Sigmoid and Cecal Volvulus 

Updated: Nov 28, 2018
Author: Scott C Thornton, MD; Chief Editor: John Geibel, MD, MSc, DSc, AGAF 

Overview

Background

The term volvulus is derived from the Latin word volvere (“to twist”). A colonic volvulus occurs when a part of the colon twists on its mesentery, resulting in acute, subacute, or chronic colonic obstruction. The main types of colonic volvulus are sigmoid volvulus and cecal volvulus.[1, 2]

See Can't-Miss Gastrointestinal Diagnoses, a Critical Images slideshow, to help diagnose the potentially life-threatening conditions that present with gastrointestinal symptoms.

Before the 19th century, management of patients with volvulus was largely expectant. Gradually, as nonintervention became associated with a high mortality, early surgical treatment became a widely accepted practice.

By 1920, three surgical approaches (ie, open detorsion and mesenteric plication, resection with colostomy, and resection with anastomosis) were widely used for the surgical treatment of patients with sigmoid volvulus. Emergency resection carried a mortality of well over 50%. The Mikulicz operation, the Hartmann procedure, and sigmoidopexy combined with partial resections were also attempted, with variable results.

In 1947, the technique of transanal deflation of the volvulus using sigmoidoscopy was described. This method of treatment was supported by subsequent studies,[3] but nonoperative detorsion as the only treatment was found to be associated with a high recurrence rate. Consequently, elective resection after a few days of decompression of the colon was adopted, and this approach remains the current surgical treatment of patients with sigmoid volvulus.

Surgical treatment of cecal volvulus paralleled that of sigmoid volvulus. Before the early 19th century, expectant management was widely practiced; as experience accrued, surgical treatment became accepted. Detorsion and cecopexy were commonly performed, as was placement of cecostomy tubes. The high recurrence and complication rates led to the adoption of right hemicolectomy for the treatment of cecal volvulus, which remains the accepted approach. Cecostomy is reserved for patients who are too debilitated to withstand resection.

Anatomy

The embryonic right colon typically has a mesentery that eventually fuses to the parietal peritoneum; this fusion results in adherence to the posterior abdominal wall. Developmental variations in the degree of fusion lead to differences in the mobility of the ascending colon and the cecum (see the image below). Hendrick, in a review of cadaver studies, found that 10-25% of the general population had a propensity for cecal volvulus on the basis of the length of the colonic mesentery.[4] The long mesentery of the ascending colon results in a mobile cecum.

Variable degrees of attachment of ascending colon 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.

Two conditions must be present for the development of a cecal volvulus: (1) an abnormally mobile segment of cecum and colon and (2) a fixed point around which the mobile segment can twist. The second condition is created through normal ileocolic attachments, as well as through abnormal adhesions after surgery or appendicitis.

The Jackson veil is an abnormal membrane that passes anterior to the ascending colon and permits the cecum to be mobile around the lower point of the fixation permitted by the membrane (see the image below).

Jackson veil over ascending colon contains numerou Jackson veil over ascending colon contains numerous small blood vessels from renal and lumbar arteries.

At the level of the iliac crest, the descending colon becomes the sigmoid colon. The mesosigmoid has variable attachments to the posterior body wall; most often, it is attached diagonally downward toward the right. Cadaver studies in the United States found the average length and breadth of the sigmoid mesentery to be 7.9 cm and 5.6 cm, respectively (see the image below).[5] Cadaver studies from the Middle East reported a mesenteric breadth of 15.2 cm. This difference may be developmental or may reflect differences in diet.

Average measurements of sigmoid mesocolon. Average measurements of sigmoid mesocolon.

Resection of the colon is based on the arterial supply to its various anatomic divisions (see the image below). The ascending colon and cecum are supplied by the superior mesenteric artery via the ileocolic and right colic arteries. Adjacent to the colonic wall, these arteries form arcades that give off the vasa recta. The vasa recta divide into short and long branches that supply the medial and lateral aspects of the colon, respectively.

Arterial blood supply to colon. Arterial blood supply to colon.

