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Colonic Volvulus

Scott R. Steele, MD, FACS, FASCRS
Chief, Colon & Rectal Surgery
Madigan Army Medical Center
Fort Lewis, WA


 
Introduction and Definition

Colonic volvulus occurs when the bowel twists around its mesenteric blood supply causing obstruction and ischemic changes.  Recognized as far back as the ancient Egyptians’ period, even Hippocrates recommended a 12-inch long suppository with air insufflation to relieve the obstruction. [1]  Although uncommon in the United States and Western society, it still remains the third leading cause of large bowel obstruction in adults behind cancer and diverticulitis. [2]  Although standard goals remain the same--to relieve the obstruction, avoid colonic ischemia, and prevent recurrence—trends of early endoscopic decompression, resection with primary anastomosis, even in the setting of necrotic bowel, and the use of minimally invasive techniques continue.  This update will review the presentation and management strategies for approaching these oft-time challenging patients.
Epidemiology
Although not as frequently encountered, volvulus is not a rare disease by any account.  This condition remains more prominent in the “volvulus belt”--a region extending along Africa, the Middle East, India and Russia.  In a recent study out of Jordan, sigmoid volvulus was responsible for 9.2% of all large bowel obstruction cases over a 6-year period. [3]  In these areas of the world, males tend to outnumber females in frequency (2:1), are most commonly younger in age (40-50 years old), and healthy.  In contrast, in the United States and Great Britain, patients with sigmoid volvulus are more often older (60-80 years), have multiple co-morbidities, and there is a more even gender distribution (though still male predominance).  Collective series from the United States spanning the 1950-70s demonstrated a predominance of African-Americans (2/3rd) to Caucasians (1/3rd), with only rare cases reported in other ethnicities. [4]  In English-speaking countries, colonic volvulus has been described in younger people in their second decade, [3] as well as children as young as 15 months.  A fairly consistent finding in the pediatric population is the majority of these children tend to be developmentally delayed. [5]

While sigmoid volvulus accounts for approximately 60% of cases of colonic volvulus, the cecum is the location of the torsion in 20-40%.  Although historically described as a cecal volvulus, this condition most commonly occurs in the ascending colon, superior to the ileocecal valve.  In addition, rare metachronous cases have been reported in this location following previous repair of a sigmoid volvulus. [6]  Patients with cecal volvulus tend to be younger than their sigmoid counterparts, with average ages between 20-50 years old, though the male predominance remains. [7]  Also, unlike the sigmoid volvulus cohort that may show a predominance of elderly, nursing home patients with underlying chronic constipation, cecal volvulus tends to be associated with more acute medical conditions such as illness, surgery, or pregnancy.
Etiology and Pathophysiology
Although the exact cause of volvulus is unknown, multiple different factors likely play a role.  Yet the most basic tenet encompasses the need for the colon and accompanying mesentery to have sufficient length such that the two bases of the colonic loop can come into contact and subsequently rotate around one another.  Some authors have suggested a need for a primary peritoneal point of fixation for this to take place, although others have disagreed.  Bhatnagar and associates have studied human and cadaveric sigmoid colon and corresponding mesenteric measurements demonstrating seven distinct patterns, and suggested that the ratio of length to width of the mesocolon in males (longer than wide or narrow-based) versus females (wider than long or broad-based) may contribute to the male predilection. [8]  Various other factors have been associated with the development of volvulus.  In the sigmoid location, pelvic tumors, adhesions, and previous abdominal surgery have all been cited. [9]  In addition, a diet high in fiber, as seen in the volvulus belt region, is felt to have a significant role in contributing to an elongated sigmoid colon.  Tomita and associates have suggested a slightly different angle, suggesting that volvulus may be on the same continuum as Hirschsprung’s disease, [10] and as such presents more often in children as an acute obstruction, while adults experience chronic constipation and defecation difficulties. [11]  A neurological origin is also suggested by the finding of increased incidence of volvulus in areas where Chaga’s disease is prevalent.  Infection with Trypanosoma cruzi results in underlying damage to the myentric and submucosal plexus leading to dysmotility, progressive bowel enlargement, and thus creates ideal conditions for the development of volvulus. [12]  Even more interesting is the finding of increased incidence in patients that live in high altitude locations.  Asbun and colleagues described a series of 230 patients with sigmoid volvulus in the high areas of the Andes, and proposed a mechanism by which the intraluminal pressure of the bowel at this altitude is much greater, contributing to chronic distension and eventual megacolon. [13]

