Factors precipitating volvulus formation in sigmoid volvulus

BACKGROUND

Sigmoid volvulus (SV), the wrapping of the sigmoid colon around itself, is a rare intestinal obstruction form world-wide. For this reason, the physiopathology of SV, particularly the precipitating factors, are not clearly identified. The aim of this study is to evaluate the precipitating factors in SV.

METHODS

The clinical records of consecutive 416 patients with SV were reviewed prospectively from January 1986 to July 2020. As a control, the records of consecutive 100 patients with non-volvulus intestinal obstruction were reviewed prospectively in the past 24 months. The premorbid symptoms including acute diarrhea, sudden and excessive body motions, overeating after a prolonged starvation, coughing spell, and labor was evaluated.

RESULTS

Among the premorbid symptoms, 1-5-day interval of diarrhea (42 patients, 10.1%, p<0.05), harvesting activation (35 patients, 8.4%, p<0.05), and overeating after Ramadan fasting (31 patients, 7.5%, p<0.05) were found to be statistically significant precipitating factors in SV.

CONCLUSION

Although there are few studies about the precipitating factors of SV in the literature, increased bowel motility, excessive body motions, and overeating following a prolonged starvation look like the precipitating factors in the development of SV.

Use of ultrasound findings to predict bowel ischemic changes in pediatric patients with intestinal volvulus

OBJECTIVES

Early diagnosis and prompt surgical intervention are important to prevent intestinal necrosis in patients with volvulus. The purpose of this study was to determine which ultrasound (US) findings may predict bowel ischemic changes in pediatric patients with intestinal volvulus.

METHODS

Thirty-one pediatric patients with surgically proven intestinal volvulus were retrospectively reviewed. We compared the demographics and US findings (eg, superior mesenteric artery collapse, ascites, echogenic ascites, and degree of intestinal twist) between patients with and without bowel ischemic changes during surgery. Data are presented as median and range. The Fisher exact test, Mann-Whitney U test, and Wilcoxon signed rank sum test were used for statistical analyses.

RESULTS

Eleven patients had bowel ischemic changes. Significant differences existed between patients with and without ischemic changes for age (2 days [range, 0-137 days] versus 6.5 days [range, 2-1618 days]; P = .02), superior mesenteric artery collapse (present/absent, 10/1 versus 9/11 patients; P = .02), the presence of ascites (present/absent, 8/3 versus 6/14 patients; P = .03), and intestinal twist degree on US imaging (540° [range, 180°-720°] versus 360° [range, 180°-720°]; P = .02). The groups did not significantly differ for sex, the time from the US examination to the operation, or echogenic ascites. The intestinal twist degree insignificantly differed between US and surgical findings (360° [range, 180°-720°] versus 360° [range, 0°-1080°]; P = .36).

CONCLUSIONS

The presence of superior mesenteric artery collapse, ascites, and a large intestinal twist on US imaging were significant predictors of intestinal ischemic changes. Pediatric surgeons should perform prompt surgical interventions in cases of volvulus with these US findings.

Transverse colon volvulus in a patient with sickle cell disease

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

Death caused by appendicular knotting and small-bowel strangulation in a child: A case report and review

Acute appendicitis is one of the most common surgical emergencies in paediatrics. However, acute appendicitis in early infancy is an uncommon condition. Furthermore, strangulation of the small intestine through appendicular knotting is described as very unusual in the literature and is generally not well-diagnosed in the clinical context. This article reports the case of a 23-month-old girl who entered the emergency department with a three-day history of abdominal symptoms and who died in less than 24 hours without receiving surgical intervention. The case turned judicial at the request of the parents who claimed lack of clarity in the diagnosis. A medico-legal autopsy was ordered to clarify the cause and manner of death. The autopsy documented herniation, strangulation and torsion of a 70 cm segment of the jejunum/ileum through an appendicular knot caused by the attachment of the distal end of the inflamed appendage to the ileum. The case is relevant because it is the first case of death by appendicular knot and strangulation of small bowel in an infant reported in the literature. The importance of autopsy to clarify the clinical diagnosis is noted.

