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Sigmoid and Cecal Volvulus Treatment & Management

  • Author: Scott C Thornton, MD; Chief Editor: John Geibel, MD, DSc, MSc, MA  more...
 
Updated: Nov 30, 2015
 

Approach Considerations

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).

Algorithm for treatment of patients with sigmoid a Algorithm for treatment of patients with sigmoid and cecal volvulus.

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.

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Initial Measures

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.

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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.

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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).

Extent of resection required for sigmoid volvulus Extent of resection required for sigmoid volvulus is limited to resection of omega loop of sigmoid volvulus and resection of sigmoid mesentery.
Divided descending colon and rectum are reanastomo Divided descending colon and rectum are reanastomosed in hand-sewn manner or with GI stapling device.

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

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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.

Hartmann procedure for sigmoid volvulus. Hartmann procedure for sigmoid volvulus.

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.

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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.

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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).

Extent of resection for cecal volvulus is similar Extent of resection for cecal volvulus is similar to that in right hemicolectomy for benign disease.
Terminal ileum is anastomosed to transverse colon Terminal ileum is anastomosed to transverse colon in reconstruction after right hemicolectomy.
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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.

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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%)
  • Sepsis (2%)
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Contributor Information and Disclosures
Author

Scott C Thornton, MD Associate Clinical Professor of Surgery, Yale University School of Medicine; Director, Colorectal Teaching, Bridgeport Hospital; Private Practice, Park Avenue Surgical Associates

Scott C Thornton, MD is a member of the following medical societies: American Society of Colon and Rectal Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Neelu Pal, MD General Surgeon

Neelu Pal, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow

John Geibel, MD, DSc, MSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Received royalty from AMGEN for consulting; Received ownership interest from Ardelyx for consulting.

Acknowledgements

Brian James Daley, MD, MBA, FACS, FCCP, CNSC Professor, Associate Program Director, Department of Surgery, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine

Brian James Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Eastern Association for the Surgery of Trauma, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, and Tennessee Medical Association

Disclosure: Nothing to disclose.

David L Morris, MD, PhD, FRACS Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia

David L Morris, MD, PhD, FRACS is a member of the following medical societies: British Society of Gastroenterology

Disclosure: RFA Medical None Director; MRC Biotec None Director

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
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  2. Elsharif M, Basu I, Phillips D. A case of triple volvulus. Ann R Coll Surg Engl. 2012 Mar. 94(2):e62-4. [Medline].

  3. DRAPANAS T, STEWART JD. Acute sigmoid volvulus. Concepts in surgical treatment. Am J Surg. 1961 Jan. 101:70-7. [Medline].

  4. HENDRICK JW. TREATMENT OF VOLVULUS OF THE CECUM AND RIGHT COLON. A REPORT OF SIX ACUTE AND THIRTEEN RECURRENT CASES. Arch Surg. 1964 Mar. 88:364-73. [Medline].

  5. Vaez-Zadeh K, Dutz W, Nowrooz-Zadeh M. Volvulus of the small intestine in adults: a study of predisposing factors. Ann Surg. 1969 Feb. 169(2):265-71. [Medline]. [Full Text].

  6. Halabi WJ, Jafari MD, Kang CY, Nguyen VQ, Carmichael JC, Mills S, et al. Colonic volvulus in the United States: trends, outcomes, and predictors of mortality. Ann Surg. 2014 Feb. 259(2):293-301. [Medline].

  7. Grossmann EM, Longo WE, Stratton MD, Virgo KS, Johnson FE. Sigmoid volvulus in Department of Veterans Affairs Medical Centers. Dis Colon Rectum. 2000 Mar. 43(3):414-8. [Medline].

 
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Sigmoid volvulus. (A) Counterclockwise torsion at base of mesentery. (B) Adhesions at base of sigmoid mesocolon leading to formation of fixed omega loop that is susceptible to repeat torsion.
Cecal volvulus. (A) Clockwise torsion of mesentery of cecum, ascending colon, and terminal ileum. (B) Absence of dorsal mesenteric attachments of cecum and proximal ascending colon, leading to lack of fixation to retroperitoneum.
Cecal bascule. (A) Anterior folding of cecum. (B) Lack of dorsal mesenteric fixation of cecum to retroperitoneum.
Plain abdominal radiograph demonstrating massively dilated sigmoid colon loop and convergence of walls of colon into beaklike formation.
CT scan of abdomen demonstrating massive dilation of sigmoid colon and normal caliber of proximal bowel.
Barium enema of sigmoid volvulus revealing termination of contrast in bird's-beak formation at base of volvulus.
Cecal volvulus with associated small bowel obstruction.
Extent of resection required for sigmoid volvulus is limited to resection of omega loop of sigmoid volvulus and resection of sigmoid mesentery.
Divided descending colon and rectum are reanastomosed in hand-sewn manner or with GI stapling device.
Hartmann procedure for sigmoid volvulus.
Extent of resection for cecal volvulus is similar to that in right hemicolectomy for benign disease.
Terminal ileum is anastomosed to transverse colon in reconstruction after right hemicolectomy.
Algorithm for treatment of patients with sigmoid and cecal volvulus.
Variable degrees of attachment of ascending colon to abdominal wall by reflection of overlying parietal peritoneum. (A) Normal attachment. (B) Reflection of peritoneum to create paracolic gutter. (C) Mobile colon with reflection of peritoneum to create colonic mesentery.
Jackson veil over ascending colon contains numerous small blood vessels from renal and lumbar arteries.
Average measurements of sigmoid mesocolon.
Arterial blood supply to colon.
Cecal volvulus with ischemic changes of distended cecum and terminal ileum. Remainder of small bowel involved in volvulus appears distended but not ischemic. No obvious peritoneal contamination is observed.
 
 
 
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