The middle colic artery forms an arcade with the left colic artery, which is a branch of the inferior mesenteric artery. This arcade, termed the marginal artery of Drummond, lies in the mesenteric border adjacent to the colonic wall. The marginal artery gives off vasa recta to the transverse colon, the splenic flexure, and the descending colon. The sigmoid colon is supplied by branches of the left colic artery, as well as by two to four sigmoidal arteries, which are branches of the inferior mesenteric artery.

In 3-5% of the population, the right colic and ileocolic arteries do not anastomose, creating an area of poor blood supply. Similarly, the point of Griffith is an area of poor blood supply in the region of the splenic flexure.

The critical point of Sudeck was previously considered to be a similar watershed area of poor blood supply at the junction of the rectum with the sigmoid colon. Because of the extensive and intramural submucosal plexus of arteries formed by the branches of the superior, middle, and inferior rectal arteries, the rectum and distal sigmoid colon are well vascularized. In contrast, the vasa recta (the end arteries in the colon wall) are not well vascularized. For this reason, the clinical implications of the critical point of Sudeck are not as important.

To avoid injuring the ureters, the surgeon must always be aware of the location of these structures in the retroperitoneum. The ureter is easily identified at the pelvic brim where it crosses over the external iliac artery. It is visible as a white structure that, on gentle compression, demonstrates characteristic propulsive movement.

Pathophysiology

Chronic constipation in Western society and a high-fiber diet in developing nations lead to an overloaded sigmoid colonic loop. The weight of this loaded sigmoid colon makes it susceptible to torsion along the axis of the elongated mesentery. The presence of a gravid uterus or a large pelvic mass alters the relative positions of the intra-abdominal organs, also predisposing to formation of volvulus.

As a result of repeated subacute attacks of torsion, the base of the sigmoid mesocolon becomes foreshortened. The associated mild, chronic inflammation at the base of the mesentery and the two limbs of the sigmoid colon loop leads to the formation of adhesive tissue. This causes the sigmoid loop to become chronically fixed into a paddlelike configuration, which, in turn, predisposes to recurrence of the torsion (see the image below).

Sigmoid volvulus. (A) Counterclockwise torsion at 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 may be organoaxial (true cecal or cecocolic volvulus) or mesentericoaxial (cecal bascule). The former involves the distal ileum and ascending colon twisting around each other, in much the same way as a sigmoid volvulus. Compared with sigmoid volvulus, in which the torsion is in a counterclockwise direction, cecal volvulus usually occurs in a clockwise direction.

Incomplete cecal and ascending colonic fixation occurs because of a lack of embryologic development of the dorsal mesentery. The lack of development predisposes the patient to clockwise torsion of the cecum, terminal ileum, and ascending colon (see the images below). Vascular compromise is common because of mesenteric torsion.

Cecal volvulus. (A) Clockwise torsion of mesentery 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 volvulus with ischemic changes of distended 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.

In contrast, a cecal bascule occurs when the malfixed cecum folds anteriorly over the ascending colon (see the image below) in an axis at right angles to the mesentery. Because no torsion of the ileocolic mesentery is present, vascular compromise of the cecum rarely occurs. Vascular compromise occurs more commonly in cases in which significant distention is present, which prevents the cecum from unfolding into its normal position.

Cecal bascule. (A) Anterior folding of cecum. (B) Cecal bascule. (A) Anterior folding of cecum. (B) Lack of dorsal mesenteric fixation of cecum to retroperitoneum.

A complete volvulus leads to the development of a closed-loop obstruction of the affected colonic segment. Increased dilation of the bowel loop compromises the vascular supply of the bowel, eventually leading to ischemic gangrene and bowel wall perforation.

Etiology

The presence of a long mesentery with a narrow base of fixation to the retroperitoneum and elongated, redundant bowel predisposes to the formation of volvulus. Volvulus can develop in any portion of the large bowel. However, it is most common in the sigmoid colon because of the mesenteric anatomy. Less commonly, volvulus develops in the right colon and terminal ileum (cecal or cecocolic volvulus) or the cecum alone (termed a cecal bascule). In rare cases, volvulus may develop in the transverse colon or the splenic flexure.