The preventive effects of atorvastatin and N-acetyl cysteine in experimentally induced ischemia-reperfusion injury in rats

AIM

We investigated the effects of atorvastatin and N-acetyl cysteine in decreasing ischemia-reperfusion damage after detorsion of a volvulus of the cecum and ascending colon.

METHODS

Wistar albino rats (250-300 g) were divided into four groups. A cecal-ascending colon volvulus was created by the intestinal clockwise 720° rotation. At the end of one hour, the bowel was detorsioned. Group I (n = 7) was the sham (laparotomy) group, Group II (n = 7) the control (no treatment, volvulus or detorsion), Group III (n = 7) (N-acetyl cysteine administered ) , and Group IV (n = 7) (atorvastatin administered ) group. Blood samples were collected from each group via peripheral veins and centrifuged one hour after detorsion. The parameters of ischemia including malondialdehyde, glutathione peroxidase, catalase, and superoxide dismutase were then observed in the serous fluid.

RESULTS

Malondialdehyde and superoxide dismutase increased in the control group, whereas they were reduced in the Group III and Group IV (p = 0.005; p = 0.008, respectively). The glutathione peroxidase levels revealed no significant differences (p > 0.05), whereas the catalase levels of the group III was higher than in each of the other three groups (p < 0.001). Histopathological evaluation detected reduced lesioning of the organ in the groups which were given atorvastatin and N-acetyl cysteine.

CONCLUSION

Atorvastatin and of N-acetyl cysteine have a similar preventive effect in experimental ischemia-reperfusion injury (Tab. 8, Fig. 6, Ref. 24).

The efficiency of sonography in diagnosing volvulus in neonates with suspected intestinal malrotation

This study is to prospectively evaluate the efficiency of sonography for volvulus diagnosis in neonates with clinically suspected intestinal malrotation.A total of 83 patients with suspected intestinal malrotation who underwent detailed abdominal sonography and upper gastrointestinal contrast study were included. Malrotation was characterized by inversion of the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) in sonographic examination. The "whirlpool sign" of Color Doppler Sonography was recognized as a characteristic for malrotation with volvulus. The degrees of rotation of the SMV winding around SMA were also detected by sonography. Surgery was performed in patients with sonography diagnosed malrotation.A total of 39 patients were sonographically diagnosed as malrotation which was subsequently confirmed by surgery. The sensitivity and positive predictive value of the sonographic diagnosis were both 100% (39/39). The sensitivity, specificity and accuracy of "whirlpool sign" for the detection of midgut volvulus were 95.2% (20/21), 88.9% (16/18), and 92.3% (36/39), respectively. Greater degrees of rotation (equal or greater than 720°) showed higher risk (odds ratio, 5.0; P < .01) for intestinal necrosis occurrence.Sonography is more accurate in diagnosing suspected malrotation than upper gastrointestinal contrast study. Specific sonographic "whirlpool sign" related to volvulus may be used as a potential indicator for intestinal necrosis. In addition, sonography can exclude malrotation and may help the diagnosis of other diseases, such as annular pancreas and duodenal atresia.

Small Gut Volvulus, A Rare Twist, In The Setting Of An Even Rarer Entity; Multiple Giant Jejuno Ileal Diverticula

Small gut volvulus with multiple Jejuno-ileal diverticulosis is an unusual pathology of the small intestine with a scarce number of cases reported so far. It usually goes unnoticed because it is often asymptomatic but complications like diverticulitis, perforation, bleeding or intestinal obstruction can occur in 10-30% of the cases. Mechanical obstruction, if it occurs, can be caused by adhesions or stenosis due to diverticulitis, intussusception at the site of the diverticulum and volvulus of the segment containing the diverticula. Acute volvulus of the small bowel is a serious abdominal emergency that poses a difficulty in diagnosis and delayed operative intervention can lead to dire consequences. We herein report the case of a 42-yearold man presented at the emergency department with acute abdominal pain, absolute constipation and vomiting. Preoperative investigations followed by laparotomy revealed small gut volvulus and multiple giant jejunal and ileal diverticula.

Malrotation syndrome resulting in fatal ileus in children

BACKGROUND

This report deals with two deaths of children involving intestinal volvulus, i. e. a pathological knotting and twisting of the mesenterial root on the basis of congenital malrotation followed by obstruction and extensive ischaenia.

