Elective Treatment of Large-Bowel Obstruction in Asymptomatic Sigmoid Volvulus

BACKGROUND

Sigmoid volvulus is an uncommon cause of intestinal obstruction representing the 5% of all Western cases, associated with old age and a history of neurological and psychiatric condition. Generally, its diagnosis is established by clinical and radiologic findings. It often represents an emergency and it is commonly associated with pain, vomit and abdominal tenderness.

CASE PRESENTATION

We present a case of a 59 years old man, admitted to our emergency department, showing an abdominal X-Ray reporting a distention of large bowel,which was required due to presence of multiple diarrhea episodes during the previous 7 days. He had no significant past medical history and did not report constipation or subocclusive episode.

CONCLUSIONS

Volvulus should be considered in the differential diagnosis in adult and healthy patients with bowel obstructions. Surgery is, in all cases, the radical and definitive treatment since there is a higher mortality in case of recurrent volvulus. Despite the massive bowel distention, our choice was the elective open surgery. Primary anastomosis is feasible and safe and did not lead to any complications. In case of unsuccessful colonic decompression, evidence to support or refute the safety and effectiveness of laparoscopic surgical resection for treatment of patients with sigmoid volvulus disease is not yet proven.

Large-bowel obstruction: CT findings, pitfalls, tips and tricks

Large bowel obstruction (LBO) is associated with high morbidity and mortality due to delayed diagnosis and/or treatment. MDCT has become the standard of care to identify the site, severity, and etiology of obstruction. The goal of this review is fourfold. The first objective is to give clues to differentiate LBO from colonic pseudo-obstruction. The second objective is to describe CT features in the most common cause of LBO which is colonic cancer by illustrating classical and atypical features of colonic cancer responsible for LBO and by giving the features which must be reported when differentiating malignant from benign: presence of local lymph nodes, other colic localizations, length of involved segment, presence of diverticula, or other. The third objective is to illustrate the various causes of LBO which can mimic a colon cancer by leading to a thickening of the colonic wall: diverticulitis, ischemic colitis, endometriosis, inflammatory disease and to give tips which permit to evoke another diagnosis than a colon cancer in patient with a LBO and a thickening of the colic wall. The fourth objective is to describe the common signs of cecal and sigmoid volvulus and to give tips for a diagnosis sometimes difficult particularly for cecal volvulus: one of two transition points according to the type of volvulus and the presence of a whirl sign with a torsion of the mesenteric vessels.

Palliative treatment for incurable malignant colorectal obstructions: A meta-analysis

AIM: To perform a meta-analysis of palliative stent placement vs palliative surgical decompression for management of incurable malignant colorectal obstructions.

METHODS: The databases of Medline, Web of Science, Embase, and the Cochrane Central Register of Controlled Trials were searched from their inception to July 2012 for studies (prospective, retrospective, randomized controlled trials, and case-control trials) designed as comparative analyses of patients with incurable malignant colorectal obstructions treated by self-expanding metallic stents (SEMS) or palliative surgery. No language restrictions were imposed. The main outcome measures were hospital stay, intensive care unit admission, clinical success rate, 30-d mortality, stoma formation, complications, and overall survival time. The data extraction was conducted by two investigators working independently and using a standardized form. The Mantel-Haenszel χ² method was used to estimate the pooled risk ratios with 95%CI under a fixed-effects model; when statistical heterogeneity existed in the pooled data (as evaluated by Q test and I² statistics, where P < 0.10 and I² < 25% indicated heterogeneity), a random-effects model was used.

RESULTS: Thirteen relevant articles, representing 837 patients (SEMS group, n = 404; surgery group, n = 433), were selected for analysis. Compared to the surgery group, the SEMS group showed lower clinical success (99.8% vs 93.1%, P = 0.0009) but shorter durations of hospital stay (18.84 d vs 9.55 d, P < 0.00001) and time to initiation of chemotherapy (33.36 d vs 15.53 d, P < 0.00001), and lower rate of stoma formation (54.0% vs 12.7%, P < 0.00001). Additionally, the SEMS group experienced a significantly lower rate of 30-d mortality (4.2% vs 10.5%, P = 0.01). Stent-related complications were not uncommon and included perforation (10.1%), migration (9.2%), and occlusion (18.3%). Surgery-related complications were slightly less common and included wound infection (5.0%) and anastomotic leak (4.7%). The rate of total complications was similar between these two groups (SEMS: 34.0% vs surgery: 38.1%, P = 0.60), but the surgery-related complications occurred earlier than stent-related complications (rate of early complications: 33.7% vs 13.7%, P = 0.03; rate of late complications: 32.3% vs 12.7%, P < 0.0001). The overall survival time of SEMS- and surgery-treated patients was not significantly different (7.64 mo vs 7.88 mo).

CONCLUSION: SEMS is less effective than surgery for palliation of incurable malignant colorectal obstructions, but is associated with a shorter time to chemotherapy and lower 30-d mortality.