Conservative management of a caecal volvulus secondary to reversal of loop ileostomy following ultra-low anterior resection.

Abstract

Dear Editor: We describe the first case of caecal volvulus complicating ultra-low anterior resection and discuss the potential role of prophylactic caecopexy in such cases. To our knowledge, it is the first description of a caecal volvulus to have occurred secondary to ultra-low anterior resection and in a patient with no previously identified risk factors for its formation. Furthermore, it is one of the few cases within the literature that has been successfully managed conservatively. A 71-year-old Caucasian female with a past medical history of hypothyroidism and anxiety-related illness was admitted for elective reversal of a loop ileostomy formed 6 months previously following laparoscopically assisted ultra-low anterior resection for a suspected low rectal carcinoma. Mobilisation of the whole transverse and hepatic flexure with resection to the distal transverse colon was performed and a handsewn coloanal anastomosis formed with 3/0 PDS sutures. On direct visualisation, the ascending colon was not found to be mobile or inadequately fixed. Subsequent histology demonstrated the presence of a 6-cm tubulovillous adenoma but no malignant disease. Reversal of the defunctioning ileostomy was performed without complication 6 months following anterior resection, fashioning an end-to-end anastomosis with 4/0 PDS with no evidence of serosal tears or enterotomies. Intra-operatively, dilatation of the coloanal anastomosis due to moderate stenosis was also performed using Hagar dilators. On postoperative day 4, the patient complained of reduced appetite, vomiting and lower left-sided abdominal pain with the absence of any peritonism on clinical examination. A subsequent abdominal radiograph demonstrated a caecal volvulus. A large-bore nasogastric tube (Anderson) under low-grade suction was placed and intravenous fluids prescribed. Blood tests showed a raised C-reactive protein of 198 mg/dL; however, the white cell count (9.8×10/L) and other blood results were unremarkable. Computed tomography confirmed the presence of a caecal volvulus within the left iliac fossa measuring approximately 7 cm with a small volume of free fluid but no pneumoperitoneum. On postoperative day 6, the patient remained stable, with a soft abdomen and their inflammatory markers stable (C-reactive protein 178 mg/dL, white cell count 5.8×10/L). However, a gastrografin follow-through with 4 h plain abdominal radiograph demonstrated a persistent gaseous distension of the caecum in the upper abdomen with oral contrast absent from the colon. However, pneumoperitoneum was absent. Subsequently, on day 10 postoperatively, the patient passed faeces, and the nasogastric tube was successfully removed without further episodes of vomiting. The patient was deemed fit for discharge on day 11 post-op to be reviewed at 6 weeks. Caecal volvulus is an uncommon cause of bowel obstruction, accounting for less than 1 % of cases in Western countries. There are only four reported cases of postoperative caecal volvulus described previously following left hemicolectomy or sigmoid colectomy, with three occurring in patients already anatomically susceptible to its development secondary to a mobile caecum visualised intra-operatively. In the remaining case, an adhesion formed following laparoscopic-assisted sigmoid S. R. Knight (*) Perth Royal Infirmary, Taymount Terrace, Perth PH1 1NX, UK e-mail: stephenknight@doctors.org.uk