colonic volvulusvolvulus” is a more appropriate description because the cecum cannot technically...

Scientifi c American SurgeryDOI 10.2310/7800.2126

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© 2014 Decker Intellectual Properties Inc

gastrointestinal tract and abdomen

C O L O N I C V O L V U L U S

Kevin R. Kasten, MD, Peter W. Marcello, MD, and Todd D. Francone, MD, MPH

Colonic volvulus is a rarely encountered surgical entity whose etymology derives from the Latin volvere, meaning “to roll” or “to twist.” The diagnosis dates to the Papyrus Ebers, circa 1550 bc in ancient Egypt, whereby if a patient “… [did] not evacuate it for a twist in the bowel and if the phlegm does not fi nd a way out then it shall rot in the belly.” In ancient Greece, Hippocrates described the use of injecting air or a long suppository to manage volvulus.1 Current data reveal sigmoid volvulus as the most common colonic volvu-lus, followed by volvulus of the cecum, transverse colon, and splenic fl exure.1 Overall, colonic volvulus accounts for 3 to 5% of bowel obstructions in the United States. This percentage increases to nearly 50% of bowel obstructions in countries with endemic rates of colonic volvulus.2 Despite a low incidence in the United States, diagnosis, manage-ment, and patient outcome depend on an appropriate index of suspicion and adherence to the proposed algorithm [see algorithm].

Defi nition, Pathogenesis, and Epidemiology

cecal volvulus

Remarkably, cecal volvulus was fi rst described in 1646 by Hildanus3 and observed by von Rokitansky 200 years later in 1837.4 Although originally reported as a rotation of the cecum, more specifi c defi nitions and classifi cations have evolved. In 1905, Corner and Sargent described three forms of cecal volvulus,5 which were later adapted by Graham6 and clarifi ed by Weinstein.7 Cecal volvulus may be defi ned as (1) rotation along an oblique axis with the cecum occupy-ing the periumbilical or left upper quadrant, (2) rotation along the cecum’s long access, or (3) cecal bascule, whereby the posterior surface folds forward, creating a transverse axis of rotation.5–7 Rotation along an oblique axis is consid-ered most common due to rotation around two fi xed points as opposed to one in rotation along the long axis. In a 20-year Mayo Clinic experience, only 10% of cecal volvulus cases involved a cecal bascule, which is sometimes attribut-ed to a transverse cecal band from previous surgical inter-vention.2 Although some authors suggest that “right colon volvulus” is a more appropriate description because the cecum cannot technically volvulize, we subscribe to and use the more common nomenclature of “cecal volvulus” in this topic review.8,9

The pathogenesis of cecal volvulus likely involves myriad factors, including embryologic development, colonic dys-motility, adhesion formation, and dietary intake. During embryologic development, failure of complete intestinal rotation creates an elongated mesentery and a lack of right colon fi xation to the lateral sidewall. Based on cadaver stud-ies, abnormality in cecal fi xation allowing for volvulus or folding is present in upwards of 37% of the population.9–11 However, the incidence of cecal volvulus is drastically lowe r, suggesting that other factors may be essential in the

development of pathologic disease. Published observations implicate adhesions from previous abdominal surgery as the lead point to initiate the twisting of the colon in cecal volvu-lus.2,12,13 Ballantyne and colleagues demonstrated that 27% of volvulus patients were within 2 weeks of a previous opera-tion.2 In addition to abdominal adhesions, the study also suggested decreased colonic motility, adynamic ileus, and distal obstruction as contributing factors to cecal volvulus formation by creating a heavy dilated cecum more suscep-tible to twisting.2 This may in part explain why 12 to 28% of acute volvulus patients are diagnosed during admission for another medical reason.12,14 For example, delayed colonic transit may contribute to cecal volvulus formation in preg-nant females; however, upward displacement of a mobile right colon is believed to be a more likely culprit.15,16 Perhaps the strongest contributor is consumption of a high-fi ber diet. Worldwide data consistently demonstrate a signifi cantly higher rate of volvulus within the “volvulus belt” countries, where “rough” diets are common.17 Currently, the patient is likely predisposed due to an anatomic variant producing a mobile colon, with volvulus occurring due to tension from obstruction, adhesion, pregnancy, or other processes elongating and dilating the colon.

An entity exists known as “mobile cecum syndrome,” which was originally described by Inglefi nger in 194218 and expounded on by Rogers and Harford in 1984.19 It is marked by chronic, subacute, intermittent torsion due to the lack of right colon mesenteric fusion at the lateral peritoneum. Signs and symptoms are vague, including abdominal distention and chronic periumbilical or right lower quadrant pain. Patients often require multiple evaluations without a defi nitive diagnosis that distinguishes it from a “true” cecal volvulus.20,21 Up to 50% of acute volvulus patients report recurrent symptoms associated with “mobile cecum syn-drome.”19 However, roughly one in 40 patients with “mobile cecum syndrome” are subsequently treated for acute volvu-lus.22 Although typically diffi cult to diagnose due to nonspe-cifi c symptoms, awareness of the condition may allow for elective correction prior to presentation of an acute volvulus.

The demographics and epidemiology of cecal volvulus are diffi cult to ascertain, even in “high-risk” parts of the world [see Table 1]. Much of the data comes from single-center series and case reports, making generalization across a heterogeneous population tenuous at best. In the United States and other Western countries, the rate of cecal volvulus is about 1 to 3% of all acute intestinal obstructions,10,22,23 equivalent to 2.8 to 7.1 per million population per year.22 Interestingly, the incidence of cecal volvulus over the past 3 to 5 years in the United States is increasing.24 Cecal volvulus accounts for 10 to 60% of all colonic volvulus cases per year.2,14,22,25 The worldwide incidence of cecal volvulus, in particular areas located in eastern Europe, Russia, and Africa, is considered much higher than in the Westernized world. At the turn of the 20th century, Scandinavian coun-tries cited cecal volvulus as the source of obstruction in

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Scientifi c American Surgery

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gastro colonic volvulus — 2

Approach to the Patient with Colonic Volvulus

Peritonitis, Shock,Suspected Gangrene Stable

Gangrenous Bowel

Low-Risk Patient

Resection + 1˚ Anastomosis(All volvulus types)

Resection + Stoma Creation(All volvulus types)

Viable Bowel

Resection + 1˚ Anastomosis(All volvulus types)

Failure or Complication

A. Observation + Bowel RegimenB. Endoscopic Colonic Fixation (PEC)C. T-Fastener Colonic FixationD. Resection + Stoma Creation

Resection + 1˚ Anastomosis

High-Risk Patient

Low-Risk Patient

A. Resection + Stoma Creation (All volvulus types)B. Detorsion with colopexy or mesocoloplasty

High-Risk Patient

Cecal, Transverse, & SplenicVolvulus; Ileosigmoid Knot

Emergent Surgery

Imaging (CT, WSE)

