Volvulus

Miss Lesley Hunt, Northern General Hospital, Sheffield, S5 7AU

Powerpoint File

A century ago aggressive surgery was the treatment for colonic volvulus. Since non-operative decompression was introduced in 1947(1) many aspects of management of volvulus have been controversial.

Its rarity, coupled with the fact that it predominantly affects elderly, psychiatric and institutionalised patients, makes it an unfavourable subject for study. UK incidence is probably around 1.7 per 100 000 in UK(2) and mortality is 7 -30% per episode (3,4,5) (both vary widely between series).

A literature review shows no randomised or controlled trials or prospective audits. Retrospective reports rarely exceed 20 patients and are dogged by diagnostic uncertainty (AXR is diagnostic in only 37- 83%) (5,6), and failure to correlate mode of presentation, bowel viability and patient co-morbidity with outcome. Most published data is 30-50 years old.

Prompt non operative de-rotation of colonic volvulus in cases without colonic infarction is widely accepted. It is successful using rigid sigmoidoscope (1) or colonoscope in 80-90 % of cases (7). Both carry risk. Mortality is estimated at 5-8% but some deaths are attributable to co-morbidity (3). Prior percutaneous decompression is successful but poses a risk of peritoneal contamination (8). A small minority of authors advocate immediate surgery (3,4). Recurrence after de-rotation is high (22 -90 % of cases) (3,4,9,10). The expectant management policy common in the UK is largely unreported in the literature.

Operative management aims to relieve obstruction and prevent recurrence. Resection is the only option for non-viable bowel, Hartmann’s procedure being most accepted. Mortality ranges from 0-75% (3,4,5,11).

There is no clear view on the operative management of viable bowel and no evidence that choice of operation affects survival. Elective surgery should be performed early. Patients often refuse. Although sigmoid colectomy aims to avoid recurrence and may give good results in able-bodied patients, advocates of total colectomy cite a recurrence rate of 37% with anastomosis and 20% with stoma. Pre-operative evidence of an associated mega colon increases recurrence rate to 82% (13). Elective resection mortality ranges from 0-of 15%. Laproscopic surgery is reported with some success.

Several small series detail non-resection options. Mini meta analysis suggests colopopexy mortality is 11% and recurrence 21% (3,6,12). Tube sigmoidostomy appears successful with low mortality and recurrence in small series (14).

Percutaneous endoscopic colostomy has used safely and effectively in patients not suitable for conventional surgery (15). A number of these procedures have been carried out in Sheffield and will be discussed (16).

Caecal volvulus is rarer than sigmoid vovlulus. Nearly all authors agree prompt surgery is indicated (5). Successful colonoscopic decompression has been reported but has a high failure rate and may delay operation (2,7). Operative options are de-rotation with ceacostomy or fixation, or right hemicolectomy. Operative mortality appears similar for both (9 and 4.5%). Recurrence after caecopexy is around 30% but is reported to be zero after tube caecostomy which may be an option in frail patients (5). Other forms of colonic volvulus are very rare. Colpopexy can be successful in these situations.

A case scenario of an elderly demented patient with sigmoid volvulus was presented to surgical members of the Association of Coloproctology GBI Northern Chapter. 65% of respondents felt that surgery was inappropriate and 26% felt any intervention at all was inappropriate. There was wide variation in surgeons approach (17).

1 Bruusgard C. Volvulus of the sigmoid colon and its treatment. Surgery 1947;22:466-478.

2 Anderson JR Lee D The management of acute sigmoid volvulus Br J Surg 1981;68:117-120.

3 Gibney EJ Volvulus of the sigmoid colon. Surg Gyn Obst 1991;173:243-255

4 Madiba TE Thomson SR The management of sigmoid volvulus. JRCollSurgEdinb 2000;45:74-80

5 Ballantyne GH Bandner MD Beart RW et al. Volvulus of the colon. Ann Surg 1985;202;83-92

6 Welch GH Anderson JR. Acute volvulus of the sigmoid colon. World J Surg1987;11:258-262

7 Strodel WE Brothers T Colonic decompression of pseudo-obstruction and volvulus. Surg Clinic North Am 1989;69:1327-1335.

8 Salim AS Management of acute volvulus of the sigmoid. World J Surg 1991;15:68-73

9 Drapanas T Steart JD. Acute sigmoid volvulus. Concepts in surgical treatment. AmJ Surg 1961;101:70-77.

10 Siroospour D Berardi RS. Volvulus of the sigmoid colon A ten year study. Dis Col Rect 1976;19:535-541

11 Arnold GJ Nance FC Volvulus of the sigmoid colon AnnSurg1973;177:527-37

12 Avots-Avotins KV Waugh DE Colon volvulus and the geriatric patient. Surg Clinic North Am 1982;62:249-260.

13 Morrissey TB Deitch EA Recurrence of sigmoid volvulus after surgical intervention. Am Surg 1994;60:329-331.

14 Tanga MR. Sigmoid volvulus: a new concept in treatment. Am J Surg 1991;173:243-255.

15 Daniels JR Lamparelli MJ Chave H Recurrent sigmoid volvulus treated by percutaneous endoscopic colostomy, Br J Surg 2000;87:1419

16 McAlindon M unpublished data

17 Gallagher P Clark K The ethics of surgery in the elderly demented patient with bowel obstruction. J Med Eth 20002;28:105-8.