Recurrent Volvulus Research Articles

Cas radiologique du mois

Cas radiologique du mois

Nonresective alternative for the cure of nongangrenous sigmoid volvulus.

Recurrence in sigmoid colon volvulus is a very vexing problem, because it occurs after all types of treatment including a resection of the sigmoid. A nonresective procedure that prevents recurrence in the long term has been devised and tried during the period 1968 to 1992. The procedure involves extraperitonealization of the whole sigmoid colon via a left paracolic gutter incision in a manner akin to an extraperitonealized colostomy and placing it in the left half of the infraumbilical abdominal wall. This article presents a study of 84 patients who underwent this operation and who were followed-up. Some very useful practical points for ensuring the success of the procedure are also presented. The subjects comprised 58 male and 26 female patients, aged 10 to 81 (median, 60) years. The operating time ranged from 40 to 70 (median, 50) min. The operative mortality (9 percent) and morbidity of the procedure including cardiopulmonary complications (7 percent), incidence of small-bowel obstruction (1 percent), and incisional hernia formation (2.3 percent), were reasonably low. The incidence of wound-healing problems was significantly (P < 0.02) reduced in the 1980s and 1990s. Seventy-six patients were available for follow-up ranging from 0.5 to 25 (mean+/-standard error, 6.671+/-0.573; median, 6) years. Forty-eight patients were followed-up for five or more years. No patients developed recurrence of volvulus during the entire follow-up period. This nonresective, recurrence-free procedure provides a cure for nongangrenous sigmoid volvulus. It may be performed safely, even in relatively poor-risk patients, with acceptably low morbidity and mortality rates.

Recurrent colonic volvulus in children

Recurrent intestinal obstruction caused by colonic volvulus is a rare cause of intestinal obstruction in children. Because the condition is self rectifying at times, the diagnosis can be missed or delayed. The authors present two patients, one with sigmoid volvulus and the other with sigmoid and cecal volvulus, and discuss the diagnosis and management of this condition in children. In view of the recurring nature of this condition, the authors believe that nonoperative treatment of this condition in children has no place beyond the emergency situation and that the definitive treatment should always be surgical.

Large Colon Resection

Strangulating large colon volvulus presents the surgeon with the dilemma of determining the extent of compromise to the affected tissue and the most appropriate surgical treatment of this tissue. This decision is complicated because there is a significant volvulus recurrence rate. Large colon resection and anastomosis is the most aggressive treatment option but prevents recurrence and may provide an alternative to euthanasia for some horses.

Ileosigmoid knotting

To study the presentation, management, and outcome of patients with ileosigmoid knotting admitted to a district general hospital in an area of relatively high incidence. A retrospective study of 15 patients treated for ileosigmoid knotting at Holy Family Hospital, Berekum, Ghana, during the period 1984 to 1990 inclusive. The overall mortality was 47 percent and did not differ between those with viable bowel and those with gangrenous bowel. There appeared to be a significant risk of recurrent volvulus in patients who did not undergo resection at initial presentation. Ileosigmoid knotting carries a significant risk of mortality, and sigmoid resection should be considered for all patients with this unusual condition.

Experience with colonic volvulus.

Fifty-eight cases of colonic volvulus were reviewed including 30 cases of sigmoid volvulus, 27 cases of cecal volvulus, and 1 of transverse colon volvulus. Decompression procedures were attempted in 31 instances of sigmoid volvulus in 27 patients and were successful 25 times (81 percent). Seven patients with sigmoid volvulus did not undergo surgery and of those, two died of unrelated causes, one was lost to follow-up, one was well, and three had recurrent volvulus. Twenty-four operations were performed on 23 patients and there were three deaths (13 percent mortality). There was one recurrence in two patients who underwent simple detorsion. Chronic large-bowel motility disturbances were a persistent problem in 9 of 20 (45 percent) surgical survivors. Among 27 instances of cecal volvulus, one was reduced by contrast enema and ten endoscopic attempts at decompression were unsuccessful. Twenty-six operations were done and there were four operative deaths (15 percent mortality). There were no recurrences. Large-bowel motility disorders were noted in follow-up in 3 of 22 patients (14 percent). Overall there were 10 deaths in 58 patients for a 17 percent mortality rate. These data support the importance of endoscopic decompression for sigmoid volvulus but not for cecal volvulus. Definitive treatment of both forms of volvulus should include assessment of colonic motility.

Endoscopy in colonic volvulus.

