Management of acute sigmoid volvulus in a provincial centre-a 20-year experience

AIM

At our institution there has been a long-standing early operative approach to large bowel volvulus as well as initial decompression with rigid sigmoidoscopy. The primary aim of this study was to investigate the safety and efficacy of this approach on reducing readmissions and complications. Secondary aims were to investigate the safety and efficacy of bedside rigid sigmoidoscopy in decompression of sigmoid volvulus and investigate the sensitivity of abdominal x-ray in the diagnosis of acute large bowel volvulus.

METHOD

A retrospective study was conducted on all patients presenting with acute obstruction due to large bowel volvulus between 1 January 1998-1 January 2018.

RESULTS

Thirty-four patients with acute sigmoid volvulus were identified that met the inclusion criteria with a median age of 81 years. The majority of patients 27/34 (79%) were booked for surgery on the first admission. Readmissions were reduced in the index operative group 1/20 (5%) vs the non-operative decompression group 3/4 (75%) RR 0.07 (CI 0.01-0.49 P=0.01).

CONCLUSION

Early sigmoid colectomy was associated with low morbidity and found to be safe in the elderly, and the results suggest that early surgery is associated with reduced readmissions and a low complication rate, with index surgery preferable to urgent elective surgery. Rigid sigmoidoscopy is a safe method of decompression as a bridge to index surgery and was not associated with any complications in this series.

[Intestinal occlusion due to Meckel's diverticulum: a case study]

Meckel's diverticulum is a remnant of the omphalomesenteric channel. Diverticulum may result in perforation, inflammation an even in occlusion. We here report the case of a 30-year old man, hospitalized and treated for bowel obstruction at the university clinics of Lubumbashi. Intraoperative findings showed small bowel volvulus due to Meckel's diverticulum associated with intestinal necrosis. Patient's outcome was favorable after surgery.

Transverse colon volvulus in a patient with sickle cell disease

Although colonic volvulus is a relatively rare cause of large bowel obstruction, accounting for up to 5% of all cases of intestinal obstruction, transverse colon volvulus is extremely uncommon compared with volvulus of the sigmoid colon or caecum and is responsible for only 3% of all reported cases. We report an unusual case of spontaneous volvulus of the transverse colon in a young man with sickle cell disease who underwent resection with primary anastamosis. Having a high index of suspicion and early operative intervention allowed for this patient to have an uneventful postoperative course.

Reoperation after Ladd's procedure in the neonatal period

AIM OF THE STUDY

To investigate (1) the indications for reoperation after neonatal Ladd's procedure, (2) the type of reoperation and (3) its outcome.

METHODS

We reviewed all neonatal Ladd's procedures in our hospital from 2003 to 2017 and the outcomes of reoperation in these patients.

MAIN RESULTS

252 neonates had Ladd's procedure: 59 were laparoscopic (23.4%) and 193 open (76.6%). 15 (6.0%) required reoperation with no difference between laparoscopic and open (p = 0.12). Overall, the indications for reoperation were: adhesive intestinal obstruction (n = 10, 4.0%), recurrent midgut volvulus (n = 4, 1.6%), and missed diagnosis of associated anomaly (n = 1, 0.4%). The incidence of recurrent midgut volvulus was higher after laparoscopic Ladd's procedure (3/59; 5.1%) compared to open Ladd's procedure (1/193; 0.5%) (p = 0.04). Adhesive intestinal obstruction developed after both open (8/193, 4.1%) or laparoscopic Ladd's procedure (2/59, 3.3%). The duration of reoperation and the length of post-operative hospital stay were 63.4 ± 27.1 min and 10.1 ± 5.2 days, respectively. After reoperation, there were no post-operative complications. All children were well at follow-up (6 months-14 years).

CONCLUSIONS

In neonates, laparoscopic Ladd's procedure compared to the open Ladd's procedure is associated with a significantly higher risk of recurrent volvulus. The risk of developing this potentially dangerous complication after laparoscopic Ladd's procedure raises doubts about the effectiveness and safety of the laparoscopic approach in neonates.

