Contemporary Management of Sigmoid Volvulus

Colonic Volvulus

Colonic volvulus represents 10 to 15% of all large bowel obstructions in the United States. It most commonly occurs in the sigmoid colon or cecum. Morbidity and mortality from colonic volvulus are high. It is therefore essential to have a high level of suspicion based on presentation and expedient diagnosis and management to prevent progression to ischemia or perforation. Broad goals of management include evaluation of colon viability, relief of obstruction, and prevention of recurrence. Endoscopic and surgical approaches vary based on the site of volvulus, presence of ischemia or perforation, and patient characteristics. This review outlines the epidemiology, presentation, diagnosis, and management of colonic volvulus. A contemporary diagnostic and treatment algorithm is included.

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.

Comparison of the ability of resection versus nonresection surgery to prevent the recurrence of sigmoid volvulus: A protocol of a meta-analysis and systematic review

PURPOSE

Based on clinical research guidelines and clinical practice, patients with sigmoid volvulus (SV) who receive conservative treatment have a greater recurrence rate than patients who do not receive conservative treatment, which is almost without any controversy. Surgical treatment is usually the final treatment for patients with SV. However, there are multiple surgical methods for the treatment of SV, which can be roughly divided into resection and nonresection methods. The available evidence on the effectiveness of surgery for preventing postoperative recurrence is still inadequate. Therefore, we drafted this systematic review protocol with meta-analysis aimed to compare the effects of these two major types of surgery on preventing the recurrence of SV.

METHODS

We comprehensively and systematically reviewed the PubMed, EMBASE, MEDLINE and Cochrane Library databases of articles on SV from inception to November 16, 2023. Two independent authors will screen and analyze the detected literature, and disputes will be resolved through communication with a third experienced person. After evaluating the quality of the literature and estimating the risk of bias, we calculate the pooled effect size and 95% confidence interval. Heterogeneity is analyzed by subgroup analysis, and sensitivity analysis can be carried out to assure the reliability of the results. Finally, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) will be used to evaluate the strength of the evidence. The results of each analysis will be recorded in detail. The whole process was carried out in strict accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines (PRISMA-P).

TRIAL REGISTRATION

Protocol registration: The study protocol has been registered at the International Prospective Register of Systematic Reviews platform (PROSPERO) (CRD42024508350). Protocol version 1.0, 13 Feb 2024.

A Case of Redundant Sigmoid Colon and Sigmoid Volvulus

The torsion of a dilated sigmoid colon around its own mesenteric axis is the cause of sigmoid volvulus, which frequently results in constipation and intestinal obstruction. The clinical presentation of sigmoid volvulus can be observed as nausea, constipation, abdominal distension, and abdominal pain. It is also reported to be insidious. Additionally, it causes blood obstruction, resulting in necrosis, bowel ischemia, and even intestinal perforation if not addressed on time. Physical symptoms might vary depending on the course of the disease but are usually observed as the classical trio of abdominal distension, abdominal pain, and constipation. Computed tomography imaging presents the sign of an inverted U, or classic coffee bean, aiding in the diagnosis of the sigmoid volvulus. A 38-year-old male was admitted to the emergency department of our tertiary care center with significant complaints of obstipation and abdominal pain. The medical history and physical examination revealed peritoneal symptoms, which warranted a prompt radiological imaging diagnosis. The patient was subjected to computed tomography, which was suggestive of sigmoid volvulus. The patient underwent an emergency laparotomy and sigmoidectomy, which were uneventful with no postoperative complications.

Unveiling a Coalescing Catastrophe: Pre-pyloric Perforation Co-existing With Sigmoid Volvulus in a Middle-Aged Patient

