Sigmoid Volvulus Presentation and Management

INTRODUCTION Volvulus describes a condition in which a segment of bowel becomes twisted on its own mesenteric axis resulting in complete or partial obstruction. Compromised blood supply along with increase in intraluminal pressure leads to gangrene and perforation if unrelieved. Volvulus is generally uncommon and the colon is the most common part of GIT to form a volvulus. The most frequent site is the sigmoid colon. The other sites include caecum, ascending colon and transverse colon. In the vast majority of cases, sigmoid volvulus is an acquired condition resulting from elongation of sigmoid loop and stretching of sigmoid mesocolon. Detailed records of this disease were found in the Egyptian papyrus ebers and in ancient Greek and Roman writings. Insufflations with air to untwist the sigmoid volvulus as a mode of treatment, which Hippocrates had advocated, are still the basis for the non-operative treatment of sigmoid volvulus accepted by surgeons worldwide. In the developed world, sigmoid volvulus occurs in elderly and frail patients with illness. Therefore, initial treatment in the absence of clinical features of large bowel gangrene or peritonitis, consists of detorsion by sigmoidoscopy and transrectal intubation as described by BRUDSGAARD. AIM OF THE STUDY: 1. To analyse the mode of presentation of sigmoid volvulus. 2. To alalyse the various options available for management of sigmoid volvulus. 3. To analyse the outcome ie morbidity and mortality of the various Procedures for sigmoid volvulus. PATIENTS AND METHODS: Twenty-five consecutive patients with acute sigmoid volvulus treated over a 3-year period (2006-2008) in Government Royapettah Hospital were retrospectively reviewed. The diagnosis of sigmoid volvulus was made from a history of large bowel obstruction (constipation, abdominal distension, and abdominal pain), which were often recurrent and plain abdominal radiographs. In the latter, the cardinal features were the inverted ‘coffee bean’ or ‘omega’ sign of the distended, twisted, sigmoid colon. Laparotomy was performed on all patients after active fluid resuscitation, correction of any electrolyte and acid base disturbances, and establishment of satisfactory urine output.Inj.Cefotaxime 1 gm and Inj metronidazole 500 mg were administered intravenously at the time of induction of anesthesia and were continued postoperatively. At laparotomy, viability of the bowel was assessed through a midline incision. Gaseous distension of the large bowel was relieved by needle aspiration. Depending on the viability of the colon, general condition of the patient and surgeons experience either resection and primary anastamosis or Hartmann’s procedure or sigmoidopexy was done. A Closed tube drain without suction was inserted in the left flank through a separate stab incision. The vertical; midline incisions were closed by mass closure using monofilament prolene. The clinical course and postoperative complication were also reviewed. Wound infection was defined as a presence of pus, either discharging spontaneously as requiring drainage. Anastamotic leak was defined as the presence of a fecal fistula or anastamotic breakdown seen at laparotomy following peritonitis. Hospital stay was defined as the total time spent in the hospital for the presenting complaint. Mortality was considered as death occurring in hospital. CONCLUSION: 1. Use of sigmoidoscopic detorsion for viable colon should be encouraged. 2. Sigmoidopexy, which is associated with a recurrence rate of 20% in our series of patients, should be used selectively. 3. Primary anastamosis in emergency situation can be carried out with morbidity and mortality in patients with viable colon. 4. Hartmann’s procedure is a safe option in sigmoid volvulus with gangrenous bowel