[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.

Megacolon andino y vólvulo del sigmoides de la altura: Presentación de 418 casos entre 2008 - 2012 en el hospital C. Monge - Puno, Perú / Andean megacolon and sigmoid volvulus in the high altitude: Presentation of 418 cases between 2008 - 2012 at C. Monge Hospital, Puno, Peru

Objetivo: El presente estudio describe el manejo médico y quirúrgico del vólvulo de sigmoides debido a dolicomegacolon andino en un hospital a una altitud mayor a 3000 msnm. Material y métodos: Estudio descriptivo, observacional, transversal de 418 pacientes con diagnóstico de vólvulo de sigmoides; admitidos inicialmente por cuadros de obstrucción intestinal, en el Hospital de Juliaca Carlos Monge - Puno, Perú, durante el periodo 2008-2012. Los datos fueron procesados a través del programa SPSS versión 21. Resultados: Se registraron 418 pacientes, la media de edad fue de 60 años, rango 18-89 años, con una proporción hombre/mujer de 3,5/1. El manejo no quirúrgico se hizo en 64 (15,4%), el tratamiento empleado fue de enema salino 20 casos 31% y sonda rectal 44 (69%), se presentó recurrencia en 27 pacientes (45%), los cuales tuvieron cirugía con resección anastomosis primaria, de estos la mortalidad correspondió a 8 pacientes (30%). De los 354 pacientes sometidos a manejo quirúrgico de emergencia 325 fueron sometidos a sigmoidectomia con anastomosis primaria (92%), mientras 29 tuvieron colostomía a lo Hartmann (8%), la morbilidad para ambos procedimientos fue de 52 casos (14,7%), la mortalidad para ambos procedimientos fue de 45 casos (12,7%). Conclusiones: El vólvulo sigmoides debido a megacolon andino tuvo una edad media de 60 años. El 15,4% tuvo manejo no quirúrgico, la tasa de recurrencia fue de 45%, mortalidad de 30%. El 84,7% tuvo manejo quirúrgico; el 92% tuvo resección anastomosis primaria y 8% colostomía a lo Hartmann, la morbilidad fue de 14,7% y la mortalidad de 12,7%.

Objective: The present study describes the medical and surgical management of sigmoid volvulus due to Andean dolicomegacolon in a hospital at an altitude above 3000 m. Material and methods: A descriptive, observational, crosssectional study of 418 patients diagnosed with sigmoid volvulus; Admitted initially due to intestinal obstruction, in the Hospital of Juliaca Carlos Monge. Puno-Perú, during the period 2008-2012. The data were processed through the SPSS software version 21. Results: A total of 418 patients were enrolled, the mean age was 60 years, range 18-89 years, and the male/female ratio was 3.5/1. Nonsurgical management was done in 64 (15.4%), the treatment used was saline enema 20 cases (31%) and rectal catheter 44 (69%), recurrence was present in 27 patients (45%), who had surgery with primary anastomosis resection, of which the mortality corresponded to 8 patients (30%). Of the 354 patients undergoing emergency surgical management, 325 were submitted to sigmoidectomy with primary anastomosis (92%), while 29 had Hartmann's colostomy (8%), the morbidity for both procedures was 52 cases (14.7%), Mortality for both procedures was 45 cases (12.7%). Conclusions: In patients with sigmoid volvulus due to Andean megacolon the mean age was 60 years. The 15.4% had non-surgical management, the recurrence rate was 45%, and mortality 30%. Patients with surgical management was 84.7%, from this group; 92% had primary anastomosis resection and 8% Hartmann colostomy, morbidity was 14.7% and mortality was 12.7%.

[Andean megacolon and sigmoid volvulus in the high altitude. Presentation of 418 cases between 2008 - 2012 at C. Monge Hospital, Puno, Peru]. / Megacolon andino y vólvulo del sigmoides de la altura. Presentación de 418 casos entre 2008 - 2012 en el hospital C. Monge Puno, Perú.

