Endoscopic Sigmoidopexy with T-fasteners in Recurrent Sigmoid Volvulus: A Report of Two Cases and Review

Abstract

Introduction: Sigmoid volvulus (SV) is the third leading cause of large-bowel obstruction in the United States after colon cancer and diverticular disease. Following diagnosis, the endoscopic decompression and detorsion of the volvulus should be attempted if there is no evidence of bowel necrosis. Endoscopic detorsion is usually a temporizing measure, with hospitalization and surgical resection being the standard of care. Operative treatment is associated with a relatively high morbidity and mortality and therefore may not be an option for select patients. Patients who do not undergo surgical resection have a high rate of recurrence(40-50%). We report two cases of recurrent SV which were treated definitively with the novel approach of endoscopic sigmoidopexy with T-fasteners. Case 1: An 88-year-old male with PMH CAD, HTN, COPD, Alzheimer's dementia, CHF, with history of six episodes of recurrent SV within the past 2 years presented to the ER with abd pain of 2 days duration. Abd CT revealed a large SV. Given his multiple episodes of recurrent volvulus, the patient underwent endoscopic sigmoidopexy during which four T-fasteners were placed across the site of torsion (two proximal to the site and two distal to the site). The patient tolerated the procedure well and was discharged without subsequent hospital admissions after 6 months of follow-up. Case 2: A 68-year-old male with PMH CVA, seizures, and HTN presented from a nursing home with a 1-day history of constipation, abdominal distention, diffuse abdominal pain and lack of flatus for. An abd CT scan revealed a SV with marked distention of the closed loop of sigmoid without free air. As the patient was not a surgical candidate, he underwent successful endoscopic reduction of the volvulus with sigmoidopexy using four T-fasteners. The patient tolerated the procedure well and was discharged on 2 weeks of antibiotics in stable condition. Discussion: There are less than 10 published reports in literature that describe endoscopic sigmoidopexy with only one utilizing a T-fastener. Most of the previously published reports utilized percutaneous endoscopic gastrostomy tubes to fix the colon in place. The morbidity associated with fixation of the colon to the abdominal wall is significant given the large defect created and the potential for peritonitis. In our cases, we have demonstrated the efficacy of T-piece anchors to affix the bowel to the abdominal wall, which requires a small puncture thus minimizing the risk of leakage of colonic contents into the peritoneal cavity. Conclusion: T fastener-assisted sigmoidpexy is an effective and minimally invasive tool available to gastroenterologists for definitive treatment of recurrent SV.