Prise en charge du volvulus du sigmoïde

Abstract

Sigmoid volvulus is the third leading cause of large bowel obstruction in adults. The main predisposing factor is a long redundant sigmoid colon with an elongated mesocolon. Sigmoid volvulus presents as an abdominal emergency but its management is controversial. Clinical exam is usually poor and must search gravity signs (septic shock and peritonitis). The CT-scan is now the gold standard radiological procedure that confirms the diagnostic and also looks for the radiological gravity signs. In patients with complicated sigmoid volvulus associated with peritonitis, bowel gangrene or unsuccessful endoscopic reduction, emergency surgery is required; sigmoid resection with colostomy (no anastomosis) is recommended. In the absence of complications, conservative management is indicated and endoscopic decompression is accepted in many institutions as the first therapeutic option in stable patients. It confirms the diagnosis, evaluates the sigmoid viability and admits detorsion of the SV; however, due to the high recurrence rate, emergency enscoscopic decompression should be regarded as a temporizing measure and delayed prophylactic treatment appears necessary. In patients in good general health with a low surgical risk, this may be followed by elective sigmoid resection to prevent recurrence, after the first episode and with an interval between decompression and subsequent surgery of at least 2 days to allow adequate resuscitation and bowel preparation. In high-risk surgical patients, the indications for prophylactic treatment are unclear. Surgical approaches are not appropriate in frail patients owing to the high risk of perioperative morbidity and mortality, and percutaneous endoscopic colopexy appears to be an interesting alternative which has gained popularity.