CASE REPORTS

(1) A 10-year-old girl (premature, 25th week) with severe disability, amaurosis and epilepsy was admitted to hospital due to general agitation and a bloated abdomen without peristaltic sounds, but died some hours later. Autopsy revealed a volvulus of 2/3 of the small intestine based on congenital malrotation with additional clamping of the intestine underneath adhesions (previous appendectomy). The abdominal cavity showed beginning peritonitis as the cause of death. (2) A 2-month-old premature male baby (surviving twin, 29th week) with a persisting ductus arteriosus was hospitalised for four weeks after failed vascular surgery due to acute general deterioration. Radiological diagnostics using a contrast medium revealed a vascular anomaly (right-sided aortic arch). Around 10 hours later, the infant developed an acute abdomen with ileus symptoms. Emergency surgery showed infarction of the entire small intestine due to an anti-clockwise 180⁰-volvulus, with death occurring 24h later. Further examination showed a malrotation as anomaly. Apparently, the volvulus had been caused by extensive use of contrast medium resulting in increased intestinal mobility.

[Late recognition of intestinal malrotation]

BACKGROUND

Intestinal malrotation is a congenital intestinal abnormality caused by abnormal intestinal rotation during foetal development.

CASE DESCRIPTION

We describe a 20-year-old woman with many years' history of abdominal symptoms and eating disorders that were labelled as psychosomatic following repeated and extensive investigations. The diagnosis of malrotation was only made after an emergency laparotomy, with right hemicolectomy for intestinal necrosis.

CONCLUSION

The reason that diagnosis was missed in this patient was probably not only because malrotation is accompanied by non-specific symptoms. The cognitive strategies used by doctors to make a diagnosis on the basis of symptoms may also have led to ignoring details that did not fit, and to clinging to earlier diagnoses. Furthermore, eating disorders and gastrointestinal disorders are sometimes difficult to distinguish and are often linked. Even with extra vigilance a misdiagnosis cannot always be avoided.

Intestinal Infarction Through Arterial Vascular Obstruction - Case Series from 1st and 3rd Surgery Clinics Cluj-Napoca

This article presents a case series of intestinal infarction through obstruction of superior mesenteric artery - two cases of acute mesenteric artery embolism, two cases of acute mesenteric artery thrombosis and a case of volvulus.

Diagnostic and therapeutic applications of water-immersion colonoscopy

Colonoscopy techniques combining or replacing air insufflation with water infusion are becoming increasingly popular. They were originally designed to reduce colonic spasms, facilitate cecal intubation, and lower patient discomfort and the need for sedation. These maneuvers straighten the rectosigmoid colon and enable the colonoscope to be inserted deeply without causing looping of the colon. Water-immersion colonoscopy minimizes colonic distension and improves visibility by introducing a small amount of water. In addition, since pain during colonoscopy indicates risk of bowel perforation and sedation masks this important warning, this method has the potential to be the favored insertion technique because it promotes patient safety without sedation. Recently, this water-immersion method has not only been used for colonoscope insertion, but has also been applied to therapy for sigmoid volvulus, removal of lesions, lower gastrointestinal bleeding, and therapeutic diagnosis of abnormal bowel morphology and irritable bowel syndrome. Although a larger sample size and prospective head-to-head-designed studies will be needed, this review focuses on the usefulness of water-immersion colonoscopy for diagnostic and therapeutic applications.

GIANT MORGAGNI HERNIA IN A FEMALE WITH MALROTATION SYNDROME AND THORACIC TRANSPOSITION OF SMALL BOWEL, COECUM, ASCENDING AND TRANSVERSE COLON

The sterno-costal hernia of Morgagni is a congenital vice in which is represented unfinished fusion of the transverse septum and the muscular diaphragmal wall. The malrotation syndrome is an embryonic vice as well, with various degree of incomplete and even reverse rotation of the gut, because of disturbed or unfinished development of the midgut. The described case presents a 37 years old female without anamnesis of any previous complains, who was pointed to the clinic after a X-ray photograph because of breathless and asteno-adynamic syndrome. After a precise CT investigation performance was found the presence of the above described anomalities, as well as ectopy of the right kidney and the right liver part. An operative treatment was performed with correction of the hernia and the bowel malrotation. The patient was followed up to the 12th month post-operatively. After a review of the literature in the discussion we inspect the diagnostics and the definition of the right surgical tactics and operative approach in this case with combined malformative pathology.