[A Case of Rectosigmoid Cancer with Intestinal Malrotation Treated with Laparoscopic Surgery]

A 67-year-old woman was diagnosed with rectal cancer using colonoscopy. Computed tomography revealed the so-called superior mesenteric vein rotation sign, and intestinal malrotation was suspected. We planned chemotherapy after the surgical resection of the primary cancer because she had multiple lung metastases. Laparoscopic high anterior resection with D3 dissection of lymph nodes was performed. Intraoperative findings showed a non-rotation type intestinal malrotation and severe intra-abdominal adhesion. However, careful releasing operation enabled the typical approach of laparoscopic surgery for rectal cancer. The postoperative course was generally good, and she was discharged on the 17th postoperative day. The pathological diagnosis was rectal cancer(T3, N0, M1a, pStage Ⅳ). In laparoscopic surgery for colorectal cancer with intestinal malrotation, determining the anatomy of blood vessels and the site of the tumor before surgery is important. Furthermore, awareness that some cases have severe intra-abdominal adhesions even without a history of laparotomy is necessary.

A huge completely isolated duplication cyst complicated by torsion and lined by 3 different mucosal epithelial components in an adult: A case report

RATIONALE

Intestinal or enteric duplication (ED) does exit as a rare congenital malformation of the gastrointestinal system clinically. It is a separate entity, but can be communicated with the gastrointestinal tract. It is characterized by a well-developed muscular wall and lumen endowed with ectopic mucosa, simulating a portion of normal bowel. A completely isolated duplication cyst (CIDC) refers to an extremely uncommon variant of ED, which is secluded from the alimentary tract and possesses its own exclusive blood supply. Surgical procedure is the treatment of choice, because most often, a definitive diagnosis can only be confirmed intraoperatively.

PATIENT CONCERNS

A 20-year-old male patient presented with a 10-day history of intermittent episodes of abdominal pain. The pain evolved from dull into progressive and intolerable, accompanied by vomiting, nausea, and abdominal distention.

DIAGNOSES

Closed-loop small-bowel obstruction with volvulus.

INTERVENTIONS

The patient underwent an emergency exploratory laparotomy.

OUTCOMES

A huge CIDC was observed upon operation, which was affixed to the mesentery with only a narrow base, just like a pedicle; 720° counterclockwise twisting around its base was definitely noted, provoking the compromised blood supply. Complete excision of the cyst was performed along its base safely without violating the intestinal tract. Furthermore, the ectopic mucosa of the cyst exhibited 3 different epithelial lining components histopathologically.

LESSONS

Clinicians should be aware of the possibility of the existence of a duplication and raise a high index of suspicion in case of equivocal diagnosis, particularly in adult population. A low threshold for surgical management should be recommended in order to prevent lethal outcomes.

From Endoscopic Detorsion to Sigmoid Colectomy-The Art of Managing Patients with Sigmoid Volvulus: A Survey of the Members of the American Society of Colon and Rectal Surgeons

This study queried American Society of Colon and Rectal Surgeons members for management of sigmoid volvulus and aimed to determine whether surgeon experience impacts decision-making. American Society of Colon and Rectal Surgeons members received a 16-item survey in March, 2017. Items included endoscopic detorsion technique and colonic decompression, preoperative dietary considerations, surgical approach, and respondents' demographics. Respondents were separated into low experience (LE; ≤10 years in practice) and high experience (HE; >10 years in practice). Of 1996 survey recipients, 10 per cent (197) responded; 124 were HE and 73 were LE. Most were fellowship-trained (93.8%) and primarily in colorectal surgery practice (74.6%), however only 27.4 per cent managed >20 sigmoid volvulus cases as attendings. Fifty-two per cent use rectal tubes for continued colonic decompression after successful endoscopic detorsion; 81.2 per cent would perform sigmoid colectomy on the index admission after successful detorsion, but within a variable timeframe (one to seven days postdetorsion) and with variable dietary restrictions in the interval period; 49.7 per cent would perform a laparoscopic colectomy and 68.3 per cent would perform a stapled colorectal anastomosis. LE surgeons reported a higher proportion of gastrointestinal-performed endoscopic detorsions (P = 0.015), were more likely allow regular diet in the interval period (P = 0.031), and were more inclined to use laparoscopy (P = 0.008), versus HE surgeons. There remains controversy among many of the components in the management of sigmoid volvulus after successful endoscopic detorsion.

[Complications after laparoscopic Ladd operation for intestinal malrotation in neonates]

OBJECTIVE

To analyze complications after laparoscopic Ladd operation for intestinal malrotation, related causes and possible solutions.

METHODS

Clinical data of 81 neonates who underwent laparoscopic Ladd operations for intestinal malrotation in the Children's Hospital, Zhejiang University School of Medicine between January 2015 and January 2018 were reviewed. The abdominal complications and findings during operation and reoperation were analyzed.

