Endoscopic Sigmoidopexy for Recurrent Sigmoid Volvulus as Alternative to Surgical Management

Abstract

Purpose: Sigmoid volvulus is the most-common form volvulus of the gastrointestinal tract and is responsible for 8% of all intestinal obstructions. Sigmoid volvulus is particularly common in elderly persons and constipated patients; one study of 40 patients showed an average age of 71.6 years. Sigmoidoscopic decompression is advocated, although the rate of recurrence is high, varying between 45 and 90%, and is associated with the need for emergency surgery and a higher mortality. Sigmoidopexy has been shown in the literature to reduce the recurrence of symptoms in up to 75% with one site of adherence; however we advocate two points of fixation on the abdominal wall to effectively reduce the risk of recurrent volvulus as demonstrated by the following case. Methods: An 84 year old female with a PMH significant for atrial fibrillation, hemiplegia due to prior CVA, peripheral vascular disease, and recurrent sigmoid volvulus presented to the ER with complaints of vague abdominal pain, difficulty moving her bowels, and bloating for the past 3 days. The patient denied any nausea, vomiting or diarrhea, and her routine lab values were within normal limits. Physical exam was remarkable only for distension, with positive bowel sounds and generalized tenderness. Abdominal radiographs were consistent with sigmoid volvulus; however the patient refused surgery and thus was scheduled for proctosigmoidoscopy with placement of 2 percutaneous endoscopic colostomy tubes (PEC). Endoscopic examination revealed a focally dilated segment of sigmoid colon extending 20–45 cm which represented the volvulized segment. Two 20 Fr standard PEG tubes were placed in the sigmoid colon via push technique approximately 10 cm apart. The colon aspects of the tubes were then irrigated with betadine; no immediate complications were noted. Results: The patient was then discharged and was followed up 2 months later at which time the PEC tubes were removed. APC ablation of the stoma was performed from the colonic aspect prior to endoclip closure. No further episodes of sigmoid volvulus have recurred to date. Conclusion: In conclusion, we believe the two point fixation method may be superior to single tube placement as has been previously reported. Our case once again establishes endoscopic percutaneous colostomy tube placement as a alternative to surgical therapy in patients with recurrent sigmoid volvulus. We recommend randomized clinical trials to compare the two methods.