Diagnostic imaging of intestinal malrotation in association with other inborn malformations in children and adults--case presentations and a review of the literature on the subject

Intestinal malrotation is defined as a group of anomalies in the rotation and fixation of the small intestines and the colon during the embryological development. It can affect the duodenojejunal segment, the cecocolic segment or both. Its most common complication is the midgut volvulus. It is considered to be a childhood pathology, as it usually affects newborns and infants, but with the advent of modern imaging modalities in everyday practice, it is discovered in adults more often. This places it in the group of rare, but important causes for acute and chronic abdominal complaints in children and adults. When it is asymptomatic, it is hard to predict if and in whom complications will occur, which imposes the need to know its variants and diagnostic techniques to prove it. Extremely often the malrotation is associated with other inborn malformations and congenital cardiovascular defects. We report 6 cases of intestinal malrotation, diagnosed in the Medical Imaging Department of Tokuda Hospital Sofia between 2011 and 2014, in order to revise the condition's potential risks and to mark the role of the different imaging modalities in the diagnostic process.

Hepatic flexure in right sub diaphragmatic space and its embryological basis and clinical importance

The knowledge of variations in the large intestine and liver is of clinical importance from the anatomical and embryological points of view. Different positions of the hepatic flexure of large intestine, although generally asymptomatic, may have different impact on manifestations of disease. During routine cadaveric study of the abdominal region we observed a case where the hepatic flexure was interposed between the right dome of the diaphragm and the anterior surface of the liver. The liver appeared bilobulated and on the anterior surface the right and left hepatic lobes were separated by a deep furrow. The left wall of the furrow was attached to the falciform ligament. We have tried to explain such high position of hepatic flexure from an embryological point of view and to evaluate its possible clinical relevance. This abnormal site of hepatic flexure could cause chronic respiratory infections, twisting of the gut, volvulus and intestinal obstruction. Moreover it may alter the normal liver dullness on percussion. So clinicians and surgeons should be aware of this variant position of the hepatic flexure.

Factors affecting bowel gangrene development in patients with sigmoid volvulus

BACKGROUND AND OBJECTIVES

Sigmoid gangrene develops in 6.1% to 93.4% of sigmoid volvulus (SV) cases, and increases the mortality rate from 0% to 40% without bowel gangrene to 3.7% to 80%. This study aimed to investigate factors that induce bowel gangrene development in SV patients.

DESIGN AND SETTINGS

Retrospective study from a single center.

PATIENTS AND METHODS

We determined whether there was any correlation between sigmoid gangrene and the following factors: age, gender, a previous history of a volvulus, previous history of abdominal surgery, pregnancy, major comorbidities, shock, duration of symptoms, direction and degree of rotation of volvulus, and ileosigmoid knotting.

RESULTS

Of 442 patients, 271 (61.3%) had sigmoid gangrene. The presence of pregnancy was negatively cor.related with sigmoid gangrene development (P < .05), while comorbid diseases (P < .01), associated shock (P < .01), prolonged symptom duration (P < .05), overrotation (P < .05), and associated ileosigmoid knotting (P < .01) were positively correlated with bowel gangrene. However, no correlation was observed between sigmoid gangrene and the other studied factors.

CONCLUSION

An inverse correlation between pregnancy and sigmoid gangrene was observed. On the other hand, a positive correlation was noted between bowel gangrene and comorbid diseases, shock, prolonged duration of symptoms, overrotation, and associated ileosigmoid knotting.

Resection and primary anastomosis with modified blow-hole colostomy or Hartmann's procedure. Which method should be performed for gangrenous sigmoid volvulus?

AIM

To evaluate the efficacy of Hartmann's procedure and RPA with modified blow-hole colostomy for gangrenous sigmoid volvulus.

