Sigmoid and Cecal Volvulus Treatment & Management

Surgery is the definitive treatment of sigmoid and cecal volvulus. If the patient with sigmoid volvulus has evidence of ischemic bowel or peritonitis or if endoscopic decompression has failed, perform emergent surgery. Conversely, if the patient has neither of the above and endoscopic decompression and detorsion are successful, semi-elective surgery during the same hospital stay is acceptable. Bowel decompression is continued via a rectal tube while the bowel is prepared and the patient stabilized. The image below depicts an algorithmic overview of colonic volvulus management.

The currently accepted surgical procedures for sigmoid volvulus include sigmoid resection with primary anastomosis and resection and Hartman procedure. Primary anastomosis is performed if the divided bowel ends are viable, peritoneal contamination is not evident, and the patient is hemodynamically stable. If evidence of ischemic bowel or gross peritoneal contamination is observed or if the patient is hemodynamically unstable, a rapid resection of the volvulus and an end colostomy (Hartman procedure) are safer. Various surgical techniques for sigmoidopexy and mesenteric plication have been described. These are associated with high volvulus recurrence rates and are not commonly performed.

Because endoscopic decompression is successful in only 15-20% of patients with cecal volvulus, emergent surgical intervention is mandated. The selection of surgical procedure depends on the patient's clinical condition. In severely debilitated patients, cecostomy is a valid option. However, cecostomy is associated with a wound infection rate of 40-50% and a recurrence rate of approximately 2-5%. If the patient can withstand surgery, a right hemicolectomy with primary ileocolic anastomosis is the surgical procedure of choice. Rarely, an end ileostomy is performed. Cecopexy is associated with volvulus recurrence in 20-30% of patients. An extensive form of fixation of the right colon and cecum, which reportedly carries a lower recurrence rate, has been described. The time taken to perform this procedure is as long if not longer than that for required for colectomy, which is the definitive procedure. Hence, most fixation procedures for volvulus are not recommended.

The patient is resuscitated with intravenous isotonic crystalloid solution to correct fluid deficits and hypovolemia. This is performed while the patient is being examined and arrangements are being made to attempt endoscopic reduction of volvulus. Laboratory tests and plain radiographs of the abdomen are obtained in the emergency department.

Broad-spectrum antibiotics with anaerobic coverage are given to patients in whom peritonitis, ischemic bowel, or sepsis is evident. A Foley catheter is inserted to assess fluid balance, and a nasogastric tube is placed if the patient has been vomiting. Because pressure on the inferior vena cava may compromise venous return, place the patient in the left lateral position to improve venous return.

Recognition of the typical radiologic findings of a sigmoid volvulus on plain abdominal radiographs is followed by emergent sigmoidoscopy or colonoscopy to detorse and deflate the volvulus. A soft rectal tube is placed to allow continued decompression and bowel preparation prior to the planned surgical procedure. Placement of a rectal tube without endoscopic visualization is not advised because of the risk of perforation. Although it has been described with variable success, the procedure is often unsuccessful in detorsing the volvulus.

Sigmoidoscopic detorsion is successful in more than 90% of patients with sigmoid volvulus. In contrast, only 10-15% of patients with cecal volvulus can be successfully detorsed with colonoscopy. CT scanning of the abdomen and pelvis can be obtained in hemodynamically stable patients. This can better define a cecal volvulus as the cause of the obstruction.

Following the endoscopic detorsion of sigmoid volvulus, a soft rectal tube left in place maintains the decompression. Decompression is evident through passage of large amounts of gas and fecal material but should be radiologically confirmed.

Volvulus recurrence occurs in as many as 60% of patients who are treated solely with decompression. Elective surgery should be undertaken during the same admission. The patient can be further stabilized and mechanical bowel preparation given.

Clinical evidence of peritonitis, unsuccessful endoscopic detorsion, or a radiologically evident cecal volvulus necessitates emergent surgical intervention.

Following successful endoscopic decompression of sigmoid volvulus, the simplest approach with the lowest rate of recurrence is sigmoid colectomy and primary anastomosis.

The patient is placed in a dorsal lithotomy position using Lloyd Davis stirrups. This allows for the possibility that an unexpectedly low anastomosis may be required, which can be accomplished using transanal passage of an end-to-end anastomosis (EEA) stapler. The abdomen and perineum are prepared and draped separately. The perineum remains draped until the stapling device needs to be passed.

