were managed by either primary resection and anastomosis (16 patients) or Hartman’s colostomy (18 patients). Six patients died of which 5 had primary resection and anastomosis (2 for viable and 3 for gangrenous bowel obstruction).The predominant postoperative complication was wound infection in 11(10.7%) patients. Factors associated with unfavorable outcome were female sex, primary resection & end to end anastomosis and presentation of illness more than 24 h.

Conclusion

The most common management was primary resection and anastomosis. The overall mortality rate was 4.5% and the mortality rate related to primary resection and end to end anastomosis was 6.4%. Mortality rate was higher in those patients who had resection and anastomosis for gangrenous bowel compared to those who had viable bowel (19% vs 3%). Generally factors associated with poor outcome were duration of illness, primary resection and anastomosis and being female.

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.

Sigmoid volvulus in young patients: Ą new twist on an old diagnosis

According to the literature, sigmoid volvulus typically develops in patients of an older age with co-morbidities such as a psychiatric illness or a bed-bound chronic illness. Recent reports suggest that it should also be considered in young individuals without any preceding medical history. Abdominal roentgenography is a cheap and effective diagnostic modality that can avoid a delay in diagnosis. The treatment of colonic volvulus remains controversial and relies upon the procedure selected and the most appropriate therapeutic approach in terms of the clinical status of the patient, the location of the problem, the suspected existence or identification of peritonitis, bowel viability, and the expertise of the surgical team. Presented here are four cases of young male patients with sigmoid volvulus. All of the patients were diagnosed radiologically prior to surgical intervention. Two of the patients initially underwent an endoscopic procedure that succeeded in one and that failed in the other. Three of the patients underwent a laparotomy.

Volvulus of the Small Bowel and Colon

Volvulus of the intestines may involve either the small bowel or colon. In the pediatric population, small bowel volvulus is more common, while in the adult population, colonic volvulus is more often seen. The two most common types of colonic volvulus include sigmoid and cecal volvulus. Prompt diagnosis and treatment is imperative, otherwise bowel ischemia may ensue. Treatment often involves emergent surgical exploration and bowel resection.

Prevalence, causes and management outcome of intestinal obstruction in Adama Hospital, Ethiopia

BACKGROUND

In Africa, acute intestinal obstruction accounts for a great proportion of morbidity and mortality. Ethiopia is one of the countries where intestinal obstruction is a major cause of morbidity and mortality. This study aims to determine prevalence, causes and management outcome of intestinal obstruction in Adama Hospital in Oromia region, Ethiopia.

METHOD

A hospital based cross-sectional study design was used. Data covering the past three years were collected from hospital medical records of sampled patients. The collected data were checked for any inconsistency, coded and entered into SPSS version 16.0 for data processing and analysis. Descriptive and logistic regression analyses were used. Statistical significance was based on confidence interval (CI) of 95 % at a p-value of < 0.05.

RESULT

262 patients were admitted with intestinal obstruction. The prevalence of intestinal obstruction was 21.8 % and 4.8 % among patients admitted for acute abdomen surgery and total surgical admissions, respectively. The mortality rate was 2.5 % (6 of 262). The most common cause of small bowel obstruction was intussusceptions in 48 patients (30.9 %), followed by small bowel volvulus in 47 patients (30.3 %). Large bowel obstruction was caused by sigmoid volvulus in 60 patients (69.0 %) followed by colonic tumor in 12 patients (13.8 %). After controlling for possible confounding factors, the major predictors of management outcome of intestinal obstruction were: duration of illness before surgical intervention (adjusted odds ratio (AOR) = 0.49, 95 % CI: 0.25-0.97); intra-operative findings [Viable small bowel volvulus (SBV) (AOR = 0.08, 95 % CI: 0.01-0.95) and viable (AOR = 0.17, 95 % CI: 0.03-0.88)]; completion of intra-operative procedures (bowel resection & anastomosis (AOR = 3.05, 95 % CI: 1.04-8.94); and length of hospital stay (AOR = 0.05, 95 % CI: 0.01-0.16).

CONCLUSION

Small bowel obstruction was more prevalent than large bowel obstruction. Intussusceptions and sigmoid volvulus were the leading causes of small and large bowel obstruction. Laparotomy was the most common methods of intestinal obstruction management. Bowel resection and anastomosis was the commonest intra-operative procedure done and is associated with postoperative complications. Wound infection in the affected area should be improved because it is the most common postoperative complication. This can be decreased by appropriate surgical technique and wound care with sterile techniques.

