Clinical Practice Guidelines for Colon Volvulus and Acute Colonic Pseudo-Obstruction

Three twisted tales: A case series of caecal volvulus

INTRODUCTION

Caecal volvulus is a form of intestinal obstruction with life-threatening potential. While rare, it represents a perilous aetiology of intestinal blockage, with clinical manifestations spanning from abdominal discomfort to mortality.

CASE SERIES

We report the cases of three young adults (two males and one female) who presented to the emergency department with different manifestations of severe abdominal pain. All occurred within one month in a tertiary referral centre. Radiological evaluations confirmed the diagnosis of caecal volvulus in all. Subsequently, these individuals underwent right hemicolectomies with end-to-end anastomosis. All experienced an uncomplicated perioperative course.

CLINICAL DISCUSSION

Caecal volvulus is uncommon, but its yearly incidence is increasing. Early detection and a heightened level of suspicion lead to a timely diagnosis, reducing morbidity and mortality rates.

CONCLUSION

We report a case series of caecal volvulus, emphasizing its variable presentation and highlighting the critical importance of an early diagnosis. Typically, patients have a history of similar episodes that resolve without any medical intervention. Definitive treatment involves right hemicolectomy while conservative management is associated with very high recurrence rates. Early detection allows for prompt intervention, resulting in reduced morbidity and mortality rates.

A Case Report of Appendicitis Causing Cecal Volvulus: A Rare Occurrence

This case report presents a fascinating scenario involving a 60-year-old female who was diagnosed with cecal volvulus secondary to appendicitis. The patient's initial presentation included a three-day history of periumbilical pain accompanied by reduced oral intake and an inability to pass stool. Through a systematic approach involving detailed history-taking, comprehensive physical examinations, and pertinent imaging studies, a precise diagnosis of cecal volvulus induced by appendicitis was established. Subsequently, the patient underwent a timely operation, leading to a successful resolution of her condition and a remarkably swift recovery post-surgery. This unique case prompts a deeper exploration into the incidence and management of this rare phenomenon, where the seemingly unrelated condition of appendicitis precipitated a cecal volvulus. Given the unusual nature of this presentation, it underscores the importance of considering atypical etiologies in patients presenting with signs and symptoms of bowel obstruction. This discussion aims to shed light on the diagnostic challenges, treatment strategies, and outcomes associated with this intriguing interplay of pathologies, offering valuable insights for clinicians encountering similar cases in their practice.

Management of Colonic Emergencies

The etiology of colonic emergencies includes a wide-ranging and diverse set of pathologic conditions. Fortunately, for the surgeon treating a patient with one of these emergencies, the surgical management of these various causes is limited to choosing among proximal diversion, segmental colectomy with or without proximal diversion, or a total abdominal colectomy with end ileostomy (or rarely, an ileorectal anastomosis). The nuanced complexity in these situations usually revolves around the nonsurgical and/or endoscopic options and deciding when to proceed to the operating room.

Percutaneous endoscopic cecostomy for management of Ogilvie's syndrome: a case series and literature review with an update on current guidelines (with video)

INTRODUCTION

Percutaneous endoscopic cecostomy (PEC) is a viable treatment option for patients with persistent or recurrent acute colonic pseudo-obstruction (ACPO; Ogilvie's syndrome). It should be generally considered in patients that are refractory to pharmacologic and endoscopic decompression, especially those not amenable to surgical intervention due to an increased perioperative risk. Physicians are rather unfamiliar with this approach given the limited number of reports in the literature and paucity of guideline resources, although guidelines concerning ACPO and covering the role of endoscopy were recently published by three major expert societies, all within the last 2 years.

PATIENTS AND METHODS

We retrospectively identified three consecutive patients who underwent PEC placement at a Czech tertiary referral center between May 2018 and December 2021: all for recurrent ACPO. In addition, we summarized the current guidelines in order to present the latest knowledge related both to the procedure and management approach in patients with ACPO.

RESULTS

The placement of PEC was successful and resulted in clinical improvement in all cases without any adverse events.

CONCLUSION

The results of our experience are in line with previous reports and suggest that PEC may become a very useful tool in the armamentarium of modalities utilized to treat ACPO. Furthermore, the availability of guideline resources now offers comprehensive guidance for informed decision-making and the procedural aspects.

Endoscopic management of acute sigmoid volvulus in high risk surgical elderly patients: a randomized controlled trial

BACKGROUND

Most patients with sigmoid volvulus are of old age with multiple comorbidities. So, the risk of surgery for those elderly patients is usually associated with increased rates of morbidity and mortality. Early intervention is required for managing sigmoid volvulus to avoid its serious complications; therefore, early endoscopic untwist of sigmoid colon can be performed followed by endoscopic fixation of sigmoid colon under sedation in this category of the patients to avoid development of high risk surgical complications following surgical fixation of sigmoid colon or sigmoidectomy after initial simple loop colostomy procedure to relieve obstruction.