Sigmoid Volvulus

Endoscopic Decompression+ Rectal Tube

Success

Elective Surgery

Low-Risk PatientHigh-Risk Patient

Volvulus Suspected

Clinical Evaluation


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almost 12% of cases.26 The higher incidence of cecal volvulus in these countries is theoretically attributed to higher fi ber intake in non-Western countries.6,27 However, more recent data suggest that the incidence in endemic countries is closer to 1%, similar to that of the United States and Canada.28

Historically, the mortality of cecal volvulus was above 50% in operative and 100% in nonoperative cases.29 Modern advancements in diagnosis and management have reduced operative mortality to 12 and 33% for viable and nonviable colon, respectively.2,30 The contribution of gender to the risk of volvulus is diffi cult to determine. Some groups have dem-onstrated a male27 or female predominance,2,24,31,32 whereas others cite equal distribution.28 The age at presentation is usually in the 5th and 6th decades of life, which is younger than sigmoid volvulus2,24,33 but older than previously reporte d during the fi rst part of the 20th century.5 Groups suggest that age at presentation is related to exterior infl uences, such as diet, culture, and geographic region.15 Due to the heterogeneous nature of the disease, identifi cation of inde-pendently associated risk factors, aside from anatomic predisposition, may prove diffi cult to defi ne.

transverse colon volvulus

Volvulus of the transverse colon is an exceedingly rare cause of abdominal pain and intestinal obstruction. Review of the literature demonstrates fewer than 100 cases, although the absolute number of patients with this diagnosis is likely much higher.34,35 In a 20-year review of 137 colon volvulus patients at a tertiary referral center, authors at the Mayo Clinic identifi ed four cases of transverse colon volvulus, consistent with an incidence of 3 to 4% of colonic volvulus cases.2,34,36,37 Mortality in patients with ischemic bowel at presentation is estimated at 33%, versus approximately 6% in nongangrenous cases.34,38–40 From 2002 to 2010 in the National Inpatient Database, Halabi and colleagues showed 16.7% mortality for all transverse volvulus patients undergoing resection.24

Volvulus of the transverse colon is rare; hence, elucidation of predisposing factors is diffi cult, supporting the broadly accepted observation that a short, broad-based transverse colon mesentery protects against volvulus. Scattered reports suggest that chronic constipation causing colonic elonga-tion,34 a history of adhesive bands from previous abdominal surgery,34 distal bowel obstruction from stricture or carci-noma,41,42 and congenital anatomic abnormalities creating a fl oppy mesentery are potential risk factors for the develop-ment of a transverse colon volvulus.34,42,43 Some data suggest a higher incidence in women, which is ascribed to female predominance of mesenteric elongation.2,34,36 A peak inci-dence in the second, third, and seventh decades of life was suggested in one review; however, patients of any age have been reported [see Table 1].36 Gerwig published four anatomi c

Table 1 Demographics of Colonic Volvulus in the United StatesFactor Cecal Transverse Splenic Flexure Sigmoid Ileosigmoid Knot

Gender M:F F>M M:F M>F M>>F

Age 5th–6th decade 2nd–3rd, 7th decades 5th–7th decades 7th–8th decades 4th–5th decades

Race Black, Middle Eastern > white

Unknown Unknown Black, Middle Eastern > white

Black, Middle Eastern > white

variations felt to predispose patients to a transverse colon volvulus, including (1) elongation of the mesentery, (2) absence of mesentery with mobile bowel, (3) closely approx-imated points of fi xation at the hepatic and splenic fl exures, and (4) congenital or acquired adhesions.44

splenic flexure volvulus

Volvulus of the splenic fl exure is the rarest form of colonic volvulus, accounting for 1 to 3% of all cases.1,2,45–47 Review of the literature demonstrates fewer than 75 cases, with Ballantyne and colleagues reporting only three cases over 20 years at the Mayo Clinic.2 Some authors suggest that it may be a more common disease entity that is underre-ported due to spontaneous detorsion or reduction induced by imaging studies.45,48 The fi rst case report was published by Glazer and Adlersberg in 1953,49 shortly followed by Buenger in 1954.48 Males and females are equally likely to be diagnosed.2,45 Most reports are of patients in the fi fth, sixth, and seventh decades of life, although any age may be affected [see Table 1].1,2,45 Minimal racial data exist to demon-strate any clear etiologic differences. According to limited data, a predisposition for splenic fl exure volvulus is stron-gest in patients with absence of gastrocolic, phrenocolic, and splenocolic ligaments, occurring congenitally or opera-tively.1,45,46 Adhesive bands from previous surgery,48,50,51 chronic constipation,1,2 and pseudo-obstruction have all been implicated.52 As with other forms of colonic volvulus, a distal obstruction, either from mass or colonic dysmotility, predisposes to splenic fl exure twisting. Splenic fl exure vol-vulus is suggested as more likely to reduce spontaneously, explaining its lower incidence, lower mortality, and higher relative success rates with nonoperative intervention in the acute setting.48,53

sigmoid volvulus

von Rokitansky is credited with the fi rst report of sigmoid volvulus in the West.4 Sigmoid volvulus is defi ned by the axis of bowel rotation, either mesenteroaxial or organo-axial.54 Interestingly, the existence of an organoaxial form is disputed based on data stating that torsion during sigmoid volvulus relates only to mesenteroaxial rotation.54–56 In a small anatomic study, Bhatnagar and colleagues illustrated seven patterns of sigmoid colon shape, the most common being a mesocolon that is vertically longer than wide (doli-chomesocolic).57 The opposite, brachymesocolic, is a meso-colon wider than vertical length. Although men were more likely than women to have a dolichomesocolic sigmoid, no differences based on age were shown. Some authors argue that this anatomic predisposition is genetic, illustrated by endemic rates of sigmoid volvulus among certain ethnicities, such as Indians, Africans, and Turks.54,55,57–62 Others suggest the lack of pediatric cases and high


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incidence within elderly and psychiatric patients as support for an acquired etiology of sigmoid volvulus.63 Ultimately, the question of genetic versus sporadic sigmoid volvulus remains unanswered.