Sigmoid volvulus may occur because of sigmoid elongation, resulting in a redundant loop. Most commonly, this is the result of chronic constipation and the progressive dilatation and lengthening of the sigmoid colon and its mesentery.

Institutionalized patients with neuropsychiatric disorders often develop sigmoid volvulus. A higher incidence of the condition is observed in patients with Parkinson disease, multiple sclerosis, or spinal cord injury. Psychotropic drugs interfere with colonic motility and are etiologically implicated in the high incidence observed in patients in psychiatric institutes.

Patients in nursing homes also commonly develop sigmoid volvulus. This association may be a manifestation of the prolonged recumbency and chronic constipation that patients in chronic care facilities experience. Not surprisingly, the excessive use of laxatives, cathartics, and enemas is highly associated with the development of sigmoid volvulus.

In developing countries, a high-fiber diet leads to overloading of the sigmoid colon, which twists around its mesentery and results in volvulus. Megacolon, either congenital or acquired through Chagas disease, predisposes to the development of sigmoid volvulus. In areas of South America where Chagas disease is endemic, the development of sigmoid volvulus in affected patients is reported to be as high as 30%.

The presence of a pelvic mass also increases the risk of developing sigmoid volvulus. The mass displaces the sigmoid colon sufficiently to result in torsion of the mesentery and subsequent volvulus. The association of pregnancy and large ovarian tumors with sigmoid volvulus is well known. In Western societies, as many as 45% of pregnant patients with intestinal obstruction have sigmoid volvulus.

Less common conditions resulting in sigmoid volvulus include postoperative adhesions, internal herniations, intussusceptions, omphalomesenteric abnormalities, intestinal malrotations, and carcinoma. A rare condition in patients with abnormally long mesenteries of the stomach, splenic flexure, and sigmoid colon has been described as traveling volvulus. The abnormal mesenteric fixation of intraperitoneal organs predisposes these patients to recurrent spontaneous torsion and detorsion.

Whereas sigmoid volvulus is usually an acquired condition, cecal volvulus is due to congenital incomplete dorsal mesenteric fixation of the cecum or ascending colon associated with an abnormally elongated mesentery distal to this area of absent mesentery. In autopsy studies, marked mobility of the right colon occurs in an estimated 15-20% of the population.

Other anomalies that predispose to cecal volvulus include undescended right colon and previous surgical mobilization of the cecum, both permitting sufficient mobility for volvulus. Appendicitis, with resultant formation of adhesions, predisposes to cecal volvulus as well.

As in sigmoid volvulus, a pelvic space-occupying lesion (eg, a gravid uterus or an ovarian tumor) may precipitate an episode of cecal volvulus by altering the relative positions of the intra-abdominal organs. Gaseous dilation of the sigmoid colon and cecum after colonoscopy has also been described as a cause of volvulus.

Epidemiology

United States statistics

Colonic volvulus ranks after cancer and diverticulitis as a cause of large-bowel obstruction in the United States; it is responsible for approximately 5% of all cases of intestinal obstruction and 10-15% of all cases of large-bowel obstruction. In these populations, the most common site of large-bowel torsion is the sigmoid colon (80%), followed by the cecum (15%), the transverse colon (3%), and the splenic flexure (2%).[6]

In Western societies, the average age of patients with sigmoid volvulus is in the eighth decade, and the two sexes are equally affected. Various series have reported that of all patients diagnosed with volvulus, 25-35% are admitted to an acute care facility from a neuropsychiatric care institution, and 10-15% are admitted from a long-term nursing care facility.

International statistics

Worldwide geographic variations in the incidence of sigmoid volvulus are well described. Much higher frequencies are reported in African, Asian, Middle Eastern, Eastern European, and South American countries. In all of these regions, the inhabitants consume a high-fiber diet, which is considered a predisposing factor for the development of sigmoid colon volvulus. In these endemic areas, patients are younger and predominantly male.