RESULTS

Operations were successfully completed in all patients, and there was no patient converted to open surgery. The annular pancreas in 6 cases and duodenal diaphragm in 4 cases were confirmed during the operation. The recurrent volvulus developed in 3 patients (3.7%), of whom 2 cases were confirmed to have midgut necrosis during open surgery 1 week and 3 months after laparoscopic Ladd operation, and both finally died; 1 case was corrected by second laparoscopic operation. Cecal perforation occurred in 1 patient (1.2%), which was caused by intensive high frequency coagulation of the appendiceal stump. One patient (1.2%) developed chylous ascites and improved after conservative treatment. Adhesive small bowel obstruction was observed in 3 cases (3.7%), and all relieved after conservative treatment.

CONCLUSIONS

Laparoscopic Ladd operation for intestinal malrotation in neonates was effective, and the incidence of abdominal complications may be minimized by experienced skills and strict perioperative management.

Enterocutaneous fistula treatment: case report and review of the literature

OBJECTIVE

The aim of this work is to evaluate the treatment strategies for a common major surgery complication like the enterocutaneous fistula (ECFs). Since there is not any standard treatment for this common disease and since new therapies, like NPWT and fibrin sealants, have come up a review of all their indications seemed useful. We also present two clinical cases treated in this way.

PATIENTS AND METHODS

A research was made in the principle databases such as: "Cochrane", "Pubmed", "Google Scholar" and "Google" using the following Key words "enterocutaneous fistula", "fibrin glue", "VAC", "VAC treatment", "fistula", "conservative treatment", "surgery" and using the MESH Function to search similar key words and expand the research. When two or more article with the same design were encountered (e.g. systematic reviews or case reports etc.) the newest one was chosen as data source.

RESULTS

As far as somatostatine and its analogues are concerned, they showed a significant reduction of both time (13.95 vs 20.5 days) and percentage (72% vs 44%) of fistula closure against placebo in 2 meta-analysis. NPWT showed a high success rate between 90% and 100% but longer closure time between 4 weeks and 6 months. Fibrin glues showed heterogeneous results due to the great differencies in fistulas anatomy and treatment technique in the various studies, with 64-100% success rate in closure and a median 11,25 vs 23,25 days against total parenteral nutrition (TPN) alone.

CONCLUSIONS

Because of ECFs often come up in patient in bad conditions who are not fitted for surgery and because of their high Mortality and Morbidity, a multimodal approach is necessary. Although TPN is a cornerstone of their treatment, NPWT showed is superiority in reducing fistula output and in some cases leading to fistula closure, nevertheless it often needs long treating time. Fibrin glues often needs complex devices and are nota s good as NPWT in treating the around tissues, but they can be useful when fistulas are only accessible from a little external orifice or they show a complex branched tract; thus they are good when surgery is not possible and the fistula has a mid- or low- output. The lack of prospective randomized studies or meta analysis and systematic review to compare the different methodics makes it impossible to show any evidence of superiority, but the combined application seems reasonable for a tailored treatment.

Distal Duodenogastrostomy or Proximal Jejunogastrostomy in the Management of Ultra-Short Bowel

Inflammatory bowel disease, vascular disease, volvulus, adhesions, or abdominal trauma may necessitate extensive small-bowel resection resulting in an ultra-short distal duodenal or jejunal stump. If this distal duodenal or short jejunal stump is too short for stoma creation and bowel continuity restoration is hazardous or not possible at all, a distal duodenogastrostomy or proximal jejunogastrostomy in combination with drainage of the stomach is an option to prevent stump leakage. Although successful, this distal duodenogastrostomy has been described only in very few patients and in older records. We reintroduced this technique and describe a recent series of patients that confirms its usefulness in certain conditions. The technique of the distal duodenogastrostomy or proximal jejunogastrostomy with gastric drainage was used for the management of the difficult distal duodenum stump in five critically ill patients undergoing extensive bowel resection. Four patients with small-bowel ischemia and one patient suffering from perforating Crohn's disease and small-bowel volvulus were treated  successfully. The gastrostomies were subsequently converted to a duodenotransversostomy (in two patients) or the patients underwent small-bowel transplantation (two patients). One patient still has a jejunogastrostomy just after the duodenal-jejunal transition. In all five patients, the distal duodenogastrostomy or proximal jejunogastrostomy in combination with gastric drainage functioned well up to restoration of bowel continuity. In one patient, distal duodenogastrostomy and transabdominal gastric drainage functioned well for 5 years. No anastomotic leakage occurred. This procedure provides a feasible solution for an ultra-short bowel at emergency laparotomy. It enhances the surgical armamentarium and provides treatment options for these patients that were perhaps previously deemed unsalvageable.