Regardless of the underlying cause, once this torsion occurs, initial venous engorgement followed by lack of arterial flow leads to ischemic changes in the bowel, with eventual necrosis and perforation. [14]  The obstruction may also cause ischemic changes in the adjacent bowel due to mesenteric thrombosis, leading to gangrene in those segments.  Finally, in cases of sigmoid volvulus, progressive cecal dilatation and eventual perforation can occur in those patients with a competent ileocecal valve as a result of the distal obstruction.
 
Volvulus of the cecum is felt to occur as a result of the loss of development of the peritoneal fixation of the cecum, allowing both it and the proximal bowel to be fully mobile to any part of the abdominal cavity.  In addition, a focal point of fixation can then serve as a fulcrum for the bowel to twist around its associated ileocolic-based mesentery, forming an intermittent or closed-loop obstruction. [15]  Cecal volvulus occurs classically in two different patterns—twisting in an axial plane around its long axis in approximately half the patients in either a clockwise or counterclockwise motion, or in the other half of patients in which the cecum both twists and inverts along with the terminal ileum. [16]  Another variant is known as the cecal “bascule,” where the cecum folds on itself anteriorly without any concomitant torsion.  The latter creates a ball-valve type obstruction at the level of the ileocecal valve, and is associated with inflammatory bands extending across the ascending colon, demonstrating a characteristic fixed dilated loop of bowel in the mid-abdomen on plain films. [17]
Clinical Presentation

Clinical features of volvulus depend, in part, on location of the volvulus as well as the degree of obstruction, and viability of the colon.  As such, they vary from chronic dysmotility complaints to acute obstruction and perforation.  Most patients with sigmoid volvulus will give a chronic history of constipation and abdominal distension long before the onset of volvulus.  This may present more emergently with acute onset of abdominal pain, constipation, and distension, with peritonitis suggesting the presence of ischemia or perforation.  Vomiting is not as common, even with acute presentation.  Regrettably, the clinical manifestations for ischemic changes are inconsistent, especially in patients with mental illness or the elderly. [18]  Most commonly, patients with ischemia present with abdominal pain, fever, and distension anywhere from hours to days.  They may have diarrhea that is bloody or non-bloody depending on the location, degree, and extent of the colon affected.  Abdominal examination may show widely variable findings ranging from mild localized tenderness to diffuse peritonitis.  Patients may even have a palpable colon or a visible abdominal mass.  Rectal examination may be completely normal or demonstrate blood ranging from bright red to melena.  Most often there is an absence of stool in the rectal vault, as with a closed-loop obstruction, distal evacuation may have preceded presentation and evaluation.  Laboratory examination is often noteworthy for a leukocytosis and metabolic acidosis, and may also present with significant electrolyte abnormalities.  Therefore, identifying those patients at the onset of their clinical course entails a high index of suspicion.  Complete history and physical examination, focusing on the abdomen and evaluation for peritoneal signs is of utmost importance.  Any peritonitis mandates emergent exploratory laparotomy for evaluation of bowel viability.  Again, due to the high morbidity and mortality once ischemia ensues, the ultimate goal remains to continue to avoid its onset altogether. 
 