Sigmoid volvulus is a common cause of colonic obstruction worldwide and constitutes the majority of all cases of colonic volvulus. It is more prevalent in those who are older than 70 years. The sigmoid colon, an S-shaped portion of the large intestine, is susceptible to this condition due to its redundancy and mobile nature. Treatment involves endoscopic detorsion with sigmoidectomy. Laparoscopic surgery has been found to be useful in terms of reduced morbidity, blood loss, analgesics, and hospital stay; contrarily, surgical management has been found to be associated with reduced recurrence. Early diagnosis is crucial to prevent complications and recurrence rates. Gastroduodenal perforation, whether spontaneous or traumatic, is predominantly associated with peptic ulcer disease. Specifically, the majority of perforated peptic ulcers are attributed to Helicobacter pylori infection. The presence of perforation as a comorbidity complicates surgical management, particularly when the patient has a history of H. pylori infections, as evidenced in our case. Addressing these infections is crucial for optimizing treatment outcomes and reducing potential complications. Laparoscopic surgery is popular due to its benefits and faster recovery periods, especially in the aged population. This is a case presentation of a 48-year-old male who presented at our tertiary care center with abdominal pain, multiple episodes of vomiting, obstipation, and abdominal distention. The patient was diagnosed with sigmoid volvulus with pre-pyloric perforation which was managed surgically by initial detorsion followed by sigmoidectomy with modified Graham's patch technique. He recovered well with no post-operative complications.

Outcomes for sigmoid volvulus managed with and without early definitive surgery: 20-year experience in a tertiary referral centre

BACKGROUND

Sigmoid volvulus is rare in Western countries. Patients at risk of sigmoid volvulus are often older with significant co-morbidity. Without sigmoid colectomy there is a high recurrence rate, but indications for surgery are controversial.

METHODS

A retrospective observational study was conducted by reviewing clinical records of patients admitted to Waikato Hospital 1 January 2000 to 1 January 2020 with a diagnosis of sigmoid volvulus. Patient characteristics, clinical features, investigations, management, and outcomes were recorded.

RESULTS

One hundred and thirty-two patients (87 male) were included with 203 volvulus episodes. Median age 76 years, median Charlson co-morbidity index (CCI) 4. Median follow-up 11 years. 44/132 (33.3%) had surgery during the index admission, two had elective surgery and the remainder had planned non-operative management. 73/132 (55.3%) had surgery at any stage. 42/86 (48.8%) patients managed non-operatively recurred; 66.7% of recurrences were within 6 months. Forty-three (32.6%) died within 12 months of index admission; 28 (21.2%) died during an admission for volvulus. On univariate analysis higher age and abnormal vital signs were associated with inpatient and 12-month mortality; higher CCI was associated with 12-month mortality. On multi-variate analysis increasing age in years was associated with increased risk of death (HR 1.089 [1.052-1.128, P < 0.001]). Normal vital signs at presentation were associated with decreased risk of death (HR 0.147 [0.065-0.334, P < 0.001]).

CONCLUSION

Sigmoid colectomy should be considered at index presentation with sigmoid volvulus. Half of patients managed non-operatively recurred, with two-thirds recurring within 6 months. The mortality rate remains high for subsequent volvulus episodes.

Epidemiology and age-related trends in surgical outcomes for sigmoid volvulus: a 17-year analysis

BACKGROUND

Sigmoid volvulus, a gastrointestinal disorder characterized by twisted bowel, often requires medical intervention, either through endoscopic or surgical means, to avoid potentially severe outcomes. This study examined the challenges elderly patients face in undergoing surgical treatment, encompassing both mortality and morbidity. Furthermore, it aimed to determine how medical practices and outcomes have changed over a period of 17 years.

METHODS

We utilized data from the National Surgical Quality Improvement Project, which covers the period from 2005 to 2021, to identify patients who underwent left hemicolectomy for colonic volvulus. The patients were categorized into three age groups: < 60 years, 60-75 years, and > 75 years. We performed a meticulous logistic regression analysis, carefully adjusted for risk factors, to compare mortality, morbidity, and types of surgical treatment administered among the different age groups.

RESULTS

Our study included 6775 patients. The breakdown of the patient population was as follows: 2067 patients were < 60 years of age, 2239 were between 60 and 75 years of age, and 2469 were > 75 years of age. The elderly cohort, those aged above 75 years, were predominantly male, had lower BMIs, underwent fewer laparoscopic surgeries, required more diverting stomas and end-ostomies, and had longer hospital stays. Notably, the elderly population faced a mortality risk that was 5.67 times (95% CI 3.64, 9.20) greater than that of their youngest counterparts, with this risk increasing by 10% (95% CI 1.06, 1.14) for each additional year of age. Furthermore, the odds of mortality associated with emergency surgery were 1.63 times (95% CI 1.21, 2.22) higher than those associated with elective surgery. The postoperative morbidity odds were also elevated for emergency surgeries, 1.30 times (95% CI 1.08, 1.58) greater than that for elective cases. Over the 17-year period, we observed a decline in mortality rates, an increase in the utilization of laparoscopic procedures, and overall stability of morbidity rates.