As with cecal volvulus, pathogenesis of sigmoid volvulus begins with a freely mobile, frequently redundant colon and an elongated, narrow mesentery.54,62,64 The directionality of torsion can be counterclockwise or clockwise, with the majority of patients experiencing counterclockwise rotation.55 Increasing degrees of colonic rotation produce physiologic (< 180º), obstructive (> 180º), and strangulating (> 360º) volvulus.54,65,66 As rotation increases, venous outfl ow decreases, leading to bowel edema and eventual vascular insuffi ciency as arterial infl ow becomes limited. Factors for the development of sigmoid volvulus include anatomic predisposition combined with sources of colonic distention, creating a torsion effect. Excessive distention may result from several factors, including rapid fecal loading after fast-ing (the Islamic holiday of Ramadan, postwar, postharvest), adhesions from previous surgery, pregnancy, and chronic constipation.54,55,58,59,62,64,67,68 Several sources of chronic consti-pation include customs of holding stooling for long periods of time, medication or narcotic use, decreased activity level, and increased age. Recent work implicates colonic disten-tion as the inciting event leading to torsion, especially at the antimesenteric border, where this portion of colon gains more length than the mesenteric side during distention. Subsequent peristalsis forces a predisposed colon to further twist, leading to varying degrees of volvulus.54,69,70 Despite a proposed understanding of how sigmoid volvulus may occur, a defi nite precipitating event or series is currently unknown.

Sigmoid volvulus is the most common form of colonic volvulus. In endemic parts of the world, upwards of 50% of intestinal obstructions are related to sigmoid volvulus.54 However, sigmoid volvulus is responsible for less than 5% of all intestinal obstructions in the United States. Nonethe-less, these fi gures do not necessarily represent a signifi cant difference in the incidence of sigmoid volvulus between these parts of the world. In fact, recent evaluation of sigmoid volvulus in the United States reported an incidence of 1.67 per 100,000 person-years, almost identical to an endem-ic African cohort.2,54,71 Not surprisingly, sigmoid volvulus is associated with the elderly population (mean age 68, peak incidence in the eighth decade) in the United States versus a predominance in young males in more endemic parts of the world [see Table 1].24,54 Several studies demonstrate a strong male predominance due to higher rates of dolichomesocolia and factors such as stooling patterns.24,54,57,72 Theories for lower female incidence include more accommodating abdominal musculature and a wider pelvis, allowing for a distended sigmoid to spontaneously reduce.66

ileosigmoid knot

Ileosigmoid knot is a variant of sigmoid volvulus fi rst described by Parker in 1845 and later illustrated by Faltin in autopsy studies.73,74 Rare in the United States, ileosigmoid knot is a signifi cant cause of intestinal obstruction within the developing world, which is considered the “volvulus belt.” A recent review identifi ed more than 280 cases in the worldwide literature.75 This volvulus variant involves ileum

wrapping around an elongated sigmoid mesentery with eventual creation of a “knot.”76 Four distinct types of knot exist, originally described by Alver and colleagues [see Figure 1].77 The most common is type I, whereby the ileum actively wraps itself around the sigmoid mesentery in a clockwise or counterclockwise direction; it occurs in 48.5% of patients. In type II, the sigmoid colon wraps around the ileum in a clockwise or counter-clockwise direction, occurring in 13.2% of patients. Less commonly, the surgeon is unable to defi ne how the knot occurred (type IV or undeter-mined); rarely, the ileocecum actively wraps around the sigmoid mesentery (type III).77 A recently proposed change to this classifi cation involves simply identifying the patient by the presence or absence of gangrenous bowel.78

The pathogenesis of ileosigmoid knot is multifactorial, with dietary intake reported to be the most important. As with all forms of volvulus, congenital or surgical manipula-tion of mesentery produces a hypermobile small bowel and a largely redundant sigmoid colon with a narrow mesen-tery.76,77,79 When anatomic factors are present in a patient population known for prolonged fasting followed by rapid intake of high fi ber and liquid, ileosigmoid knotting is more likely to occur.77,79 In Uganda and Afghanistan, the Bagan-dans and Mohammedans eat an entire day’s worth of food and liquid at a single sitting.77,79 During Ramadan, the inci-dence of ileosigmoid knot increases 10-fold in Mohammed-ans, further supporting the role of diet and dietary habits in the development of this disease process.77,79 The prevailing theory states that rapid movement of a high-bulk meal forc-es previously empty small bowel loops (from fasting) into a clockwise rotation around a redundant sigmoid mesentery. Peristalsis of the small bowel then forces the bowel to progressively wrap, creating a knot.74,77,79,80 The end result is formation of double closed-loop obstructions that require emergent surgical intervention.

Ileosigmoid knot causing bowel obstruction is so exceed-ingly rare in the United States that one report described only two known cases.76 As such, our understanding comes from countries at highest risk, including Finland, Uganda, and Turkey.77,79 Males account for more than 80% of patients.75 In a review of 280 cases, patients ranged in age from 4 to 90 years, with a mean age of 40 [see Table 1].75 The reported mortality for ileosigmoid knot spans 0 to 48%, with a mean of 35.5%.75 Higher mortality is attributed to the fact that 80% of patients have gangrenous bowel at laparotomy.77,79,81 Aside from dietary practice, predisposing factors may include embryologic herniation at the ligament of Treves, whereby the incidence of volvulus approaches 17% as bowel herniates upwards.82 Adhesive disease from previous surgical intervention, fi brous omphalomesenteric duct, or Meckel diverticulum may create a fulcrum by which volvulus occurs.75,82 Less commonly, pericecal herniation and mesentericoparietal hernia at Waldeyer fossa can incite volvulus.82 Patients with an ileosigmoid knot must be moni-tored for future development of sigmoid volvulus if the colon is not resected during the initial operative interven-tion. These patients often harbor a narrow-based sigmoid colon mesentery, which predisposes them to both ileosig-moid knot and sigmoid volvulus.74,80 Knowledge of predis-posing anatomic and dietary factors aids the surgeon in quickly diagnosing this rapidly fatal condition.


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a

Ileum Wrapped AroundSigmoid ColonSigmoid Colon

Cecum

Rectum

b

Sigmoid ColonWrappedAround Ileum

c

Cecum and Terminal IleumWrapped AroundSigmoid Colon Figure 1 Types of ileosigmoid knot. (a) The most common is type

I, whereby the ileum actively wraps itself around the sigmoid mesen-tery in either a clockwise or counterclockwise direction; it occurs in 48.5% of patients. (b) Type II, whereby the sigmoid colon wraps around the ileum in a clockwise or counterclockwise direction, occurs in 13.2% of patients. Less commonly, the surgeon is unable to defi ne how the knot occurred (type IV or undetermined) (not pictured); rarely, the ileocecum actively wraps around the sigmoid mesentery (type III) (c).