Cecal volvulus is notoriously more difficult to diagnose, as clinical symptoms can be even more non-specific.  Patients classically have intermittent abdominal cramping, vague abdominal pain, nausea, and occasionally emesis.  Like sigmoid volvulus, most will give a history of chronic constipation.  Radiological work-up identifies the source in 30-70% of plain films and 88% of barium enema studies, although up to 15% of cecal volvulus are identified only at the time of laparotomy. [19, 20]  The remainder of the history and physical examination are as described above.
Diagnosis
 As stated, the key component is for the physician to have a high index of suspicion and begin with a thorough history and physical examination, appropriate laboratory evaluation, along with concomitant resuscitation and correction of metabolic abnormalities.  In those stable patients without urgent indications for the operating room, radiological and endoscopic studies can provide useful information.

Plain Film
Plain film radiographs are often characteristic for both sigmoid and cecal volvulus (Figures 1, 4a).  Plain film evaluation of a sigmoid volvulus is classically described by the “bent inner tube” or “coffee bean sign” from the dilated air-filled bowel arising from the left lower quadrant and extending towards the diaphragm.  Similar findings can be seen in cases of cecal volvulus as well, [21] though volvulus in the cecal location classically demonstrates a large, gas-filled, ahaustral colon extending from the pelvis in the right lower quadrant to the upper abdomen.  In both cases, there is often a lack of distal air or stool.  Plain films should also be examined for signs of more proximal small bowel obstruction, concomitant cecal volvulus (in the case of sigmoid torsion), or pneumoperitoneum consistent with perforation.  Although not necessary, additional installation of rectal contrast may demonstrate the “bird’s beak” sign at the site of the torsion.  Patients with suspected perforation or necrotic bowel should not undergo contrast studies, and the practice of attempting to reduce the volvulus via barium studies has largely fell out of favor due to high morbidity and risk of perforation. [22]  Finally, it is important to point out that the volvulus can be missed on plain films under certain conditions: presence of a closed-loop obstruction with fluid-filled bowel loops, orientation of the volvulus parallel to the radiographic plane, or when the volvulus is obscured by overlying air-filled small bowel loops. [23]

Computed Tomography
As CT is commonly used in many patients presenting with abdominal pain, this modality has also seen increased frequency of detection of volvulus.  Like endoscopy, CT may demonstrate a “whirl sign,” in which spiraled loops of collapsed bowel and mesentery are twisted around its vascular supply (Figure 2). [24]  In addition, it can demonstrate a closed-loop obstruction or concomitant pathology that may have led to the onset of the torsion. [25]  It has also been useful in providing additional information when the diagnosis is in doubt.  More importantly, CT provides the ability to evaluate the bowel as well as the surrounding tissue for signs of ischemia or perforation with findings such as wall thickening, mesenteric fat stranding, mucosal enhancement, intramural air, dilatation, or even more ominous signs such as portal venous gas or free air.

Endoscopy
Endoscopy provides a plethora of information regarding diagnosis, viability of the bowel, as well as therapeutic ability.  As stated, there may be a paucity of clinical symptoms of ischemia in the early setting, leading to a delay in diagnosis and increasing the likelihood of complications or even death.  Endoscopy can identify the site of distal obstruction in sigmoid volvulus with funneling of the bowel into a point of occlusion, also referred to as a “whirl” sign.  Ischemia has a wide extent of luminal changes when viewed endoscopically (Table 1).  Biopsy is rarely useful for diagnosing ischemia and is more likely to demonstrate either nonspecific ischemic or inflammatory changes, and rarely shows the ghost cells that are classic for ischemia. [26]  In general, it should be avoided.
Treatment

Patients should be initially resuscitated with correction of fluid and electrolyte disorders.  In addition, broad-spectrum antibiotics to cover aerobic and anaerobic bacteria should be initiated, especially in any patient with a possibility of ischemic bowel.  Those patients with peritonitis or concerns for perforation or non-viable bowel should proceed urgently to the operating room.  Patients without immediate operative indications may undergo attempt at endoscopic detorsion.  The therapeutic goals remain to relieve the obstruction, assess bowel viability, and ultimately prevent recurrence.  With these three in mind, both endoscopic and surgical (including minimally invasive) approaches have been employed.