CONCLUSION

Our findings highlight the increased vulnerability of patients over 75 years of age, who are not only at an elevated risk of mortality compared to their younger counterparts, but also a continuously increasing risk with age. By focusing on elective surgeries for younger patients and minimizing emergency surgeries for the elderly, it may be possible to reduce the mortality risk associated with surgical interventions in this population.

Comparing Resection and Primary Anastomosis versus Hartmann's Stoma on the Mortality and Morbidity of Gangrenous Sigmoid Volvulus: Systematic Review and Meta-Analysis

Background

Gangrenous sigmoid volvulus has a significant impact on morbidity and mortality. This study was conducted to compare sigmoid resection and primary anastomosis (RPA) with sigmoid resection and end colostomy (Hartmann's procedure) for gangrenous sigmoid volvulus.

Methods

A systematic review and meta-analysis study design was employed to summarize retrospective cohort, prospective cohort, and randomised control trial studies published from inception to march 31, 2023. Searching was performed on Medline, CINAHAL, Web of Science, Google Scholar, the Cochrane Library, and ClinicalTrials.gov to locate eligible articles. Data searching, selection and screening, quality assessment of the included articles, and data extraction were done by two separate reviewers. RevMan 5.4 software with a fixed-effect Mantel-Haenszel model and Stata version 14 were used to analyze the data. The protocol registered on PROSPERO registration website (CRD42023413367).

Results

Ten cohort studies and one randomised control trial with 724 patients were found; all of them were rated as being of moderate quality. The overall mortality after RPA was 15% (95%CI: 11-19%), and after Hartmann's procedure it was 19% (95%CI: 15-23%). Resection and primary anastomosis (RPA) for gangrenous sigmoid volvulus had slightly lower mortality rate than stoma (OR=0.98(95%CI: 0.68-1.42), p=0.07, I2=43%), which had no statistically significant difference. Resection and primary anastomosis (RPA) had a slightly higher morbidity rate than Hartmann's procedure (OR=1.01(95%CI: 0.66-1.55), p=0.30, I2=18%), which had no statistically significant difference.

Conclusion

Sigmoid resection and primary anastomosis (RPA) and Hartmann's procedure had no significant differences in mortality and morbidity for the treatment of gangrenous sigmoid volvulus. Choice of the intervention for gangrenous sigmoid volvulus should be individualized with consideration of different detrimental factors.

Analysis of clinical diagnosis and treatment of intestinal volvulus

BACKGROUND

The aim of this study is to investigate the clinical characteristics and treatment experience of intestinal volvulus, and to analyze the incidence of adverse events and related risk factors of intestinal volvulus.

METHODS

Thirty patients with intestinal volvulus admitted to the Digestive Emergency Department of Xijing Hospital from January 2015 to December 2020 were selected. The clinical manifestations, laboratory tests, treatment and prognosis were retrospectively analyzed.

RESULTS

A total of 30 patients with volvulus were enrolled in this study, including 23 males (76.7%), with a median age of 52 years (33-66 years). The main clinical manifestations were abdominal pain in 30 cases (100%), nausea and vomiting in 20 cases (67.7%), cessation of exhaust and defecation in 24 cases (80%), and fever in 11 cases (36.7%). The positions of intestinal volvulus were jejunum in 11 cases (36.7%), ileum and ileocecal in 10 cases (33.3%), sigmoid colon in 9 cases (30%). All 30 patients received surgical treatment. Among the 30 patients underwent surgery, 11 patients developed intestinal necrosis. We found that the longer the disease duration (> 24 h), the higher the incidence of intestinal necrosis, and the higher the incidence of ascites, white blood cell count and neutrophil ratio in the intestinal necrosis group were significantly higher than those in the non-intestinal necrosis group (p < 0.05). After treatment, 1 patient died of septic shock after operation, and 2 patients with recurrent volvulus were followed up within 1 year. The overall cure rate was 90%, the mortality rate was 3.3%, and the recurrence rate was 6.6%.

