Volvulus of the sigmoid colon in Brazil: a report of 230 cases

Is Laparoscopy Underutilized for Sigmoid Volvulus?

PURPOSE

Minimally invasive surgery has become increasingly prevalent. However, the majority of colectomies for volvulus are still performed via an open technique. The purpose of this study is to determine whether there is a difference in outcomes between laparoscopic and open procedures for sigmoid volvulus.

MATERIALS AND METHODS

The American College of Surgeons National Surgical Quality Improvement Program and colectomy-targeted procedure databases were queried from 2013 to 2018. Patients undergoing partial colectomy without ileal resection for the indication of volvulus were compared based on approach (planned laparoscopic vs. planned open). The 2 groups were propensity score matched for perioperative variables. A subgroup analysis was performed comparing unplanned laparoscopic conversion to open (CTO) with planned open procedures. The primary outcomes were overall morbidity, mortality, and length of stay.

RESULTS

Total 2493 patients were identified. Four hundred ninety-two cases began laparoscopically (20%), of which 391 were completed laparoscopically (79%). Laparoscopic approach was associated with longer operative times (133 vs. 104 min, P<0.001). Laparoscopic approach was associated with decreased overall morbidity (OR: 0.71, 95% CI, 0.54 to 0.93) and decreased length of stay when >7 days (OR: 0.70, 95% CI, 0.52 to 0.94). On subgroup analysis, there was no difference in outcomes when comparing unplanned CTO to planned open approach.

CONCLUSIONS

Laparoscopic approach is used in a fraction of cases for colonic volvulus. When utilized, the majority are completed without CTO. Laparoscopy is associated with fewer complications and shorter hospital stays. Even with unplanned conversion to open, there is no difference in outcomes compared against planned open procedures. Surgeons should consider the utilization of laparoscopy for colonic volvulus.

A tale of two twists: mesentero-axial and organo-axial sigmoid volvulus

INTRODUCTION

Sigmoid volvulus is a potentially devastating and life-threatening condition associated with sigmoid colon redundancy. Many of the classical radiological signs are considered to represent the two adjacent loops of bowel in a mesentero-axial volvulus. However, limited case reports and series have reported on an organo-axial subtype of sigmoid volvulus. This clinical entity is not widely understood. In this study, we assess the radiological and clinical features of mesentero-axial and organo-axial sigmoid volvulus.

METHODS

After institutional board approval (CH62/6/2016-228), all computed tomography (CT) studies from 2011 to 2017 reported as sigmoid volvulus at a single institution were reviewed. The cases were reviewed by three radiologists retrospectively and the course of the bowel followed with a focus on assessing its rotational axis. In each case, the sigmoid volvulus was independently subclassified as mesentero-axial or organo-axial volvulus based on the axis of rotation of the volvulus. In addition, X-ray signs including disproportionate sigmoid dilatation, distended inverted 'U' in sigmoid, coffee bean sign, opposed wall sign, direction of apex of sigmoid loop, liver overlap sign, northern exposure sign and proximal colonic dilatation and CT features including whirl sign, 'X' marks the spot sign, split wall sign and number of transition points were reported for each case. The clinical management and outcomes including morbidity, mortality, endoscopic decompression and need for surgery were also evaluated. The subtype of volvulus was correlated with the above X-ray signs, CT features and clinical management and outcomes. Statistical analysis was conducted using Stata/MP, version 15 (StataCorp LP, College Station, TX, USA).

RESULTS

A total of 38 scans were reviewed. There were 19 patients identified. Of these, six (32%) were reported as mesentero-axial and 13 (68%) as organo-axial volvulus. No X-ray signs were able to distinguish the two types of volvulus. The number of transition points on CT was predictive of volvulus subtype (OR 25, 95% CI: 1.30-1295.30, P = 0.01). Within the limitations of a small cohort, there was no statistically significant difference in unsuccessful endoscopic decompression, need for colectomy, repeated admissions or mortality between the groups.

CONCLUSION

This study has demonstrated that organo-axial sigmoid volvulus may be as common as mesentero-axial volvulus. Distinguishing organo-axial from mesentero-axial volvulus can be achieved on CT, but not on abdominal X-ray. The number of transition points (two for mesentero-axial and one for organo-axial) may be used as a diagnostic feature for differentiating the two forms of volvulus.