METHODS

Sixty-one patients operated on between January 2004 to September 2010 were reviewed retrospectively. The demographic data of the patients,clinical features, type of surgical procedure performed, postoperative complications, mortality and duration of hospital stay (DHS) after surgery were reviewed.

RESULTS

The mean hospital stay, wound infection and mortality did not differ significantly between the groups. Superficial wound infection rate was higher in group A (32% vs15%). Development of leaks secondary to stoma closure was not observed in any patient. During hospitalisation period; the postoperative complications were wound infection in four patients, intraabdominal abscess in two, evisceration and wound dehiscence in two, arrhythmia in six, pneumonia in eight.Medical and surgical complication rates of the groups were not different (p>0.05). When compared, the durations of intensive care unit (ICU) stay were not statistically different (p>0.05), but mean duration of hospital stay (DHS) was longer in group A than group B (p less than 0.05).

CONCLUSION

Sigmoidectomy should be the basic principle in the management of sigmoid volvulus.RPA with modified blow - hole colostomy provides satisfactory results. It is easy to perform in patients with sigmoid volvulus. RPA with modified blow - hole colostomy can be performed safely in selected patients without increasing morbidity and DHS.

Twists and turns in the body: an imaging spectrum

Life is full of twists and turns. These surprises can sometimes be wonderfully invigorating. Twists and turns can also occur in the body, however, sometimes with dangerous consequences. Torsion and volvulus are important causes of acute abdominal pain. The clinical symptoms and signs associated with torsion and volvulus are often non-specific and are difficult to diagnose clinically. Clinicians frequently rely on imaging methods to make the diagnosis. Prompt and accurate diagnosis is important to avoid the life-threatening complications of torsion and volvulus. Therefore, it is helpful to be familiar with the features of torsion and volvulus.

[A right sided colon volvulus with necrosis in a young patient. A case reported]

BACKGROUND

Colon volvulus (CV) is the twisting or rotation of an intestinal segment over the mesenterium, which causes occlusion and vascular compromise. It is a frequent disease in individuals over 65 years-old. We report a young patient with right CV and necrosis.

CLINICAL CASE

A 17 year-old male with clinical findings of acute abdomen presented in the emergency room. During the surgical procedure, a right sided was found, CV with ileocecal valve and caecum ischemia and right colon necrosis with mesenteric vessels thrombosis. The case presented begun with sudden abdominal pain, with intestinal occlusion data, and widespread peritoneal rebound tenderles which suggested an intestinal occlusion. A simple abdomen Rx showed prominent right side colon distention with air levels in small bowel and a "coffee bean" image, suggestive of CVA hemicolectomy with termino-lateral ileocolic anastomosis was performed.

CONCLUSIONS

Right-sided CV is considered as congenital in origin. They corresponded to 21% of cases in Mexico, with an average age of presentation at 62 years. The CV represents 10% of the causes of large bowel obstruction in Mexico. This is the first case in young people reported in Mexican literature.

A cruel twist: post-operative cecal volvulus

Cecal volvulus is an uncommon cause of intestinal obstruction, accounting for less than 1% of cases in Western countries. In the literature, it has been described as a complication following numerous common surgeries as well as a number of minimally invasive procedures. Presumably, it is more likely to occur following any surgical procedure which might require some degree of medial visceral rotation or disruption of the fusion plane between the cecum or ascending colon with the lateral peritoneum, providing sufficient mobility to allow for cecal volvulization to occur. In addition, cadaver and autopsy studies have also suggested that 10-20% of the population may have sufficient mobility of the colon to allow for volvulization. We present a review of the literature pertaining to the diagnosis and management of cecal volvulus as well as the case of J.R., a 78-year-old male with cecal volvulus six days following a right radical nephrectomy for renal cell carcinoma.

Mesenteric volvulus in children: two autopsy cases and review of the literature

Small bowel mesenteric volvulus when compared with mesocolonic volvulus, have not high incidence. Two autopsy cases of small bowel mesenteric volvulus in infants, highlighting the importance of a suspicion in early recognition of this rare but potentially fatal intra-abdominal emergency are reported. We also review the literature on possible aetiologies and mechanism of small bowel mesenteric volvulus, as well as its management.