Sigmoid Volvulus
Treatment options for sigmoid volvulus depend on both the clinical condition of the patient as well as the viability of the bowel.  For hemodynamically stable patients with no signs of ischemia or perforation, initial attempts at non-operative therapy are justified.  Historically, rectal lavage and saline or barium enemas were used, with success rates ranging from 65-80%. [27, 28] Yet, the inability to evaluate the bowel for ischemic changes, high recurrence rates, and increased morbidity and mortality with perforation has largely done away with these methods.  First described by Bruusgaard in 1947, [29] decompression through endoscopy has quickly become a standard initial treatment for these patients.  While both rigid proctoscopy and flexible endoscopes have been described, flexible sigmoidoscopy or colonoscopy has more recently been the preferred method.  In a review of 81 patients with sigmoid volvulus, Turan and colleagues found a higher success rate for detorsion with the use of flexible colonoscope versus rigid proctoscope (60% vs. 40%). [30]  Other studies have reported varying success rates of 30-91%, with similar improved results using flexible instrumentation. [22, 31, 32]  The scope is inserted and passed under direct observation to the point of obstruction.  Care should be taken to initially minimize air insufflation.  If possible, the scope is then passed into the twisted segment of bowel with evacuation of the liquid stool and gas.  A long rectal tube may then be placed proximal to the point of obstruction and left in place for 24-72 hours. [33]  Successful decompression should be followed by abdominal radiographs to look for free air in cases of perforation.
  
Decompression alone accomplishes the goals of relieving the obstruction and assessing for viability, though it is hindered by high recurrence rates of up to 70%. [22, 34]  Therefore reduction of the volvulus should, in general, be followed with surgical repair in almost all patients after adequate resuscitation and correction of metabolic derangements.  In patients deemed too high risk to tolerate a surgical procedure, one must weigh the risks of recurrent volvulus with that of an operation.  Bak and Boley found a mortality rate of 30% in those patients developing recurrent volvulus after not undergoing any further therapy versus only 6% in their surgical cohort. [35]  Although not a controlled or randomized study, it does highlight the concerns regarding development of a recurrence, and its associated physiological changes.  A successful “watch and wait” strategy has been employed with the use of repeated endoscopic decompression when recurrence develops, especially with younger and healthier patients. [4]  Yet this should be used with caution, and only after discussion with the patient and balancing the risks of both approaches.  Finally, though not widely used, other authors have described minimally invasive techniques such as endoscopic sigmoidopexy in patients at high risk for surgical complications. [36]  Baraza and colleagues have also described the use of a percutaneous endoscopic colostomy. [37]  Similar to a PEG tube used in the stomach, the authors demonstrated success in 18 of 19 patients with recurrent sigmoid volvulus by leaving the tube in indefinitely.  One patient did die secondary to tube-related complications, with 7 additional patients developing minor complications.  Although further use with long-term data awaits solid recommendations regarding these methods, they highlight the attempt to avoid recurrence via the least invasive techniques possible.

Surgical options include sigmoidopexy alone, resection with primary anastomosis, and a 2-stage procedure of resection with proximal diversion followed by subsequent takedown.  In part, the procedure selected depends on both the patient co-morbidities and viability of the bowel (Figure 3).  Gangrenous changes mandate a resection, though the decision regarding whether or not to restore continuity (with or without proximal diversion) is left to the attending surgeon.  For uncomplicated volvulus, the past decade has seen sigmoid resection with primary repair to be increasingly used as a result of the low recurrence, morbidity, and mortality rates.  Akcan and colleagues reviewed 136 patients with non-complicated sigmoid volvulus (defined as no perforation or gangrene at presentation) of which 45 underwent resection with Hartman’s procedure and primary anastomosis was performed in 91. [38]  They found no differences in complication (27% vs. 26%) or mortality rates (4.4 vs. 5.5%) between the Hartmann’s and primary anastomosis groups, respectively.  Anastomotic dehiscence occurred in 5 of 91 (5.5%) patients in the primary repair cohort.  In an additional prospective review of 197 cases, De and Ghosh found an overall mortality rate of 1% , along with 1% anastomotic leak rate following resection with primary anastomosis without pre-operative or intra-operative colonic lavage. [39]  Despite 12% of their patients presenting with gangrene and 5.1% with perforation, the only stomas in the cohort were performed following re-exploration for the 2 anastomotic leaks.  The authors used an intra-operative rectal tube to evacuate the bowel contents and noted no recurrences at a follow-up of two years.  Other authors have found similar success using resection and primary repair, with mortality rates ranging from 4-15% and recurrence rates under 5%. [2, 40]  Yet, recurrence rates as high as 37% have been described by Morrissey and Deitch in a series of 19 patients undergoing resection and primary repair. [41]  They, like Chung and colleagues, have emphasized that those patients with concomitant megacolon at presentation are at significant risk for recurrence and a subtotal colectomy should be considered in this select group. [42]

