Treatment of Recurrent Sigmoid Volvulus with Percutaneous Endoscopic Sigmoidopexy

Abstract

Purpose: In the United States, sigmoid volvulus is second only to cancer and diverticulitis as a cause of colonic obstruction. Prompt endoscopic decompression followed by surgical correction has become the accepted treatment method in most patients. There is, however, a small subset of patients in which comorbidities preclude the possibility of surgical intervention. Recurrence rates in these patients after nonoperative reduction are as high as 70%, with a resultant mortality rate of 21%. Percutaneous endoscopic sigmoidopexy has been proposed as a safe and effective treatment option in this population. We present a case of one such patient. Methods: A 93 year old female nursing home patient with a history of advanced Alzheimer's dementia, Parkinson's disease, CHF, PEG tube, and eight previous episodes of sigmoid volvulus within the prior year presented with a two day history of abdominal pain and distention. Abdominal X-ray confirmed the presence of sigmoid volvulus. The patient underwent directly visualized endoscopic reduction of volvulus with no evidence of gangrenous bowel wall or other pathology. As the patient was deemed a poor surgical candidate (ASA score 4), percutaneous endoscopic sigmoidopexy was considered as an alternative therapy. The patient received intensive bowel prep, conscious sedation and premedication with IV antibiotics prior to the procedure. On colonoscopy, a massively dilated rectum and sigmoid colon were noted. An area of the sigmoid with good 1:1 and transillumination was identified as the likely apex of the volvulus. Two 16 French PEG tubes were placed via pull technique per rectum and confirmed endoscopically at 40 cm and 55 cm from the anal verge. There were no immediate complications noted. Results: Diet was advanced after two days. The patient remained afebrile, and was subsequently transferred back to her nursing home with instructions on tube maintenance. No further episodes of confirmed revolvulus have occurred 12 months post procedure. Conclusion: A small number of reports of percutaneous endoscopic sigmoidopexy have appeared in the literature, most notably from the U.K., where the National Health Service has issued guidelines for its use in the treatment of sigmoid volvulus. To our knowledge, PES use has only been reported once prior in the United States. As surgical correction is the accepted modality in the majority of patients, PES is suggested as an alternative to expectant management in patients too ill to undergo general anesthesia or surgical intervention. As so few cases have thus been reported, many questions pertaining to methodology and outcomes must be answered prior to this procedure becoming a well accepted tool in the treatment of sigmoid volvulus.