CONCLUSION

Laboratory examination, abdominal CT and dual-source CT are very important for the diagnosis of volvulus in patients with abdominal pain as the main symptom. Increased white blood cell count, neutrophil ratio, ascites and long course of disease are important for predicting intestinal volvulus accompanied by intestinal necrosis. Early diagnosis and timely intervention can save lives and prevent serious complications.

Sigmoid volvulus: Evaluating identification strategies and contemporary multicenter outcomes

BACKGROUND

There is limited epidemiologic data on sigmoid volvulus (SV) from non-endemic regions. Therefore, we performed a multicenter study to report contemporary outcomes and appraise literature-based methods that pair diagnostic and procedural codes to identify SV.

METHOD

Using an automated search for patients with 'volvulus' in our system from 2011 to 2021, we reviewed electronic charts to clarify the diagnosis, automatically replicate three strategies to identify SV, and retrieved 6-month outcomes.

RESULTS

Of 895 patients, 109 had SV. Literature-based strategies poorly identified SV. At the index admission, patients underwent endoscopic reduction alone (33%), emergent (16.5%), semi-elective (34%), or elective (16.5%) surgery. Endoscopic reduction alone had high recurrence rates and delayed surgery was associated with worse outcomes.

CONCLUSION

Literature-based strategies to identify SV suffer from misclassification bias which affects patient counseling. In this large series, one-third of patients do not undergo during their index admission despite improved outcomes with earlier surgery.

Sigmoid Colectomy for Sigmoid Volvulus Through a Limited Left Lower Quadrant Transverse Laparotomy Incision Without Laparoscopy

Sigmoid volvulus (SV) is a relatively rare cause of large bowel obstruction encountered by general surgeons in the United States. It predominantly affects the elderly, infirm, and institutionalized. Surgery after endoscopic reduction is the mainstay of treatment. Given the frail nature of the population requiring partial colectomy for SV, formal laparotomy and laparoscopic sigmoid colectomies come with significant risks. Much of the risk related to a minimally invasive, laparoscopic approach is due to the physiologic impacts of pneumoperitoneum. This series demonstrates a technique whereby a complete sigmoid resection with or without anastomosis can be achieved via a single, small incision equivalent to a laparoscopic extraction port. This technique took advantage of the redundancy in the sigmoid colon characteristic of SV. All patients tolerated their procedures well and had rapid return to their baseline function.

Laparoscopic fixation of volvulus by extra-peritonealization: a case series

BACKGROUND

Volvulus is one of the leading causes of colonic obstruction with a high recurrence rate following endoscopic decompression. Although colonic resection remains the treatment of choice, it is often associated with significant morbidity and mortality, especially in elderly patients. Colonic fixation with extra-peritonealization has been suggested as an alternative to colonic resection. The aim of this study was to evaluate the surgical outcomes of patients with colonic volvulus in our initial experience with this procedure.

METHODS

A retrospective analysis of a prospectively maintained database of all patients who underwent colonic extra-peritonealization for volvulus between January 2016 and April 2021 in Sheba medical center (Ramat-Gan, Israel) was performed. Patients' demographics, clinical, peri-operative and post-operative data were recorded and analyzed.

RESULTS

One hundred and thirty nine patients were admitted due to acute colonic volvulus, 48 of whom were treated surgically. Eleven patients underwent extra-peritonealization of the sigmiod or cecum during the study period. Mean age was 64.5 years. Six patients (54.55%) were males. Seven patients (63.63%) presented with sigmoid volvulus and 4 (36.36%) with cecal volvulus. Median American Society of Anesthesiologists (ASA) class was 3 (range 2-4). One patient (9.09%) was required urgent surgery. The majority of patients was operated on using a laparoscopic approach (10 patients, 90.9%). Median length of stay was 3 days (range 1-6 days) and no post-operative complications or readmissions within 30 days after surgery were recorded. Median length of follow-up was 283 days (range 21-777 days). During the follow-up period, three patients (27.27%) presented with recurrent volvulus and required an additional surgical intervention with colonic resection. Of the patients with volvulus recurrence, one patient (9.09%) required an urgent surgical intervention.