Despite these excellent results, there remains some controversy regarding the optimal method of handling the two bowel ends following successful resection of the volvulized segment.  Anastomotic leaks, though reported in 0-6%, [38, 43] remain a concern and are associated with a high morbidity and mortality.  Additionally, these are certainly more of a concern in this cohort often presenting acutely with ischemic changes and multiple underlying co-morbidities.  Ideally successful detorsion can be followed by a colectomy in an elective setting.  Yet this is not always possible secondary to inability to endoscopically decompress the torsion or with concerns for necrotic or perforated bowel.  Toure and colleagues demonstrated a 31% mortality rate in those patients undergoing colectomy with primary anastomosis versus 5% in those undergoing colostomy, and recommended avoidance of in-continuity management. [44]  In part, this high mortality rate is secondary to not only the pathophysiology associated with the disease process itself, but the patient population in which it occurs.  Younger patients with less medical co-morbidities and those in developed countries tend to have improved outcomes, and should be taken into account when evaluating the literature.  Greater access to care, more urgent diagnosis and “state of the art” treatment all may contribute to this difference. [45]  Yet, simple open decompression even with the addition of suture rectopexy or other fixation techniques have comparable mortality rates as resection (5-11%), and are plagued by much higher recurrence rates from 30-80%. [2, 46]  Thus, consideration should be given in all cases of uncomplicated sigmoid volvulus for resection with primary anastomosis, especially in the elective setting, but even in those cases without colonic lavage or in the absence of initial colonic decompression.

Cecal Volvulus
As in the sigmoid, options for the management of cecal volvulus include: endoscopic decompression versus surgical detorsion alone, cecopexy, cecostomy, and right colectomy with primary or delayed anastomosis or proximal stoma--all through open or minimally invasive approaches.  Also, like torsion in the sigmoid location, resection is required for those patients with grossly necrotic bowel, yet also must be considered in patients with massive distension involving the very thin-walled cecum.  Unlike its left-sided counterpart, endoscopic decompression with cecal volvulus is less successful, with rates ranging from 30-50%. [31]  Thus, when deciding on the appropriate surgical option for cecal volvulus, it is again imperative to weigh the operative morbidity with the risk of recurrence.  Simple surgical detorsion alone is plagued by recurrence rates greater than 50%, [47] as well as a not insignificant morbidity and mortality rates of 10-20%. [20, 48]  Less extensive procedures such as detorsion with cecopexy have an overall low morbidity of 10-30%, but still are associated with high recurrence (10-30%).  With increasing use of minimally invasive techniques, the morbidity associated with cecopexy may decrease, although its effect on long-term recurrence remains to be seen. [49]  Cecostomy has been associated with even higher complication rates greater than 50% in some series, and has largely been abandoned. [20]  More often, surgical resection with primary anastomosis has become a mainstay of therapy, with low morbidity and mortality, and recurrence rates <10% (Figure 4b). [50]  Even in the presence of gangrenous changes, resection of the involved segment with primary anastomosis has demonstrated acceptable results (see below). [51, 52]