Clinical Evaluation

history

Accounting for 10 to 15% of all colonic obstructions, colonic volvulus follows malig-nancy and diverticulitis as the third most common cause of colonic obstruction in the United States.2 This represents 9,000 to 15,000 surgical

admissions annually at a cost of $69 to 115 million.83 In several parts of the “volvulus belt,” indirect and direct costs are considered much higher due to the impact on lost pro-duction and use of limited overall health care resources. As such, it is incumbent on the clinician to reduce morbidity through prompt decision making and diagnosis. The patho-physiology of colonic volvulus results in colonic obstruc-tion, varying degrees of ischemia from obstruction of venous outfl ow and arterial infl ow, and a clinical history consistent with the diagnosis. Admittedly, these symptoms create a


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long differential, including other sources of small and large bowel obstruction (mass, stricture, infl ammatory bowel disease, hernia, malrotation, adhesive disease, pseudo-obstruction, paralytic ileus), giant colonic diverticulum, Hirschsprung disease, acute and chronic pancreatitis, and mesenteric ischemia [see Table 2].

The diagnosis of colonic volvulus results from a detailed history supplemented by appropriate diagnostic imaging. Lindner and Marcus showed an appropriate history com-bined with specifi c radiographic fi ndings allowed for preop-erative diagnosis.84 Most volvulus patients will present with acute onset of crampy, colicky abdominal pain.2,32,85 The duration of pain preceding the presentation of cecal volvu-lus is often shorter (24 to 48 hours) than in patients with sigmoid volvulus (3 to 4 days).12,86 In a study of sigmoid volvulus, only 17% of patients sought medical care in less than 48 hours because of worsening abdominal pain and distention.87 All patients with ileosigmoid knot present in less than 24 hours with complaints of acute, rapidly worsen-ing abdominal pain.75 The delay in presentation, excluding iatrogenic from nursing home holdup, is inversely propor-tional to outcome as more serious etiologies produce isch-emic pain more acutely.54 Up to 5% of patients suffering from sigmoid volvulus may experience sudden death prior to diagnosis.79,88

Although fewer than half of patients with cecal volvulus present with nausea and emesis, many transverse colon volvulus patients report these symptoms due to duodenal compression.74,78 Early emesis in the presentation of sigmoid volvulus may occur as a vagal response to a fulminant volvulus and portends a worsened prognosis. In contrast, delayed emesis indicates a recurrent or subacute form and relates to distal bowel obstruction. Patients with an ileosig-moid knot complain of nausea and emesis 87 to 100% of the time.75 This history helps distinguish forms of colonic obstruction from that of small bowel. If emesis is present, feculent or foul-smelling vomitus may indicate protracted disease. Careful description of a patient’s diet may give clues to the underlying etiology. Patients with a history of prolonged fasting followed by ingestion of a coarse, high-fi ber diet may be presenting with either a sigmoid volvulus or ileosigmoid knot. The onset and amount of abdominal

distention reported by the patients are also helpful. Less dis-tention suggests a more acute form versus patients reporting worsening of long-standing abdominal distention in the face of repeated bouts of abdominal pain. Less commonly, the patient reports a questionable “mass” along with a previous history of distention and pain.

A thorough bowel history should be elicited, including recent passage of fl atus or stools, although their absence does not exclude the diagnosis of volvulus. A history of diarrhea or constipation, and its relation to onset of symp-toms, is important in light of chronic constipation as a potential risk factor [see Table 3]. Patients may comment on chronic use of laxatives or enemas, which further suggests chronic constipation as an etiology. Reports of melena or hematochezia with abdominal pain may suggest ischemia from fulminant volvulus.

The past medical history should focus on bowel dysmotility from chronic constipation, psychiatric disorders (parkinsonism, organic brain syndrome, dementia, multiple sclerosis, and paralysis), or narcotic use. The remote or recent surgical history suggests a possible adhesive source or narcotic-associated bowel dysfunction. Late pregnancy is a known risk factor and will likely be readily apparent on patient presentation. Chilaiditi syndrome involves the trans-position of transverse colon between the diaphragm and liver and has been suggested as a possible risk factor for the development of transverse colon volvulus.89–91 The pertinent surgical history includes all previous abdominal operations, especially those involving surgical correction of previous malrotation or surgery requiring previous colonic mobilization [see Table 3].

physical examination

The physical examination involves quick assessment of acuity with immediate evaluation of vital signs and determi-nation of instability. Eisenstat and colleagues described acute fulminating and subacute progressive forms of trans-verse colon volvulus, with acute fulminating volvulus demonstrating a higher mortality due to rapid clinical dete-rioration.34,38,40 Volvulus of the sigmoid may produce fulmi-nant, indolent, or recurrent subtypes, with acuity highest for fulminant disease presentation.54 Similarly, upwards of 60% of ileosigmoid knot patients present in acute shock.75

Table 2 Differential Diagnosis of Colonic Volvulus

Distal rectal massDiverticular or ischemic strictureInfectious colitis with associated megacolonColonic pseudo-obstruction (Ogilvie syndrome)Mesenteric ischemiaDiverticulitisAcute or chronic pancreatitisInflammatory bowel diseaseDistal bowel obstruction from herniaDistal bowel obstruction from adhesive diseaseAdynamic ileusHirschsprung diseaseGiant colonic diverticulumColonic duplication with obstructionCongenital malrotation with obstruction

Table 3 Risk Factors for Colonic VolvulusCongenital risk factors

Thin, narrow mesenteryLack of congenital colonic attachments to peritoneal surfaceColonic dysmotilityHirschsprung diseaseDiseases associated with chronic constipation (i.e.,

parkinsonism, cerebral palsy)Congenital malrotation

Acquired risk factorsIntra-abdominal adhesions from previous surgeryAdynamic ileus or colonic dysmotility induced by surgery or

medicationsHigh-fiber and -liquid dietPrevious colonic mobilizationDistal bowel obstructionPregnancy


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After an initial evaluation for hemodynamic instability, focus shifts to the abdominal examination, whereby the patient is usually diffusely tender but without rebound. Rebound tenderness suggests peritonitis from free perfora-tion due to ischemia and bowel gangrene. Abdominal dis-tention may be worse on the physical examination compared with other obstructive etiologies as a larger, more distensible colon fi lls the abdominal cavity. Additionally, the chronicity of volvulus symptoms may contribute to a signifi cantly dis-tended abdomen.45 Rarely will the surgeon see improvement in distention with placement of a nasogastric tube. A midab-dominal mass may suggest a sigmoid volvulus, whereas a right upper quadrant mass and a left upper quadrant mass suggest a transverse or cecal volvulus, respectively. An empty left iliac fossa is considered pathognomonic for sig-moid volvulus in the setting of abdominal pain and disten-tion; however, it occurs in fewer than 35% of patients.54 The surgeon should expect a tympanitic abdomen to percussion. Auscultation may reveal high-pitched sounds early in the course, later replaced by quiet bowel due to ischemia. A rectal examination at the time of evaluation should rule out a distal mass or other cause of distal large bowel obstruc-tion. The remainder of the physical examination, including the heart and lung examination, should be completed in a timely fashion based on patient status.

investigative studies

Blood Tests

Blood work for suspected bowel obstruction, large or small, does not aid in the differentiation of underlying pathology. Instead, laboratory values aid the clinician in determining acuity. An elevated or severely depressed white blood cell count suggests an infl ammatory process and possible sepsis. Elevated hemoglobin or hematocrit suggests hemoconcentration and volume depletion in the setting of vomiting. Electrolyte abnormalities such as hypo-kalemic hypochloremic metabolic alkalosis may occur from repeated emesis. Metabolic acidosis may be determined using an electrolyte panel, lactate level, or arterial/venous blood gas. Some studies suggest coagulopathy as an inde-pendent risk factor for poor outcomes, so determination

of the international normalized ratio (INR) and partial thromboplastin time (PTT) is appropriate. Please search the publication for further discussion of acid-base disorders and water-sodium balance.

