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.

[Colonoscopic restoration for sigmoid vovulus in the elderly]

OBJECTIVE

To investigate the emergency therapeutic strategy for sigmoid vovulus in the elderly.

METHODS

Clinical data of 14 elderly patients with sigmoid vovulus were analyzed retrospectively.

RESULTS

The mean age was(79.1±7.2) years(range, 70-93), and 11 patients (78.6%) were male. Emergency decompression and restoration with colonoscopy was performed in all the patients with a success rate of 100%. No patient required emergent surgery. Four patients(28.6%) recurred and they were managed well by repeat colonoscopic restoration.

CONCLUSION

Emergency colonoscopic restoration is the first treatment of choice for sigmoid vovulus in the elderly because it is safe and effective, and can be performed repeatedly.

Resection and primary anastomosis with modified blow-hole colostomy or Hartmann's procedure. Which method should be performed for gangrenous sigmoid volvulus?

AIM

To evaluate the efficacy of Hartmann's procedure and RPA with modified blow-hole colostomy for gangrenous sigmoid volvulus.

METHODS

Sixty-one patients operated on between January 2004 to September 2010 were reviewed retrospectively. The demographic data of the patients,clinical features, type of surgical procedure performed, postoperative complications, mortality and duration of hospital stay (DHS) after surgery were reviewed.

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% vs15%). Development of leaks secondary to stoma closure was not observed in any patient. During hospitalisation period; the postoperative complications were wound infection in four patients, intraabdominal abscess in two, evisceration and wound dehiscence in two, arrhythmia in six, pneumonia in eight.Medical and surgical complication rates of the groups were not different (p>0.05). When compared, the durations of intensive care unit (ICU) stay were not statistically different (p>0.05), but mean duration of hospital stay (DHS) was longer in group A than group B (p less than 0.05).

CONCLUSION

Sigmoidectomy should be the basic principle in the management of sigmoid volvulus.RPA with modified blow - hole colostomy provides satisfactory results. It is easy to perform in patients with sigmoid volvulus. RPA with modified blow - hole colostomy can be performed safely in selected patients without increasing morbidity and DHS.

Urgent surgical management of a prenatally diagnosed midgut volvulus with malrotation

Midgut volvulus is a life-threatening condition that commonly presents during the first year of life rarely antenatally. Here we report successful urgent surgical management of an unusual case with malrotation exhibiting the sonographic findings of volvulus in utero that leads to premature birth. This 34-wk, 2700 g infant was born via spontaneous vaginal delivery. Prenatal ultrasound showed polyhydramnios and 30 x 40 mm cystic lesion showing whirlpool sign in abdomen that made us think midgut volvulus. The patient had distended abdomen with skin discoloration. An emergency surgical management was performed showing malrotation, volvulus and a 15 cm ischemic necrotic region of terminal ileum.

Unusual presentation of midgut malrotation with incidental nutcracker syndrome in adulthood: case report and literature review

Malrotation of the midgut is generally regarded as paediatric pathology with the majority of patients presenting in childhood. The diagnosis is rare in adults, which sometimes results in delayed diagnosis and treatment. We present the case of a 28-year-old woman who presented with vomiting and mild acute pain in the abdomen. CT scan showed abnormal location of the midgut and abnormal relation of the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) and duodenal jejunal flexure, confirming midgut malrotation. Peroperative findings showed the duodenum, small bowel loops located on the right side of the abdomen. The caecum and appendix were located at the midline in the epigastrium with the presence of Ladd's bands. SMA right and anterior to SMV whirled around SMA. Incidentally, the intraoperatively dilated left renal vein was compressed between the SMA and the aorta, which was confirmed retrospectively on CT scan with no symptoms related to the condition.

Cecal volvulus during pregnancy. Case report

INTRODUCTION

Acute intestinal obstruction in pregnancy is a rare, but life-threatening complication associated with high fetal and maternal mortality.

CASE REPORT

A 20-year old gravida presented with a 24 hour history of several episodes of vomiting, complete constipation and severe crampy abdominal pain. The patient was admitted with the diagnosis of acute abdomen associated with septic shock. On examination echography showed distended intestinal loops and presence of free peritoneal fluid. Abdominal X-ray with shielding of the fetus revealed colonic air-fluid levels. The obstetrician consult diagnosed dead fetus in utero and was decided to operate immediately. On laparotomy was found complete cecal volvulus with gangrene of cecum, part of ascending colon and terminal ileum. A right hemicolectomy was performed with side to side ileotransverse anastomosis. Afterwards a lower segment cesarean section was made and a stillborn fetus was delivered. The patient made an uneventful recovery and was discharged on 9th postoperative day.