Transverse Colon, Splenic Flexure Volvulus, and Ileosigmoid Knotting
Volvulus associated with the transverse colon or splenic flexure is especially rare, comprising only ~3-4% and 2% of all colonic volvulus cases, respectively. [53]  This segment of the colon naturally has limited mobility secondary to the ligamentous attachments at the flexures, thus some or all of these points of fixation must be congenitally missing or surgically altered to predispose its onset.  As such, presentation can vary from chronic constipation and recurrent abdominal pain to life-threatening perforation and sepsis.  Although colonoscopic decompression is described for both conditions, they are best treated via resection with either an extended right hemicolectomy or a left colectomy in those patients with splenic flexure volvulus. [54]

Ileosigmoid knotting occurs when the distal ileum twists around the sigmoid colon and its mesentery, thus causing synchronous obstruction.  Although the true incidence is unknown, this is a rare condition hallmarked by difficulty in diagnosis, high rates of gangrenous bowel, and poor outcomes.  Bhatnagar and colleagues demonstrated ileosigmoid knotting in 11/76 cases of gangrenous sigmoid volvulus, with an overall mortality of 64% in this subset of patients. [55]  In an additional retrospective review of 15 Ethiopian patients, 14 presented with necrotic bowel requiring resection, with an overall mortality rate of 20%. [56]  Management in these cases involves vigorous resuscitation along with urgent laparotomy and resection of all non-viable bowel.  Especially with rates of concomitant gangrene reported to be up to 100%, [57] prompt diagnosis and appropriate surgical management must ensue in attempt to limit morbidity and mortality.

Laparoscopy
First described in 1992, [58] laparoscopy continues to have an evolving role in the management of volvulus.  Cartwright-Terry and colleagues demonstrated its effectiveness in 9 cases with sigmoid volvulus that were initially successfully managed by endoscopic detorsion followed by same-admission laparoscopic-assisted resection with primary anastomosis. [59]  Liang and associates used a similar pathway of laparoscopic-assisted resection following detorsion resulting in successful resection for 14 sigmoid volvulus patients, with no mortality and only one patient requiring a proximal diversion following in-continuity repair. [60]  Chung also described a laparoscopic-assisted approach for mobilization and exteriorization followed by resection with subsequent stoma or anastomosis (both with and without proximal diversion.) [61]  Thus, although large-scale series and long-term follow-up data are lacking, increasing experience in minimally invasive techniques (as in many disease processes) is likely to bring equivalent, or potentially improved, results.