Perforated colon volvulus coiling around the uterus in a pregnant woman with a history of severe constipation

A case of intestinal volvulus in both the sigmoid colon and cecum in a pregnant woman suffering from severe constipation is reported herein. The fetus was dead and the mother developed acute shock. The twisted sigmoid colon coiled twice around the uterus and was perforated. The mother died 10 h after the onset of severe abdominal pain. Volvulus should be considered when examining severe abdominal pain in a pregnant woman with a history of severe constipation. Early suspicion together with prompt intervention will minimize maternal and fetal morbidity and mortality of this rare complication of pregnancy.

Intestinal malrotations: a review and report of thirty cases

Intestinal malrotation is a developmental anomaly affecting the position and peritoneal attachments of the small and large bowels during organogenesis in foetal life. It has been defined as absent or incomplete rotation and fixation of the embryonic gut around the superior mesenteric artery. In the present paper, we review the definition, history, embryology/aetiology, epidemiology, symptoms and signs, diagnosis and treatment of intestinal malformations. Moreover, we report the records of 30 cases of malrotation admitted to our department over a period of five years. The final intraoperative diagnosis of the cases presented was 53.3% pure malrotation, 33.3% malrotation with mid-gut volvulus, 6.7% malrotation with duodenal atresia, 3.3% malrotation with Meckel's diverticulum and duodenal atresia, and 3.3% malrotation and biliary atresia. Preoperative imaging studies were performed for 27 cases and surgical management was successfully conducted without any mortality among the cases studied. This article provides an overview of basic and clinical aspects of intestinal malrotation. In addition, the signs and symptoms, imaging findings, and final intraoperative diagnoses presented by the subjects reported on are of potential use and clinical interest.

[Ulcerations in Chagas' megacolon operated at urgency and electively]

BACKGROUND

[corrected] The megacolon is a frequent disease in our emergencie hospital, and approached in the urgency by your complications as fecal impaction, volvulus and perforations. The ulcerations in the megacolons contribute as probable sites of perforations

AIM

To compare the frequencies of stercoral ulceration in Chagas' megacolon operated at urgency, by volvulus or fecal impaction, and electively, aiming at a better surgical conduct in the urgency surgery

METHODS

It was analyzed 356 anatomy-pathological exams from colon resection of operated patients due to Chagas' megacolon at urgency (102 cases; 29%) and electively (254 cases; 71%), from 1980 to 2000. The surgical urgency indications were attributed to volvulus (71 cases; 69,6%), fecal impaction (25 cases; 24,5%), perforated acute abdomen after rectal catheter or sigmoidoscopy (6 cases; 5,9%). The ulceration frequency was compared in both groups of resections, using chi-square

RESULTS

The pathological anatomy - of surgery resection obtained at urgency surgeries, showed 26 cases of ulceration (25,5%) and in electively resections were verified 21 cases of ulceration (8,25%). The difference observed was statistically significant. The comparison among the groups of volvulus; fecal impaction and volvulus with fecal impaction, separately with electively surgery group evidenced significant differences in relation to volvulus and fecal impaction

CONCLUSIONS

The higher frequency of ulcerations in the megacolon operated at urgency character emphasizes the needs of immediate resection of sigmoid colon, instead of conservative conduct of simple decompression colostomy, even in exploration laparotomy which the macroscopic examination of sigmoid does not show necrotic signs. This way, should prevent the occurrence of perforation in megacolon at mediate postoperative, with serious results.

Clinical considerations and therapeutic strategy for sigmoid volvulus in the elderly: A study of 33 cases

AIM: To evaluate different types of treatment for sigmoid volvulus and clarify the role of endoscopic intervention versus surgery.

METHODS: A retrospective review of the clinical presentation and imaging characteristics of 33 sigmoid volvulus patients was presented, as well as their diagnosis and treatment, in combination with a literature review.