METHODS

This prospective randomized controlled clinical trial included all patients who developed acute sigmoid volvulus and were referred to the Zagazig University Hospital Emergency Department between December 2020 and August 2022. The study was prospectively approved by Zagazig University Faculty of Medicine Institutional Review Board (Approval Number: 9989/23-10-2022) and was retrospectively submitted in http://clinicaltrials.gov in November 2022 ( http://clinicaltrials.gov ID: NCT05620446). Included eligible patients were simply randomized at a 1:1 ratio to "Endoscopic Group (EG)" or "Surgical Group (SG)" via drawing of sealed envelopes containing computer-generated random numbers prepared by a third party before start of intervention.

RESULTS

Sample size included 18 patients divided into 2 equal groups. (1) Endoscopic group included 9 patients who were subjected to endoscopic untwist of sigmoid colon followed by endoscopic fixation of sigmoid colon under sedation; (2) Surgical group included 9 patients who were subjected to surgical fixation of sigmoid colon or sigmoidectomy after initial simple loop colostomy under general anesthesia. In comparison between both groups, there were statistically significant differences regarding length of hospital stay and procedure time. Unfortunately, there were no statistically significant differences regarding postoperative complications and co-morbidities. Eight patients in the endoscopy group demonstrated excellent quality of life, and one demonstrated good quality of life; unlike the surgical group, there were 3 patients with excellent quality of life, 5 patients with good quality of life, and 1 patient with poor quality of life. So there was statistically significant difference regarding quality of life between both groups. During the 9-month follow-up period, both groups demonstrated no cases of recurrence post-fixation.

CONCLUSION

Endoscopic management of acute sigmoid volvulus is effective and safe in elderly high risk surgical patients (either in managing the intestinal obstruction caused by volvulus or in definitive treatment of volvulus).

Acute Colonic Pseudo-Obstruction: Colonoscopy versus Neostigmine First?

INTRODUCTION

Neostigmine (NEO) and decompressive colonoscopy (COL) are two efficacious treatment modalities for acute colonic pseudo-obstruction (ACPO). We hypothesize that a COL first strategy is associated with better outcomes compared to a NEO first strategy.

METHODS

A single-center retrospective analysis was performed from 2013 to 2020. Patients ≥18 y with a diagnosis of ACPO were included. The outcome was a composite measure of acute operative intervention, 30-day readmission with ACPO, and 30-day ACPO-related mortality. A P-value of ≤ 0.05 indicated statistical significance.

RESULTS

Of 910 encounters in 849 patients, 50 (5.5%) episodes of ACPO in 39 patients were identified after exclusion of one patient with colon perforation on presentation. The median (interquartile range) age was 68 (62-84) y. NEO and COL were administered in 21 and 25 episodes, respectively. In 16 (32%) episodes, no NEO or COL was administered. When patients were given NEO first, COL or additional NEO was required in 12/18 (67%) compared with a COL first strategy where a second COL and/or NEO was given in 5/16 (32%) (P = 0.05). Both strategies had similar outcomes (NEO, 4/18 versus COL, 4/16, P = 0.85). Twenty-two (44%) episodes had an early intervention (≤48 h) with NEO and/or COL. There was no difference in outcome between those that received an early intervention and those who did not (5/22 versus 5/28, P = 0.71).

CONCLUSIONS

For patients failing conservative measures, a COL first approach was associated with fewer subsequent interventions, but with similar composite outcomes compared to a NEO first approach. Early (≤48 h) intervention with NEO and/or COL was not associated with improved outcomes.

Sigmoid volvulus management, only endoscopic devolvulation?

Intestinal obstruction due to sigmoid volvulus (SV) represents a relevant percentage of abdominal diseases presenting at the emergency department. Treatment is based on early endoscopic devolvulation (ED), followed by elective surgery as definitive treatment. A 78-year-old man institutionalized with Lewy body dementia presents with abdominal pain, distention, and absence of stool in 72 hours. Coffee bean sign was seen in abdominal x-ray. Previously, he had been admitted three times last year with recurrent SV, managed with ED succesfully. Despite the recurrence, no surgical treatment was indicated after resolution of the acute situation and recovery of intestinal transit. This time, urgent colonoscopy was performed and a 20 cm length of purplish-black (isquemic) sigmoid mucosa was observed. With these findings of stablished intestinal ischemia urgent surgical intervention was performed (sigmoidectomy and terminal "Hartmann" colostomy). Histologically, necrosis, severe ulceration and mixed inflammation was noticed in the surgical piece. The patient develops favorably during a postoperative period without incidents. Therefore, he is discharged to his center. At the moment he is asymptomatic one year after the intervention with no new episodes. Recurrency of SV after ED is up to 86% of cases. In every episode, the incidence of complications such as intestinal ischemia or perforation increases significantly, as well as urgent surgery and mortality. Definitive treatment must be surgical, sigmoidectomy and terminal anastomosis is the choice technique.

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.

Endoscopic sigmoidopexy for recurrent sigmoid volvulus in inoperable patients: a retrospective series of 15 patients

BACKGROUND

Recurrent sigmoid volvulus is frequent and sometimes occurs in frail patients with contraindications to surgical sigmoidectomy. Percutaneous endoscopic sigmoidopexy (PES) has recently been proposed as an alternative to elective sigmoidectomy. We aimed to describe the efficacy and safety of PES.

