[Sigmoid volvulus at the University Hospital of Iceland 2000-2013].

Backround Sigmoid volvulus is an uncommon cause of bowel obstruction in most western societies. Treatment options include colonoscopy in uncomplicated disease with elective surgery later on. The aim of this study was to assess what treatment sigmoid volvulus patients receive along with long-term outcomes at Landspitali University Hospital. Methods The study was retrospective. Patients diagnosed with sigmoid volvulus at Landspitali University Hospital from 2000-2013 were included. Information regarding age, sex, and duration of hospital stay, treatment, short and long-term outcomes were gathered. Results Forty-nine patients were included in the study, of which 29 men and 20 women. Mean age was 74 (25-93). One patient underwent acute surgery on first arrival due to signs of peritonitis. Others (n=48) were treated conservatively in the first attempt with colonoscopy (n=45), barium enema (n=2) and rectal tube (n=1). Three other patients underwent acute surgery due to failed colonoscopy, 8 patients had planned surgery during the index admission. Thirty-six patients were discharged after conservative treatment with colonoscopy (n=35), barium enema (n=1) or rectal tube (n=1). Two patients came in for elec-tive surgery later on. Twenty-two patients (61%) had recurrence. Median time to recurrence was 101 days (1-803). Disease-free probability in 3, 6 and 24 months was 66%, 55% and 22% respec-tively. Total disease related mortality was 10.2%. Mortality (30 days) after acute surgery was 25% (1/4) and 16,6% (3/18) after planned surgery. Conclusions Sigmoid volvulus has high recurrence rate if not treated operatively. Total mortality due to sigmoid volvulus at Landspitali is low but surgery related mortality high.

More patients should undergo surgery after sigmoid volvulus.

AIM: To assess the outcome of patients treated conservatively vs surgically during their first admission for sigmoid volvulus. METHODS: We conducted a retrospective study of 61 patients admitted to Aarhus University Hospital in Denmark between 1996 and 2011 for their first incidence of sigmoid volvulus. The condition was diagnosed by radiography, sigmoidoscopy or surgery. Patients treated with surgery underwent either a sigmoid resection or a percutaneous endoscopic colostomy (PEC). Conservatively treated patients were managed without surgery. Data was recorded into a Microsoft Access database and calculations were performed with Microsoft Excel. Kaplan-Meier plotting and Mantel-Cox (log-rank) testing were performed using GraphPad Prism software. Mortality was defined as death within 30 d after intervention or surgery. RESULTS: Among the total 61 patients, 4 underwent emergency surgery, 55 underwent endoscopy, 1 experienced resolution of the volvulus after contrast enema, and 1 died without treatment because of large bowel perforation. Following emergency treatment, 28 patients underwent sigmoid resection (semi-elective n = 18; elective n = 10). Two patients who were unfit for surgery underwent PEC and both died, 1 after 36 d and the other after 9 mo, respectively. The remaining 26 patients were managed conservatively without sigmoid resection. Patients treated conservatively on their first admission had a poorer survival rate than patients treated surgically on their first admission (95%CI: 3.67-14.37, P = 0.036). Sixty-three percent of the 26 conservatively treated patients had not experienced a recurrence 3 mo after treatment, but that number dropped to 24% 2 years after treatment. Eight of the 14 patients with recurrence after conservative treatment had surgery with no 30-d mortality. CONCLUSION: Surgically-treated sigmoid volvulus patients had a higher long-term survival rate than conservatively managed patients, indicating a benefit of surgical resection or PEC insertion if feasible.

An algorithm for the management of sigmoid colon volvulus and the safety of primary resection: experience with 827 cases.

PURPOSE: This study was designed to review the outcomes of emergent treatment of sigmoid colon volvulus. METHODS: The records of 827 patients were reviewed retrospectively. RESULTS: The mean age was 57.9 years (range, 10 weeks to 98 years), and 688 patients (83.2 percent) were male. Nonoperative reduction was applied in 575 patients (barium enema in 13, rigid sigmoidoscopy in 351, and flexible sigmoidoscopy in 211, with rectal tube placement in all patients). The results were as follows: success of 78.1 percent, mortality of 0.9 percent, complication of 3 percent, and early recurrence of 3.3 percent. Surgical treatment was performed on 393 patients (detorsion in 46, mesosigmoidopexy in 56, exteriorization in 4, resection with Hartmann's procedure in 146, resection with Mikulicz procedure in 14, resection with primary anastomosis in 51, tube cecostomy and colonic cleansing with resection in 75, and laparotomy in 1). The results were as follows: mortality of 15.8 percent, complication of 37.2 percent, early recurrence of 0.8 percent, and late recurrence of 6.7 percent. CONCLUSIONS: Nonoperative reduction is the initial treatment of sigmoid colon volvulus, and flexible sigmoidoscopy with rectal tube placement can be used successfully. Patients in whom bowel gangrene or peritonitis is present or nonoperative treatment is unsuccessful need emergency surgery. In surgical treatment, resection and primary anastomosis is the first choice, and it can be performed with acceptable mortality and morbidity rates if the patient is stable and a tension-free anastomosis is possible. Nondefinitive procedures have high recurrence rates; thus, definitive surgical techniques must be preferred.