Elective Laparoscopic Sigmoidectomy with Preservation of the Superior Rectal Artery Prior to Endoscopic Decompression in Sigmoid Volvulus

Sigmoid volvulus is a frequent cause of intestinal obstruction. Its management has evolved with the use of laparoscopic surgery, achieving an elective sigmoid resection with anastomosis after a flexible endoscopic detorsion. A female patient was admitted to the emergency room with abdominal pain, distention, and constipation. The abdominal computed tomography showed a whirled sigmoid mesentery in addition to dilated sigmoid loops, and coffee bean sign. The patient successfully underwent a flexible endoscopic detorsion and was scheduled for elective sigmoid colectomy with rectal superior artery preservation and primary anastomosis. During the sigmoid resection, the superior rectal artery preservation is related to a better prognostic, with less bleeding, anastomotic leakage, and hospital stay. Currently, there are few reports of the laparoscopic preservation of the superior rectal artery in patients with sigmoid volvulus.

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.

Volvulus

Intestinal volvulus, regardless of location, is a rare disease process, but one that requires high suspicion and timely diagnosis given the increased incidence of intestinal necrosis and potential mortality. Most patients with intestinal volvulus require some form of surgical intervention. However, over the last few decades, the work-up and management of intestinal volvulus has changed given constant advancements in technology and patient care. Most importantly, however, is recognizing the need for emergent versus more elective surgery because this influences the morbidity and mortality for the individual patient.

Colon cancer presented with sigmoid volvulus: A case report

INTRODUCTION

Sigmoid volvulus is the most prevalent type of colonic volvulus. Colon cancer is seen less where sigmoid volvulus is common, so it is rare to see that colon cancer is synchronous with sigmoid volvulus.

PRESENTATION OF CASE

We would like to present a case of sigmoid volvulus caused by colon cancer in a male patient aged 80 who was referred to the hospital with toxaemic shock presentation.

DISCUSSION

Sigmoid cancer can be presented as sigmoid volvulus to the emergency department. In intestinal obstruction early diagnosis is of crucial importance. Computarized tomography is a diagnosis tool that should be preferred both in the diagnosis of obstruction and in detecting its cause, localisation, degree and complications.

CONCLUSION

When surgery is performed due to the urgent colonic obstruction in colonic volvulus diagnosed patients, a colon tumour should be considered in the same column loops or in the distal colon. We believe that CT is the method that should be preferred in large-bowel obstruction suspected patients.

New perspectives in the diagnosis and management of enteric neuropathies

Chronic disturbances of gastrointestinal function encompass a wide spectrum of clinical disorders that range from common conditions with mild-to-moderate symptoms to rare diseases characterized by a severe impairment of digestive function, including chronic pain, vomiting, bloating and severe constipation. Patients at the clinically severe end of the spectrum can have profound changes in gut transit and motility. In a subset of these patients, histopathological analyses have revealed abnormalities of the gut innervation, including the enteric nervous system, termed enteric neuropathies. This Review discusses advances in the diagnosis and management of the main clinical entities--achalasia, gastroparesis, intestinal pseudo-obstruction and chronic constipation--that result from enteric neuropathies, including both primary and secondary forms. We focus on the various evident neuropathologies (degenerative and inflammatory) of these disorders and, where possible, present the specific implications of histological diagnosis to contemporary treatment. This knowledge could enable the future development of novel targeted therapeutic approaches.

Colonic volvulus: presentation and management in metropolitan Minnesota, United States

BACKGROUND

Management approaches for colonic volvulus are infrequently described in the literature in the United States, and many studies only report operative cases.

OBJECTIVE

The aim of this study was to define the demographics, diagnostic and treatment approaches, and outcomes for patients with this disorder in the United States.

DESIGN

This study is a retrospective review.

SETTINGS

The study was conducted at a 7-hospital health system.

PATIENTS

All patients diagnosed with colonic volvulus by International Classification of Diseases, Ninth Revision code were included.

MAIN OUTCOME MEASURES

The primary outcomes measured were recurrence, complications, and mortality.

RESULTS

One hundred three cases of volvulus (50 sigmoid, 53 cecal) were identified in 92 patients. Compared with cecal volvulus, sigmoid volvulus was more common in men, patients with neurologic diagnoses, and residents of skilled nursing home. Eighty-five percent of the cases presented were acutely obstructed. The diagnosis was established by abdominal x-ray (17%), contrast enema study (27%), CT scan (35%), or laparotomy (17%). Abdominal x-rays were insufficient for definitive diagnosis in 85% of cecal and 49% of sigmoid cases (p = 0.002). All patients with cecal volvulus were treated surgically. Seventy-nine percent of patients with sigmoid volvulus underwent successful nonoperative reduction, of whom 38% had subsequent surgery. Fifty-eight percent of patients with sigmoid volvulus were treated operatively. Resection with primary anastomosis was chosen in most cases (78%). Resection with end ostomy (10%), reduction and pexy (7%), and reduction alone (4%) were other approaches. The mortality rate was 5% (cecal 0%, sigmoid 10%; p = 0.012). There were no readmissions for recurrent cecal volvulus. Nonoperative treatment for sigmoid volvulus often failed (48%). Complication rates were higher in sigmoid volvulus cases (cecal 17%, sigmoid 34%; p = 0.047).

