Sigmoid volvulus management, only endoscopic devolvulation?

ABSTRACT

Intestinal obstruction due to sigmoid volvulus (SV) represents a relevant percentage of abdominal diseases presenting at the emergency department. Treatment is based on early endoscopic devolvulation (ED), followed by elective surgery as definitive treatment. A 78-year-old man institutionalized with Lewy body dementia presents with abdominal pain, distention, and absence of stool in 72 hours. Coffee bean sign was seen in abdominal x-ray. Previously, he had been admitted three times last year with recurrent SV, managed with ED succesfully. Despite the recurrence, no surgical treatment was indicated after resolution of the acute situation and recovery of intestinal transit. This time, urgent colonoscopy was performed and a 20 cm length of purplish-black (isquemic) sigmoid mucosa was observed. With these findings of stablished intestinal ischemia urgent surgical intervention was performed (sigmoidectomy and terminal "Hartmann" colostomy). Histologically, necrosis, severe ulceration and mixed inflammation was noticed in the surgical piece. The patient develops favorably during a postoperative period without incidents. Therefore, he is discharged to his center. At the moment he is asymptomatic one year after the intervention with no new episodes. Recurrency of SV after ED is up to 86% of cases. In every episode, the incidence of complications such as intestinal ischemia or perforation increases significantly, as well as urgent surgery and mortality. Definitive treatment must be surgical, sigmoidectomy and terminal anastomosis is the choice technique.