METHODS

All consecutive patients who underwent PES for recurrent sigmoid volvulus at two French centers between January 2017 and March 2021 were included in this retrospective case series. Recurrent sigmoid volvulus was defined as at least two symptomatic episodes treated by endoscopic decompression. Under endoscopic guidance, anchors were placed to attach the sigmoid to the anterior abdominal wall, allowing the placement of pigtail Chait catheters.

RESULTS

15 patients (60 % female; median age 74 years [range 49-96]) were included. Median number of previous sigmoid volvulus episodes was 3 (range 2-6). Procedures were technically successful with no intraprocedural adverse events for 14 patients (93 %). Peritonitis occurred at Day 2 in one patient (serious adverse event rate 7 %). Median follow-up time was 10 months (range 1-30). No sigmoid volvulus recurrence occurred during follow-up.

CONCLUSION

PES using Chait catheters was feasible and effective for recurrent sigmoid volvulus and should be considered as an alternative to sigmoidectomy in inoperable patients.

Acute Colonic Pseudo-Obstruction

Acute colonic pseudo-obstruction (ACPO) is a functional disorder of the large intestine distinguished by colonic dysmotility resulting in colonic distension in the absence of mechanical obstruction. The underlying pathophysiology of ACPO remains unclear despite technological advances in understanding the physiology of colonic motility, such as spatio-temporal mapping and high-resolution manometry. In many ways, the management of ACPO has remained relatively unchanged for 40 years. Patients with perforation or suspected ischemia undergo operative intervention, while patients without undergo initial conservative management with bowel rest, correction of electrolyte disturbances, and mobilization. Patients who fail conservative management or have prominent cecal dilatation undergo decompression with either neostigmine or colonoscopy. A subset of patients with ACPO will have recurrent symptoms despite endoscopic and medical management. For these patients who are difficult to manage, an underlying colonic functional disorder, such as slow-transit dysmotility or chronic intestinal pseudo-obstruction may be considered. The following review of ACPO aims to provide a concise update of the causes, diagnosis, and management of this emergency surgical condition.

Back Propagation Neural Network-Based Magnetic Resonance Imaging Image Features in Treating Intestinal Obstruction in Digestive Tract Diseases with Chengqi Decoction

This study was to explore the adoption effect of magnetic resonance imaging (MRI) image features based on back propagation neural network (BPNN) in evaluating the curative effect of Chengqi Decoction (CD) for intestinal obstruction (ileus), so as to evaluate the clinical adoption value of this algorithm. Ninety patients with ileus were recruited, and the patients were treated with CD and underwent MRI scans of the lower abdomen. A BPNN model was fabricated and applied to segment the MRI images of patients and identify the lesion. As a result, when the overlap step was 16 and the block size was 32 × 32, the running time of the BPNN algorithm was the shortest. The segmentation accuracy was the highest if there were two hidden layer (HL) nodes, reaching 97.3%. The recognition rates of small intestinal stromal tumor (SIST), colon cancer, adhesive ileus, and volvulus of MRI images segmented by the algorithm were 91.5%, 88.33%, 90.3%, and 88.9%, respectively, which were greatly superior to those of manual interpretation (P < 0.05). After the intervention of CD, the percentages of patients with ileus that were cured, markedly effective, effective, and ineffective were 65.38%, 23.16%, 5.38%, and 6.08%, respectively. The cure rate after intervention of CD (65.38%) was much higher in contrast to that before intervention (13.25%) (P < 0.05). In short, CD showed a good therapeutic effect on ileus and can effectively improve the prognosis of patients. In addition, MRI images based on BPNN showed a good diagnostic effect on ileus, and it was worth applying to clinical diagnosis.

Prognostic factors in the decision-making process for sigmoid volvulus: results of a single-centre retrospective cohort study

Background

Sigmoid volvulus is a common cause of emergency surgical admission. Those patients are often treated conservatively with a high rate of recurrence. We wondered if a more aggressive management might be indicated.

Methods

We have reviewed data of patients diagnosed with acute sigmoid volvulus over a 2-year period. The primary endpoint was patient survival.

Results

We analysed 332 admissions of 78 patients. 39.7% underwent resection. Survival was 54.9 ± 8.8 months from the first hospitalization, irrespective of the treatment. Long-term survival was positively influenced by being female, having a low “social score”, a younger age and surgery. Multivariate analysis showed that only being female and surgery were independently associated with better survival.

Conclusion

Early surgery may be the best approach in patients with recurrent sigmoid volvulus, as it ensures longer survival with a better quality of life, regardless of the patient’s social and functional condition.

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.