LIMITATIONS

This study was limited by its retrospective, nonexperimental design.

CONCLUSIONS

Although incidences of cecal and sigmoid volvulus are similar in the present series, sigmoid volvuli are more common in men, individuals with neurologic disease, and residents of nursing homes. Plain radiograph is insufficient to confirm cecal volvulus. The diagnosis is most often made with CT scans. The nonoperative management of sigmoid volvulus is associated with a high recurrence rate.

Laparoscopic approach for metachronous cecal and sigmoid volvulus

This report indicates that laparoscopic techniques may be a safe approach for acute colonic volvulus.

Background:

Metachronous colonic volvulus is a rare event that has never been approached laparoscopically.

Methods:

Here we discuss the case of a 63-year-old female with a metachronous sigmoid and cecal volvulus.

Results:

The patient underwent 2 separate successful laparoscopic resections.

Discussion and Conclusion:

The following is a discussion of the case and the laparoscopic technique, accompanied by a brief review of colonic volvulus. In experienced hands, laparoscopy is a safe approach for acute colonic volvulus.

Sigmoid volvulus in the Middle East

Little is known about sigmoid volvulus in the Middle East despite textbooks referring to the region as part of the "volvulus belt." Our objectives were to assess the prevalence, clinical presentations, radiological findings, operative treatments, and postoperative outcomes of patients managed for sigmoid volvulus in Jordan as a model for the region. The medical records of patients with large bowel obstruction who were managed at King Abdullah University Hospital and its affiliated institutes, northern Jordan, over a 6-year period between January 2001 and January 2007 were retrospectively reviewed to identify patients with a confirmed diagnosis of sigmoid volvulus. Sigmoid volvulus was responsible for 9.2% of all cases of large bowel obstruction seen during the study period. There were 32 patients with sigmoid volvulus, 24 (75%) of whom were men. The median age of the patients was 59 years (range 21-83 years). Abdominal pain and distention were the main presentations. Colonoscopic detorsion was applied in 25 patients, which was achieved in 17 (68%) of them after the first attempt. Six patients had a gangrenous sigmoid colon, four of which required resection and a Hartmann procedure. Sigmoid resection with primary anastomosis was performed in 28 patients, including 2 with a gangrenous colon. Postoperative complications were observed in five patients, including one patient with viable colon who develop an anastomotic leak. Two patients died, making the mortality rate 6%. Sigmoid volvulus is uncommon in Jordan. Resection of the sigmoid colon with primary anastomosis appears to be the preferred procedure.

Sigmoid volvulus an update

Sigmoid volvulus is the third most common cause of colonic obstruction in the United States after cancer and diverticulitis. Etiologic factors include anatomic variation, chronic constipation, neurologic disease, and megacolon. Management of sigmoid volvulus involves relief of obstruction and the prevention of recurrent attacks; the outcome depends on the population and selection of patients. Although volvulus is uncommon, it may be encountered during pregnancy and is a condition that poses significant risk to both mother and fetus requiring a management strategy that varies with each trimester.

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.

Sigmoid volvulus in Department of Veterans Affairs Medical Centers

PURPOSE

Sigmoid volvulus is the third leading cause of large-bowel obstruction. The optimal management strategy remains controversial. This study was undertaken to evaluate the care of patients with sigmoid volvulus recently treated at Department of Veterans Affairs hospitals.

METHODS

All patients with the International Classification of Diseases, Ninth Revision, Clinical Modification, Third Edition code for colonic volvulus during the period 1991 to 1995 were identified in the computerized national Department of Veterans Affairs database. Data on patient demographics, clinical course, and outcomes were analyzed.

RESULTS

Two hundred twenty-eight patients had volvulus of the sigmoid colon and sufficient clinical data for evaluation. The mean age was 70; all were males. Endoscopic decompression was attempted in 189 of 228 (83 percent) patients and was successful in 154 of 189 (81 percent). Management included celiotomy in 178 of 228 (78 percent) patients. There were no intraoperative deaths. Twenty-five of 178 (14 percent) patients died within 30 days of surgery. The mortality rate was 24 percent for emergency operations (19/79), and 6 percent for elective procedures (6/99). Mortality was correlated with emergent surgery (P < 0.01) and necrotic colon (P < 0.05). Among those 50 patients managed by decompression alone, six (12 percent) died during the index admission. Ten of the remaining 44 (23 percent) patients eventually developed recurrent volvulus requiring further treatment, and 2 of 10 (20 percent) patients died.

CONCLUSIONS

In this cohort sigmoid volvulus often presents as a surgical emergency. Initial endoscopic decompression resolves the acute obstruction in the majority of cases. Surgical intervention carries a substantial risk of mortality, particularly in the setting of emergent surgery or in the presence of necrotic colon.