In the “volvulus belt” of Africa and the Middle East, nearly 50% of large-bowel obstructions are a result of volvulus, almost exclusively of the sigmoid colon. Cecal volvulus is much less common than sigmoid volvulus, accounting for 10-15% of all cases of volvulus and predominately affecting women in the sixth decade of life.

Prognosis

Delay in diagnosis and treatment of sigmoid and cecal volvulus is associated with substantial morbidity and mortality. Studies report a mortality of 30-40% in patients in whom diagnosis and treatment of cecal volvulus are delayed.

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.

Even when volvulus is adequately treated with endoscopic decompression and surgical resection, mortality is in the range of 12-15%, according to various studies. In part, these figures reflect the poor general health of this patient population. A retrospective review of patients in Veterans Affairs (VA) hospitals with sigmoid volvulus quoted a mortality of 24% for emergency procedures and a mortality of 6% for elective procedures (after decompression).[7]

As many of 50% of patients who undergo endoscopic decompression alone experience recurrence. Endoscopic decompression alone for sigmoid volvulus carried a recurrence rate of 40-50%, with a mortality of 25-30% after surgical treatment of the recurrent volvulus.

 

Presentation

History

Patients with volvulus are commonly elderly, debilitated, and bedridden. Often, the patient has a history of dementia or neuropsychiatric impairment. As a result, only a limited history is available.

More than 60-70% of patients present with acute symptoms; the remainder present with subacute or chronic symptoms. A history of chronic constipation is common. The patient may describe previous episodes of abdominal pain, distention, and obstipation, which suggest repeated subclinical episodes of volvulus.

Physical Examination

The presentation of volvulus is much the same, regardless of its anatomic site. Cramping abdominal pain, distention, obstipation, and constipation are present. With progressive obstruction, nausea and vomiting occur. The development of constant abdominal pain is ominous and indicates the development of a closed-loop obstruction with significant intraluminal pressure. This, in turn, portends the development of ischemic gangrene and bowel wall perforation.

Abdominal distention is commonly massive and characteristically tympanitic over the gas-filled, thin-walled colon loop. Overlying or rebound tenderness raises the concern of peritonitis due to ischemic or perforated bowel. The patient may have a history of episodes of acute volvulus that spontaneously resolved; in such circumstances, marked abdominal distention with minimal tenderness may occur.

Depending on the extent of bowel ischemia or fecal peritonitis, signs of systemic toxicity may be apparent. Because of the massive abdominal distention, the patient may have respiratory and cardiovascular compromise.

 

DDx

Diagnostic Considerations

The differential diagnosis of colonic volvulus includes a rare condition known as an ileosigmoid knot. An ileosigmoid knot occurs when the ileum and sigmoid colon become entangled, creating a knot that results in vascular compromise of the bowel. The patient presents with acute onset of abdominal pain and rapidly developing shock. Ileosigmoid knot is a life-threatening condition that requires urgent surgical treatment.

 

Workup

Laboratory Studies

Laboratory tests include a complete blood count (CBC) with differential and a comprehensive metabolic profile. An elevated white blood cell (WBC) count and left shift indicate bowel ischemia, peritoneal infection, or systemic sepsis. Bowel obstruction may cause significant changes in electrolyte levels.

Other diagnostic studies include plain abdominal radiography, computed tomography (CT), barium enema, and sigmoidoscopy or colonoscopy (see below).

Plain Abdominal Radiography

Massive dilation of the sigmoid colon loop arising from the pelvis and extending to the diaphragm is a typical finding of sigmoid volvulus. The walls of the loop are evident as three bright lines converging in the pelvis to create a beaklike appearance (see the image below).

Plain abdominal radiograph demonstrating massively Plain abdominal radiograph demonstrating massively dilated sigmoid colon loop and convergence of walls of colon into beaklike formation.

Cecal volvulus produces large- and small-bowel obstruction. Radiographic findings reveal a markedly distended loop of bowel extending from the right lower quadrant upward to the left upper quadrant. The small bowel is distended, whereas the distal colon is decompressed (see the image below).

Cecal volvulus with associated small bowel obstruc Cecal volvulus with associated small bowel obstruction.

