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General Surgery > Colorectal
Volvulus, Sigmoid and Cecal
Article Last Updated: Mar 17, 2008
AUTHOR AND EDITOR INFORMATION
Section 1 of 12  
Author: Neelu Pal, MD, Fellow in Bariatric Surgery, Department of Surgery, University Medical Center at Princeton
Neelu Pal is a member of the following medical societies: American College of Surgeons, American Medical Association, Association of Women Surgeons, and Society of American Gastrointestinal and Endoscopic Surgeons
Editors: Brian James Daley, MD, MBA, FACS, Associate Program Director, Professor, Department of Surgery, Division of Trauma and Critical Care, University of Tennessee School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; David L Morris, MD, PhD, Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia; Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy; John Geibel, MD, DSc, MA, Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
Author and Editor Disclosure
Synonyms and related keywords:
sigmoid and cecal volvulus, colonic obstruction, colonic torsion, cecocolic volvulus, cecal bascule, acute colonic obstruction, subacute colonic obstruction, chronic colonic obstruction, cecostomy, colonic volvulus, cecum, detorsion, Hartman procedure, right hemicolectomy, endoscopic decompression, torsion, chronic constipation, laparoscopic sigmoid resection
The term volvulus is derived from the Latin word volve, which means to twist. A colonic volvulus occurs when a part of the colon twists on its mesentery, resulting in acute, subacute, or chronic colonic obstruction.
History of the Procedure
More than 2500 years ago, Hippocrates noted that "the intestines tend to become sluggish and bloated with age." In his treatise "Diseases," he described the deflation of volvulus by "placement of a suppository 10 digits long" into the rectum. In 1859, in England, Gay again suggested this mode of deflating the volvulus, but it did not gain widespread acceptance until the middle of the next century. In 1841, von Rokitansky was the first to reference this condition in Western medicine. He described volvulus as a cause of intestinal strangulation. In 1898, von Zoege Manteuffel published an exhaustive description of colonic volvulus.
Prior to the 19th century, the management of patients with volvulus remained largely expectant. Gradually, as nonintervention became associated with a high mortality rate, early surgical treatment became a widely accepted practice. In 1883, Atherton first described open reduction of the volvulus at laparotomy. Simple detorsion was found to carry an unacceptably high recurrence rate, and attempts at plication of the mesentery and fixation of the sigmoid colon produced no significant improvement in outcome. The failure of sigmoidopexy was illustrated during re-exploration of the abdomen for recurrent volvulus, which often revealed little evidence of the attempted fixation.
By 1920, all 3 surgical approaches (ie, open detorsion and mesenteric plication, resection with colostomy, resection with anastomosis) were widely used for the surgical treatment of patients with sigmoid volvulus. Emergency resection carried a mortality rate of well over 50%. The Mikulicz operation (exteriorization of the sigmoid loop, resection, creation of a double barrel colostomy), Hartman procedure (resection of sigmoid loop, proximal colostomy, closure of distal rectum), and sigmoidopexy combined with partial resections were also attempted, with variable results.
In 1947, Bruusgaard described the technique of transanal deflation of the volvulus using sigmoidoscopy. This method of treatment was further supported by Drapanas and Stewart, who cited no mortality using this approach compared with the 50% mortality rate associated with emergent surgical treatment.1 Nonoperative detorsion as the only treatment was associated with a high recurrence rate. Elective resection after a few days of decompression of the colon was adopted and remains the current surgical treatment of patients with sigmoid volvulus.
von Rokitansky first described cecal volvulus in 1841, and, in 1899, Treves reported a process later designated by Weinstein as cecal bascule. The surgical treatment of patients with cecal volvulus paralleled that of those with sigmoid volvulus; prior to the early 19th century, expectant management was widely practiced. As experience accrued, surgical treatment became accepted. Detorsion and cecopexy were widely practiced, as was placement of cecostomy tubes. The high recurrence and complication rates led to the currently accepted procedure of right hemicolectomy for treatment of patients with cecal volvulus. Cecostomy is reserved for patients who are too debilitated to withstand resection.
Frequency
Colonic volvulus ranks after cancer and diverticulitis as a cause of large bowel obstruction in the United States. Colonic volvulus is responsible for approximately 5% of all cases of intestinal obstruction and 10-15% of all large bowel obstructions. In these populations, the most common site of large bowel torsion is the sigmoid colon (80%), followed by the cecum (15%), transverse colon (3%), and splenic flexure (2%).
In Western society, the average age of patients with sigmoid volvulus is in the eighth decade, and both sexes are equally affected. Various series have reported that 25-35% of all patients diagnosed with volvulus are admitted to an acute care facility from a neuropsychiatric care institution and 10-15% from a long-term nursing care facility.