A low midline laparotomy incision is made. The massively dilated sigmoid colon loop is immediately encountered. It is exteriorized and the volvulus is detorsed by rotating it clockwise (since a sigmoid volvulus usually occurs by torsion in a counterclockwise direction). The colon proximal and distal to the site of torsion is circumferentially isolated and clamped. The inferior mesenteric artery is divided where easily accessible (see the image below).

Often, detorsion is not possible because of adhesions at the base of the mesentery. In these instances, the omega loop is resected by clamping and dividing the bowel proximal and distal to the loop. The sites of transection are chosen to allow a well-perfused, tension-free anastomosis (see the image below). The anastomosis can be completed in a hand-sewn fashion or with a GI stapling device.

In the event of a failed sigmoidoscopic reduction or suspected ischemic bowel, the divided bowel is carefully inspected to ensure good supply.

In the presence of fecal peritonitis or if the patient is hypotensive, a Hartman procedure is preferred. The patient is placed in a supine position and a low midline laparotomy incision is made. The omega loop of the sigmoid colon is resected. The proximal divided end of the colon is mobilized sufficiently to create a tension-free end colostomy. The distal stapled end of bowel remains in the pelvis (see the image below). A Hartman procedure is also a good option in a severely debilitated, bedridden patient who requires long-term care.

The Paul Mikulicz resection is of historic interest only and is rarely performed. It involves exteriorization of the volvulus via a lateral oblique incision. The sigmoid loop is amputated and a double-barrel colostomy is created. Sigmoidopexy is never a surgical option because it is associated with a recurrence rate of 40-50%. Mesenteric plication procedures have been described but are not recommended because of the associated high recurrence rates.

The preferred surgical procedure for the treatment of patients with cecal volvulus is right hemicolectomy. The patient is placed in a supine position and the abdomen is prepared and draped. A low midline laparotomy incision is made. The area of the volvulus and the terminal ileum are exteriorized. The volvulus is reduced through counterclockwise detorsion, since the torsion occurs in a clockwise direction. The terminal ileum is clamped and divided. The transverse colon immediately proximal to the middle colic artery is circumferentially isolated and divided between clamps. The colon is mobilized by dividing the mesentery and the peritoneal reflections. The divided bowel ends are approximated in a tension-free manner using a hand-sewn technique or GI stapler. See the images below.

In extremely debilitated patients who are unable to tolerate a surgical procedure, a percutaneous cecostomy can be attempted. Percutaneous cecostomy is associated with a recurrence rate of only 1-3% but a high incidence of wound infection and persistent fecal fistula.

Cecopexy is mentioned only to be condemned. The recurrence rate associated with cecopexy is 15-20%, the same as that for detorsion alone.

Postoperative care includes continued fluid resuscitation and antibiotic therapy as guided by the patient's clinical condition.

Patients who undergo a Hartman procedure may be candidates for colostomy reversal in 3-6 months. This decision is based on the patient's overall clinical condition and ability to withstand another major surgical procedure. Debilitated patients who require long-term institutional care may not benefit from colostomy reversal.

Delay in diagnosis and treatment of sigmoid and cecal volvulus is associated with rates of high morbidity and mortality.

As many of 50% of patients who undergo endoscopic decompression alone develop recurrence. The suggested interval between endoscopic decompression and definitive surgical intervention is 48-72 hours. This is adequate time for resuscitation, investigation, and intervention to further reduce surgical risk. Possible postoperative complications include the following:

• Surgical wound infection (8-12%)
• Anastomotic leak (3-7%)
• Colocutaneous fistula (2-3%)
• Abdominal or pelvic abscess (1-7%)
• Sepsis (2%)

Despite adequate treatment with endoscopic decompression and surgical resection, a mortality rate of 12-15% is quoted in various studies. This partially reflects the poor general health of this patient population. A retrospective review of patients in VA hospitals with sigmoid volvulus quoted mortality rates of 24% for emergent procedures and 6% for elective procedures (after decompression), respectively.^[4]

Endoscopic decompression alone for sigmoid volvulus carried a recurrence rate of 40-50%, with a mortality rate of 25-30% following surgical treatment of the recurrent volvulus. Studies quote a mortality rate of 30-40% in patients in whom diagnosis and treatment of cecal volvulus are delayed.

Elective laparoscopic sigmoid resection and right hemicolectomy following endoscopic decompression is increasingly being described and performed to treat patients with volvulus. In these patients, who are often elderly and chronically ill, minimally invasive surgery may provide significant benefit. Further studies comparing the outcomes of laparotomy versus laparoscopy for colectomy for volvulus are required.