The role of sigmoidoscopy in thediagnosis and treatment of sigmoid volvulus

Sigmoid volvulus (SV) is a rare form of acute intestinal obstruction in which the sigmoid colon wraps around itself. The disease generally presents as a mechanical bowel obstruction with clinical features that are not pathognomonic. Similarly, X-ray films are not diagnostic in most cases. It is difficult to establish the correct preoperative diagnosis when CT and MRI are not used. The principal strategy in the treatment of SV in uncomplicated patients is emergency endoscopic detorsion followed by elective surgery; emergent surgery is required in patients with bowel gangrene, bowel perforation, peritonitis, or unsuccessful endoscopic treatment. In this review, we have discussed the role of sigmoidoscopy in the diagnosis and treatment of SV. Additionally, we have retrospectively and prospectively evaluated our 49-year, 987-patient clinical experience, the largest single-center SV series ever reported.

Morphology of Sigmoid Colon in South Indian Population: A Cadaveric Study

INTRODUCTION

Sigmoid volvulus is a common etiological factor in acute large bowel obstruction. The increased length of sigmoid colon is attributed as one of the causes of sigmoid volvulus.

AIM

The aim of this study was to find the morphology of sigmoid colon in South Indian population using cadavers.

MATERIALS AND METHODS

The present study was performed with 31 cadavers used for teaching purpose. The sigmoid colon was classified into classical, long-narrow and long- broad types by their disposition in the abdominal cavity. The sigmoid loop's relation to pelvic brim was also observed and grouped as pelvic and suprapelvic in position. The length of sigmoid colon along the mesenteric and antimesenteric border, height and width of sigmoid mesocolon in relation to the pelvic brim and the root of mesentery were measured in the study.

RESULTS

The study showed that the majority of the sigmoid colons fell into the classical type (47.6%). The sigmoid colon in pelvic position was significantly more prevalent. The mean length of sigmoid colon was 15.2 ± 4.4cm and 19.2 ± 6cm considering the pelvic brim and root of mesentery as reference points of measurement respectively. The mean length along antimesenteric border was 22.3 ± 7.9cm and 25 ± 8.7cm along the same reference points. The mean length of mesocolon height was 6.5 ± 3cm with reference to pelvic brim and 7.3 ± 3cm with reference to root of Sigmoid mesocolon respectively. The mean width of mesocolon was 7.4 ± 3cm (pelvic brim) and 8 ± 2cm (root of Sigmoid mesocolon) There was a positive correlation of sigmoid colon length with the height of the mesocolon. The gender analysis showed that males had statistically significant longer sigmoid colon and mesocolon.

CONCLUSION

This study documents that the South Indian population has a more classical type of sigmoid colon and that the anatomical dimensions of sigmoid colon and its mesocolon is significantly longer in males.

Treatment of sigmoid volvulus: a single-center experience of 952 patients over 46.5 years

BACKGROUND

Sigmoid volvulus describes the wrapping of the sigmoid colon around itself and its mesentery, causing an intestinal obstruction. The aim of this study was to assess the outcomes of 952 patients treated for sigmoid volvulus over a period of 46.5 years.

METHODS

Clinical records were reviewed retrospectively.

RESULTS

Nonsurgical detorsion was performed in 686 patients with 77.1 % success, 2.5 % morbidity, 0.7 % mortality, and 4.5 % early recurrence rates; emergency surgical procedures were performed in 447 patients with 35.3 % morbidity, 16.1 % mortality, 0.7 % early recurrence, and 7.4 % late recurrence rates, while elective surgical treatment was performed in 104 patients with 12.5 % morbidity, no mortality, and no recurrence.

CONCLUSIONS

The principal strategy in the treatment for sigmoid volvulus is early nonsurgical detorsion followed by elective surgery in uncomplicated patients, while emergency surgical treatment is performed for patients with bowel gangrene, perforation, or peritonitis, other difficulties with diagnosis, unsuccessful nonsurgical detorsion, and early recurrence.

Sigmoid volvulus: diagnosis in 938 patients over 45.5 years

BACKGROUND

Sigmoid volvulus (SV) is the wrapping of the sigmoid colon around itself and its mesentery. The goal of this study was to investigate the diagnosis approach to 938 patients with SV treated at our institution and their clinical outcomes.

METHODS

The clinical records of 938 patients with SV treated at our institution between June 1966 and January 2012 were retrospectively reviewed.

RESULTS

The mean age was 58.6 years (range 10 weeks to 98 years), and 774 patients (82.5 %) were male. A total of 210 (25.1 %) of 837 patients, who provided information on anamnesis and clinical features, had recurrent episodes of volvulus; 215 patients (25.7 %) had comorbidities, and 108 patients (12.9 %) presented with toxic or hypovolemic shock. The mean duration of symptoms was 38.7 h (range 6 h to 7 days), and the most common clinical features were abdominal pain and tenderness (827 of 837 patients, 98.8 %), distention (805 patients, 96.2 %), and obstipation (771 patients, 92.1 %). The final diagnosis was made with endoscopy in 519 patients (55.3 %), endoscopy followed by surgery in 154 patients (16.4 %) and at surgery in 265 patients (28.3 %). The correct diagnosis rate was 71.6 % based on clinical findings compared with 66.7 % based on plain X-ray films, 81.4 % based on both clinical and plain X-ray findings, and 100.0 % based on CT or MRI findings.