Worsening anemia associated with volvulus in a stable neonate with intestinal obstruction

Intrauterine intestinal obstruction complicated by midgut volvulus is a serious life-threatening diagnosis. Immediate surgical intervention is generally the course of action upon diagnosis to prevent morbidity and mortality. We report a case of intrauterine intestinal obstruction where the neonate then presented with an unusual onset of volvulus within the first 12 hours of life. The patient was born with generalized edema, a distended abdomen, and pallor. Unlike many cases, the patient did not present with typical signs of volvulus. Diagnostic imaging preceding delivery and the stable postnatal clinical course did not offer a justification for immediate laparotomy. Less than 24 hours later, the patient's hemoglobin significantly dropped leading to an emergent laparotomy. Findings included a volvulus of the terminal ileum and large amounts of intraluminal blood. Our case report includes an analysis of clinical observations that should be considered so that patients presenting with similar signs receive earlier surgical intervention.

A case report and literature review of sigmoid volvulus in children

RATIONALE

Sigmoid volvulus (SV) is an exceptionally rare but potentially life-threatening condition in children.

CHIEF COMPLAINT

Abdominal distention for 1 week.

DIAGNOSES

Sigmoid volvulus.

PATIENT CONCERNS

We present a case of a 12-year-old boy with mechanical ileus who was finally confirmed to have SV with the combination of abdominal plain film, sonography, and computed tomography (CT) with the finding of mesenteric artery rotation.

INTERVENTIONS

Because bowel obstruction was suspected, abdominal plain film, sonography, and CT were performed. The abdominal CT demonstrated whirlpool sign with torsion of the sigmoid vessels. In addition, lower gastrointestinal filling study showed that the contrast medium could only reach the upper descending colon. Therefore, he received laparotomy with mesosigmoidoplasty for detorsion of the sigmoid.

OUTCOMES

The postoperative recovery was smooth under empirical antibiotic treatment with cefazolin. A follow-up lower gastrointestinal series on the seventh day of admission showed no obstruction compared with the previous series. He was finally discharged in a stable condition 8 days after admission.

LESSONS

SV is a congenital anomaly and an uncommon diagnosis in children. Nevertheless, case series and case reports of SV are becoming more prevalent in the literature. Failure to recognize SV may result in life-threatening complications such as sigmoid gangrene/perforation, peritonitis, sepsis, and death. Thus, if the children have persistent and recurrent abdominal distention, abdominal pain, and vomiting, physicians should consider SV as a "do not miss diagnosis" in the differential diagnosis.

[Andean megacolon and sigmoid volvulus in the high altitude. Presentation of 418 cases between 2008 - 2012 at C. Monge Hospital, Puno, Peru]

OBJECTIVE

The present study describes the medical and surgical management of sigmoid volvulus due to Andean dolicomegacolon in a hospital at an altitude above 3000 m.

MATERIAL AND METHODS

A descriptive, observational, crosssectional study of 418 patients diagnosed with sigmoid volvulus; Admitted initially due to intestinal obstruction, in the Hospital of Juliaca Carlos Monge. Puno-Perú, during the period 2008-2012. The data were processed through the SPSS software version 21.

RESULTS

A total of 418 patients were enrolled, the mean age was 60 years, range 18-89 years, and the male/female ratio was 3.5/1. Nonsurgical management was done in 64 (15.4%), the treatment used was saline enema 20 cases (31%) and rectal catheter 44 (69%), recurrence was present in 27 patients (45%), who had surgery with primary anastomosis resection, of which the mortality corresponded to 8 patients (30%). Of the 354 patients undergoing emergency surgical management, 325 were submitted to sigmoidectomy with primary anastomosis (92%), while 29 had Hartmann's colostomy (8%), the morbidity for both procedures was 52 cases (14.7%), Mortality for both procedures was 45 cases (12.7%).

CONCLUSIONS

In patients with sigmoid volvulus due to Andean megacolon the mean age was 60 years. The 15.4% had non-surgical management, the recurrence rate was 45%, and mortality 30%. Patients with surgical management was 84.7%, from this group; 92% had primary anastomosis resection and 8% Hartmann colostomy, morbidity was 14.7% and mortality was 12.7%.

