Sigmoid and Cecal Volvulus Treatment & Management
- Author: Scott C Thornton, MD; Chief Editor: John Geibel, MD, DSc, MSc, MA more...
Surgery is the definitive treatment of sigmoid and cecal volvulus. The decisions regarding timing of surgery and choice of procedure depend on the clinical presentation (see the image below).
In patients with no evidence of peritonitis or ischemic bowel, treatment starts with resuscitation and detorsion of the sigmoid volvulus. This is accomplished by means of sigmoidoscopy or colonoscopy and concomitant rectal tube placement. The bowel is then prepared, and surgery is undertaken electively during the same hospitalization. Inability to detorse the sigmoid volvulus endoscopically is an indication for immediate surgical intervention.
If the patient has evidence of peritonitis or ischemic bowel, emergency surgery is indicated, and the operative procedure is chosen on the basis of intraoperative findings.
Radiologic diagnoses of cecal volvulus or cecal bascule are also generally considered indications for surgical intervention because the obstruction in these conditions cannot be reliably reduced with colonoscopy. However, there is some controversy on this point; the increasing number of reports citing successful detorsion of cecal volvulus suggest that in stable patients, a single attempt at colonoscopic decompression is reasonable.
For sigmoid volvulus, the currently accepted surgical procedures include sigmoid resection with primary anastomosis and resection and the Hartmann 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 Hartmann procedure is 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.
For cecal volvulus, the success rate of endoscopic decompression is only 15-20%, and emergency surgical intervention is therefore mandated. The choice of procedure depends on the patient’s clinical condition. In severely debilitated patients, cecostomy is a valid option; however, it 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 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 required for this procedure is as long as, if not longer than, that required for colectomy, which is the definitive procedure. Hence, most fixation procedures for volvulus are not recommended.
Elective laparoscopic sigmoid resection and right hemicolectomy after 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.
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, the patient is placed in the left lateral position to improve venous return.
Endoscopic Detorsion and Decompression
Recognition of the typical radiologic findings of a sigmoid volvulus on plain abdominal radiography is followed by emergency sigmoidoscopy or colonoscopy for detorsion and decompression of the volvulus.
The sigmoidoscope or colonoscope is advanced into the rectum under direct vision. The rectum is insufflated to provide good visibility and facilitate identification of the apex of the volvulus. Occasionally, the pressure of the air causes detorsion, reducing the volvulus.
If detorsion does not occur, the spiraling rectal mucosa is followed upward to the apex, and a soft rectal tube is passed up through this under direct vision. The tip of the endoscope can also be used to apply constant pressure at the apex, which can lead to detorsion and decompression.
Placement of a soft rectal tube allows continued decompression and bowel preparation before the planned surgical procedure. Placement of a rectal tube without endoscopic visualization is not advised, because of the risk of perforation. Decompression is evident through passage of large amounts of gas and fecal material but should be radiologically confirmed.
Sigmoidoscopic detorsion is successful in more than 90% of patients with sigmoid volvulus, but colonoscopic detorsion is successful in only 10-15% of patients with cecal volvulus. Computed tomography (CT) 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.
Volvulus recurs 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 emergency surgical intervention.
Sigmoid Colectomy for Sigmoid Volvulus
After successful endoscopic decompression of sigmoid volvulus, the surgical approach that is simplest and has the lowest rate of recurrence is sigmoid colectomy with primary anastomosis.
The patient is placed in a dorsal lithotomy position with Lloyd Davis stirrups. This allows for the possibility that an unexpectedly low anastomosis may be required, which can be accomplished through transanal passage of an end-to-end anastomosis (EEA) stapler. The abdomen and perineum are prepared and draped separately. The perineum remains draped until it is time to pass the stapling device.
A low midline incision is made. The massively dilated sigmoid colon loop is immediately encountered. This is exteriorized, and the volvulus is detorsed by rotating it clockwise (because a sigmoid volvulus is usually the result of counterclockwise torsion). The colon proximal and distal to the site of torsion is circumferentially isolated and clamped. The inferior mesenteric artery is divided where it is easily accessible.
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 first image below). The anastomosis can be completed in a hand-sewn fashion or with a gastrointestinal (GI) stapling device (see the second image below).
In the event of a failed sigmoidoscopic reduction or a suspected ischemic bowel, the divided bowel is carefully inspected to ensure good supply.
Hartmann Procedure for Sigmoid Volvulus
If fecal peritonitis is present or the patient is hypotensive, a Hartmann procedure (rapid resection of the volvulus with an end colostomy) is preferred.
The patient is placed in a supine position, and a low midline 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 the bowel remains in the pelvis (see the image below). A Hartmann procedure is also a good option in a severely debilitated, bedridden patient who requires long-term care.
Patients who undergo a Hartmann procedure may be candidates for colostomy reversal in 3-6 months. This decision whether to proceed with reversal 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.
Other Procedures for Sigmoid Volvulus
The Mikulicz resection is of historic interest only and is rarely performed today. 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.
Right Hemicolectomy for Cecal Volvulus
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 incision is made. The area of the volvulus and the terminal ileum are exteriorized. The volvulus is reduced through counterclockwise detorsion, because 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 (see the first image below). The divided bowel ends are approximated in a tension-free manner by using a hand-sewn technique or a GI stapler (see the second image below).
Other Procedures for Cecal Volvulus
In extremely debilitated patients who are unable to tolerate a surgical procedure, a percutaneous cecostomy may be attempted. This procedure has a low recurrence rate (only 1-3%) but is associated with 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.
Complications of Surgery
Postoperative care includes continued fluid resuscitation and antibiotic therapy as guided by the patient’s clinical condition. Possible postoperative complications include the following:
Surgical wound infection (8-12%)
Anastomotic leakage (3-7%)
Colocutaneous fistula (2-3%)
Abdominal or pelvic abscess (1-7%)
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