Hand-Assisted Laparoscopic Subtotal Colectomy for Ogilvie Syndrome Associated With Idiopathic Fibrosis of Colon After Simultaneous Pancreas Kidney Transplant

Ogilvie syndrome (acute colonic pseudo-obstruction) is a rare, acquired, life-threatening disorder for which treatment plans vary from simple observation to surgical intervention. Ogilvie syndrome has been reported in patients after renal or liver transplant, but its occurrence after simultaneous pancreas-kidney transplant is rare. Herein, we present the case of a 45-year-old female recipient of a deceased donor simultaneous pancreas-kidney transplant who developed Ogilvie syndrome 10 days after a previous fecal ileus that had resolved at posttransplant week 3. She demonstrated Ogilvie syndrome with obstructive colitis features (severe abdominal pain and high-grade fever), which we immediately treated with colonic decompensation by placement of a transanal ileus tube. After several screening examinations and discontinuation of unnecessary medicines, we were not able to confirm the cause of Ogilvie syndrome in our patient. After 2 weeks, the patient remained unresponsive to the conservative treatment, and so hand-assisted laparoscopic subtotal colectomy was performed to remove the dilated colon. Her symptoms gradually resolved after surgery. Histologically, we confirmed submucosal fibrotic changes, especially at the distal end of the resected colon, without evidence of amyloidosis, and the number of Auerbach plexus ganglia had decreased. Nevertheless, we observed no degenerated appearance of ganglion cells in the Auerbach plexus or the Meissner plexus. After exclusion of several collagen diseases, including systemic sclerosis, we determined that idiopathic colonic fibrosis was the likely cause of Ogilvie syndrome in our patient. When surgery is indicated in transplant patients with Ogilvie syndrome with obstructive colitis features, colectomy should be considered.

Neostigmine for Treating Acute Colonic Pseudo-Obstruction in Neurocritically Ill Patients

Background and Purpose

Acute colonic pseudo-obstruction (ACPO) is a common but understudied complication in neurocritically ill patients. The acetylcholinesterase inhibitor neostigmine can be used to treat ACPO in patients who do not respond to conventional treatment. This study investigated the effectiveness and adverse events when using neostigmine to manage ACPO in neurocritically ill patients.

Methods

This retrospective study investigated patients with ACPO who were treated using neostigmine in the neurological intensive-care units at two centers between March 2017 and August 2020. Neostigmine was administered intravenously or subcutaneously (at doses ranging from 0.25 mg to 2 mg) according to the protocols at the two centers. The outcomes were bowel movements and the changes in colon diameters on abdominal radiographs. Safety events such as bradycardia, vomiting, salivation, and sweating were evaluated.

Results

This study included 31 subjects with a mean age of 46.8 years (65.4% males). All patients had a bowel movement at a median of 120 minutes after administering neostigmine. The colon diameter decreased by a median of 17.5 mm (paired t-test: p<0.001) regardless of the dose and treatment protocols. Multilevel analysis confirmed that the mean colon diameter decreased from 66 mm pretreatment to 47.5 mm posttreatment (p<0.001), with an intraclass correlation coefficient of 13%. Three patients (9.7%) exhibited hypersalivation, sweating, bradycardia, and vomiting. Bradycardia (heart rate, 42 beats/minute) occurred in one patient (3.2%), and was successfully managed by injecting atropine.

Conclusions

Neostigmine injection is a safe and effective treatment option for ACPO in neurocritically ill patients who fail to respond to conservative management.

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.

Endoscopic Decompression of Recurrent Sigmoid Volvulus in Pregnancy

Sigmoid volvulus is a rare condition seen during pregnancy with high maternal and fetal morbidity and mortality. We report a case of a young 26-year-old woman, primipara, in her third trimester who presented with recurrent sigmoid volvulus at both 30 and 32 weeks of gestation. She underwent successful repetitive endoscopic decompression on both admissions with uneventful recovery. Endoscopic evaluation is safe in pregnancy and uncomplicated volvulus. It allows for diagnostic confirmation and assessment of complications; and it has successful outcomes in the presence of a multidisciplinary team.

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.

A comprehensive radiologic review of abdominal and pelvic torsions

The clinical manifestations of abdominal and pelvic organ torsion can often be non-specific and can affect a wide range of ages and demographic groups. Radiologists have a key role in not only establishing the diagnosis of organ torsion, but also in the assessment of potential complications. As multiple imaging modalities may be utilized in the evaluation of abdominal and pelvic pain, recognizing the various appearances of organ torsion is important to ensure early diagnosis and thereby reducing patient morbidity and mortality, particularly since abdominal and pelvic organ torsion may not be clinically suspected at the time of initial patient presentation.

Risk factors affecting failure of colonoscopic detorsion for sigmoid colon volvulus: a single center experience

PURPOSE

Colonoscopic detorsion (CD) is the first treatment option for uncomplicated sigmoid volvulus (SV). We aim to examine the factors affecting the failure of CD.

METHODS

The files of patients, treated after diagnosis of SV between January 2015 and September 2020, were retrospectively reviewed. Patients' demographic data, comorbidities, endoscopy reports, and surgical and other treatments were recorded. Patients were divided into two groups, as the successful CD group and unsuccessful CD group. The data were compared between the groups, and multivariate analysis of statistically significant variables was performed.