CONCLUSION

Cecal volvulus during pregnancy is a rare, but serious surgical problem. Correct diagnosis may be difficult until exploratory laparotomy is performed. Undue delay in diagnosis and surgical treatment can increase the maternal and fetal mortality.

Pictorial Interlude: caught up in a 'whirl'

A patient with the 'whirl sign' on computed tomography (CT) is 25.3 times as likely as a patient without to have small-bowel obstruction (SBO) necessitating surgery. There is therefore an important role for the 'whirl sign' in assessment of patients with clinical and radiological signs of SBO.

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.

[Volvulus in pregnancy: a case report]

There are several etiologies of abdominal pain during pregnancy, including an extremely rare: the intestinal volvulus. Have been reported about 78 cases in the literature of intestinal volvulus complicating pregnancy, we reported this case occurred in our hospital and to assess the difficult diagnosis of intestinal volvulus in pregnancy.

Sigmoid volvulus: long-term surgical outcomes and review of the literature

OBJECTIVE

Little has been published regarding long-term surgical outcome after the initial management of acute sigmoid colon volvulus.

METHODS

Patients undergoing primary resection and anastomosis (PRA) or Hartmann's procedure (HP) for sigmoid volvulus between September 1992 and August 2000 were reviewed. Eligible patients who had had the initial procedure at least 5 years previously were contacted and completed a questionnaire regarding recurrence, current symptoms and bowel habits.

RESULTS

Data on 42 PRA patients and 36 HP patients were analysed. Follow-up (mean 7.2 years, range 5 - 11 years) was completed for 63 patients (37 PRA, 26 HP). Restoration of bowel continuity was successfully performed in 25 of 26 HP patients. No patient had megacolon. Constipation was reported by 83% of PRA and 65% of HP patients. Of these patients, 51% regularly used laxatives. No patient complained of incontinence, and no recurrences of sigmoid volvulus were recorded during the follow-up period.

CONCLUSION

Sigmoidectomy with primary anastomosis is a good option for the definitive management of sigmoid volvulus. Despite the high constipation rate, no recurrence occurred during long-term follow-up.

[A woman with nausea and epigastric pain]

An 48-year old woman presented at the emergency room with epigastric pain and nausea. 6 months earlier she had a distended ascending colon, which resolved quickly after conservative treatment with nasogastric tube. Now she had similar complaints. A plain abdominal radiograph was not conclusive; barium enema examination demonstrated a cecal volvulus. Patient required right hemicolectomy. She recovered uneventfully.

Sigmoid volvulus in pregnancy

A 27-year-old woman, gravida 1, was seen at our surgical emergency department with abdominal pain at 25 weeks' gestation. She had pain, nausea and vomiting, a temperature of 37°C and a blood pressure of 100/70 mmHg. The cervix was closed, and an ultrasound scan showed a normal single fetus. A plain abdominal radiograph showed distension of the colon and a sigmoid volvulus. At emergency laparotomy, non-gangrenous sigmoid colon was resected with primary anastomosis. There were no complications, and 4 months later the patient delivered a healthy infant. Early diagnosis of sigmoid volvulus in pregnancy and prompt intervention minimise maternal and fetal morbidity and mortality.

Emergency management of sigmoid volvulus--institutional experience over four years

Sigmoid volvulus is a serious surgical emergency and a common cause of large bowel obstruction in India. Patients present with abdominal pain, distension and obstipation and abdominal skiagram usually reveals the characteristic omega sign. Non-operative detorsion with early elective sigmoidectomy is the procedure of choice where gut viability is not in doubt and features of peritonitis are absent. The objective of this study was to demonstrate the most suitable procedure for management of patients with sigmoid volvulus needing emergency surgery. Results revealed a high incidence of burst abdomen and anastomotic leak as well as a high mortality rate in patients undergoing resection with primary anastomosis without proximal colostomy. Mortality was least with Hartmann's procedure although there was a higher incidence of wound infection. Thus, in the hospital setting, we consider Hartmann's procedure to be the best emergency surgical procedure for sigmoid volvulus as it limits mortality to the least.