RESULTS: In 26 patients endoscopic detorsion was achieved after the first attempt and one patient died because of uncontrollable sepsis despite prompt operative treatment. Seven patients had unsuccessful endoscopic derotation and were operated on. On two patients with gangrenous sigmoid, Hartmann’s procedure was performed. In five patients with viable colon, a sigmoid resection and primary anastomosis was carried out. Three patients had a lavage “on table” prior to anastomosis, while in the remaining 2 patients a diverting stoma was performed according to the procedure of the first author. Ten patients were operated on during their first hospital stay (3 to 8 d after the deflation). All patients had viable colon; 7 patients had a sigmoid resection and primary anastomosis, 2 patients had sigmoidopexy and one patient underwent a near-total colectomy. Two patients (sigmoidectomy-sigmoidopexy) had recurrences of volvulus 43 and 28 mo after the initial surgery. Among 15 patients who were discharged from the hospital after non-operative deflation, 3 patients were lost to follow-up. Of the remaining 12 patients, 5 had a recurrence of volvulus at a time in between 23 d and 14 mo. All the five patients had been operated on and in four a gangrenous sigmoid was found. Three patients died during the 30 d postoperative course. The remaining seven patients were admitted to our department for elective surgery. In these patients, 2 subtotal colectomies, 3 sigmoid resections and 2 sigmoidopexies were carried out. One patient with subtotal colectomy died. Taken together of the results, it is evident that after 17 elective operations we had only one death (5.9%), whereas after 15 emergency operations 6 patients died, which means a mortality rate of 40%.

CONCLUSION: Although sigmoid volvulus causing intestinal obstruction is frequently successfully encountered by endoscopic decompression, however, the principal therapy of this condition is surgery. Only occasionally in patients with advanced age, lack of bowel symptoms and multiple co-morbidities might surgical repair not be considered.

[Cecal volvulus: anatomical bases and physiopathology]

The aim of this study was to report on 7 cases of cecal volvulus and to evaluate anatomical variations allowing this pathology.

METHODS

7 consecutive patients (4 women) treated for cecal volvulus were included. The clinical and paraclinical parameters, the management of patients, were studied through an analysis of medical histories. Contributing factors for cecal volvulus were analysed by an anatomical study and literature analysis.

RESULTS

all patients complained about abdominal pain associating or not to acute intestinal obstruction. The diagnosis was radiographically carried out for 3 patients. All patients were treated by surgical procedures (right colectomy: n = 6, cecopexy: n = 1). The mortality and morbidity rates were 0 percent and 28 percent. Fifteen anatomical subjects had complete dorsal fixation (75 percent). Seven out of them had retrocecal recessus. Five subjects (25%) had a non fixed cecum, according to the literature relating a non-fixation of ascending colon to parietal peritoneum in 11 to 25 percent of the cases. The main factor of risk is the female gender.

CONCLUSION

cecal volvulus can be advocated for patients having abdominal pain. The diagnosis is rarely based on an only clinical examination or abdominal radiographs alone. Tomodensitometry is most performing examination for diagnosis. An early and appropriate management of patients is necessary to avoid significant morbidity and mortality rates.

Ileal resection for gangrenous ileal volvulus in a term pregnancy: a case report

Mechanical bowel obstruction is a rare complication of pregnancy, usually seen in small bowel, and most commonly due to an adhesive band or hernia. Surgical evaluation is the method of treatment in cases that do not answer to conservative support procedures. A very rare case of small-bowel strangulation caused by herniation of a loop of ileum through another ileoperitoneal adhesion is presented.

[Volvulus of the lienal flexure of the colon]

The authors present the case-report of a 72-year-old man who was admitted to our clinic with acute abdomen symptoms and signs of acute peritonitis. The cause was rather rare diagnosis of left colon flexure volvulus. This find caused extensive gangrene of colon. Solution was subtotal colectomy, the patient is now 4 months after surgery in good shape.