Worldwide geographic variations in the incidence of sigmoid volvulus are well described. A much higher frequency is reported in Africa, Asia, and 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, the 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.
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. Any portion of the large bowel can develop a volvulus. However, volvulus is most common in the sigmoid colon because of the mesenteric anatomy. Less commonly, the right colon and terminal ileum (usually referred to as cecal or cecocolic volvulus) or the cecum alone (termed a cecal bascule) are the sites of volvulus. Rarely, the transverse colon or splenic flexure of the colon develops a volvulus.
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 dilation 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 results in overloading of the sigmoid colon, which twists around its mesentery and results in volvulus. Megacolon, either congenital or acquired because of 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 a resultant 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.
Compared with sigmoid volvulus, which 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.
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. A cecal bascule involves the cecum folding in an axis at right angles to the mesentery.
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, also predisposes to cecal volvulus.
As in sigmoid volvulus, a pelvic space-occupying lesion, such as 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 sigmoid colon and cecum following colonoscopy has also been described as a cause of volvulus.
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.
Because of subacute, repeated attacks of torsion, the base of the sigmoid mesocolon becomes foreshortened. The associated mild, chronic inflammation at the base of the mesentery and the 2 limbs of the sigmoid colon loop lead 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 Media file 1).
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 Media file 2). Vascular compromise is common because of mesenteric torsion. In contrast, a cecal bascule occurs when the malfixed cecum folds anteriorly over the ascending colon (see Media file 3). As 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 distension is present, which prevents the cecum from unfolding into its normal position.
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.
The differential diagnosis includes an ileosigmoid knot, which is a rare condition. 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.
Clinical
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, distension, and obstipation suggestive of repeated, subclinical episodes of volvulus.
The presenting symptoms are similar, regardless of the anatomical site of the volvulus. 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 distension 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 distension, the patient may have respiratory and cardiovascular compromise.
The decisions regarding timing of surgery and type of surgical procedure depend on the patient's condition at the time of presentation.
In patients with no evidence of peritonitis or ischemic bowel, treatment is started with resuscitation and detorsion of the sigmoid volvulus. This is accomplished using a sigmoidoscope or colonoscope 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 via endoscope requires immediate surgical intervention. If the patient has evidence of peritonitis or ischemic bowel, emergent surgery is undertaken, and the operative procedure is chosen based on intraoperative findings.
Radiologic diagnoses of cecal volvulus or cecal bascule are also indications for surgical intervention, since the obstruction in these conditions cannot be reliably reduced with colonoscopy. This remains controversial, as increasing reports of successful detorsion of cecal volvulus suggest that, in patients who are stable, a single attempt at colonoscopic decompression is reasonable.
The embryonic right colon typically has a mesentery that eventually fuses to the parietal peritoneum, resulting in adherence to the posterior abdominal wall. Developmental variations in the degree of this fusion lead to differences in the mobility of the ascending colon and the cecum (see Media file 14). Hendrick, in a 1964 review of several cadaver studies, indicated that 10-25% of the general population has a propensity for cecal volvulus based on the length of the colonic mesentery.2 The long mesentery of the ascending colon results in a mobile cecum.
Two conditions must be present for the development of a cecal volvulus: an abnormally mobile segment of cecum and colon and 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 following surgery or appendicitis.
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 Media file 15).
The descending colon becomes the sigmoid colon at the level of the iliac crest. The mesosigmoid has variable attachments to the posterior body wall; the most common is attached diagonally downward toward the right side. Cadaver studies in the United States reported by Vaez-Zadeh in 1969 demonstrated the average length and breadth of the sigmoid mesentery as 7.9 cm and 5.6 cm, respectively.3 Comparatively, cadaver studies from the Middle East reported a mesenteric breadth of 15.2 cm. This racial difference may be developmental or may reflect the effects of the high-fiber diet of this region (see Media file 16).
The arterial supply of the colon is depicted in Media file 17. The resection of the colon is based on the arterial supply of its various anatomical divisions.
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.
The middle colic artery forms an arcade with the left colic artery, which is a branch of the inferior mesenteric artery. The arcade is termed the marginal artery of Drummond. It 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 2-4 sigmoidal arteries, which are branches of the inferior mesenteric artery (see Media file 17).
In 3-5% of the population, the right and the 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.
The surgeon must always be aware of the location of the ureters in the retroperitoneum to avoid injuring them. The ureter is easily identified at the pelvic brim where it crosses over the external iliac artery. The ureter is visible as a white structure, which, on gentle compression, demonstrates characteristic propulsive movement.
Lab Studies
- CBC with differential count: An elevated WBC count and left shift indicate bowel ischemia, peritoneal infection, or systemic sepsis.
- Comprehensive metabolic profile: Bowel obstruction may cause significant changes in electrolyte levels.
Imaging Studies
- 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 3 bright lines converging in the pelvis to create a beaklike appearance (see Media file 4).