Imaging Studies

Plain fi lm radiograph Currently available im-aging techniques are vastly superior to those from even a decade ago, let alone the early 1900s [see Table 4]. However, abdominal radiographs and water-soluble studies remain valuable in the early diagnosis of colonic volvulus. Plain radiographs of the abdomen are expeditious and low cost and produce minimal radiation exposure to the patient (i.e., pregnancy). However, in a large review of 568 cecal volvulus cases spanning 30 years, 46% of plain fi lms suggested cecal volvulus, but only 17% were read as “defi nitive.”33 Additionally, 30% were misread as small bowel obstruction. In 1948, McGaw and colleagues suggested that the following fi ndings are necessary for diag-nostic certainty in a single plain fi lm of the abdomen: (1) dilated cecum in an abnormal position (90% in the left upper quadrant), (2) loops of distended small bowel with gas proximal to the cecum, (3) ileocecal valve on the right of the distended viscus, (4) spiral distortion of mucous mem-brane folds at the site of twisting, and (5) a single fl uid level in the upright colon [see Figure 2].92 Other reports suggest dilation of the large bowel with a twist pointing to the left upper quadrant, absence of gas and intestinal contents within the distal colon, cecal shadow out of position, and serial studies over a few hours demonstrating enlargement of a distended large bowel loop as diagnostic.20,50,93 Findings on plain fi lm for transverse colon and splenic fl exure volvu-lus are generally unhelpful but may show proximal colonic dilatation, distal decompression, a “bent inner tube,” and two high air-fl uid levels on upright abdominal fi lm [see Figure 3].42,94–97 Sigmoid volvulus is visualized as the classic “coffee bean sign” in fewer than 60% of patients, but plain fi lms are historically diagnostic in 57 to 90% of patients.2,98,99 Other fi ndings, such as absence of rectal gas, sigmoidal wall

Table 4 Important Radiographic Findings in Colonic VolvulusType Plain Film Water-Soluble Enema CT Scan

Cecal Distended bowel with long axis from RLQ to LUQ

Nondilated bowel distal to twist; bird’s beak appearance

“Whirl sign” of cecum and ileocolic mesentery

Transverse Distended proximal bowel, decompressed distal bowel, “bent inner tube”; double-obstruction sign

Nondilated bowel distal to twist; bird’s beak appearance at region of transverse colon

“Whirl sign” of transverse and associated mesentery, double obstruction

Splenic flexure Distended proximal bowel, decompressed distal bowel, “bent inner tube”; double-obstruction sign

Nondilated bowel distal to twist; bird’s beak appearance at region of spleen

“Whirl sign” of transverse and associated mesentery, double obstruction, mobilized spleen

Sigmoid “Coffee bean sign”; dilated pelvic colon loop toward RUQ with ends pointed to pelvis

Nondilated bowel distal to twist; bird’s beak appearance at pelvic brim

“Whirl sign” of sigmoid and mesentery

Ileosigmoid knot

Dilated pelvic colon loop, stool in nondistended right colon, signs of small bowel obstruction

Nondilated bowel distal to twist; bird’s beak appearance at pelvic brim

“Whirl sign” of ileocolic and sigmoid mesentery, medial deviation of ascending and descending colon

CT = computed tomography; LUQ = left upper quadrant; RLQ = right lower quadrant; RUQ = right upper quadrant.


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radiographs demonstrate colonic distention, usually consis-tent with sigmoid volvulus, which confuses the clinician who is expecting a small bowel obstruction based on the clinical presentation.75,77,81 Abdominal radiographs will demonstrate colonic distention, the “omega” sign of sigmoid volvulus with apex pointing toward the right upper quad-rant, stool in the proximal colon, and air-fl uid levels within the small bowel suggesting obstruction.77,79,81,100–102 Medial

thickening, pneumatosis, proximal colonic distention, and apex of sigmoid loop under the left hemidiaphragm, may suggest sigmoid volvulus [see Figure 2].54 When properly interpreted, a plain abdominal radiograph can be a high-yield diagnostic study in the patient with bowel obstruction.

Preoperative diagnosis of an ileosigmoid knot occurs in less than 30% of cases, although recent diagnostic improve-ments are attributed to cross-sectional imaging. Abdominal

a b

Figure 2 Plain fi lm radiographs of cecal and sigmoid volvulus. (a) Cecal volvulus with arrows indicating colonic wall pointing toward the right lower quadrant. (b) Sigmoid volvulus with arrows indicating colonic wall pointing toward the pelvis.

a b

Figure 3 Plain fi lm radiographs of transverse and splenic fl exure volvulus. (a) Transverse colon volvulus with proximally dilated and distally decompressed bowel as indicated. Staples and clips are present from recent intra-abdominal surgery. (b) Severely dilated colon at the splenic fl exure with a paucity of distal colon gas and a normal proximal transverse colon bowel gas pattern. Arrows indicate colonic wall. Circle indicates point of volvulus.


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deviation of the distal descending colon is considered highly specifi c for the diagnosis.102

Contrast enema studies Although computed tomogra-phy (CT) is surely becoming the test of choice when encoun-tered with a query of intra-abdominal pathology, a contrast enema should remain in the consulting surgeon’s diagnostic repertoire. Diagnosis is confi rmed in upwards of 90% of patients, despite being ordered in fewer than 50% of patients who ultimately come to surgical intervention for cecal vol-vulus.33 Cone-shaped obstruction with spiral mucosal folds

seen on study suggests and confi rms the diagnosis, along with demonstration of a “bird’s beak” at the site of volvulus [see Figure 4].34,42,45,50,92,95,97 For patients with incomplete or spontaneously reducing volvulus, the contrast study may demonstrate spiral bands of linear density and increased radiance.45 In recurrent sigmoid volvulus, a “twisted tape” sign representing twisting of mucosal folds visualized after evacuation of rectal contrast may aid the diagnosis [see Figure 5].103 Water-soluble and barium enemas are unhelpful in an ileosigmoid knot as the clinician is lulled into treating a sigmoid volvulus, with a subsequent delay in defi nitive

a b

c

Figure 4 Contrast enema of cecal, transverse, and splenic fl exure volvulus. Classic fi nding of “bird’s beak” with abrupt cutoff at the point of volvulus. The distance of the contrast column indicates the location of volvulus, including (a) cecum, (b) transverse colon, and (c) splenic fl exure.