Organo-axial volvulus of the small intestine: radiological case report and consideration for its mechanism

Gastrointestinal volvulus is mainly classified into two subtypes, mesentero-axial volvulus and organo-axial volvulus. The detailed imaging findings of organo-axial volvulus of the small intestine have never been reported as far as we know. In this article, we report a case of organo-axial volvulus of the small intestine, focusing on the computed tomography (CT) findings. An 80-year-old man was radiologically diagnosed as having organo-axial volvulus of the terminal ileum and it was confirmed by open surgery without adhesion or any other anatomical abnormalities. CT showed two specific findings, split-bowel sign and rotating-C sign, which we think reflect pathophysiologic features of organo-axial volvulus. We think the pathogenic mechanism of organo-axial volvulus can be explained by the convergence of the reversed-rotational twist following the formation of a twisted but non-obstructive circular loop, even if there is no adhesion. Radiologists should be aware that organo-axial volvulus can occur even in the small intestine, and in the case of small bowel obstruction with single transition point, the two pathophysiologic signs mentioned above must be looked for to diagnose the possibility of organo-axial volvulus.

Antenatal diagnosis and management of foetal intestinal volvulus

In-utero intestinal volvulus is a rare but potential life threatening foetal complications. It is a surgical emergency and delay in diagnosis or treatment can increase the morbidity and mortality to the foetus. We report a case of mild foetal bowel dilatation diagnosed at 21 weeks of gestation. She was closely follow up and at 31 weeks of gestation, in-utero intestinal volvulus was diagnosed with the characteristic 'whirlpool' sign on ultrasound examination. This case emphasises the importance of early recognition and quick decision to delivery when intestinal volvulus is diagnosed. This enabled early surgical intervention to prevent further foetal morbidity.

[Congenital mesenteric band simulating a small-bowel volvulus in a mesenteric rotation anomaly]

A congenital mesenteric band is a rare cause of intestinal obstruction. We describe a case of upper gastrointestinal obstruction on a jejunal congenital band in a 2-year-old child. The challenge is to make the diagnosis in a patient with no history of previous surgery.

Bilateral robotic transabdominal adrenalectomy in a patient with intestinal malrotation

Bilateral adrenalectomy is the preferred surgical approach for patients with failed treatments for pituitary-based Cushing's syndrome. Intestinal malrotation (IM) is a rare congenital anatomic variant that rarely affects adults. The abnormal abdominal anatomy is concerning to surgeons planning elective procedures in such patients. Here, we describe a bilateral robotic transabdominal adrenalectomy (RTA) in a patient with IM. A 29-year-old female presented with refractory pituitary-based Cushing's syndrome and was found to have IM on preoperative CT scan. The RTA was performed using one 10-12 mm camera trocar, two 8 mm robotic trocars per side and two midline 5 mm assistant ports. The 8 mm robotic cardiere forceps and the 8 mm robotic cautery hook were used on the left and right ports, respectively. Total operation time was 165 min (62 min on the right, 93 min on the left and 21 min for re-positioning). Total console time was 114 min (45 min on the right and 69 min on the left). Blood loss was minimal and there were no complications. She was discharged on post-operative day one. Anatomic variations were noted and the procedure modified. To our knowledge, this is the first reported case of bilateral RTA in a patient with IM. Surgeons should always review the anatomy on preoperative imaging. During the procedure, care should be taken to avoid damage to the multiple loops of small bowel located in the right upper quadrant. On the left side, the colonic splenic flexure is not encountered making access to the underlying left adrenal and kidney easier. The vascular anatomy was normal.

An Unusual Case of Caecal Volvulus due to Appendicitis, Successfully Managed by Caecopexy

Caecal volvulus is a rare cause of intestinal obstruction. Caecal volvulus precipitated by acute appendicitis is even rarer. We report an unusual case of caecal volvulus with acute appendicitis as a cause. A 55-year female presented in surgical emergency with 3 days history of abdominal pain, distension and absolute constipation; and 2 days history of vomiting. Her past surgical history was significant for hysterectomy 5 years back. On examination, abdomen was distended and bowel sounds exaggerated. X-ray abdomen erect showed a single large air fluid level in the right hemiabdomen. A preoperative diagnosis of intestinal obstruction due to adhesions was made and patient prepared for exploratory laparotomy. On exploration, a huge caecum was lying in the midline and was twisted around a band arising from the appendix and attached deep into the pelvis. The appendix was densely inflammed. The volvulus was de-twisted in a counter clockwise manner. Viability of the caecum was confirmed and appendectomy was done. Caecopexy was performed and abdomen was closed. Postoperative recovery of the patient was uneventful and she was safely discharged on 5th postoperative day.