Colonoscopic decompression of pseudo-obstruction and volvulus

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.

Acute Colonic Pseudo-Obstruction (Ogilvie's Syndrome)

Acute colonic pseudo-obstruction is a complication that occurs in hospitalized patients with serious underlying medical or surgical conditions; it is characterized by acute colonic dilatation in the absence of mechanical obstruction. The pathogenesis is incompletely elucidated, but changes in autonomic nervous system function are likely to contribute, as are metabolic and pharmacologic factors. Early diagnosis and appropriate intervention are critical in this disorder, which carries with it considerable morbidity and mortality. Treatment options, consecutively applied, include conservative measures, pharmacologic treatment with neostigmine, and endoscopic decompression. Surgical decompression or resection is necessary in case of refractoriness or perforation, respectively.

Motility disorders in the patient with neurologic disease

Gastrointestinal symptoms are common in the patient with chronic neurologic disease and may loom large in terms of impact on quality of life and on nutrition and mobility. A knowledge of the range of gastrointestinal disorders associated with a given neurologic disease, together with an understanding of the risks and benefits of various therapeutic options and approaches, should aid gastroenterologists in their efforts to contribute to the care of these patients. In most instances a multidisciplinary team (neurologist/neurosurgeon, gastroenterologist, nutritionist, therapist, specialist nurse) aware of the wishes and needs of the family and their carers and mindful of the nature and the natural history of the underlying disease process are best placed to assess and manage these problems.

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.

Retrospective Study of Neostigmine for the Treatment of Acute Colonic Pseudo-Obstruction

Acute colonic pseudo-obstruction (ACPO) typically develops postoperatively or after severe illness. Studies suggest that pharmacologic manipulation with intravenous (IV) neostigmine (NSM) may be an effective and less invasive treatment modality for ACPO with minimal side effects. The purpose of this study was to retrospectively assess the efficacy and incidence of complications of an IV NSM bolus in patients with ACPO. Eight patients with ten episodes of ACPO were treated with a bolus dose of NSM. Rapid and effective decompression of the colon was achieved in six episodes after a single dose of NSM at a mean of 22.8 ± 13.5 minutes. In three episodes decompression occurred after a second dose of NSM at a mean of 44.7 ± 37.7 minutes. One patient failed NSM treatment but responded to a Cystografin enema. One patient experienced significant bradycardia. NSM is a simple, safe, and effective treatment for ACPO and based on result comparison of this study and previous studies both bolus and slow infusion dosing practices of NSM are effective. The NSM bolus dosing side effect profile has been shown to include significant bradycardia, whereas when NSM was infused over one hour significant bradycardic episodes requiring treatment have not been encountered. We propose that a prospective study evaluating NSM dosing as an IV bolus versus an IV infusion would be useful in determining whether NSM infusion can be proven safer than bolus dosing for the treatment of ACPO.

Acute Intestinal Pseudo-obstruction

Acute pseudo-obstruction may manifest clinically in one of three forms--acute gastroparesis, ileus, and acute colonic pseudo-obstruction (Ogilvie's syndrome). Though formerly associated primarily with the postoperative state, these entities are increasingly recognized in association with a wide variety of major medical problems. There are few controlled studies to guide the clinician in the management of these disorders. Treatment remains largely empirical, and time-honored, based primarily on "bowel rest," nasogastric decompression, and supportive care. While a wide variety of pharmacologic approaches have been advocated, few have been subjected to, or survived, the rigors of a properly controlled trial. Neostigmine is a notable exception, and has been shown to be effective in Ogilvie's syndrome. Perforation is a significant threat in megacolon; colonoscopic, or surgical decompression may, therefore, be indicated. Both are associated with significant risks in this context, but may prevent progression to perforation with its attendant mortality. New approaches seek to exploit current concepts in the pathophysiology of ileus and megacolon but have not, as yet, achieved efficacy in human studies.

Diagnostic laparoscopy and laparoscopic cecostomy for colonic pseudo-obstruction

Marked cecal dilatation due to colonic psuedo-obstruction (Ogilvie's syndrome) is most often treated by colonoscopic decompression. When this fails, cecostomy is usually indicated if the bowel is not infarcted. We describe a new technique of laparoscopy-guided percutaneous cecostomy using T-fasteners to retract and anchor the cecum to the anterior abdominal wall and using a Foley catheter as a cecostomy tube. We performed this procedure successfully in a patient with colonic pseudo-obstruction who had marked cecal dilatation that could not be decompressed by colonoscopy. Laparoscopic inspection showed that the cecum was viable, and a laparoscopic cecostomy was placed. This procedure can be performed easily and safely and with much less morbidity than laparotomy and open cecostomy.

Therapeutic colonoscopy

Therapeutic colonoscopy has replaced or lessened to a significant degree the need or extent of traditional open surgical procedures. The common uses of therapeutic colonoscopy are hemostasis, resection and ablation of benign and malignant disease, decompression and recanalization of obstructed or dilated bowel, as well as foreign body extraction. Bleeding from arteriovenous and other vascular abnormalities can be controlled with 40% to 80% success rates using endoscopically delivered, monopolar, bipolar, or laser coagulation. The palliation of bleeding recurrent or inoperable colorectal cancer is achieved in up to 90% of patients. Virtually all pedunculated adenomas and most sessile adenomas are regularly removed colonoscopically, while large and recurrent villous adenomas in high risk individuals can be successfully managed by endoscopically delivered laser ablation techniques. Emergency colonoscopic reduction of sigmoid volvulus is performed pre-operatively and decompression of the dilated colon of non-obstructive colonic ileus is now regularly achieved. Colonic strictures have been dilated with a variety of techniques ranging from divulsion with through-the-scope balloon dilators to laser recanalization. Pre-operative endoscopic laser relief of tumor obstruction is employed to avoid preliminary or decompressing colostomy. Endoscopic laser debulking and recanalization of recurrent or inoperable cancer has been achieved with up to 80% success and various foreign bodies may be extracted from the colon with a number of endoscopic techniques. The morbidity of therapeutic colonoscopy has ranged from 1% to 2% for polypectomy to 11% for laser palliation of bleeding from advanced cancer, often with obstruction.

Management variability in surgery for colorectal emergencies

A prospective study was made of 92 patients who underwent emergency colorectal surgery during a 1-year period. A dedicated emergency theatre allowed half of the patients to be operated on between 09.00 and 17.00 hours with greater seniority of operating surgeons. The overall mortality rate was 14 per cent and the primary resection rate was 79 per cent. The mortality rate was 12 per cent for right-sided resection with anastomosis and 24 per cent for left-sided resection without anastomosis, including those undergoing Hartmann's procedure which had a 35 per cent mortality rate. Immediate left-sided anastomosis was performed safely in all 14 patients in whom it was attempted. Firms headed by consultants with and without a special interest in colorectal disease made differing use of primary resection and immediate anastomosis (67 versus 41 per cent, P less than 0.05) and Hartmann's (7 versus 25 per cent, P less than 0.05) and non-resectional (15 versus 29 per cent, P not significant) procedures. Retrospective surveys of perioperative deaths examine inadequate management and subsequent mortality rates, but do not reveal the significant morbidity rate that occurs in survivors. This audit revealed significant differences in the management of patients with colorectal emergencies between firms headed by specialist and non-specialist consultants. In order to minimize these differences we believe that recent advances in colorectal practice should be included in the training of all surgeons.

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.