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invagination from surrounding pericolic fat and is present in half of all cecal volvulus scans.105 Other descriptions in the literature, including dilation of small bowel and prominence of cecal haustra, are considered poor discriminators of cecal volvulus. However, a fi nding of decompressed distal colon in the face of dilated cecum and ascending colon is both sen-sitive and specifi c for the diagnosis of volvulus.105 If cross-sectional imaging reveals an abnormal splenic fl exure in the appropriate clinical setting, splenic fl exure volvulus should be considered.96 With sigmoid volvulus, the most sensitive fi ndings include a single sigmoid colon transition point (95%) and disproportionate enlargement of the sigmoid colon (86%).106 When combined with scout fi lm fi ndings, cross-sectional imaging is superior for the diagnosis of colonic volvulus.

Along with volvulus location, a CT scan may delineate secondary fi ndings, including distal mass or bowel ischemia. Unfortunately, fi ndings such as bowel wall thickening, fat stranding, and even pneumatosis correlate very poorly with pathologic ischemia.105 Other concerns attributed to CT scans are misdiagnosis. Cross-sectional imaging of an ileosigmoid knot will demonstrate a whirl sign of both terminal ileal and sigmoid mesenteries, along with medialization of the right colon [see Figure 9].110 Unfortunately, this diagnosis is over-looked as evaluation focuses on the sigmoid mesenteric “whirl” and misses the small bowel twisting around the mesentery.111 Additional fi ndings suggestive of ileosigmoid knot include the convergence of superior and inferior mesenteric vasculature toward the sigmoid colon, a fi nding surgeons must seek.112

diagnosis.102 Despite concerns in high-risk patients, Ritvo and Golden suggested that it is quite safe when liquid is administered slowly under fl uoroscopic control without elevation above 18 to 24 inches.50

Computed tomography The use of CT for evaluation of abdominal pain in the United States has skyrocketed. In a review of national imaging trends, Kocher and colleagues demonstrated a 330% increase in cross-sectional imaging performed from 1996 to 2007.104 Additionally, many patients are undergoing imaging prior to surgical evaluation. The University of Minnesota evaluated the ability of cross-sectional imaging to aid in the diagnosis of cecal volvulus versus other imaging modalities and found it to be far supe-rior.32 Cross-sectional imaging confi rms the diagnosis in almost 90% of cases, without the need for a radiologist or technician to complete the fl uoroscopic procedure [see Figure 6].25,32,105 For sigmoid volvulus, CT or MRI accuracy approaches 100% [see Figure 7].79,106 With imaging studies likely available at the time of consultation, surgeon knowl-edge of salient fi ndings is important and allows for timely diagnosis and management.85 The “whirl sign,” with a sen-sitivity of 100%, a positive predictive value of 100%, and a negative predictive value of 80%, demonstrates a directional swirling of the mesentery, indicative of cecal versus sigmoid volvulus [see Figure 8].25,105,107–109 Another sign, demonstrating two transition points and a characteristic crossing, repre-sents an “X marks-the-spot” fi nding.105 Unfortunately, this sign is not present in all cases of volvulus. The “split-wall sign” resembles plain radiograph fi ndings of bowel wall

a b

Figure 5 Contrast enema of sigmoid volvulus. Sigmoid volvulus indicated by (a) “bird’s beak” sign and (b) “tape sign” after evacuation of contrast. Arrows point to “tape sign.”


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Treatment

nonoperative therapy

Most reports demon-strate observational mortality of nearly 100% in acutely ill or septic volvulus patients, with spontaneous reduction occurring in fewer than 2% of patients. Radio-graphic reduction with water-soluble or barium enema is

not advocated as a management strategy for most forms of colonic volvulus. Although effective almost 90% of the time in diagnosis, enema for therapeutic reduction is successful in less than 5% of adult patients.39,113,114 Additionally, watch-ful waiting of colonic volvulus is strongl y discouraged [see Table 5].

Since initial attempts in the 1970s, the endoscopic reduc-tion of cecal volvulus remains successful in less than 30% of cases, with a procedural perforation risk of 1 to 3%.2,115–117 Success is equally bleak in the management of transverse

a b

c

Figure 6 Cross-sectional abdominal imaging of cecal volvulus. Diagnosis of cecal volvulus is confi rmed by computed tomography more than 90% of the time. Findings such as (a) an enlarged cecum with terminal ileal twisting and (b, c) the “whirl sign” indicate inappropriate rotation of the mesentery. Arrow indicates dilated cecum. Circle indicates “whirl sign.”


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colon endoscopic decompression because it often proves technically diffi cult compared with reduction of splenic fl exure or sigmoid volvulus.118,119 Following decompression, the patient remains at high risk for recurrence.34,36,37,118,119 Rectal tube placement, due to distance from the anal canal in cecal and proximal colon volvulus, does little to prevent recurrence or provide patient relief.120 When attempting endoscopic reduction of proximal colon volvulus, it is rec-ommended to set a time limit less than 30 minutes.117,121 The authors also suggested the use of CO2 colonoscopy rather than the more traditional air insuffl ation endoscopy during attempted decompression because carbon dioxide is readily absorbed from the colon, allowing the colon to desuffl ate more rapidly than when fi lled with air.

In contrast, urgent endoscopic decompression of sigmoid volvulus is considered fi rst-line therapy in patients without signs of peritonitis or shock. Successful decompression occurs 90% of the time, with rigid and fl exible modalities being equally effective.66,122 Care is required to limit air insuf-fl ation, which may worsen the patient’s condition. Overt ischemic signs mandate surgical intervention [see Figure 10]. If vascular compromise is in question, using a biopsy for-ceps to induce mucosal bleeding is advocated. A semirigid stent across the volvulus in the hope of prevention can be achieved by esophageal overtubes and a range of catheters [see Figure 11].123,124 Despite newer technologies, recurrence rates for sigmoid volvulus reduction preclude this as defi ni-tive management.122,125 For high-risk patients managed with endoscopic decompression, initiation of a bowel regimen, including fi ber supplementation, stool softeners, and suppositories, is suggested. In cases of successful sigmoid volvulus reduction, surgical management is currently recommended within 2 to 5 days after decompression.54