Sigmoid volvulus in children and adolescents.

BACKGROUND: Sigmoid volvulus is an exceptionally rare and potentially life-threatening condition in the pediatric age group. STUDY DESIGN: We report our experience with three children treated for sigmoid volvulus and review the cases reported in the medical literature since 1940. RESULTS: Since 1940, 63 cases of sigmoid volvulus in children (including this series) have been reported. The median age was 7 years and the male to female ratio was 3.5:1. Two distinct presentations (acute and recurrent) were identified. Abdominal symptoms dominated the clinical picture. Barium enemas either confirmed or were highly suggestive of sigmoid volvulus. Reduction by barium enema was successful in 77% (10 of 13) of the attempts. Forty-nine patients underwent operative treatment, with sigmoidectomy (with or without primary anastomosis) being the most common. The overall mortality rate was 6%, operative mortality was 8.1%, and neonatal mortality was 14%. Associated conditions were frequent. Particular emphasis should be placed on ruling out Hirschsprung's disease (present in 11 of 63 patients). CONCLUSIONS: Sigmoid volvulus remains a rare occurrence in children, but it should be included in the differential diagnosis of pain in children when colonic distention is present. An algorithm for treatment is proposed.

[Volvulus of the colon. Apropos of 37 cases]. / Les volvulus du côlon. A propos de 37 cas.

A retrospective study of 37 case reports of patients with volvulus of the colon was carried out to define diagnostic and therapeutic strategies. The group comprised 22 men and 15 women, mean age 69 +/- 4 years (range 26-88 years), the volvulus being located in the sigmoid colon (n = 23), ascending colon (n = 13) or transverse colon (n = 1). The diagnosis, suggested by the straight abdominal film in almost all cases, was confirmed by a barium enema in 70% of cases. Treatment was surgical in 30 patients (81%) including 12 as emergency operations. Mortality was 5.4% (2 cases), and morbidity high (43% including fatal complications) the majority of adverse reactions being respiratory. Volvulus of the ascending colon was treated by hemicolectomy in 9 cases with no mortality or relapse. In patients with sigmoid volvulus, a "medical" reduction was performed in 7 patients, with success in 5 cases, one recurrence and no mortality, ideal sigmoidectomies in 14 cases resulting in one recurrence and no mortality. Right hemicolectomy appears to be the technique of choice even for urgent cases, there being no contraindications to a one-stage re-establishment of continuity. Inversely, an urgent intervention should at all costs be avoided in cases of sigmoid volvulus, a "medical" reduction (radiology, intubation, endoscopy) allowing preparation of the patient for a deferred ideal sigmoidectomy. Obviously, failure to reduce the volvulus or signs of colon necrosis require urgent surgery and raise the problem of whether or not to re-establish colon continuity.

[Volvulus of the sigmoid colon]. / Volvulus du côlon sigmoïde.

The authors report of 34 cases of sigmoid colon volvulus occurring in young subjects (15%) and in elderly subjects (60% over the age of 75 years). The diagnosis is frequently suggested by the clinical features and the history (30% of patients have a history of a previous identical episode) and is confirmed by a plain abdominal x-ray and/or an opaque enema. Endoscopy is performed in every case, except in the presence of peritoneal signs, in an attempt to perform detorsion and colonic intubation under direct vision in order to avoid emergency surgery; this procedure is effective in 87% of cases. Emergency surgery has a high mortality rate (43.5%). Elective or deferred emergency surgery after preparation is much safer (6.6% mortality). In patients with multiple diseases, non-surgical conservative management after detorsion too frequently results in repeated complications, leading to decompensation of the concurrent illnesses and a mortality rate of 34%. Endoscopic detorsion followed by surgical resection after a short 3 to 4 day preparation seems to be the best guarantee of therapeutic success.

Survival after colonic perforation during barium-enema examination. Modified radical surgical debridement.

Four of five patients survived perforation of the colon incidental to barium-enema examination, while the other survived without sequela of infection until hemiplegia and pneumonia supervened two and 36 days, respectively, postoperatively. It is postulated that adequate intravenous fluids, early operation, with complete cleansing by antibiotic irrigation and mechanical debridement of the abdominal cavity, along with excision of the perforated segment of bowel with establishment of an end colostomy or ileostomy and distal mucous fistula, if possible, are keys to survival in these patients. Triple antibiotics, using ampicillin, gentamicin, and clindamycin, or metronidazole, should be administered in all patients as soon as the diagnosis is made, and continued postoperatively as indicated until there is no evidence of infection. An intraluminal intestinal tube, for stichless plication of the small bowel, may be helpful in some patients. A stomacone should be used for a barium enema through a colostomy stoma. Care should be exercised in performing barium contrast studies in patients with inflammatory bowel disease.