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Surgical Management of Sigmoid Volvulus
Maria Georgiades, MD October 18, 2012
www.downstatesurgery.org
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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
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Case Presentation O PMH: none O PSH: none O Meds: none
O VS: T 97.4F BP 136/98 HR 85 RR 16 O2 sat 95%
O General: AAO x3, no acute distress
O CV: RRR, S1S2 normal O Pulm: clear to auscultation
O Abd: soft distended, tympanic
to percussion; no bowel sounds, diffusely tender
O DRE: no stool in vault, no masses,
no gross blood
9.9 14
45 213 138
3.9 101 22
12 0.7
113
7.3 4.6
20 13
59 1
Lactate: 1.7
A/L: 17/15
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AXR
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CT SCAN
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CT SCAN
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CT SCAN
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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
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BARIUM ENEMA
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BARIUM ENEMA
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BARIUM ENEMA
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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
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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
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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
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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
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Epidemiology of sigmoid volvulus
O Africa, India, the Middle East, and Latin America- 54%!
O Young; 80% male
O High fiber diet
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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
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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
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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
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AXR AND DIAGRAM OF SIGMOID VOLVULUS
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Bird’s beak
BARIUM ENEMA OF SIGMOID VOLVULUS
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CT scan of colonic volvulus
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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
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Preopeative Preparation O Correct electrolyte imbalances
O Nasogastric decompression
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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
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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
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Sigmoidopexy
O Suturing the sigmoid colon to the anterior abdominal
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Mesosigmodoplasty O Plicating and
shortening the sigmoid mesocolon O 2-28%
recurrence rate
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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
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Sigmoid volvulus: Long- term clinical outcome and review of literature
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Sigmoid volvulus: Long- term clinical outcome and review of literature
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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
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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
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AXR AND DIAGRAM OF CECAL VOLVULUS
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ALGORITHM FOR SIGMOID VOLVULUS
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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
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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
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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
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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
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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
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