CONCLUSIONS

Extra-peritonealization of colonic volvulus is feasible and safe. Although recurrence rates are fairly high, the low morbidity associated with the procedure makes it an appealing alternative to colonic resection, especially in patients with high risk for post-operative complications.

Sigmoid volvulus: outcomes of treatment and predictors of morbidity and mortality

Purpose

To analyze the treatment outcomes for sigmoid volvulus (SV) and identify risk factors of complications and mortality.

Methods

Observational study of all consecutive adult patients diagnosed with SV who were admitted from January 2000 to December 2020 in a tertiary university institution for conservative management, urgent or elective surgery. Primary outcomes were 30-day postoperative morbidity, mortality and 2-year overall survival (OS), including analysis of risk factors for postoperative morbidity or mortality and prognostic factors for 2-year OS.

Results

A total of 92 patients were included. Conservative management was performed in 43 cases (46.7%), 27 patients (29.4%) underwent emergent surgery and 22 (23.9%) were scheduled for elective surgery. Successful decompression was achieved in 87.8% of cases, but the recurrence rate was 47.2%. Mortality rates following episodes were higher for conservative treatment than for urgent or elective surgery (37.2%, 22.2%, 9.1%, respectively; p = 0.044). ASA score > III was an independent risk factor for complications (OR = 5.570, 95% CI = 1.740–17.829, p < 0.001) and mortality (OR = 6.139, 95% CI = 2.629–14.335, p < 0.001) in the 30 days after admission. Patients who underwent elective surgery showed higher 2-year OS than those with conservative treatment (p = 0.011). Elective surgery (HR = 2.604, 95% CI = 1.185–5.714, p = 0.017) and ASA score > III (HR = 0.351, 95% CI = 0.192–0.641, p = 0.001) were independent prognostic factors for 2-year OS.

Conclusion

Successful endoscopic decompression can be achieved in most SV patients, but with the drawbacks of high recurrence, morbidity and mortality rates. Concurrent severe comorbidities and conservative treatment were independent prognostic factors for morbidity and survival in SV.

Colonic Volvulus in Children: Surgical Management of a Challenging Condition

Colonic volvulus (CV) is a rare but potentially life-threatening condition with unclear etiopathogenesis. To date, less than 80 pediatric cases have been described. Hirschsprung’s disease (HD) is associated with CV in 17% of cases, representing a significant risk factor. Non-HD CV is an even more complex entity. The aim of this study is to describe a series of patients with CV to accentuate some peculiar aspects of this disease. We performed a retrospective study (period: 2012–2021) collecting information of patients with CV. Data analyzed included: demographics, medical history, presenting symptoms and radiological and surgical details. Eleven patients (12.5 ± 2.8 years; 7F/4M) had CV (eight sigmoid, two transverse colon, one total colon). Five patients had associated anomalies and three had HD. A two-step approach with volvulus endoscopic/radiological detorsion followed by intestinal resection was attempted in eight cases (one endoscopic approach failed). Three patients required surgery at admission. At follow-up, two patients developed recurrent intestinal obstruction, one of whom also had anastomotic stenosis. Colonic volvulus is a challenging condition that requires prompt patient care. A missed diagnosis could lead to severe complications. The evaluation of the patient should include a careful histological examination (searching for HD and alpha-actin deficiency), immunologic and metabolic screening, neurological tests and detection of chronic intestinal pseudo-obstruction (CIPO). Lifelong follow-up is mandatory for the early recognition and treatment of progressive diseases involving the proximal gastrointestinal tract.

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.

Sigmoid volvulus: definitive surgery is safe and should be considered in all instances

Background

Acute sigmoid volvulus (ASV) represents a small but significant portion of cases of large bowel obstruction, especially in the elderly and co-morbid. Given the characteristics of the patient cohort most commonly affected, a non-operative/conservative approach is often undertaken but is associated with a high rate of recurrence.