CONCLUSIONS

Sigmoid volvulus is common in adult men. The disease is generally associated with recurrent episodes, comorbidity, and shock. SV generally presents as a large-bowel obstruction. Although plain X-rays may help with diagnosis, CT and MRI are more reliable diagnostic tools, and flexible endoscopy is always diagnostic. However, surgery is used to diagnose SV in limited situations.

Factors affecting bowel gangrene development in patients with sigmoid volvulus

BACKGROUND AND OBJECTIVES

Sigmoid gangrene develops in 6.1% to 93.4% of sigmoid volvulus (SV) cases, and increases the mortality rate from 0% to 40% without bowel gangrene to 3.7% to 80%. This study aimed to investigate factors that induce bowel gangrene development in SV patients.

DESIGN AND SETTINGS

Retrospective study from a single center.

PATIENTS AND METHODS

We determined whether there was any correlation between sigmoid gangrene and the following factors: age, gender, a previous history of a volvulus, previous history of abdominal surgery, pregnancy, major comorbidities, shock, duration of symptoms, direction and degree of rotation of volvulus, and ileosigmoid knotting.

RESULTS

Of 442 patients, 271 (61.3%) had sigmoid gangrene. The presence of pregnancy was negatively cor.related with sigmoid gangrene development (P < .05), while comorbid diseases (P < .01), associated shock (P < .01), prolonged symptom duration (P < .05), overrotation (P < .05), and associated ileosigmoid knotting (P < .01) were positively correlated with bowel gangrene. However, no correlation was observed between sigmoid gangrene and the other studied factors.

CONCLUSION

An inverse correlation between pregnancy and sigmoid gangrene was observed. On the other hand, a positive correlation was noted between bowel gangrene and comorbid diseases, shock, prolonged duration of symptoms, overrotation, and associated ileosigmoid knotting.

Article Commentary: The Twisted Colon: A Review of Sigmoid Volvulus

Sigmoid volvulus (SV) is the third leading cause of colon obstruction in adults. In infants and children, it is exceedingly rare with only sporadic cases reported so far. SVs from secondary causes, with congenital megacolon being the most important, are nevertheless more common in young people. The etiology of this disorder is not completely understood. It is known to occur in the setting of redundant sigmoid loop, which rotates around its narrow and elongated mesentery. Although the latter occurs in the setting of constipation, a congenitally elongated colon, and other predisposing factors, there is no consensus on the precipitating factor leading to SV formation. The symptoms are suggestive of small bowel obstruction, but the presentations can be acute or indolent. Plain abdominal radiography is used to diagnose SV in most cases with computed tomography scan or magnetic resonance imaging as the confirmatory tests when necessary. After it has been untwisted, the definitive and standard therapy for SV is sigmoid resection and primary anastomosis. The nonresective alternatives have also been widely used with mixed success, but a large, randomized controlled trial is needed to compare their efficacy with resection and primary anastomosis. Laparoscopic surgery in SV management is unwarranted and costly. Complications of SV include hemorrhagic infarction, perforation, septic shock, and death. The mortality data from SV vary, but the latest literature cites an overall range of 14 to 45 per cent.

Side-to-side anastomosis fashioned as stoma after sigmoid resection for sigmoid volvulus: a case report

PURPOSE

Colonic volvulus is one of the causes of large bowel obstruction with sigmoid colon being the most usually affected part. Surgery is the gold standard when signs of peritonitis are present or endoscopic decompression fails.

MATERIALS AND METHODS

We report the case of 65-year-old man with acute large bowel obstruction due to sigmoid volvulus who underwent a laparoscopic-assisted sigmoid resection on an emergency basis. The condition of the bowel wall precluded a primary anastomosis. But instead, a side-to-side anastomosis that its common blind stump was brought out as an end stoma was performed.

RESULTS

The postoperative period was eventless. The patient was discharged on the 6th postoperative day. Eight weeks after the initial operation, the patient was readmitted for the secondary closure of the anastomotic stoma. Local anesthesia and minor sedation were enough in order to perform the stoma take down.

CONCLUSION

Laparoscopic-assisted sigmoid resection is a useful adjunct to the surgical armamentarium when facing the problem of sigmoid volvulus. When a safe restoration of the alimentary tract continuity cannot be achieved safely with a primary anastomosis, the proposed anastomotic stoma technique is a useful and practical alternative.