RESULTS

There were 21 patients in the unsuccessful CD group and 52 patients in the successful CD group. The unsuccessful CD rate was found to be 28.76%; this is likely a function of more neuropsychiatric disease, more accompanying sigmoid diverticulum, previous abdominal surgery, abdominal tenderness, onset of symptoms for more than 48 h, higher mean intra-abdominal pressure (IAP), IAP over 15 mmHg, larger mean diameter of the cecum, the cecum diameter over 10 cm, and higher mean C-reactive protein (CRP) values as statistically significant. In the multivariate analysis, previous abdominal surgery and cecum diameter over 10 cm were seen as predictive factors for failure of CD (p=0.049, OR=0.103, and p = 0.028, OR=10.540, respectively).

CONCLUSIONS

CD failure rate was significantly associated with previous abdominal surgery and a cecum diameter over 10 cm. We found that patients with these factors will tend to need more emergency surgery.

The rare Ogilvie's Syndrome in pregnancy. How to manage? A case report and literature review

Acute colonic pseudo-obstruction, or Ogilvie's syndrome (OS), is a complication in gynaecology and obstetrics. Its occurrence during pregnancy is rare, redefining the therapeutic decision-making and treatment options. In this review we describe the case of a 37-year-old pregnant patient who developed OS at the 30th week of gestation. A laparotomy with colonic decompression was performed. Foetal condition, regularly monitored throughout the hospital stay, remained normal. The patient experienced an uncomplicated, natural delivery at 40 weeks. A comprehensive literature search, describing the occurrence of OS during pregnancy, was conducted. We identified six cases of OS arising during pregnancy. Demographic, clinical, diagnostic and therapeutic features were analysed. Non-surgical management is generally the first-line option, with intravenous drug administration, rectal and nasogastric tube positioning and colonoscopic decompression the treatments of choice. Surgical decompression in usually performed in cases of failure of the first-line treatments. Including our own experience, in all cases, neither maternal nor foetal mortality was reported. A conservative approach is mandatory as first-line treatment, but when prompt resolution is not achieved, a multidisciplinary team, involving the gynaecologist/obstetrician, the surgeon, the radiologist and the intensivist is mandatory to avoid diagnostic delays, thereby reducing morbidity and mortality rates.

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.

Initial Computed Tomography Findings of Long and Distended Colon Are Risk Factors for the Recurrence of Sigmoid Volvulus

BACKGROUND

Sigmoid volvulus is a common condition in elderly patients with elongated colons. Although endoscopic de-torsion is effective as the primary treatment of sigmoid volvulus, elective surgery is recommended because of the high risk of recurrence and high mortality rate.

AIM

The aim of this study was to determine the risk factors for the recurrence of sigmoid volvulus.

METHODS

Clinical records of patients treated at Shimane Prefectural Central Hospital were reviewed retrospectively. Among 41 sigmoid volvulus patients who were successfully treated by endoscopic de-torsion and followed up, 30 were observed over 1 year. Among the 30 patients, eight (26.7%) did not experience recurrence, while 22 (73.3%) did. Initial computed tomography (CT) findings indicating the sigmoid colon extending to the diaphragm or ventral to the liver were defined as "extension findings." Extension findings and sigmoid diameter were evaluated in relation to sigmoid volvulus recurrence.

RESULTS

Extension findings were significantly more frequent in the recurrent group (77.3%) than in the nonrecurrent group (25.0%) (P = 0.009). Distended sigmoid colon diameter was significantly larger in the recurrent group (11.7 ± 3.8 cm) than in the nonrecurrent group (7.1 ± 1.1 cm) (P = 0.044). Receiver operating characteristic curve analysis demonstrated that the performance threshold was greater than 8.9 cm. Kaplan-Meier analysis showed the significantly high sigmoid volvulus recurrence rate in the patients with extension findings and a distended sigmoid colon greater than 8.9 cm.

CONCLUSIONS

CT findings of a long and distended sigmoid colon in initial sigmoid volvulus are risk factors for the recurrence of sigmoid volvulus.

Recurrent sigmoid volvulus: Cause of colon perforation, sepsis, and fetal death

Sigmoid volvulus is one of the most common reasons for intestinal obstruction. Recurrent sigmoid volvulus occurred in only a few cases. Torsion of the sigmoid colon around the mesenteric portion initiates ischemia, gangrene, and perforation. Here, we presented a case with recurrent sigmoid volvulus. A 19-year-old Syrian refugee has been admitted to emergency room during 30th gestation week with acute abdomen, constipation, and lack of gas passage. She had a medical history of rectosigmoidoscopy and detorsion of sigmoid volvulus 6 days ago. Her vital signs showed tachycardia, hypotension, and tachypne, and her body temperature was 35.6°C. Sonography revealed nonviable fetus. Emergency laparotomy has been performed. Sigmoid volvulus and contaminated intraperitoneal area with feces was evaluated. A cesarean section, total colectomy, and end-ileostomy have been performed. Patient stayed 3 days in intensive care unit and was discharged on the 17th day. Sigmoid volvulus is a real emergency. Delayed treatment of sigmoid volvulus is related to maternal and fetal mortality.