OBJECTIVE: The present study describes the medical and surgical management of sigmoid volvulus due to Andean dolicomegacolon in a hospital at an altitude above 3000 m. MATERIAL AND METHODS: A descriptive, observational, crosssectional study of 418 patients diagnosed with sigmoid volvulus; Admitted initially due to intestinal obstruction, in the Hospital of Juliaca Carlos Monge. Puno-Perú, during the period 2008-2012. The data were processed through the SPSS software version 21. RESULTS: A total of 418 patients were enrolled, the mean age was 60 years, range 18-89 years, and the male/female ratio was 3.5/1. Nonsurgical management was done in 64 (15.4%), the treatment used was saline enema 20 cases (31%) and rectal catheter 44 (69%), recurrence was present in 27 patients (45%), who had surgery with primary anastomosis resection, of which the mortality corresponded to 8 patients (30%). Of the 354 patients undergoing emergency surgical management, 325 were submitted to sigmoidectomy with primary anastomosis (92%), while 29 had Hartmann's colostomy (8%), the morbidity for both procedures was 52 cases (14.7%), Mortality for both procedures was 45 cases (12.7%). CONCLUSIONS: In patients with sigmoid volvulus due to Andean megacolon the mean age was 60 years. The 15.4% had non-surgical management, the recurrence rate was 45%, and mortality 30%. Patients with surgical management was 84.7%, from this group; 92% had primary anastomosis resection and 8% Hartmann colostomy, morbidity was 14.7% and mortality was 12.7%.

Neonatal sigmoid volvulus.

BACKGROUND: Neonatal sigmoid volvulus is a rare entity. It is associated with Hirschsprung's disease. Presentation is acute abdominal distention, vomiting and obstipation. Abdominal radiograph will show the "coffee bean" sign, but this is frequently missed and the diagnosis requires a high index of suspicion. Treatment options include contrast enema, colonoscopy or laparotomy, depending on the condition of the baby and local availability. POPULATION AND RESULTS: During the last 6years, 6 infants with sigmoid volvulus were treated in our department. Four presented during the first 48h since birth, and 2 presented at the age of 2 and 7weeks of age. One child was operated and 5 had primary contrast enema with radiologic de-volvulus. Rectal biopsy was performed in all cases; three children had Hirschsprung's disease. Those with normal biopsies responded well to rectal washouts. Two patients had early one stage transanal pullthrough and one had 2 further occasions of sigmoid volvulus prior to definitive surgery. All three recovered with an uneventful course. CONCLUSIONS: Neonatal sigmoid volvulus requires a high level of suspicion. Contrast enema is efficient for primary de-volvulus. Rectal biopsy should be performed and if positive for Hirschsprung's disease, surgery should be performed sooner rather than later.

Megarectosigmoid in children with anorectal malformations: long term outcome after surgical or conservative treatment.

PURPOSE: Megarectosigmoid (MRS) is commonly seen in children with anorectal malformations (ARM) and contributes to the high incidence of constipation. Surgical resection has been advocated by some, whereas others propose intense bowel management as the treatment of choice. The aim of this study was to evaluate outcome of both bowel function and configuration after surgical or conservative treatment of MRS in ARM patients. MATERIALS AND METHODS: The study included 79 patients with ARM, excluding perineal fistula, (48 boys, 31 girls) from 1986 to 2007. MRS was diagnosed at colostomy formation or contrast enema performed in the neonatal period. Early in the period, the majority of the patients were treated surgically, whereas in the late 1990 s, a conservative approach with intensified bowel treatment was implemented. Contrast enema and bowel function investigations were performed repeatedly during follow-up. RESULTS: MRS, according to radiological criteria, was diagnosed in 26/79 (33%) of the ARM children. Bowel functional outcome was similar regardless of surgical or conservative treatment and comparable to function in ARM children with non-MRS. The radiological signs of rectal dilatation and elongation disappeared after surgical intervention, but normalisation of the rectosigmoidal configuration was also seen with age in the conservative group. CONCLUSIONS: Bowel functional outcome in ARM children with MRS was similar after either surgical or conservative treatment during follow-up. The radiological signs of rectal dilatation and elongation disappeared also in the conservatively treated patients over time.

Treatment of sigmoid volvulus: a single-center experience of 952 patients over 46.5 years.