Flexible fiberoptic gastrointestinal endoscopy has greatly simplified the diagnosis and treatment of colonic volvulus. The management of 39 patients with colonic volvulus treated over 9 years was reviewed. Five per cent were treated with rectal tube decompression alone, 23% were treated with either sigmoidoscopic or colonoscopic reduction, and 26% were treated exclusively with operation. Endoscopic reduction was attempted in nearly half of the patients in preparation for operation. Recurrent volvulus occurred in 57% of patients initially treated with endoscopic reduction alone. Sigmoidoscopic examination did not confirm the diagnosis in 24% of instances in which it was used, although colonoscopy was always diagnostic. The overall mortality rate was 8%, but increased to 25% in patients with gangrene of the colon. Three patients who later proved to have gangrene of the colon had a normal initial sigmoidoscopic examination. Two of these patients died of intra-abdominal sepsis from a perforated colon. In five patients an accurate endoscopic diagnosis of gangrene prompted immediate exploration. None of these patients died. Endoscopy is a safe and effective diagnostic tool for the initial evaluation of patients with suspected colon volvulus. In addition, endoscopy may result in therapeutic decompression and may provide visual assessment of the viability of the bowel mucosa, thus assisting in the timing of appropriate operative treatment.

Acute volvulus of the sigmoid colon.

AbstractFifty patients presenting with acute volvulus of the sigmoid colon have been analyzed. The diagnosis was made in 39 patients from the presenting features and abdominal radiographs. Deflation by sigmoidoscopy and flatus tube was performed in 19 patients with initial success in 15. Recurrent volvulus occurred in 6 of these patients. Laparotomy was carried out in 36 patients and colonie gangrene was present in 6 patients. The operative mortality rate was 42%. Mortality was related to a combination of age, intercurrent medical illness, and sepsis. Simple operative reduction was associated with a lower mortality when compared to resection but had a higher incidence of recurrent volvulus. This study supports the use of sigmoidoscopic reduction as the primary treatment of acute sigmoid volvulus. Laparotomy and colonic resection should be reserved for those patients who are medically fit and should ideally be performed on an elective basis after preliminary decompression. In unfit patients in whom sigmoidoscopic reduction fails, detorsion and colopexy is advocated.

Sigmoid volvulus in elderly patients

We reviewed the records of 51 patients over 65 years of age admitted for an initial episode of sigmoid volvulus, and adequate information about their subsequent course was obtained in 92 percent. Nonoperative reduction of the initial volvulus was attempted in 43 patients and was successful in 39 (91 percent). Eleven patients required emergency operations, with a mortality rate of 36 percent. Six patients had elective resections with no deaths. Thirty-three patients, 32 after nonoperative reduction of a volvulus and 1 after operative reduction, were discharged without definitive treatment. Twenty-three of the 33 patients (70 percent) managed by expectant observation had one or more episodes of recurrent volvulus. Five of the 23 patients died from the recurrence without operation, and 16 were operated on either emergently (3 patients) or electively (13 patients) after nonoperative reduction. The mortality rate related to recurrent volvulus or its treatment in the 33 patients observed was 21 percent. The mortality rate for 18 elective resections (6 for initial volvulus and 12 for recurrent volvulus) was 5.6 percent. After successful nonoperative reduction of a sigmoid volvulus in elderly patients, maximal survival is achieved by early elective resection. Age alone is not an adequate reason for adopting a nonoperative approach.

Sigmoid volvulus in a young patient

The case of an 18-year-old man with sigmoid volvulus and recurrent abdominal pain is presented. He was seen in the emergency department three times in a 4-month period, each time complaining of cramping left lower quadrant pain of one to two hours duration without vomiting or diarrhea. Physical examination on each occasion revealed left lower quadrant tenderness without mass, guarding, or rebound. Radiologic evaluation on the first visit revealed sigmoid volvulus, which was reduced by barium enema. Despite identical clinical presentation on two subsequent occasions, radiologic studies showed no evidence of recurrent volvulus. During the ensuing two years, the patient has had no further symptoms.

Sigmoid volvulus with and without megacolon

Sixty-six consecutive patients, admitted to St. Vincent's Hospital, Melbourne, with sigmoid volvulus, fell into two groups, 60 without and six with acquired megacolon. In the former group, flatus tube decompression was usually successful, and sigmoid resection provided a cure. In the group with megacolon, the history was longer; patients more often had bowel symptoms before or between acute episodes of volvulus; flatus tube decompression was rarely successful; and symptoms persisted after sigmoidectomy and were sometimes associated with recurrence of volvulus of the new "sigmoid." It seems that nothing less than total colectomy will cure these patients.

Volvulus of the cecum: Choice of operation

Although it is clear that there is a significant frequency of recurrent volvulus after cecopexy, there is no evidence from either this series or previous reports that resection is associated with a lower recurrence rate than tube cecostomy. In the absence of data suggesting a clear superiority of colon resection, it appears that tube cecostomy should be the treatment of choice for cases of cecal volvulus that are not complicated by vascular compromise.