- 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 Media file 7).
- A detailed overview of the radiologic findings of colonic volvulus can be found in Sigmoid Volvulus and Cecal Volvulus.
- CT scanning of the abdomen and pelvis
- CT scanning is not often needed, since the plain radiographic findings are typical for sigmoid volvulus. The findings for cecal volvulus may be less diagnostic on plain abdominal radiographs. In these cases, CT scanning 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: Perform a contrast enema in patients with no evidence of peritonitis and in whom plain abdominal radiographs are not diagnostic. The contrast demonstrates a beaklike termination at the point of the sigmoid volvulus (see Media file 6). Similarly, a foldlike termination may be observed at the point of obstruction in the ascending colon in patients with cecal volvulus.
Diagnostic Procedures
- Sigmoidoscopy and colonoscopy
- Both sigmoidoscopy and colonoscopy are used to successfully detorse and decompress sigmoid colon volvulus in as many as 90% of patients.
- The sigmoidoscope or colonoscope is advanced into the rectum under direct vision. The rectum is insufflated to allow good visibility and 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.
Surgical therapy
Surgery is the definitive treatment of sigmoid and cecal volvulus. If the patient with sigmoid volvulus has evidence of ischemic bowel or peritonitis or if endoscopic decompression has failed, perform emergent surgery. Conversely, if the patient has neither of the above and endoscopic decompression and detorsion are successful, semi-elective surgery during the same hospital stay is acceptable. Bowel decompression is continued via a rectal tube while the bowel is prepared and the patient stabilized. Media file 13 depicts an algorithmic overview of colonic volvulus management.
The currently accepted surgical procedures for sigmoid volvulus include sigmoid resection with primary anastomosis and resection and Hartman 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 rapid resection of the volvulus and an end colostomy (Hartman procedure) are 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.
Because endoscopic decompression is successful in only 15-20% of patients with cecal volvulus, emergent surgical intervention is mandated. The selection of surgical procedure depends on the patient's clinical condition. In severely debilitated patients, cecostomy is a valid option. However, cecostomy 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 surgical 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 taken to perform this procedure is as long if not longer than that for required for colectomy, which is the definitive procedure. Hence, most fixation procedures for volvulus are not recommended.
Preoperative details
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, place the patient in the left lateral position to improve venous return.
Recognition of the typical radiologic findings of a sigmoid volvulus on plain abdominal radiographs is followed by emergent sigmoidoscopy or colonoscopy to detorse and deflate the volvulus. A soft rectal tube is placed to allow continued decompression and bowel preparation prior to the planned surgical procedure. Placement of a rectal tube without endoscopic visualization is not advised because of the risk of perforation. Although it has been described with variable success, the procedure is often unsuccessful in detorsing the volvulus.
Sigmoidoscopic detorsion is successful in more than 90% of patients with sigmoid volvulus. In contrast, only 10-15% of patients with cecal volvulus can be successfully detorsed with colonoscopy. CT scanning 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.
Following the endoscopic detorsion of sigmoid volvulus, a soft rectal tube left in place maintains the decompression. Decompression is evident through passage of large amounts of gas and fecal material but should be radiologically confirmed.
Volvulus recurrence occurs 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 emergent surgical intervention.
Intraoperative details
Following successful endoscopic decompression of sigmoid volvulus, the simplest approach with the lowest rate of recurrence is sigmoid colectomy and primary anastomosis.
The patient is placed in a dorsal lithotomy position using Lloyd Davis stirrups. This allows for the possibility that an unexpectedly low anastomosis may be required, which can be accomplished using transanal passage of an end-to-end anastomosis (EEA) stapler. The abdomen and perineum are prepared and draped separately. The perineum remains draped until the stapling device needs to be passed.
A low midline laparotomy incision is made. The massively dilated sigmoid colon loop is immediately encountered. It is exteriorized and the volvulus is detorsed by rotating it clockwise (since a sigmoid volvulus usually occurs by torsion in a counterclockwise direction). The colon proximal and distal to the site of torsion is circumferentially isolated and clamped. The inferior mesenteric artery is divided where easily accessible (see Media file 8).
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 Media file 9). The anastomosis can be completed in a hand-sewn fashion or with a GI stapling device.
In the event of a failed sigmoidoscopic reduction or suspected ischemic bowel, the divided bowel is carefully inspected to ensure good supply.
In the presence of fecal peritonitis or if the patient is hypotensive, a Hartman procedure is preferred. The patient is placed in a supine position and a low midline laparotomy 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 bowel remains in the pelvis (see Media file 10). A Hartman procedure is also a good option in a severely debilitated, bedridden patient who requires long-term care.
The Paul Mikulicz resection is of historic interest only and is rarely performed. 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.