BACKGROUND: Sigmoid volvulus describes the wrapping of the sigmoid colon around itself and its mesentery, causing an intestinal obstruction. The aim of this study was to assess the outcomes of 952 patients treated for sigmoid volvulus over a period of 46.5 years. METHODS: Clinical records were reviewed retrospectively. RESULTS: Nonsurgical detorsion was performed in 686 patients with 77.1 % success, 2.5 % morbidity, 0.7 % mortality, and 4.5 % early recurrence rates; emergency surgical procedures were performed in 447 patients with 35.3 % morbidity, 16.1 % mortality, 0.7 % early recurrence, and 7.4 % late recurrence rates, while elective surgical treatment was performed in 104 patients with 12.5 % morbidity, no mortality, and no recurrence. CONCLUSIONS: The principal strategy in the treatment for sigmoid volvulus is early nonsurgical detorsion followed by elective surgery in uncomplicated patients, while emergency surgical treatment is performed for patients with bowel gangrene, perforation, or peritonitis, other difficulties with diagnosis, unsuccessful nonsurgical detorsion, and early recurrence.

Abdominal manipulation during water-soluble contrast enema - an alternative method of non-operative decompression of sigmoid volvulus?

Sigmoid volvulus is common in some developing countries. We describe a new method of decompression using a Urograffin and saline enema with additional extra-abdominal manual massage.

Complicated sigmoid diverticulitis.

In medical practice, the colonic diverticulitis diagnosis is easy, based especially on a barium enema and an inferior digestive endoscopy, but the diverticulitis complications, especially metastatic infections, raise serious positive and differential diagnosis problems. We present the case of a 51 year old male who comes with hepatomegaly and multiple hepatic formations, in deteriorating clinical condition, context suggestive of secondary metastasis, but after investigation it was demonstrated they were of infectious nature, from a sigmoidian diverticulitic abscess. In this case, the hepatic biopsy was appropriate and it represented an important moment in the management of the patient.

The natural history of diverticulitis: fact and theory.

Epidemiological and anatomic evidence indicates that approximately 60% of humans of westernized societies living into the sixth decade will develop diverticulosis of the colon. The cause remains unknown, but epidemiological studies indicate it is a combination of decreased dietary fiber intake and increased intracolonic pressure. The intraluminal pressure exerted on the wall causes a diverticular outpocketing at any one of the three areas in which vessels enter the wall. In this paper, we advance a hypothesis that fiber deficiency not only leads to diverticula formation but also causes a change in the microecology that results in decreased colon immune response and permits a low-grade chronic inflammatory process that precedes a full-blown acute diverticulitis. Pathophysiologic studies reveal that complications do not occur until there is microperforation through the wall of the diverticulum into the pericolic tissue. The perforation might be small and cause a microabscess, or extend to a phlegmon, or extend to a large abscess formation. Free perforation occurs rarely, but fistulization does occur and most commonly to the bladder. The clinical findings vary. Most often, the clinical picture is one of fever, abdominal pain, a change in bowel habit, and localizing findings associated with leukocytosis. Computerized tomography scanning has become the procedure of choice to evaluate the symptoms since it is of less risk than a barium enema and obtains more information. The differential diagnosis may be difficult but usually can be made with accuracy. Medical treatment is preferred with appropriate antibiotic therapy and variations in fiber intake. When abscess occurs, percutaneous drainage may be tried, but when it is unsuccessful, surgical intervention is necessary. Sudden hemorrhage from a vessel in diverticula may also occur. It is estimated that approximately 20% of all patients that develop diverticula will have either inflammatory or bleeding episodes. In conclusion, fiber deficiency results in diverticular formation and a chronic inflammation that may progress to acute or chronic diverticulitis that can be treated medically but may require surgical intervention.

Giant diverticulum of the sigmoid colon.

The giant colonic diverticulum is a very rare clinical entity usually located in the sigmoid colon of elderly patients. A case of an 87-year-old woman recently treated in our hospital is reported hereinafter. The patient was non-surgically treated due to her advanced age and high surgical risk.

Diverticulitis in the young patient.

