SURGERY FOR VOLVULUS
Who and When?
Mr Graham Williams
Consultant Colorectal Surgeon
Wolverhampton
SIGMOID VOLVULUS
Worldwide Incidence
% of all intestinal obstruction
UK
USA
Africa
Iran
Russia
India
Brazil
Pakistan
0
5
10
Ballantyne Dis Colon Rectum 1982
15
20
25
30
SIGMOID VOLVULUS
Average Age at Presentation
UK
USA
Africa
Iran
Israel
India
Brazil
Age in years
Pakistan
0
20
Ballantyne Dis Colon Rectum 1982
40
60
80
SITE OF VOLVULUS
Transverse
3%
Ceacal
33%
Splenic
Flexure
1%
Sigmoid
63%
CAUSES OF VOLVULUS
•Chronic constipation
•Neuropsychotropic drugs
•Elderly population (care
homes)
•Pregnancy
• High fibre diets
• Chagas disease
VOLVULUS
Diagnosis
• Sudden onset abdominal pain
• Previous history
• Distended, resonant abdomen
–NB Tenderness and guarding
• Plain X-ray
–Contrast study
SIGMOID VOLVULUS
Issues to consider:
•Simple or complicated
•Underlying diagnosis
•Acute management
•Subsequent management
•Resect or fix
SIGMOID VOLVULUS
Colonic Infarction:
•10% at presentation
•Increasing pain
•Tachycardia
•Tenderness with guarding
•Gas in wall on x-ray
• Free gas
SIGMOID VOLVULUS
Mortality Rates
Western series
African series
70
%
%
60
40
35
30
50
25
40
20
30
15
20
10
10
5
0
0
Viable bowel
Gangrenous
Madiba & Thomson J Roy Coll Surg Edinb 2000
Emergency
Elective
SIGMOID VOLVULUS
Colonic Infarction:
•Immediate resuscitation
•Emergency laparotomy
•Resection of infarcted
segment
•Ends out!
TREATMENT OF SIGMOID
VOLVULUS
Initial Management
• Endoscopic decompression
–Rigid ∑ + flatus tube
–Flexible sigmoidoscopy
–Colonoscopy
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
Initial Management
• Endoscopic decompression
–Rigid ∑ + flatus tube
–Flexible sigmoidoscopy
–Colonoscopy
Definitive Management
• Laparotomy and Pexy
• Laparotomy and resection
–Colostomy
–Primary anastomosis
• Percutaneous Endoscopic Colostomy
• Mesosigmoidoplasty
• Laparoscopic resection
TREATMENT OF SIGMOID VOLVULUS
Factors to be considered in decision making:
• Age of patient
–Chronological & biological
• Physical state
• Co-morbidity
• Mental state
• Social circumstances
Local Resection
Pexy (fixation)
SIGMOID VOLVULUS
Resection vs Colopexy
Welch & Anderson 1987
60
Bagarini et al 1993
%
%
50
40
35
30
40
25
30
20
15
20
10
10
5
0
0
Resection
Colopexy
Mortality
Resection
Colopexy
Recurrence
MEGACOLON & VOLVULUVS
SIGMOID VOLVULUS
Influence of Megacolon on Recurrence
Number
16
Recurrent volvulus
14
12
10
15
10
8
6
4
5
2
0
2
Normal Caliber
Chung et al Br J Surg 1999
Megacolon
SURGERY FOR SIGMOID VOLVULUS
Options in presence of megacolon:
• Extended left hemi colectomy
• Subtotal colectomy
–Ileostomy
–Ileo-rectal anastomosis
–Caecorectal anastomosis
SIGMOID VOLVULUS
Percutaneous Endoscopic Colostomy
• 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
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
CAECAL VOLVULUS
• Involves caecum and ascending colon
• May resolve spontaneously
• High index of suspicion
• Laparotomy required
• Resection +/- stomas
• Caecopexy
• Caecostomy
SIGMOID VOLVULUS
Simple
? Infarction
∑ decompression
? Infarction
Unsuccessful
Urgent
Laparotomy
Unsuccessful
Colonoscopy
Viable
Dead Colon
Successful
Elective Resection
Fixation
Pex, Lap, PEC
Resection
Stoma / Anastomosis