Detailed overviews of the radiologic findings of colonic volvulus are available elsewhere (see Sigmoid Volvulus and Cecal Volvulus).

CT of Abdomen and Pelvis

Computed tomography (CT) is not often needed, because the plain radiographic findings typically suffice for diagnosis of sigmoid volvulus. However, the radiographic findings for cecal volvulus may be less diagnostic. In such cases, CT can delineate the exact site of the torsion and reveal evidence of ischemia.

Upward displacement of the appendix with large-bowel obstruction is a definitive sign of cecal volvulus. Additionally, decompressed transverse and descending colon are apparent.

Barium Enema

A contrast enema should be performed in patients who show no evidence of peritonitis and in whom plain abdominal radiographs are not diagnostic. The contrast study typically demonstrates a beaklike termination at the point of the sigmoid volvulus (see the image below). Similarly, a foldlike termination may be observed at the point of obstruction in the ascending colon in patients with cecal volvulus.

Barium enema of sigmoid volvulus revealing termina Barium enema of sigmoid volvulus revealing termination of contrast in bird's-beak formation at base of volvulus.
 

Treatment

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.

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.

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).

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.

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.

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).

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.

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

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%)
 

Medication

Medication Summary

To correct fluid deficits and hypovolemia, the patient is initially resuscitated with intravenous isotonic crystalloid solution.

Isotonic Crystalloids

Class Summary

Isotonic sodium chloride (normal saline [NS]) and lactated Ringer (LR) are isotonic crystalloids, the standard intravenous (IV) fluids used for initial volume resuscitation. They expand the intravascular and interstitial fluid spaces. Typically, about 30% of administered isotonic fluid stays intravascular; therefore, large quantities may be required to maintain adequate circulating volume.

Both fluids are isotonic and have equivalent volume restorative properties. While some differences exist between metabolic changes observed with the administration of large quantities of either fluid, for practical purposes and in most situations, the differences are clinically irrelevant. No demonstrable difference in hemodynamic effect, morbidity, or mortality exists between resuscitation with either NS or LR.

Normal saline (NS, 0.9% NaCl)

NS restores interstitial and intravascular volume. It is used in initial volume resuscitation.

Lactated Ringer

LR restores interstitial and intravascular volume. It is used in initial volume resuscitation.

Colloids

Class Summary

Colloids are used to provide oncotic expansion of plasma volume. They expand plasma volume to a greater degree than isotonic crystalloids and reduce the tendency of pulmonary and cerebral edema. About 50% of the administered colloid stays intravascular.

Albumin (Buminate, Albuminar)

Albumin is used for certain types of shock or impending shock. It is useful for plasma volume expansion and maintenance of cardiac output. A solution of NS and 5% albumin is available for volume resuscitation. Five percent solutions are indicated to expand plasma volume, whereas 25% solutions are indicated to raise oncotic pressure.

 

Questions & Answers

Overview

What is sigmoid and cecal volvulus?

What is the historical background of sigmoid and cecal volvulus?

What is the anatomy of the embryonic right colon relevant to sigmoid and cecal volvulus?

What two conditions must be present for the development of sigmoid and cecal volvulus?

What is the Jackson veil in the anatomy of sigmoid and cecal volvulus?

What is the anatomy of the mesosigmoid relevant to sigmoid and cecal volvulus?

What is the anatomy of the arterial supply of the ascending colon and cecum relevant to sigmoid and cecal volvulus?

What is the anatomy of the marginal artery of Drummond relevant to sigmoid and cecal volvulus?

What are areas of poor blood supply in sigmoid and cecal volvulus?

What is the critical point of Sudeck in the anatomy of sigmoid and cecal volvulus?

Why is the anatomy of ureters important in sigmoid and cecal volvulus surgery?

What causes an overloaded sigmoid colonic loop in sigmoid and cecal volvulus?

What causes foreshortening in sigmoid and cecal volvulus?

What is the pathophysiology of sigmoid and cecal volvulus?

What is the role of a cecal bascule in the pathophysiology of sigmoid and cecal volvulus?