Although predominantly a disease in older adults diverticulitis does affect younger patients. The disease has been described as not only rare but virulent by some authors, and a young patient age is considered to be a relative indication for early sugery. The goal of this study was to evaluate the experience of the Louisiana State University Health Sciences Center-Shreveport and affiliated hospitals with diverticulitis in young patients. This study was a retrospective chart review of 22 patients with diverticulitis age 40 years and younger over the past 20 years. Inclusion criteria were either a diagnosis of diverticulitis confirmed at surgery or positive CT findings and/or a positive contrast enema. The mean age in this study was 32.1 years (range 16-40). All 22 patients presented with abdominal pain. The next most common symptom was nausea and/or vomiting in 45 per cent followed by fever and chills in 36 per cent. Twelve patients had abdominal CTs on admission, and 87 per cent had positive findings. Eighteen patients underwent an operation. Four patients were treated nonoperatively. Nineteen patients had diverticulitis of the sigmoid colon. The remaining three had right-sided diverticulitis. Two patients underwent right hemicolectomy, and one underwent cecectomy. Of the 15 patients with sigmoid diverticulitis 12 (80%) underwent a two-stage procedure of sigmoid colectomy, end colostomy, and Hartmann's pouch. Three patients (20%) underwent a one-stage procedure of sigmoid colectomy and primary anastomosis. Two of three patients undergoing a one-stage procedure required reoperation. Postoperative complications occurred in 10 of 18 patients for an overall incidence of 56 per cent. Two of these patients had septic complications. Both of these patients had a delay in time from admission until operation: one for 7 days and the other for 10 days. There was one death in the series. Colostomy closure was performed successfully in nine of 12 (75%) patients. The mean time interval before closure was 7.7 months, (range 3-14). Patients with two-stage procedures on initial admission fared better than those with one-stage procedures. The overall mortality was 4.5 per cent. There was a high overall complication rate of 56 per cent in patients undergoing an operation. Two patients who had a delay in time from admission to operation had septic complications. Early surgical intervention should be considered in this clinical setting. In summary, although rare, diverticulitis in the young patient is often a fulminant illness requiring operation early in the disease process.

Management of uncomplicated acute diverticulitis: results of a survey.

PURPOSE: A survey was conducted to document current medical treatment of patients with uncomplicated acute diverticulitis. METHODS: A survey was mailed to 667 fellows of The American Society of Colon and Rectal Surgeons certified by the American Board of Colon and Rectal Surgery. Queries were based on a clinical scenario of a patient with uncomplicated diverticulitis. RESULTS: Three hundred seventy-three surveys (56 percent) were returned completed. The majority (66 percent) chose an abdominal computed tomographic scan as the initial diagnostic test. One-half used a single intravenous antibiotic with second-generation cephalosporins (27 percent) and ampicillin/sulbactam (16 percent) being the most common. Oral antibiotics given at discharge were ciprofloxacin (18 percent), amoxicillin/clavulanate (14 percent), metronidazole (7 percent), and doxycycline (6 percent). Combinations chosen were ciprofloxacin/metronidazole (28 percent) and metronidazole/trimethoprim sulfamethoxazole (6 percent), whereas 21 percent chose a variety of other antibiotics. The majority (74 percent) prescribed oral antibiotics for 7 to 10 days. Dietary recommendations at discharge were low residue (68 percent), regular (21 percent), and high residue (10 percent). Half of those surveyed believed avoidance of seeds and nuts were of no value. Follow-up examinations chosen included sigmoidoscopy and barium enema (29 percent), colonoscopy (25 percent), sigmoidoscopy (17 percent), barium enema (13 percent), and other (16 percent). Sixty-five percent of colon and rectal surgeons claim to handle more than half of their patients with uncomplicated diverticulitis on an outpatient basis. CONCLUSION: Variations in the management of uncomplicated sigmoid diverticulitis are noted among colon and rectal surgeons, especially in terms of antibiotic choice, discharge instructions, and follow-up outpatient studies. The survey results are compared with the conclusions reached in The American Society of Colon and Rectal Surgeons practice parameters. Documentation of practice pattern variation may serve as an educational tool for physicians to improve their quality and cost of medical care. Consideration should be given to better publicize already existing American Society of Colon and Rectal Surgeons practice parameters for this common entity.

A successfully treated case of multiple liver abscesses accompanied by portal venous gas.