Endoscopic Decompression in Colonic Distension

Background

Acute colonic distension is a medical emergency with high morbidity and mortality. Clinically important causes of colonic distension are acute colonic pseudo-obstruction, colonic volvulus, and malignant obstruction. Endoscopic decompression is one established therapeutic strategy.

Summary

This therapeutic review will give an overview of possible therapeutic strategies based on the recently published literature, focusing on endoscopic decompression and summarizing the other therapeutic possibilities. The review discusses separately the therapeutic options of acute colonic pseudo-obstruction, colonic volvulus, and malignant obstruction, providing an evidence-based orientation for clinical use.

Key Messages

Endoscopic decompression of colonic distension is an established therapy with high clinical success. The technique and its position in the therapy sequence differ depending on the medical condition, the trigger of the colonic distension, and the local expertise.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

Risk factors affecting failure of colonoscopic detorsion for sigmoid colon volvulus: a single center experience

PURPOSE

Colonoscopic detorsion (CD) is the first treatment option for uncomplicated sigmoid volvulus (SV). We aim to examine the factors affecting the failure of CD.

METHODS

The files of patients, treated after diagnosis of SV between January 2015 and September 2020, were retrospectively reviewed. Patients' demographic data, comorbidities, endoscopy reports, and surgical and other treatments were recorded. Patients were divided into two groups, as the successful CD group and unsuccessful CD group. The data were compared between the groups, and multivariate analysis of statistically significant variables was performed.

RESULTS

There were 21 patients in the unsuccessful CD group and 52 patients in the successful CD group. The unsuccessful CD rate was found to be 28.76%; this is likely a function of more neuropsychiatric disease, more accompanying sigmoid diverticulum, previous abdominal surgery, abdominal tenderness, onset of symptoms for more than 48 h, higher mean intra-abdominal pressure (IAP), IAP over 15 mmHg, larger mean diameter of the cecum, the cecum diameter over 10 cm, and higher mean C-reactive protein (CRP) values as statistically significant. In the multivariate analysis, previous abdominal surgery and cecum diameter over 10 cm were seen as predictive factors for failure of CD (p=0.049, OR=0.103, and p = 0.028, OR=10.540, respectively).

CONCLUSIONS

CD failure rate was significantly associated with previous abdominal surgery and a cecum diameter over 10 cm. We found that patients with these factors will tend to need more emergency surgery.

A case of sigmoid volvulus in an unexpected demographic

Background

A sigmoid volvulus occurs when a segment of the colon twists upon its mesentery. This infliction is associated with old age, multiple co-morbidities, and the male sex. We present a rare case of sigmoid volvulus that occurred in a healthy young female.

Case presentation

A 28-year-old female presented with a one week history of constipation and abdominal pain. Her symptoms suddenly worsened and became associated with vomiting and severe pain. A focused history taking and physical examination showed peritoneal signs that led to timely diagnostic imaging to be implemented. Computed tomography (CT) of the abdomen was consistent with sigmoid volvulus. Our patient underwent emergent laparotomy with a sigmoidectomy and recovered with no post-operative complications.

Conclusion

This case report emphasizes the importance of clinicians maintaining a sigmoid volvulus as a rare, yet important differential when approaching abdominal pain in young healthy patients.

Surgical Management of Sigmoid Volvulus: A Multicenter Observational Study

Purpose: This study aimed to evaluate real-world clinical outcomes from surgically treated patients for sigmoid volvulus.Methods: Five tertiary centers participated in this retrospective study with data collected from October 2003 through September 2018, including demographic information, preoperative clinical data, and information on laparoscopic/open and elective/emergency procedures. Outcome measurements included operation time, postoperative hospitalization, and postoperative morbidity.Results: Among 74 patients, sigmoidectomy was the most common procedure (n = 46), followed by Hartmann’s procedure (n = 23), and subtotal colectomy (n = 5). Emergency surgery was performed in 35 cases (47.3%). Of the 35 emergency patients, 34 cases (97.1%) underwent open surgery, and a stoma was established for 26 patients (74.3%). Elective surgery was performed in 39 cases (52.7%), including 21 open procedures (53.8%), and 18 laparoscopic surgeries (46.2%). Median laparoscopic operation time was 180 minutes, while median open surgery time was 130 minutes (P < 0.001). Median postoperative hospitalization was 11 days for laparoscopy and 12 days for open surgery. There were 20 postoperative complications (27.0%), and all were resolved with conservative management. Emergency surgery cases had a higher complication rate than elective surgery cases (40.0% vs. 15.4%, P = 0.034).Conclusion: Relative to elective surgery, emergency surgery had a higher rate of postoperative complications, open surgery, and stoma formation. As such, elective laparoscopic surgery after successful sigmoidoscopic decompression may be the optimal clinical option.

Surgical Management of Sigmoid Volvulus: A Multicenter Observational Study

Purpose

This study aimed to evaluate real-world clinical outcomes from surgically treated patients for sigmoid volvulus.

Methods

Five tertiary centers participated in this retrospective study with data collected from October 2003 through September 2018, including demographic information, preoperative clinical data, and information on laparoscopic/open and elective/emergency procedures. Outcome measurements included operation time, postoperative hospitalization, and postoperative morbidity.

