SURGERY FOR VOLVULUSWho and When?

Mr Graham WilliamsConsultant Colorectal Surgeon

Wolverhampton

SIGMOID VOLVULUSWorldwide Incidence

0 5 10 15 20 25 30

Pakistan

Brazil

India

Russia

Iran

Africa

USA

UK % of all intestinal obstruction

Ballantyne Dis Colon Rectum 1982

SIGMOID VOLVULUSAverage Age at Presentation

0 20 40 60 80

Pakistan

Brazil

India

Israel

Iran

Africa

USA

UK

Age in years

Ballantyne Dis Colon Rectum 1982

SITE OF VOLVULUS

Ceacal33%

Transverse3%

Splenic Flexure

1%

Sigmoid63%

CAUSES OF VOLVULUS

•Chronic constipation•Neuropsychotropic drugs•Elderly population (care

homes)•Pregnancy •High fibre diets•Chagas disease

VOLVULUSDiagnosis

• Sudden onset abdominal pain

• Previous history

• Distended, resonant abdomen–NB Tenderness and guarding

• Plain X-ray–Contrast study

SIGMOID VOLVULUS

•Simple or complicated•Underlying diagnosis •Acute management•Subsequent management•Resect or fix

Issues to consider:

SIGMOID VOLVULUS

•10% at presentation•Increasing pain•Tachycardia•Tenderness with guarding•Gas in wall on x-ray• Free gas

Colonic Infarction:

0

10

20

30

40

50

60

70

0

5

10

15

20

25

30

35

40

Viable bowel EmergencyGangrenous Elective

% %African series

SIGMOID VOLVULUSMortality Rates

Western series

Madiba & Thomson J Roy Coll Surg Edinb 2000

SIGMOID VOLVULUS

•Immediate resuscitation•Emergency laparotomy•Resection of infarcted

segment•Ends out!

Colonic Infarction:

TREATMENT OF SIGMOID VOLVULUS

• Endoscopic decompression–Rigid ∑ + flatus tube–Flexible sigmoidoscopy–Colonoscopy

Initial Management

SIGMOIDOSCOPIC DECOMPRESSION

• 1st Described by Bruusgard 1947• Successful in 70-90% of cases• Beware megacolon and pseudobstruction• Correct position of patient• Apron + incopads!• Well lubricated tube with side holes• Attach bag to tube first• Flush tube• Recurrence rate >80%

TREATMENT OF SIGMOID VOLVULUS

• Endoscopic decompression–Rigid ∑ + flatus tube–Flexible sigmoidoscopy–Colonoscopy

• Laparotomy and Pexy• Laparotomy and resection

–Colostomy–Primary anastomosis

• Percutaneous Endoscopic Colostomy• Mesosigmoidoplasty• Laparoscopic resection

Initial Management

Definitive Management

• Age of patient–Chronological & biological

• Physical state• Co-morbidity• Mental state• Social circumstances

TREATMENT OF SIGMOID VOLVULUS

Factors to be considered in decision making:

Local Resection

Pexy (fixation)

0

10

20

30

40

50

60

0

5

10

15

20

25

30

35

40

Resection ResectionColopexy Colopexy

Mortality Recurrence

% %Welch & Anderson 1987 Bagarini et al 1993

SIGMOID VOLVULUSResection vs Colopexy

MEGACOLON & VOLVULUVS

0

2

4

6

8

10

12

14

16

Normal Caliber Megacolon

Num

ber

SIGMOID VOLVULUSInfluence of Megacolon on Recurrence

1510

Recurrent volvulus

Chung et al Br J Surg 1999

2

5

• Extended left hemi colectomy• Subtotal colectomy

–Ileostomy–Ileo-rectal anastomosis–Caecorectal anastomosis

SURGERY FOR SIGMOID VOLVULUS

Options in presence of megacolon:

• 1st Described 1993• Daniels et al 2000, Br.J.Surg

–14 patients, 53-99 years old–Two point fixation–Mean follow up 12 months–Recurrence in 3/8 after early removal–No recurerence in 5 where tube left in

SIGMOID VOLVULUS

Percutaneous Endoscopic Colostomy

Mesosigmoidoplasty for Volvulus

•Broadens attachment of mesentery

•No anastomosis

•Difficult to perform with oedematous or thickened mesentery

•Subrahmanyam (1992) Br J Surg–126 patients (60% emergency)–1 death–2 recurrences

• Involves caecum and ascending colon• May resolve spontaneously • High index of suspicion• Laparotomy required• Resection +/- stomas• Caecopexy• Caecostomy

CAECAL VOLVULUS

SIGMOID VOLVULUS

Simple ? Infarction

Successful

Urgent Laparotomy

∑ decompression? Infarction

Colonoscopy

Unsuccessful

Unsuccessful

Dead ColonViable

FixationPex, Lap, PEC

Elective Resection ResectionStoma / Anastomosis