What is the result of a complete sigmoid or cecal volvulus?

What predisposes the formation of sigmoid and cecal volvulus?

What causes a sigmoid volvulus?

Which neuropsychiatric disorders increase the risk of sigmoid volvulus in institutionalized patients?

What are possible risk factors of sigmoid volvulus in nursing homes patients?

What causes sigmoid volvulus in developing countries?

What is the role of pelvic mass in the etiology of sigmoid volvulus?

What are the less common etiologies of sigmoid volvulus?

What is the difference in the etiology of sigmoid and cecal volvulus?

What are anomalies that predispose patients to sigmoid or cecal volvulus?

What is the prevalence of sigmoid and cecal volvulus in the US?

What is the global incidence of sigmoid and cecal volvulus?

How does a delay in diagnosis and treatment affect the prognosis of sigmoid and cecal volvulus?

What is the suggested interval between endoscopic decompression and definitive surgical intervention for sigmoid and cecal volvulus?

What is the prognosis of sigmoid and cecal volvulus?

What is the incidence of recurrence in sigmoid and cecal volvulus?

Presentation

Which patient history is characteristic of sigmoid and cecal volvulus?

What are the signs and symptoms of sigmoid and cecal volvulus?

How is abdominal distention characterized in sigmoid and cecal volvulus?

What are the signs of systemic toxicity in sigmoid and cecal volvulus?

DDX

Which rare condition should be included in the differential diagnoses of sigmoid and cecal volvulus?

Workup

Which lab studies are performed in the workup of sigmoid and cecal volvulus?

Which imaging studies and procedures are performed in the workup of sigmoid and cecal volvulus?

Which radiographic findings suggest sigmoid volvulus?

Which radiographic findings suggest cecal volvulus?

What is the role of CT scanning in the workup of sigmoid and cecal volvulus?

What is the role of barium enema in the workup of sigmoid and cecal volvulus?

Treatment

What is the definitive treatment of sigmoid and cecal volvulus?

How is sigmoid and cecal volvulus treated in the absence of peritonitis or ischemic bowel?

How is sigmoid and cecal volvulus treated if there is evidence of peritonitis or ischemic bowel?

What are the indications for surgical intervention in patients with cecal volvulus?

What are the surgical options for sigmoid volvulus?

Why are sigmoidopexy and mesenteric plication rarely used for the treatment of sigmoid volvulus?

What is the efficacy of endoscopic decompression for the treatment of cecal volvulus?

What is the role of cecopexy in the treatment of sigmoid and cecal volvulus?

What is the role of laparoscopic sigmoid resection in the treatment of sigmoid and cecal volvulus?

How is hypovolemia managed in patients with sigmoid and cecal volvulus?

What is the role of antibiotics in the treatment of sigmoid and cecal volvulus?

How are endoscopic detorsion and decompression performed in patients with sigmoid and cecal volvulus?

What is the efficacy of sigmoidoscopic detorsion for the treatment of sigmoid and cecal volvulus?

What is the recurrence rate of sigmoid and cecal volvulus after treatment with decompression?

Which surgical approach has the lowest rate of recurrence for the treatment of sigmoid and cecal volvulus?

How is a sigmoid colectomy for sigmoid volvulus performed?

What is the role of a Hartmann procedure in the treatment of sigmoid volvulus?

How is the Hartmann procedure for sigmoid volvulus performed?

Which surgical procedures are no longer performed in the treatment of sigmoid volvulus?

What is the preferred surgical procedure for the treatment of cecal volvulus?

How is a right hemicolectomy performed in the treatment of cecal volvulus?

What are alternative surgical procedures for the treatment of cecal volvulus?

What are the possible postoperative complications of sigmoid and cecal volvulus treatment?

Medications

Which medications are used in the treatment of sigmoid and cecal volvulus?

Which medications in the drug class Colloids are used in the treatment of Sigmoid and Cecal Volvulus?

Which medications in the drug class Isotonic Crystalloids are used in the treatment of Sigmoid and Cecal Volvulus?