www.downstatesurgery.org Surgical Management of Sigmoid Volvulus Maria Georgiades, MD October 18, 2012 www.downstatesurgery.org Case Presentation O 20 yo male with abdominal distention, nausea and 1 episode of emesis O Passed flatus one day prior to admission O Last bowel movement 5 days ago O No history of chronic constipation www.downstatesurgery.org Case Presentation O PMH: none O VS: T 97.4F BP 136/98 HR 85 RR O PSH: none 16 O2 sat 95% O General: AAO x3, no acute distress O CV: RRR, S1S2 normal O Pulm: clear to auscultation O Meds: none 14 9.9 213 45 138 101 12 113 3.9 22 0.7 O Abd: soft distended, tympanic 7.3 20 59 4.6 13 1 Lactate: 1.7 A/L: 17/15 to percussion; no bowel sounds, diffusely tender O DRE: no stool in vault, no masses, no gross blood www.downstatesurgery.org AXR www.downstatesurgery.org CT SCAN www.downstatesurgery.org CT SCAN www.downstatesurgery.org CT SCAN www.downstatesurgery.org Hospital Course O HD #1- flexible sigmoidoscopy and decompression w/ rectal tube placement HD#2: 3-4 bowel movements - rectal tube removed HD#4: Discharged to home www.downstatesurgery.org BARIUM ENEMA www.downstatesurgery.org BARIUM ENEMA www.downstatesurgery.org BARIUM ENEMA www.downstatesurgery.org Clinical Course O 8/20- Laparoscopic sigmoidectomy O POD#0- clear liquid diet O POD#1- advanced diet and discharge to home O Pathology- segment of colon with no significant pathologic changes; margins viable www.downstatesurgery.org Outline O History of volvulus O Epidemiology of sigmoid volvulus O Clinical presentation O Radiography O Surgical Techniques O Differential on colonic obstruction O Questions www.downstatesurgery.org History of Volvulus O “volvere “- to twist or turn O Ancient Egypt in the Ebers Papyrus O 400 BC –Hippocrates O High surgical mortality rates O 1947- Bruusgaard O Decreased mortality with endoscopic decompression www.downstatesurgery.org Incidence, Etiology of sigmoid volvulus O 3rd most common cause of colon obstruction O LEADING CAUSE OF ACUTE COLON OBSTRUCTION IN DEVELOPING COUNTRIES O 2-7% of intestinal obstructions in the US O Age of onset: 60-70 years; M>F O Risk factors: chronic constipation, laxatives, colonic motility disorders; pregnancy www.downstatesurgery.org Epidemiology of sigmoid volvulus O Africa, India, the Middle East, and Latin America- 54%! O Young; 80% male O High fiber diet www.downstatesurgery.org Pathogenesis of sigmoid volvulus O Redundant loop of sigmoid colon with narrow base of attachment of the mesosigmoid O Varied degree of torsion: O 180° (30%) to 540°(10%) O 50% of patients have 360° twist O Counterclockwise and 15-25 cm from anus www.downstatesurgery.org Clinical Presentation O Symptoms: O Intermittent crampy abdominal pain O Progressive distention O Nausea and vomiting O Constipation or obstipation; empty rectum O 40-60% have history of previous attacks www.downstatesurgery.org Radiographic Studies O AXR diagnostic 50% O Distended loop of bowel extending from LLQ to RUQ O “bent inner tube” or “omega” O Barium enema-90% O “bird’s beak” O Contraindicated if strangulation is suspected www.downstatesurgery.org AXR AND DIAGRAM OF SIGMOID VOLVULUS www.downstatesurgery.org BARIUM ENEMA OF SIGMOID VOLVULUS Bird’s beak www.downstatesurgery.org CT scan of colonic volvulus www.downstatesurgery.org When do we operate? O (1) possibility of colonic ischemia O Fever O Leukocytosis O Elevated lactic acid level O (2) failure of endoscopic detorsion O If successful endoscopic decompression and no ischemic changes  elective resection www.downstatesurgery.org Preopeative Preparation O Correct electrolyte imbalances O Nasogastric decompression www.downstatesurgery.org Surgical Management O If gangrenous bowel O Sigmoid colectomy + end colostomy + mucus fistula or Hartmann’s procedure O When viable bowel during emergency laparotomy: O Simple detorsion O Colopexy O Mesoplasty O Colectomy with colostomy O Colectomy with primary anastamosis www.downstatesurgery.org Simple detorsion of sigmoid volvulus O Safest O Intraoperative time is limited O 40-50% recurrence rate O MUST be followed by a second operative procedure www.downstatesurgery.org