Objective

We sought to evaluate outcomes for those patients who underwent non-operative management, emergency surgery or staged, semi-elective surgery following decompression for ASV at our institution.

Methods

Hospital in-patient enquiry (HIPE) data were used to identify all patients who presented with sigmoid volvulus between January 2005 and June 2020 inclusive. Patient notes were interrogated, including surgical and endoscopic procedures performed. Patient demographics and co-morbidities were recorded.

Results

Thirty-nine patients were treated over a 15-year period with a mean age of 73 years at first presentation (range 36–93). Twenty-two patients (56%) had just a single admission for ASV with three deaths in this group.

Seventeen patients (44%) had more than one admission with volvulus due to recurrence after a decompression-only strategy on the index admission. Of these, three succumbed to complications of their subsequent episodes of volvulus.

Twenty-five patients underwent surgical intervention (fifteen on, or shortly following, their first admission and ten following at least two admissions for ASV). The overall mortality in the operative group was 2/25 (8%) with both deaths in those undergoing emergency surgeries. Five patients were treated successfully with endoscopic measures alone and had required no further interventions at the time of compiling data.

Conclusion

There is a high recurrence rate following non-operative management of acute sigmoid volvulus and consequently, a cumulative increase in the attendant significant morbidity and mortality with subsequent episodes. Given the relatively low complication rate of definitive surgery, even in those patients perceived to be high risk, we contend that all patients should be considered for early surgery to prevent the likely recurrence of sigmoid volvulus.

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.

Diagnosis and Management of Colonic Volvulus

An 88-year-old man with no significant medical history, and in a good state of health, presented to the emergency department with 4 days of obstipation, progressive abdominal pain, and bloating. Examination revealed abdominal distension and generalized tenderness without signs of peritonitis. Laboratory values, including lactate and complete blood count, were within normal limits. Computed tomography imaging of the abdomen and pelvis revealed radiological signs of sigmoid volvulus and no evidence of bowel perforation (Fig. 1). Flexible sigmoidoscopic examination revealed no evidence of mucosal ischemia and enabled detorsion of the colon. The patient's symptoms resolved after the detorsion. He was seen in consultation by a surgeon who advised surgical treatment only if the volvulus recurred. After hospital discharge, the patient self-educated about sigmoid volvulus and sought a second surgical opinion. Five weeks after his initial presentation and 1 week after complete colonoscopy, he underwent laparoscopic sigmoidectomy with colorectal anastomosis. His postoperative course was uneventful. At 6-month follow-up, he remained well with no bowel-related concerns.

Colectomy for caecal and sigmoid volvulus: a national analysis of outcomes and risk factors for postoperative complications

AIM

Colonic volvulus is a common entity encountered by colorectal surgeons, but there are few reports of national data regarding postoperative outcomes. The aim of this study was to describe the volvulus population, 30-day outcomes following right- and left-sided colectomy and risk factors for postoperative complications.

METHOD

The American College of Surgeons National Surgical Quality Improvement Program Database from 2012 to 2015 was utilized to identify patients with the diagnosis of 'volvulus' who underwent right- or left-sided colectomy. Primary outcomes were overall morbidity and mortality.

RESULTS

A total of 2175 patients were identified (661 right colectomy and 1514 left colectomy). Risk factors for complications following right-sided colectomy included: age, male gender, smoker, systemic inflammatory response syndrome, sepsis, septic shock and American Society of Anesthesiologsts class ≥ 4. Risk factors for complications following left-sided colectomy included: age, male gender, systemic inflammatory response syndrome, sepsis and septic shock.

CONCLUSION

Several nonmodifiable risk factors were identified for complications following colectomy for volvulus. These risk factors can be used in patient/family counselling and discharge planning.

Sigmoid volvulus: Comorbidity with sigmoid gangrene

Sigmoid volvulus (SV) is the wrapping of the sigmoid colon around its mesentery, and sigmoid gangrene is a catastrophic complication of SV. Although the diagnosis of SV is generally not difficult, unfortunately, most of the clinical, laboratory and radiological signs are not pathognomonic in demonstrating sigmoid gangrene. The treatment of gangrenous SV requires emergency surgery. Sigmoid gangrene worsens the prognosis of SV by doubling the mortality rate.