A case with multiple liver abscess accompanied by massive portal venous gas is reported. A 61-yr-old male was admitted because of left lower abdominal pain, fever, and diarrhea. Abdominal x-ray examination demonstrated multiple branching lucencies in the liver. Computed tomography revealed multiple liver abscesses and massive gas in the portal system as well as a thickened wall of the sigmoid colon. Enema study using contrast medium revealed a perforation of the sigmoid colon with diverticulitis. The outcome was favorable after sigmoid colectomy in addition to intensive treatment with antibiotics. Bacteroides fragilis, which produces gas (H2 and NH3) by fermentation, was isolated not only from the resected specimen but also from blood samples. Although the presence of portal venous gas is a sign of poor prognosis in patients with intestinal infectious diseases, the sensitive detection of hepatic portal venous gas by computed tomography and the appropriate treatment may improve the patient's prognosis.

Ischemic stricture and perforation. An unusual complication after successful barium reduction of an intussusception.

Intussusception is a common cause of intestinal obstruction in infants. Use of a barium enema affords both diagnostic confirmation and a chance for nonsurgical reduction of the intussusception. While failed hydrostatic reduction is an indication for surgical intervention, delayed complications of hydrostatic reduction have not been described. We present a case of ischemic stricture and perforation developing after the successful reduction of an intussusception.

Volvulus of the sigmoid colon in paediatric patients: report of two cases.

Two cases of volvulus of the sigmoid colon in paediatric patients are presented. The condition is rare in childhood. The diagnosis was established at laparotomy in the first case while the second case was diagnosed because of heightened awareness. The clinical features of the disease are essentially as in adults.

Perforation of the rectum and sigmoid colon during barium-enema examination. Management and prevention.

Perforation of the rectum or sigmoid colon complicated 5 of 2200 barium-enema examinations performed during a 4-year period. Three patients with rectal perforations manifested by air extravasation were successfully treated with intravenous antibiotics and complete bowel rest. Two patients with barium extravasation were treated with immediate operation and colostomy. All five patients recovered. Perforation was found to be associated with a rectal stricture due to ulcerative colitis, a rectal cancer, an incarcerated inguinal hernia, fulminant ulcerative colitis, and a normal colon in an elderly patient. To determine the pressure in the rectum that could potentially be generated during a barium-enema examination, the pressures created by a standard barium delivery set were measured, using 1-meter columns of water, 25 percent diatrizoate sodium (Hypaque), 20 percent barium, and 80 percent barium. The columns generated pressures of 70, 85, 95, and 120 mm Hg respectively. Squeezing the delivery bag increased the pressure 21 to 79 percent or a maximum of 55 mm Hg. Colorectal perforation during barium-enema examination that was not accompanied by barium extravasation could be successfully treated nonoperatively. The associated pathology and our studies of pressures generated during a barium-enema examination allow us to suggest that the incidence of colorectal perforation during barium-enema radiography can be reduced by 1) performing proctoscopy prior to barium enema, 2) avoiding the use of the rectal balloon in patients with known rectal lesions, 3) avoiding barium studies in patients with active colitis, 4) avoiding generation of pressure greater than that created by a column of barium suspension of one meter, and 5) using a lower concentration of barium when possible.

Sigmoid volvulus. A four-decade experience.

During the 40 years from 1945 to 1984, 159 occurrences of sigmoid volvulus in 140 patients were diagnosed and managed. Treatment modalities gradually evolved from primarily operative decompression in the first 20 years to selective, sigmoidoscopic, nonoperative reduction in the most recent 10-year period. Operative reduction was associated with a 10 per cent mortality, while no deaths were associated with nonoperative reduction. A 60 per cent mortality was noted when gangrenous bowel was present. In the most recent 10-year period, 71 per cent of cases were associated with neuropsychiatric diseases, and one third had a previous episode of sigmoid volvulus. The diagnosis was made on the initial plain abdominal radiograph in 60 per cent, and nonoperative sigmoidoscopic reduction attained in 95 per cent. Following nonoperative reduction, elective resection was performed during the same hospitalization with a 5 per cent mortality. Initial management of sigmoid volvulus should consist of nonoperative attempts at reduction with operative reduction reserved for refractory cases or those with ischemic bowel. Elective resection can be safely performed during the same hospitalization.