Sigmoid volvulus in the elderly: outcomes of a 43-year, 453-patient experience

PURPOSE

The present study reviewed the clinical outcomes of 453 elderly patients with sigmoid volvulus (SV).

METHODS

The clinical records were reviewed retrospectively.

RESULTS

The mean patient age was 71.1 years of age, and 371 patients (81.9%) were male. Of the patients, 30.7% had recurrent volvulus, 34.6% had associated disease, and 16.5% suffered from shock. The correct diagnosis rate based on the clinical features was 66.4%. Radiography revealed SV findings in 64.9% of the patients. Computed tomography (CT) or magnetic resonance imaging (MRI) were diagnostic in all cases. Nonoperative detorsion was performed in 323 patients (71.3%) with 77.4% success, 1.2% mortality, 4.0% morbidity, and 4.4% early recurrence rates. Emergency surgery was required in 215 patients (47.5%) and resulted in 24.2% mortality, 41.4% morbidity, 0.9% early recurrence, and 8.1% late recurrence rates.

CONCLUSIONS

Elderly SV patients generally present with high percentages of recurrent volvulus, serious comorbidity, late admission, and shock. The clinical features may be less diagnostic. Radiological studies, particularly CT or MRI, may assist in an SV diagnosis. Nonoperative detorsion is advocated as the primary treatment. In emergency surgery, nonresectional or nonanastomotic procedures are preferred. The overall patient prognosis is grave, and the disease tends to recur.

Sigmoid volvulus

In sigmoid volvulus (SV), the sigmoid colon wraps around itself and its mesentery. SV accounts for 2% to 50% of all colonic obstructions and has an interesting geographic dispersion. SV generally affects adults, and it is more common in males. The etiology of SV is multifactorial and controversial; the main symptoms are abdominal pain, distention, and constipation, while the main signs are abdominal distention and tenderness. Routine laboratory findings are not pathognomonic: Plain abdominal X-ray radiographs show a dilated sigmoid colon and multiple small or large intestinal air-fluid levels, and abdominal CT and MRI demonstrate a whirled sigmoid mesentery. Flexible endoscopy shows a spiral sphincter-like twist of the mucosa. The diagnosis of SV is established by clinical, radiological, endoscopic, and sometimes operative findings. Although flexible endoscopic detorsion is advocated as the primary treatment choice, emergency surgery is required for patients who present with peritonitis, bowel gangrene, or perforation or for patients whose non-operative treatment is unsuccessful. Although emergency surgery includes various non-definitive or definitive procedures, resection with primary anastomosis is the most commonly recommended procedure. After a successful non-operative detorsion, elective sigmoid resection and anastomosis is recommended. The overall mortality is 10% to 50%, while the overall morbidity is 6% to 24%.

Management of acute sigmoid volvulus: an institution's experience over 9 years

INTRODUCTION

Management of sigmoid volvulus is often challenging because of its prevalence in high-risk patients and the associated perioperative morbidity and mortality rates. This study was designed to review the management and outcome of all patients admitted with sigmoid volvulus.

METHODS

A retrospective review of all patients who were admitted for sigmoid volvulus from October 2001 to June 2009 was performed. Diagnosis was confirmed on clinical evaluation, radiological studies, and/or intraoperative findings.

RESULTS

Seventy-one patients, median age 73 (range, 17-96) years, were admitted a total of 134 times for acute sigmoid volvulus during the study period. The majority (n = 51, 71.8%) were older than aged 60 years, and 41 (57.7%) had at least one premorbid condition. Seven (9.9%) patients underwent emergency surgery on presentation. The remaining 64 (90.1%) patients were initially managed conservatively using a flatus tube and/or sigmoidoscopic decompression. One patient had an endoscopic-related perforation and required emergency surgery. Another ten patients failed conservative management for which nine underwent operative intervention. The last patient refused surgery and died subsequently. Fifty-three (74.6%) patients had successful conservative management; seven of them underwent elective surgery subsequently. Of the remaining 46 patients, 28 (60.9%) were admitted for recurrent sigmoid volvulus. Of these 28 patients, 12 eventually had elective surgery after successful decompression, whereas the remaining 16 were not operated. In our series, three patients died after emergency surgery and there was no mortality after elective surgery. Another six patients died from medical conditions that were unrelated to sigmoid volvulus.

CONCLUSIONS

Acute sigmoid volvulus is a surgical emergency, although the majority (75%) can be successfully decompressed nonoperatively. Emergency surgery in these patients is associated with a mortality of 17.6% in our series. Elective definitive surgery is suggested in view of the high recurrence rate (>60%) and the considerable risks of emergency surgery.