Sigmoidopexy O Suturing the sigmoid colon to the anterior abdominal www.downstatesurgery.org Mesosigmodoplasty O Plicating and shortening the sigmoid mesocolon O 2-28% recurrence rate www.downstatesurgery.org Sigmoid Resection and Primary anastomosis O Performed safely even in urgent setting O Surgical resection during the SAME hospital stay is recommended O 15-20% mortality rates with significant comorbidities O 2 year follow up of 30 patients there were no wound dehiscence or postoperative abdominal abscess 1 1Naseer A et al. One state emergency resection and primary anastomosis for sigmoid volvulus. J Coll Physicians Surg Pak 2010; 20:307-9 www.downstatesurgery.org www.downstatesurgery.org www.downstatesurgery.org www.downstatesurgery.org www.downstatesurgery.org Sigmoid volvulus: Long- term clinical outcome and review of literature www.downstatesurgery.org Sigmoid volvulus: Long- term clinical outcome and review of literature www.downstatesurgery.org Cecal Bascule O Cecal bascule O Bowel folds anteriorly and superiorly over a fixed ascending colon O No axial rotation of the bowel O No mesenteric vascular obstruction www.downstatesurgery.org Cecal Volvulus O Cecal volvulus O 10-20 years younger O RF: pregnancy, surgery, obstructing lesions, congenital bands/malrotation O AXR O Distended loop of bowel in LUQ with retained haustral marking and RLQ void of cecum O Surgical resection www.downstatesurgery.org AXR AND DIAGRAM OF CECAL VOLVULUS www.downstatesurgery.org ALGORITHM FOR SIGMOID VOLVULUS www.downstatesurgery.org References O Cameron: Current Surgical Therapy, 10th edition O Fazio: Current Therapy in Colon and Rectum, 2nd edition O Katsikogiannis N et al. Management of sigmoid volvulus avoiding sigmoid resection. Case Rep Gastroenterol. 2012 May; 6 (2): 293-9. O Khan MR et al. Sigmoid volvulus in pregnancy and puerperium: a surgica and obstrectric catastrophe. World J Emerg Surg. 2012 May 2; 7(1):20 O Osiro SB et al. The twisted colon: a review of sigmoid volvulus. Am Surg. 2012 Mar; 78(3):271-9 O Suleyman O, et al. Sigmoid volvulus: a long term surgical outcomes and review of literature. S Afr J Sur. 2012 Feb 14; 50 (1): 9-15 www.downstatesurgery.org Question1 A 69 year old man with no co-morbidities presents with the gradual onset of sharp, crampy lower abdominal pain and distention beginning a day previously. 7 years ago he had an episode of sigmoid volvulus that required colonic decompression but declined surgical intervention. 2 years ago his colonoscopy was normal. 24 hours after successful endoscopic decompression with sigmoidoscopy, abdominal distention recurs and AXR confirms recurrent colonic distention. The next step in management is: (a) repeat sigmoidoscopy with rectal tube placement (b) neostigmine infusion (c) soapsuds enema (d) sigmoid colon resection (e) complete colonoscopy www.downstatesurgery.org Question 2 O All of the following are risk factors for developing sigmoid volvulus except: (a) Pregnancy (b) High fiber diet (c) Chronic constipation (d) Clostridium difficile (e) Laxative use www.downstatesurgery.org Question 3 A 65 year old institutionalized patient presents with a 2- day history of abdominal distention, nausea and obstipation. Physical exam is significant for marked distention with mild diffuse abdominal tenderness, no guarding or rebound. WBC 10,000 cells/μL. Plain films reveal a massively dilated, inverted U- shaped (omega) loop of bowel. Management should consist of: (a) Endoscopic detorsion (b) Endoscopic detorsion followed by elective sigmoid colectomy (c) Endoscopic detorsion followed by elective sigmoid colectomy if a recurrence (d) Exploratory laparotomy with sigmoid colectomy, on-table lavage, and primary anastomosis (e) Exploratory laparotomy with sigmoid colectomy, proximal colostomy and oversew rectal stump www.downstatesurgery.org Hirschsprung’s disease O Congenital megacolon O Failure of neural crest cell migration to the distal large intestine O Absence of ganglion cells in Auerbach’s plexus O Failure of relaxation and functional obstruction O Proximal bowel becomes progressively dilated O Rectoanal manometry