The preferred surgical procedure for the treatment of patients with cecal volvulus is right hemicolectomy (see Media file 11). The patient is placed in a supine position and the abdomen is prepared and draped. A low midline laparotomy incision is made. The area of the volvulus and the terminal ileum are exteriorized. The volvulus is reduced through counterclockwise detorsion, since 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. The divided bowel ends are approximated in a tension-free manner using a hand-sewn technique or GI stapler (see Media file 12).
In extremely debilitated patients who are unable to tolerate a surgical procedure, a percutaneous cecostomy can be attempted. Percutaneous cecostomy is associated with a recurrence rate of only 1-3% but 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.
Postoperative details
Postoperative care includes continued fluid resuscitation and antibiotic therapy as guided by the patient's clinical condition.
Follow-up
Patients who undergo a Hartman procedure may be candidates for colostomy reversal in 3-6 months. This decision 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.
Delay in diagnosis and treatment of sigmoid and cecal volvulus is associated with rates of high morbidity and mortality.
As many of 50% of patients who undergo endoscopic decompression alone develop recurrence. 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. Possible postoperative complications include the following: - Surgical wound infection (8-12%)
- Anastomotic leak (3-7%)
- Colocutaneous fistula (2-3%)
- Abdominal or pelvic abscess (1-7%)
- Sepsis (2%)
Despite adequate treatment with endoscopic decompression and surgical resection, a mortality rate of 12-15% is quoted in various studies. This partially reflects the poor general health of this patient population. A retrospective review of patients in VA hospitals with sigmoid volvulus quoted mortality rates of 24% for emergent procedures and 6% for elective procedures (after decompression), respectively.4 Endoscopic decompression alone for sigmoid volvulus carried a recurrence rate of 40-50%, with a mortality rate of 25-30% following surgical treatment of the recurrent volvulus. Studies quote a mortality rate of 30-40% in patients in whom diagnosis and treatment of cecal volvulus are delayed.
Elective laparoscopic sigmoid resection and right hemicolectomy following 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.
My sincere thanks to Charles D Tischler, MD, for allowing me to participate in the care of his patients and to learn from him and them.
| Media file 1:
Sigmoid volvulus. A: Counterclockwise torsion at the base of the mesentery. B: Adhesions at base of sigmoid mesocolon leading to formation of a fixed omega loop that is susceptible to repeat torsion. |
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| Media file 2:
Cecal volvulus. A: Clockwise torsion of the mesentery of the cecum, ascending colon, and terminal ileum. B: Absence of dorsal mesenteric attachments of the cecum and the proximal ascending colon leading to lack of fixation to the retroperitoneum. |
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| Media file 3:
Cecal bascule. A: Anterior folding of the cecum. B: Lack of dorsal mesenteric fixation of cecum to retroperitoneum. |
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| Media file 4:
Plain abdominal radiograph demonstrating massively dilated sigmoid colon loop and convergence of the walls of the colon into a beaklike formation. |
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| Media file 5:
CT scan of the abdomen demonstrating massive dilation of the sigmoid colon and normal caliber of the proximal bowel. |
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| Media file 6:
Barium enema of sigmoid volvulus revealing termination of contrast in a bird beak formation at the base of the volvulus. |
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| Media file 7:
Cecal volvulus with associated small bowel obstruction. |
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| Media file 8:
Extent of resection required for sigmoid volvulus is limited to resection of omega loop of sigmoid volvulus and resection of sigmoid mesentery. |
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| Media file 9:
The divided descending colon and rectum is reanastomosed in a hand-sewn manner or with a GI stapling device. |
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| Media file 10:
Hartman procedure for sigmoid volvulus. |
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| Media file 11:
The extent of resection for cecal volvulus is similar to that for a right hemicolectomy for benign disease. |
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| Media file 12:
The terminal ileum is anastomosed to the transverse colon in the reconstruction after a right hemicolectomy. |
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| Media file 13:
Algorithm for treatment of patients with sigmoid and cecal volvulus. |
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| Media file 14:
Variable degrees of attachment of the ascending colon to the abdominal wall by reflection of the overlying parietal peritoneum. A: Normal attachment. B: Reflection of peritoneum to create a paracolic gutter. C: Mobile colon with reflection of the peritoneum to create a colonic mesentery. |
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| Media file 15:
Jackson veil over the ascending colon contains numerous small blood vessels from the renal and lumbar arteries. |
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| Media file 16:
Average measurements of the sigmoid mesocolon. |
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| Media file 18:
A cecal volvulus, with ischemic changes of the distended cecum and terminal ileum is shown. The remainder of the small bowel involved in the volvulus appears distended but not ischemic. No obvious peritoneal contamination is observed. |
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Media type: Photo
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Volvulus, Sigmoid and Cecal excerpt Article Last Updated: Mar 17, 2008
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