Sigmoid volvulus in west Africa: a prospective study on surgical treatments

To evaluate the efficacy of different types of surgery, we performed a prospective, randomized trial in 31 consecutively hospitalized patients with sigmoid volvulus. These patients represented 8 percent of 377 cases of emergency surgery. At the time of surgery, the patients were divided into two groups according to the absence (Group A) or presence (Group B) of bowel gangrene. At random, each group was assigned two surgical treatments. Seventeen patients entered Group A and underwent mesosigmoidopexy (seven patients) or resection and primary anastomosis (10 patients). Fourteen patients entered Group B and underwent Hartmann's procedure (eight patients) or resection and primary anastomosis (six patients). Overall mortality was four patients among 31 (13 percent), with a significant prevalence in the group with gangrene (21.4 percent vs. 5.8 percent). In Group A, the rate of success in patients treated with resection-anastomosis was higher than that in patients undergoing mesosigmoidopexy (90 percent vs. 71.5 percent). In Group B, a meaningful difference was observed between the rate of success of patients undergoing Hartmann's procedure and that of those undergoing resection and primary anastomosis (87.5 percent vs. 50 percent). The mortality rates were 12.5 percent and 33.3 percent, respectively. The results of our study show that the therapeutic approach to sigmoid volvulus should be diversified according to the absence or presence of gangrenous colon. The treatment of choice seems to be resection with primary anastomosis in patients with viable colon and Hartmann's procedure in patients with gangrenous colon.

Sigmoid volvulus in the high altitude of the Andes. Review of 230 cases

Sigmoid volvulus (SV) is uncommon in the United States. Little has been published in the English literature about the high incidence of SV among rural areas of the Bolivian and Peruvian Andes at 13,000 feet above sea level. A review of 230 cases of SV in a Bolivian hospital is presented. SV accounted for 79 percent of all intestinal obstructions. Nonoperative reduction was attempted in all patients except those with peritonitis. Nonoperative reduction alone was performed in 31 percent of the patients, and 69 percent underwent surgical intervention, 66 percent as an emergency and 3 percent electively. Surgical treatment consisted of sigmoidectomy and primary anastomosis (50 percent), Hartmann's procedure (12 percent), and operative detorsion with sigmoid plication (38 percent). Overall mortality was 13.5 percent. Fifty-seven of the surgically treated patients developed significant complications. The etiology of SV is unclear. High altitude, along with other etiologic factors, may play an important role in SV. To our knowledge, this series represents the highest incidence of SV in bowel obstruction.

Surgical management of the acutely obstructed colon. A review of 127 cases

The surgical results in 127 cases of acute obstruction of the colon are presented. Carcinoma continues to account for the overwhelming number of cases, and there has been no appreciable change in the site of obstruction or age groups affected. In the current study, the overall mortality rate in patients with acute obstruction from all causes was 27 percent, which does not appear to be significantly different than it was 30 years ago. The overall mortality rate in patients with obstruction secondary to carcinoma was 23 percent. Under the specific circumstances of the cases reported herein, and on the basis of a limited experience, total colectomy and left colectomy as initial procedures in acute obstruction secondary to cancer had the same mortality rate as staged resection of the left colon. The only benefit found from either approach was an increase in the disease-free 5 year survival rate with staged resection. The overall survival rate was not enhanced by either approach.

Sigmoid volvulus in a West African population

The incidence, clinical presentation, etiology, and treatment of sigmoid volvulus in a West African population are described. This retrospective study, based on 146 cases in eight years, shows that the incidence of the disorder of 12 new cases per 100,000 population per year is extremely high in the area described. It also shows that good results can be obtained in the treatment of sigmoid volvulus even in suboptimal conditions in rural hospitals when adhering to sound surgical principles.

Volvulus of the colon. Incidence and mortality

Between 1960 and 1980, 137 patients with colonic volvulus (52% cecal, 3% transverse colon, 2% splenic flexure, and 43% sigmoid) were seen at the Mayo Clinic. Among the 59 patients with sigmoid volvulus, four (7%) had colonic infarction. Total mortality with sigmoid volvulus was seven per cent. There were 71 patients with cecal volvulus. Colonoscopic decompression was accomplished in two of these patients; in 15 (21%), gangrenous colon developed and mortality was 33%. Total mortality for cecal volvulus patients was 17%. Mortality for all forms of volvulus in patients with viable colons was 11%. Mortality for all patients with volvulus was 14%.

Intestinal volvulus: a new concept

A concept of the aetiology of intestinal volvulus is presented based on the fact that bowel when distended becomes elongated. The antimesenteric border of the bowel elongates more than the mesenteric border and this provides the driving force which initiates and sustains the volvulus. It is, therefore, a secondary event resulting from distention.

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.