Successful percutaneous placement of tube sigmoidosto-my was fi rst described in the 1990s.126–128 More recently, larger cohort studies demonstrated successful decompres-sion in more than 75% of sigmoid volvulus patients. Regret-tably, mortality was near 4%, the abdominal sepsis rate was 9%, and the minor complication rate approached 30%.129 The benefi ts of this minimally invasive procedure included evaluation of colonic mucosa to determine vascular insuffi ciency, direct visualization of tube entry to prevent inadvertent injury, and minimal sedative use in high-risk patients.129,130 The keys to success include successful decom-pression and clearance of stool, followed by placement of two to three percutaneous tubes such that a fulcrum for vol-vulus is not created. Additionally, T-fasteners are described for fi xation instead of percutaneous tubes.131

operative therapy

Colonic volvulus, whether acute or chron-ic, is a surgical disease requiring prompt man-agement. Strong predic-tors of perioperative mortality include age over 60 years or coagulopathy at presentation. Worsening outcomes are expected in patients with peritonitis, ischemic bowel, creation of ostomy, cancer, chronic kidney disease, congestive heart failure, associated weight loss, chronic

a

b

Figure 7 Cross-sectional abdominal imaging of sigmoid volvulus. The “whirl sign” is present in most studies of (a, b) sigmoid volvulus. Circles indicate “whirl sign.”


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obstructive pulmonary disease, or an acute electrolyte imbalance.24 A myriad of options are available to the sur-geon for defi nitive management, each with benefi ts and risks that must be tailored to the individual patient.

Simple Detorsion

Operative management of colonic volvulus has evolved over the last 100 years. Historically, surgery involved exploratory laparotomy and simple detorsion of involved bowel. Mortality for simple detorsion of colonic volvulus ranges from 0 to 25%, with a reported recurrence of 0 to 70%.2,22,132,133 Although it is technically simple to perform, Wilson recommended against this procedure in 1965, stating that “… [it is] inappropriate to simply detorse and leave alone as [the] patient [is] at high risk for recurrence.”134 Others agreed and suggested the addition of colopexy following detorsion to prevent recurrence.

Colopexy

Early attempts at cecopexy involved suturing the cecum to the anterior abdominal wall. Unfortunately, this created a fulcrum around which small bowel could herniate or an overly fl oppy right colon could torse. Later modifi cation involved pexy of the colon to psoas fascia for a signifi cant length instead of the anterior or posterior parietal peritone-um.31 Dixon and Meyer described raising a fl ap of perito-neum and sewing it to mesentery, which was reported to signifi cantly decrease recurrence.20,135 Another enhancement by Rogers and Harford involved raising a peritoneal fl ap, roughing up the mesentery, and suturing the fl ap to the antimesenteric taenia.19 Most recently, two studies reported laparoscopy to be an effective approach for cecopexy in mobile cecal syndrome, despite less than 10% of all cases being managed in this fashion.24,136 Unfortunately, all meth-ods of cecopexy suffer from inadequate long-term follow-up.

Figure 8 Cross-sectional abdominal imaging of transverse colon volvulus. Volvulus of the transverse colon is rare. Computed tomographic fi ndings of volvulus can be subtle, requiring evaluation of the colon itself to indicate a tapered point in conjunction with a mesenteric swirl. Circles indicate volvulus of transverse mesocolon mesentery.


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patient and evaluations of surgical risk, including cardiac and pulmonary risk assessment.

Tube Colostomy

For patients considered too sick to undergo detorsion and colopexy, cecostomy or appendicostomy tube placement was once considered appropriate fi rst-line treatment. Despite published recurrence rates similar to those of simple detorsion and cecopexy,22 these procedures suffer from signifi cantly higher rates of mortality, wound infection, per-sistent fi stula, and intra-abdominal sepsis due to persistent necrosis of remaining bowel.12,33,138 In patients in whom cecostomy is performed, it is important to maximize tube management to prevent failure. This involves fl ushing with increasingly higher amounts of fl uid and clamping and unclamping the tube at regular 2- to 4-hour intervals.138 Similar to colopexy, tube colostomy is indicated only in high-risk patients with sigmoid volvulus unable to undergo defi nitive resection with or without colostomy creation.

Resection with or without Primary Anastomosis

Surgical resection with primary anastomosis is now con-sidered standard of care for colonic volvulus. Through the 1990s, surgical mentors advocated detorsion and cecopexy in the presence of unprepared bowel as safest for patients.86,139 However, Melchior, one of the initial proponents of surgical resection, reported complications in six patients treated with colonic resection as similar to those undergoing colopexy alone.140 As many patients previously treated with detorsion later underwent colonic resection for recurrence, surgeons opted for defi nitive treatment at the initial presenta-tion.12,15,20,33,141–145 If gangrene or ischemic changes were pres-ent at the initial observation, resection was mandated as the mortality for this patient population ranged from 33 to 41.4% versus 14.5 to 19% in patients without gangrenous bowel [see Figure 12].14,146,147 Recent data support this approach, with lower rates of complications such as wound infection,

Published rates of recurrence are between 0 and 40%, with an operative mortality of 0 to 30%.22,34,36,37,134

Mortensen and Hoffman described a parallel colopexy for transverse colon volvulus. Following detorsion and needle desuffl ation, the proximal and distal transverse colon were sutured to a fi xed ascending and a descending colon, respec-tively.37 More recently, fi xation of the transverse colon was described using omentum at both splenic and hepatic fl ex-ures.137 Long-term recurrence data are unavailable; however, neither maneuver is recommended in patients with a mobile cecum. Open and laparoscopic sigmoidopexy are described, along with minimally invasive forms of sigmoidopexy using T-fasteners.54,131 High rates of recurrence nearing 70% outweigh the benefi ts of low procedural mortality. Exterior-ization, plication, and mesosigmoidoplasty are described but suffer from small sample sizes and selection bias regard-ing comparison against the gold standard of sigmoidal resection.54 As such, these methods are secondary options in high-risk patients unable to undergo defi nitive resection with or without stoma creation. Please search the publicatio n to review preoperative evaluation of the elderly surgical

Figure 9 Cross-sectional abdominal imaging of ileosigmoid knot. Although exceedingly rare in the United States, ileosigmoid knot presents with dual swirling patterns involving both sigmoid mesentery volvulus (A circle) and ileocolic mesentery volvulus (B circle).

Table 5 Nonoperative Management of Sigmoid Volvulus

Procedure Success Rate (%)

Rigid proctoscopy with or without rectal tube 70–90

Flexible sigmoidoscopy with or without rectal tube

70–90

Percutaneous decompression of volvulus followed by endoscopic evaluation

70–75

Blind insertion of rectal tube 5–15

Water-soluble or barium enema 5

Direct observation 2


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a b

a b

Figure 10 Endoscopic evaluation in sigmoid volvulus. Careful insertion of the endoscope with minimal insuffl ation is required to the (a) point of sigmoid volvulus. Once through, the proximal colon (b) will demonstrate signifi cant distention. Here the endoscopist must fully evaluate the mucosa for signs of ischemia.

