surgical management of sigmoid volvulus · we need to determine whether the patient with suspected...

$: Surgical Management of Sigmoid Volvulus · We need to determine whether the patient with suspected volvulus has a viable colon and is a candidate \൦or endoscopic therapy or has$
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


Presenter

Presentation Notes

Emesis was non bloody non bilious He took lactulose prior to admission without relief of symptoms

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


AXR


CT SCAN


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


BARIUM ENEMA


Presenter

Presentation Notes

Marked dilation and elongation of the sigmoid colon

BARIUM ENEMA


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


Presenter

Presentation Notes

Postoperatively doing great

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


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


Presenter

Presentation Notes

1- ebers papyrus first described the natural history of sigmoid volvulus 2- hippocrates-described that certain bowel obstructions poss sigmoid volvulus – could be decompressed with long suppository 3- bc of high surgical mortality rates the care of colonic volvulus remained noninterventional until early 20th century when improved operative techniques and periop care allowed surgical intervention to be standard.

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


Presenter

Presentation Notes

-3rd after cancer and diverticulitis in Western countries and the LEADING CAUSE OF ACUTE COLON OBSTRUCTION IN DEVELOPING COUNTRIES -accounts for 2-4% In many 3rd world countries – age of onset: 40-50 y Hirshsprungs -in pregnancy, most common cause of intestinal obstruction with 45% of all intestinal obstructions in this group

Epidemiology of sigmoid volvulus

O Africa, India, the Middle East, and Latin America- 54%!

O Young; 80% male

O High fiber diet


Presenter

Presentation Notes

-in these areas can be as high as 54% High fiber diet- lengthens the sigmoid colon and its mesentery, fostering an anatomical predisposition to volvulize

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


Presenter

Presentation Notes

Organoaxial rotation of the bowel which leads to a closed-loo obstruction of the lumen and mesenteric blood flow obstruction -as intraluminal pressure and venous obstruction increase, arterial inflow becomes compromised leading to bowel gangrene Can be clockwise or counterclockwise but 70% of patients have counterclockwise around mesocolic axis Current understanding: fecal overload distended and elongated lengthening the antimesenteric border bc the mesenteric border is tethered by the mesentery and its vessels. As the distention increases the bowel twists about the mesenteric axis. The bowel can remain viable for days but with increased peristaltic emptying of the proximal colon and fluid secretion which causes distention and increased pressure once it reaches 360 the distended sigmoid loop can become trapped within the abdominal wall before it can return to the anatomic position. Capillary perfusion is impaired leading to arterial occlusion and followed by venous occlusion thrombosis and necrosis

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


Presenter

Presentation Notes

Vague feeling of lower abdominal discomfort. ` -N/V/obstipation are all late sx -there may have been similar episodes in the past that resolved spontaneously after passage of large amounts of flatus or stool -rectal exam will reveal empty ampulla

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


Presenter

Presentation Notes

Axr is diagnostic in over 50% of cases of sigmoid volvulus -when you add a BE diagnostic in 90%- tapering opacity reminiscent of birds beak **CI: CT abd may be helpful esp if there is a whirl sign

AXR AND DIAGRAM OF SIGMOID VOLVULUS


Bird’s beak

BARIUM ENEMA OF SIGMOID VOLVULUS


CT scan of colonic volvulus


Presenter

Presentation Notes

Whirl sign described to represent the tightly twisted mesentery of the afferent and efferent limbs of the volvulus.

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


Presenter

Presentation Notes

We look at 2 criteria. We need to determine whether the patient with suspected volvulus has a viable colon and is a candidate for endoscopic therapy or has an ischemic colon and must go emergently to the operating room. -endoscopic decompression successful in 75-90% of cases and turns an emergency case into an elective one -place a rectal tube which must pass point of torsion, left in place for 48-72 hours -elective resection is recommended during the same hospital admission bc recurrence rates of 40-50% have been reported

Preopeative Preparation O Correct electrolyte imbalances

O Nasogastric decompression


Presenter

Presentation Notes

Closed loop bowel obstruction present with significant fluid and electrolyte imbalances -ngt should be performed in all forms of colonic volvulus

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


Presenter

Presentation Notes

In the presense of gangrene colectomy is fraught with a 50-80% mortality rate, endoscopic or nonop therapy has 100% mortality rate – When gangrenous bowel is encountered during laparotomy, detorsion should not be performed bc the accumulated toxins and bacteria may be released into the circulation sepsis and cardiovasc collapse 24% mortality rates are higher for emergent operations of SV compared with 6% for the elective setting.

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


Presenter

Presentation Notes

Sutures are not placed in the thin or edematous colon wall

Sigmoidopexy

O Suturing the sigmoid colon to the anterior abdominal


Mesosigmodoplasty O Plicating and

shortening the sigmoid mesocolon O 2-28%

recurrence rate


Presenter

Presentation Notes

These procedures have never been examined in a large randomized fashion but have been noted to have a high recurrence rate in several reviews Newer techniques of laparoscopic fixation of sigmoid to ant abd wall Mesosigmoidoplasty-performed by incising the elongated mesentery vertically along its axis. The periotneal flaps then approximated transversely forming a shortened broad mesentery One author reported a 28% recurrence with this technique usually there is about 2%.

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


Presenter

Presentation Notes

2 year observation study with 30 patients treated with a single stage resection and primary anastastomis


Presenter

Presentation Notes

Thighs are parallel to the abdomen so that they do not interfere with the movement of instruments 1- grasper passed through the right lateral port and peritoneum lateral to sigmoid is grasped. Left urter is identified in pelvic brim 2- scissors with cautery through the suprapubic port and dissection by incising peritoneum lateral to the sigmoid 3- white line of toldt followed up alongside the descending colon toward the splenic flexure using the same method as a left hemicolectomy


Presenter

Presentation Notes

1- to patient’s right -2-presacral space is developed by division of fine adhesions ensuring that the hypogastric nerves are protected and swept backwards toward the sacrum 3- protect ureter and iliac vessels -right peritoneum – opening presacral space to the right


Presenter

Presentation Notes

1- including the superior hemorrhoidal artery and branches of sigmoid artery - isolated by creating windows in the mesentery alongside the vessels -ligated with endovascular staplers and then divided 4- the pneumoperitoneum is vented via laparoscope ports

Sigmoid volvulus: Long- term clinical outcome and review of literature


Presenter

Presentation Notes

9/92-8/2004-the participants answered a questionairre to discuss their particular outcome

Sigmoid volvulus: Long- term clinical outcome and review of literature


Presenter

Presentation Notes

All 26 patients in Hartman’s group underent reversal. -1 atient with anastomotic dehiescence required re-operatjon and treated by HP

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


Presenter

Presentation Notes

-mistaken for cecal volvulus -gangrene soley by inceased intraluminal tension

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


Presenter

Presentation Notes

Barium enema can increase the diagnostic accuracy of plain films to 50-90%

AXR AND DIAGRAM OF CECAL VOLVULUS


ALGORITHM FOR SIGMOID VOLVULUS


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


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


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


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


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


Presenter

Presentation Notes

Although hirschsprung’s disease is primarily a disease of young infant and child it occassionaly presents later in adulthood especially if an extremely short segment of bowel affected -diagnosis- rectal biopsy- sanoles obtained at 1 cm, 2 cm and 3 cm from dentate

surgical management of sigmoid volvulus · we need to determine whether the patient with suspected...

Documents