Gangrenous Volvulus
One of the more controversial topics remains the proper management of volvulus in the setting of concomitant necrotic bowel.  Often despite a lack of statistical support, initial reports largely stated that resection with proximal stoma placement was the accepted management technique when gangrenous bowel was encountered--especially with sigmoid volvulus. [12, 62-67]  Yet, recently this strategy has been questioned.  Bhatnagar and colleagues reviewed a cohort of sigmoid volvulus patients all presenting with gangrene, and identified extension of the necrosis either proximally into the descending colon or distally into the rectum in 26% of cases. [55]  Of the forty patients that underwent primary anastomosis, thirteen had proximal diversion.  Anastomotic leaks occurred in 4/27 without proximal diversion versus 0/13 with stomas in place.  Despite this, there was no statistically significant difference amongst the entire cohort in mortality between those patients managed with or without a stoma (24% vs. 48%, p=n.s.), or in the subset undergoing primary anastomosis managed with (46%) or without (48%) proximal diversion.  Rather, the authors identified age >60 years and shock on admission as the only independent factors associated with mortality, regardless of the method of handling the bowel ends following resection.  Still others have touted the ability to perform one-stage operations, with the addition of on-table colonic lavage to lower morbidity rates. [68]  Yet lavage is not without its own difficulties and with the emerging evidence questioning the need for bowel preparation, this practice may not be necessary at all. [69]  Sule and colleagues demonstrated no mortalities or anastomotic leaks in a series of 21 consecutive patients with acute sigmoid volvulus, including 2 patients with ileosigmoid knotting and gangrenous bowel, using a protocol with decompression followed by resection and primary anastomosis without colonic lavage. [70]  In a retrospective review of 57 patients with sigmoid volvulus undergoing in-continuity management comparing those with gangrenous colons (n=27) with those with viable colons (n=30), Raveenthiran found no difference in hospital length of stay (16d vs. 12d, P=0.248), anastomotic leak (15% vs. 27%, P=0.441), or mortality (3.7% vs. 3.3%, P=0.78) between the two groups. [71]  Although the presence of gangrenous changes has historically been associated with mortality rates as high as 75%, [72, 73] others have reported lower mortality rates ranging from 11-25% following resection and primary anastomosis in the setting of necrotic changes. [43, 74]  Bagarani and associates performed the only prospective randomized trial addressing this issue, with 14 patients with gangrenous sigmoid colons allocated to a Hartmann’s procedure (n=8) versus resection with primary anastomosis (n=6).  The authors demonstrated a higher mortality in those undergoing primary repair (33% vs. 12.5%), yet the sample size was very small and the two groups were not matched. [75]  Not surprisingly in this patient cohort, mortality rate may differ between those operated on in the elective setting versus more emergent conditions (i.e., obstruction, gangrenous colon).  Safioleas and associates found a mortality rate of 5.9% (1/17) following elective resection versus 40% (6/15) for urgent cases. [76]  Yet, the presence of gangrene or method of handling the bowel ends following resection may play less of a role than previously felt.  Rather, improved critical care medicine, early recognition and treatment may account more for the improving outcomes.  This is highlighted in a study of 78 patients with sigmoid volvulus and necrotic changes where mortality rates varied from 15.4% to 65% over 4 decades. [77]  The authors found a decreasing mortality rate over the final 2 decades and attributed their improved results to more accurate determination of bowel viability and increased use of primary anastomosis.

Resection with primary anastomosis is more of an accepted technique in the setting of cecal volvulus with gangrene, with low anastomotic leak (0-9%) and mortality rates (0-23%). [51, 78, 79]  Thus, although numbers in many series are similar to those in sigmoid volvulus with concomitant gangrene, often surgeon perceptions regarding proper management for the two locations remain different.  Reasons for this remain unclear, but may entail concerns regarding bacterial count, technical ease of the operation, or perceived outcome differences.  Yet, there is emerging body of literature to support the use of resection with primary repair in this setting for both locations, and should be considered when volvulus with ischemic changes is encountered.
Conclusion 

Though volvulus remains an infrequent occurrence, surgeons should remain familiar with the diagnostic evaluation, treatment and expected outcomes.  When possible, successful colonoscopic detorsion may allow continued resuscitation and correction of metabolic disturbances prior to a subsequent elective operation.  Increasing experience has demonstrated the safety and efficacy of resection and primary anastomosis, even in the setting of ischemic bowel, over simple detorsion or fixation techniques for both cecal and sigmoid volvulus.  The role of diversion remains debatable without any strong level 1 evidence to support or refute its use, though multiple retrospective reviews have shown comparable results with in-continuity management-especially in non-complicated volvulus.  With further experience and improvements in endoscopic and minimally invasive approaches, hopefully the future will continue to see decreasing recurrence rates, morbidity, and mortality for those patients with all types of volvulus.     


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Table 1.  Endoscopic Findings of Colonic Ischemia.

StageEndoscopic Findings
AcuteHyperemia, Edema, Friable Mucosa, Superficial Ulcerations, Petechial Hemorrhage, Gangrene*
SubacuteEdema, Exudate, Ulceration
ChronicStricture, Mass, Segmental Involvement
*Irreversible damage characterized by gray, green or black appearance

Figure 1.  Plain Film Radiograph Demonstrating Sigmoid Volvulus
  











 

 

 

 

Figure 2.   CT of Sigmoid Volvulus with Mesenteric Torsion (arrow)













 

 

 

 
Figure 3.  Massive Sigmoid Volvulus












 

 

 

 
Figure 4.  Cecal Volvulus: a) Plain Film b) Intra-operative Findings


a)

















 

 

 


b)