Figure 11 Use of an esophageal overtube for placement of a rectal tube. A semirigid, clear tube is inserted under endoscopic guidance to (a) and through (b) a sigmoid volvulus. This technique allows for easier passage of a semirigid rectal tube past the point of volvulus, reducing the concern for recurrent twisting of the bowel during tube placement.

readmission rates, and rates of stoma formation compared with detorsion and colopexy (Ricciardi R, personal commu-nication, 2014). Mortality historically ranges from 0 to 40%; however, since 1990, this has decreased to less than 10% (Ricciardi R, personal communication, 2014).22,24

For transverse colon volvulus, resection may include segmental colectomy, extended right hemicolectomy, or extended left hemicolectomy without signifi cantly increased morbidity or mortality [see Figure 13].34,37,41 Laparoscopy for resection is used in less than 2% of cases, providing little opportunity for comparison of outcomes.24 Alternatives to primary anastomosis include resection with double-barrel

colostomy or anastomosis with proximally diverting loop ileostomy. Proximal diversion alone as a treatment of trans-verse colon volvulus is ill advised due to the potential for a closed-loop obstruction in patients with a competent ileocecal valve.132

Defi nitive management of splenic fl exure volvulus involves segmental resection with primary anastomosis similar to cecal and transverse colon volvulus.1,2,139,148 As most patients present with subacute disease, defi nitive resection and anastomosis in a controlled, unsoiled opera-tive fi eld are often possible. In patients with redundant transverse colon, extended resection with ileosigmoid


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anastomosis is suggested to prevent the possibility of future ascending or transverse colon volvulus.149

In patients with sigmoid volvulus, options for resection are based on the clinical picture [see Figure 14]. Patients requiring emergent management due to sepsis or peritonitis are safely treated with Hartmann resection, although the surgeon should consider the extensive mortality and mor-bidity associated with colostomy formation and subsequent attempts at closure. Compared with primary resection and anastomosis (8 to 13%), mortality associated with colostomy creation is signifi cantly higher (25 to 50%).1,54,125 These results may not be applicable to all populations due to differences in hospital resources, surgeon training, and postoperative

care facilities. In addition, patients undergoing end-colostom y formation may be inherently sicker than those undergoing resection with anastomosis.

For patients initially reduced endoscopically or with enema, resection of the sigmoid colon is recommended within the fi rst 2 to 5 days postreduction. This allows for reduction of associated edema without subjecting the patient to prolonged insertion of a rectal tube and a higher risk of recurrence. Although laparoscopy provides benefi ts in elective surgery, the emergent and semiurgent manage-ment of sigmoid volvulus limit its use. Often massive disten-tion prevents suffi cient visualization and ability to mobilize the colon unless the colon is successfully decompressed at the initiation of the procedure by colonoscopy. We again recommend the use of CO2 colonoscopy rather than air insuffl ation because carbon dioxide is readily absorbed from the colon. Alternatively, mini-laparotomy through a lower midline or Pfannenstiel incision may be feasible, with reported outcomes comparable to that of laparoscopic resection.150,151

In patients with a history of megacolon associated with sigmoid volvulus, over 22% will develop a late recurrence following sigmoid resection. This is in comparison with a recurrence rate of less than 1% in patients without megacolon or other colonic dysmotility undergoing similar resections.54,152–154 In patients with dysmotility or megacolon associated with sigmoid volvulus, one should consider total colectomy with ileorectal anastomosis as the recommended procedure.

To date, surgical resection with anastomosis remains the gold standard for the management of colonic volvulus in patients without signifi cant contraindications to surgical intervention.20,54,155,156 The surgeon must ensure that adequate margins are obtained, especially when gangrenous bowel is present. If concerns exist regarding bowel compromise, the safest course of action is creation of either an ileostomy or a

a b

Figure 12 Necrotic cecum in the operating suite. Necrotic or isch-emic bowel mandates surgical resection, regardless of patient risk. Options include primary anastomosis, anastomosis with proximal diversion, or end ileostomy.

Figure 13 Transverse colon volvulus in the operating suite. Although the bowel is viable (a), defi nitive management should include primary resection (b) with anastomosis. Depending on the site of volvulus, the surgeon may complete a right, extended right, or subtotal colectomy in these patients.


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colostomy.115,117 To review the technique for segmental colec-tomy and ostomy creation, please search the publication for segmental colon resection.

Operative management of an ileosigmoid knot can be a challenge and is often determined by the degree of ischemia and diffi culty in reducing the volvulus of both the ileum and the sigmoid colon. As discussed previously, nonoperative management is not recommended. On presentation and diagnosis, patients must be resuscitated with appropriate fl uids and monitoring. Flexible sigmoidoscopy is often performed on patients presumed to have simple volvulus; however, imminent failure of reduction must suggest an ileo-sigmoid knot. Operative intervention involves initial deter-mination of bowel viability as both small and large bowel are at risk for infarction. Some authors advocate immediate stapling of the small bowel at the point of ingress and egress, which may facilitate untying of the bowel. Increased speed, reduced risk of inadvertent enterotomy, and reduced risk of worsened sigmoid ischemia make this our procedure of choice.77,81,157 After excision of affected small bowel, sigmoidectomy is suggested to prevent recurrence and

future sigmoid volvulus. Sound surgical principles will guide the creation of primary anastomosis of both the small and large bowel, with most patients able to safely avoid stoma creation.75,100,111,112,158 Although untying and detorsion with subsequent mesosigmoidostomy of viable sigmoid are described,101,157 we recommend resection as defi nitive management for this potentially fatal disease.

Conclusion

The diagnosis and management of colonic volvulus have evolved signifi cantly since Hippocrates recommended the use of long suppositories. A thorough and expeditious history and physical examination will aid in the selection of further diagnostic imaging and potential operative inter-vention. The proposed algorithm can serve as a guide to effi cient diagnosis and management of this challenging patient population.

Financial Disclosures: Kevin R. Kasten, MD, Peter W. Marcello, MD, and Todd D. Francone, MD, MPH, have no relevant fi nancial relationships to disclose.

a b

c

Figure 14 Sigmoid volvulus in an elderly gentleman. Often chron-ic in nature, the abdominal examination may reveal (a) a signifi cantly dilated abdominal wall. At the time of exploration (b), the margin of bowel ischemia dictates the extent of resection (c).


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Acknowledgments

We recognize and thank Drs. Francis Scholz and Christopher Scheirey of the Lahey Hospital and Medical Center Department of Radiology for their contributions to this topic review. Figure 1 Christine Kenney

colonic volvulusvolvulus” is a more appropriate description because the cecum cannot technically...

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