SURGERY FOR VOLVULUSWho and When?

Mr Graham Williams

Consultant 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 ResectionResection

Stoma / Anastomosis