Results

Among 74 patients, sigmoidectomy was the most common procedure (n = 46), followed by Hartmann’s procedure (n = 23), and subtotal colectomy (n = 5). Emergency surgery was performed in 35 cases (47.3%). Of the 35 emergency patients, 34 cases (97.1%) underwent open surgery, and a stoma was established for 26 patients (74.3%). Elective surgery was performed in 39 cases (52.7%), including 21 open procedures (53.8%), and 18 laparoscopic surgeries (46.2%). Median laparoscopic operation time was 180 minutes, while median open surgery time was 130 minutes (P < 0.001). Median postoperative hospitalization was 11 days for laparoscopy and 12 days for open surgery. There were 20 postoperative complications (27.0%), and all were resolved with conservative management. Emergency surgery cases had a higher complication rate than elective surgery cases (40.0% vs. 15.4%, P = 0.034).

Conclusion

Relative to elective surgery, emergency surgery had a higher rate of postoperative complications, open surgery, and stoma formation. As such, elective laparoscopic surgery after successful sigmoidoscopic decompression may be the optimal clinical option.

Acute colonic pseudo-obstruction with bowel rupture after caesarean section in HELLP syndrome: a case report

Background

Ogilvie syndrome, also known as acute colonic pseudo-obstruction (ACPO), can occur postpartum after caesarean section (C-section), often resulting in caecal dilatation. The incidence rate is approximately 100 cases in 100,000 patients per year (Ross et al., Am Surg 82:102-11, 2016). Without proper diagnosis and treatment, it may progress to intestinal perforation or other fatal complications.

Case presentation

A 39-year-old pregnant woman underwent emergency low-segment C-section due to complications of Haemolysis, Elevated Liver enzymes and Low Platelets syndrome (HELLP) syndrome. ACPO was suspected on the third day after C-section based on inability to pass flatus, evident abdominal distension, slight abdominal pain, and computed tomography (CT) scan revealing severe, diffuse colonic distention with caecal dilatation of approximately 9 cm. Based on these findings, conservative treatment was implemented. However, 6 days after C-section, her symptoms worsened, and CT showed possible intestinal perforation; thus, an emergency laparotomy was performed. Due to a 3-cm (diameter) laceration in the anterolateral wall of the ascending colon and a 5-cm tear in the ileocecal junction, in combination with mucosal eversion in the colon, resection of the ileocecum, distal closure of the ascending colon, and a terminal ileostomy were performed. The patient was discharged 2 weeks post-laparotomy and continued to undergo nursing care for the incision and stoma. Ileostomy was performed 4 months later.

Conclusion

Ogilvie syndrome after C-section is an extremely rare but severe condition, which warrants early recognition and treatment to prevent potentially fatal complications, especially in patients with poor health status.

Management of sigmoid volvulus using percutaneous endoscopic colostomy

INTRODUCTION

The aim of this systematic review was to appraise the current literature on the use of percutaneous endoscopic colostomy (PEC) as an alternative to major surgery and endoscopic decompression alone for treating sigmoid volvulus in frail, comorbid patients.

METHODS

A systematic literature search of literature published between April 2000 and January 2017 was carried out using the MEDLINE^®, Embase™ and CINAHL^® (Cumulative Index to Nursing and Allied Health Literature) databases. The search terms were "percutaneous endoscopic colostomy", "PEC", "sigmoidopexy", "sigmoidostomy" and "sigmoid volvulus". The studies identified were screened and those that did not fulfil the inclusion criteria were excluded.

FINDINGS

Seven observational studies and seven case reports (comprising eighty-one patients) were found to match our inclusion criteria. All patients had recurrent sigmoid volvulus and were treated with PEC either with a single PEC tube or with two PEC tubes inserted. Sigmoid volvulus recurred in 10 of the 81 patients; 3 of these individuals developed recurrence with PEC tubes in situ and 7 following tube removal. There were seven deaths after the procedure. The most frequent morbidity associated with PEC tube insertion was site infection (n=6).

CONCLUSIONS

Our systematic review highlights the use of PEC as an alternative in managing recurrent sigmoid volvulus in frail, comorbid patients unfit for or refusing surgery, with the best outcomes seen in those patients where two PEC tubes were inserted and remained in situ indefinitely. Further studies are needed to improve the safety and efficacy of the procedure as well as post-procedure care.

Clinical outcomes of sigmoid volvulus and risk factors for its recurrence: a multicenter study in Korea

PURPOSE

Sigmoid volvulus is one of the leading causes of colonic obstruction. The aims of this study were to review the treatment characteristics and clinical outcomes of patients diagnosed with sigmoid volvulus over 10 years at five university-affiliated hospitals in Korea, and to identify possible risk factors for its recurrence.

METHODS

Retrospective review was performed for medical records of patients who were diagnosed with sigmoid volvulus and managed surgically or conservatively at the five Hallym University-affiliated hospitals between January 2005 and July 2018.