Elective resection for recurrent sigmoidal volvulus

A patient with recurrent sigmoidal volvulus who was treated by elective sigmoidal resection is reported. The symptoms and radiologic findings are sufficient for a confident diagnosis to be made before the onset of a major obstructive epidose. The value of barium-enema examination even in the quiescent phase is emphasized. Definitive treatment by sigmoidal resection in the absence of obstruction is safe and should be undertaken as an elective measure. Awareness of the disease and its occurrence in young patients will aid its recognition and reduce mortality from intestinal obstruction.

Volvulus of the sigmoid colon.

A study of 37 patients with sigmoid volvulus is presented. Subsequent bouts of recurrent volvulus are very common after sigmoidoscopic intubation, and overall mortality rates are high. Surgical resection is the preferred method of treatment.

Recurrent volvulus of the stomach.

A 3-month-old female child presenting with recurrent crying and vomiting since with was diagnosed radiologically to have recurrent volvulus of the stomach. She was successfuly treated by anterior gastropexy.

Chronic and recurrent volvulus of the stomach: With late results of “colonic displacement”

Chronic and recurrent volvulus of the stomach: With late results of “colonic displacement”

Volvulus of the colon

Twenty-three instances of colonic volvulus are reported; eighteen were of the sigmoid and five of the cecum. The clinical findings and plain roentgenograms of the abdomen are usually adequate to make the diagnosis. However, barium enema examination should be liberally used unless gangrenous bowel is suspected to exist. Cecal volvulus is treated by operative detorsion and cecostomy. Nonoperative detorsion of sigmoid volvulus is the initial treatment followed by elective resection of the sigmoid to prevent recurrent volvulus. If the bowel is gangrenous, resection in either type of volvulus is mandatory. There were no deaths in the five patients with cecal volvulus, and only two deaths in patients with volvulus of the sigmoid. The mortality for sigmoid volvulus was 11.1 per cent and the over-all mortality for colonic volvulus was 8.7 per cent.

Rationale and technic for stabilization of the mesentery in cases of nonrotation of the midgut

1. 1. Nonrotation of the midgut is potentially the most dangerous of the various degrees of malrotation because it predisposes the midgut volvulus. 2. 2. The characteristic anatomical feature of these cases is that of a pedicle consisting of the third part of the duodenum, the proximal jejunum, and the ascending colon, overlying and parallel to the superior mesenteric vessels and surrounded by a peritoneal covering. This pedicle constitutes the only attachment of the midgut within the abdomen, thus allowing volvulus. There are other less common anatomical variants of this entity. 3. 3. Nonrotation of the midgut may be found without other anomalies. In addition, it is found in most cases of omphalocele and gastroschisis and also in congenital hernia of the posterolateral diaphragm. 4. 4. Using the conventional operative management for these infants, there were three instances of recurrence of volvulus among 24 cases treated without stabilization. There was one instance of volvulus after diaphragmatic hernia repair in which the nonrotation was not stabilized. 5. 5. When midgut volvulus is encountered, it should be untwisted. After this is done, or when nonrotation of the midgut is found without volvulus, the components of the pedicle of the midgut should be freed by anterior division of the peritoneal bands. Blunt dissection of the duodenum from the proximal transverse colon, fixation of the cecum and its mesentery to the left colon, and suture of the duodenum to the right completes the procedure. 6. 6. A series of 10 operative cases is described.

Recurrent volvulus of the stomach: Report of a case with recurrence after simple decompression

Summary Volvulus of the stomach may occur suddenly with complete obstruction of the cardia and pylorus or it may recur with vague symptoms over many years. Differences of anatomic configuration and the presence of other upper abdominal lesions both predispose to the development of volvulus of the stomach and account for the different types and varying severity of symptoms. A case is presented illustrating the futility of simple decompression without operative fixation of the stomach in this condition.

TREATMENT OF VOLVULUS OF THE CECUM AND RIGHT COLON. A REPORT OF SIX ACUTE AND THIRTEEN RECURRENT CASES.

Volvulus of the colon, which was formerly termed intestinal strangulation, was first described by Rokitansky in 1837.16Early diagnosis and prompt treatment of this relatively rare form of intestinal obstruction not only give a sense of achievement to the surgeon but are life-saving to the patient. It is not the purpose of this report to review the literature on volvulus of the cecum and right colon, as this has been done adequately by previous authors,3,7,10,15,17,18nor is it intended to merely add cases of this disease to the literature. It is my objective to focus further attention to this problem in order to promote increased awareness of a disease which has a mortality of 30% to 60% in the reported series of cases.7,10,14,15,19 This report includes six patients with acute volvulus of the cecum and/or right colon and 13 with intermittent or recurrent volvulus treated by the