Role of ganglion cells in sigmoid volvulus

The aim of this study was to clarify the role of ganglion cells in the development and recurrence of sigmoid volvulus. We analyzed 9 samples obtained from 9 patients who had undergone sigmoidectomy for sigmoid volvulus, and, for comparison, 18 samples from 18 patients who had undergone sigmoidectomy or low anterior resection for rectal cancer. Neuron-specific enolase was used for immunohistochemical staining to detect ganglion cells, and the number of ganglion cells in 20 contiguous fields was counted at 200? magnification. The average number of ganglion cells per 1000 cm(3) was corrected using the ratio of the circumference of the resected sigmoid colon to the average circumference in the control group. The raw numbers of ganglion cells in the Meissner's and Auerbach's plexuses in the volvulus group were significantly lower than those in the non-volvulus group (Meissner: p = 0.017, Auerbach: p = 0.007). The circumference of the resected sigmoid colons with volvulus was greater than that of those without volvulus (p = 0.00013). There was no significant difference in the corrected numbers of ganglion cells in the Meissner's plexus or Auerbach's plexus per 1000 cm(3) between the volvulus and non-volvulus groups (Meissner: p = 0.410, Auerbach: p = 0.890).Furthermore, there was no significant difference in the corrected numbers of ganglion cells between the revolvulus and non-revolvulus groups. These findings led us to conclude that functional disorder of bowel movement or elongation of the bowel in sigmoid volvulus or revolvulus is not related to the number of ganglion cells in Auerbach's or Meissner's plexus.

Internal herniation concurrent with ileosigmoid knotting or sigmoid volvulus: Presentation of 12 patients

BACKGROUND

Internal herniation concurrent with ileosigmoid knotting or sigmoid volvulus is an unusual and complex form of closed-loop obstruction that may result in a fatal outcome unless treated timely and properly. The aim of this article was to review our experience with this condition, with emphasis on the etiopathogenesis, clinicopathologic features, and treatment options.

METHODS

We conducted a retrospective analysis of medical records of 12 patients treated at 2 university hospitals over a period of 30 years between 1970 and 2000.

RESULTS

In this series, the internal herniation resulted in ileosigmoid knotting in 8 cases, whereas it was concomitant with sigmoid volvulus in 4 cases. The types of internal herniation were identified as transmesenteric through the Treves field in 8 patients and as transomental, intersigmoidal, pericecal, and around omphalomesenteric fibrous cord in 1 patient each. The rate of gangrenous bowel was 100%. En bloc resection for combined gangrene of small bowel and large bowel was the treatment of choice in 7 patients, of whom 5 underwent the Hartmann's procedure and 2 underwent primary sigmoidectomy-anastomosis in addition to primary enterectomy-anastomosis. Primary sigmoidectomy-anastomosis and Mikulicz's procedure were performed in 2 patients for gangrenous sigmoid colon only. Three patients underwent primary enterectomy-anastomosis for gangrenous small bowel only. The morbidity rates and the mortality rate were both 33.3%. The mean length of hospital stay following emergency operations was 11.2 days.

CONCLUSIONS

In particular, surgeons who are from developing countries that form the world's "volvulus belt" should be aware of this entity's features and be ready to perform an appropriately selected surgical option for a given patient to accomplish the optimal clinical outcome.

Small bowel volvulus leading to gangrene and short bowel syndrome

A young man was operated for acute abdomen. Laparotomy revealed small bowel diverticulosis with very short mesentery leading to volvulus of near total small bowel. Resection and end to end anastomosis was performed. Patient ended up with short bowel syndrome.

Primary small bowel volvulus in Nepal

Small bowel volvulus is a rare cause of intestinal obstruction. Primary small bowel volvulus occurs without any predisposing cause. It is rare in Western countries but common in Africa and Asia. It is the most common cause of bowel obstruction in Nepal (excluding incarcerated external hernias). Early diagnosis and management is essential to avoid infarction of bowel. Persistent central abdominal pain is characteristic. There is no single specific diagnostic clinical sign or abnormality in laboratory or radiological findings. There is no role of conservative management and, in suspected cases, early laparotomy should be done to avoid bowel infarction. In follow-up patients may present with stricture formation or recurrence of bowel volvulus.

Cecal volvulus in two African green monkeys (Cercopithecus athiops sabeus)

Following short-term signs of weakness, depression, and/or anorexia of less than 24 h, two adult male African green monkeys (Cercopithecus aethiops sabeus) of St. Kitts origin died from complications of cecal volvulus. Gaseous distention was radiologically apparent in one animal. Necropsy of both monkeys revealed cecal volvulus, one at the ileocecal junction and one involving a segment of the distal portion of the ileum and cecum. Congestion and hemorrhage were evident microscopically in the lamina propria of the affected intestine, with variable necrosis.