RESULTS

A total of 69 patients were diagnosed, of whom 11 patients underwent emergency surgery and 58 patients were conservatively managed. Non-operative management was successful in 53 of 58 patients (91.4%) at initial admission. Of the non-operative managed patients, six patients required emergency surgery due to unsuccessful decompression or recurrence whereas 23 patients underwent regular surgery for definitive treatment. And overall recurrence rate and mortality rate were 25.8% (15/58) and 1.7% (1/58), respectively. A total of 40 patients underwent surgery; 23 underwent regular surgery and 17 underwent emergency surgery. Restoration of bowel continuity was more frequently performed in the regular surgery group than in the emergency surgery group (87.0% vs 52.9%, P = 0.03). In multivariable analysis, only non-operative management at the initial admission (P = 0.029) was independently associated with recurrence.

CONCLUSION

Although non-operative treatment can be initially attempted, surgery is required for preventing recurrence. Regular surgery should be considered to restore continuity of the bowel.

INTRAABDOMINAL HYPERTENSION SYNDROME: CURRENT STATE OF THE PROBLEM

Syndrome of intra-abdominal hypertension (SIAH) is a dangerous complication that can occur in patients with a surgical profile after surgery in the abdominal cavity. Only in the past 25 years has the SIAH been recognized. According to W. Ertel et al., In one third of patients with peritonitis, pancreatic necrosis, injuries of the abdominal cavity and after extensive surgery, there is an increase in intra-abdominal pressure (IAP), while SIAH develops in 5.5% of such patients. Mortality in SIAH is 42–68%. The reason for the development of so many deaths is the presence of diagnostic, preventive and therapeutic measures, as well as differences in the interpretation of terms. Today, much attention is paid to the study of SIAH, official attempts are being made to standardize and define terms and recommended methods of treatment, but this problem needs further study. The review presents data on the current state of the problem, current trends in the diagnosis, prevention and treatment of patients with IAP and SIAH, their use in practical research.

Case Report of Ogilvie's Syndrome Following Emergency Haemostatic Subtotal Abdominal Hysterectomy at University Teaching Hospital of Butare, Rwanda

Background

Acute colonic pseudo-obstruction or Ogilvie's syndrome is a rare condition that usually develops due to a dysregulated autonomic nervous system following a medical or surgical condition. With delayed diagnosis, it may lead to bowel ischemia and perforation with poor prognosis.

Case

We report a case of a 33 years old female, Gravida 1, Para1, who developed severe abdominal distension following abdominal haemostatic hysterectomy due to a severe postpartum haemorrhage and shock requiring epinephrine infusion after a spontaneous vaginal delivery. The postpartum haemorrhage was due to both atony and posterior cervical tear. Two initial administrations of neostigmine 2 mg mixed with atropine 0.5 mg were unsuccessful, but an insertion of a flexible recto-sigmoid cannula allowed a slight decompression. A subsequent third dose of neostigmine 2 mg mixed with atropine 0.5 mg was followed with a remarkable flatus evacuation and complete decompression.

Conclusion

Prompt diagnosis and management of Ogilvie's syndrome is crucial in order to avoid subsequent complications. In case of postoperative cecal and colonic distension without mechanical obstruction, Ogilvie's syndrome should be suspected as this will ensure timely and adequate management of patients at risk including obstetric patients.

Sigmoid Volvulus with Widespread Bowel Ischemia after Endoscopic Reduction Successfully Treated with Elective Laparoscopic Surgery

An 87-year-old man complaining of abdominal distention was referred to our hospital. Plain radiograph and enhanced computed tomography (CT) showed a dilated sigmoid colon with a coffee bean sign, leading to the diagnosis of sigmoid volvulus. Based on symptoms and the CT and laboratory test findings, we initially treated the patient with endoscopic reduction, resulting in successful reduction of the sigmoid volvulus with widespread presumed mucosal ischemia. Due both to the lack of emerging symptoms suggesting colon perforation and to the laboratory test findings after endoscopic reduction, we treated the patient without further urgent surgical intervention. Two months later, the patient underwent successful elective laparoscopic surgery with a redundant sigmoid colon resection and a functional end-to-end anastomosis. He has been well without any events for 20 months. Conservative treatment with careful observation should be taken into consideration in the treatment of sigmoid volvulus with mild to moderate ischemia after endoscopic reduction.

American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in the management of acute colonic pseudo-obstruction and colonic volvulus

Colonic volvulus and acute colonic pseudo-obstruction (ACPO) are 2 causes of benign large-bowel obstruction. Colonic volvulus occurs most commonly in the sigmoid colon as a result of bowel twisting along its mesenteric axis. In contrast, the exact pathophysiology of ACPO is poorly understood, with the prevailing hypothesis being altered regulation of colonic function by the autonomic nervous system resulting in colonic distention in the absence of mechanical blockage. Prompt diagnosis and intervention leads to improved outcomes for both diagnoses. Endoscopy may play a role in the evaluation and management of both entities. The purpose of this document from the American Society for Gastrointestinal Endoscopy's Standards of Practice Committee is to provide an update on the evaluation and endoscopic management of sigmoid volvulus and ACPO.