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Introduction
Sigmoid volvulus is a serious condition in which a
redundant sigmoid loop rotates around its narrow, elongated mesentery, producing ischaemia and necrosis of
the sigmoid colon, followed by rapid distention of the
closed loop. It is a common cause of colonic obstruction
in India, Eastern Europe, and Scandinavia (1). The highest incidences were reported in Ethiopia, among rural
areas of the Bolivian, and Peruvian Andes at 13,000 feet
above sea level, where it accounts for 50% and 79%
respectively of patients with intestinal obstruction (2-3).
It is most common in the middle aged, elderly, institutionalized population, or in neuropsychiatric patients (4).
Although exact aetiology of the sigmoid volvulus is
unknown, high residue diet, narrow attachment of pelvic
colon, long pelvic mesocolon, overloaded pelvic colon
with faeces due to chronic constipation, and band of
adhesions to the apex of the sigmoid colon are considered
main predisposing factors for this disease (1).
The diagnosis of sigmoid volvulus is determined
from history, physical examination and careful interpretation of the plain abdominal radiographs. The correct
preoperative diagnosis and early management of these
patients is essential to achieve a good outcome. If the
volvulus is not promptly relieved, the vascular supply to
the bowel is affected, leading eventually to necrosis, perforation septic shock, and death (5).
N. Agaoglu et al.
366
electively on the same hospitalization period. Patients
with signs of peritonitis and perforation or unrelieved by
sigmoidoscopy and passage of rectal tube were operated
on urgently. Depending on the condition of the patients
and the preference of the surgeons, surgical treatment
consisted of sigmoidectomy and primary anastomosis
(R&A), sigmoidectomy with either Hartmanns procedure or Paul-Mikulicz procedure colostomies (R&C),
and operative detorsion with sigmoid plication (D&P).
Follow-up data were obtained from medical records to
assess late complications and recurrence rate.
Statistical analysis : Students t-test was used to compare DHS expressed as mean standard deviation.
Comparisons of complication rates, concurrent diseases,
and recurrences were analyzed with Fishers exact test.
P value < 0.05 was considered significant.
Results
There were 21 male (66%) and 11 female patients
(34%). The age of the patients ranged from 61 to
87 years with median of 73.5 8.38 years. The common
symptoms and signs are presented in Table I. The interval between onset of symptoms and admission ranged
from 1 day to 15 days with median of 4.37 days. Preoperative radiological evaluation of the patients revealed
signs of large intestinal obstruction (n = 17, 53%),
Frimann-Dahl sign with three dense lines converging
towards the site of obstruction (n = 14, 44%) and bilateral free air under diaphragm (n = 1, 3%) due to perforation of the twisted sigmoid colon. No patient underwent contrast enema examination of the colon. The correct preoperative diagnosis was possible for sigmoid
volvulus in 44% (14/32) of cases. Six (19%) patients had
successful reduction of the volvulus after treatment by
sigmoidoscopy and passage of rectal tube and were
operated on electively on the same hospitalization period. The other patients (n = 26, 81.%) were operated on
urgently.
Peroperatively long mesocolon, with narrow attachment of sigmoid colon was found in all patients.
Surgical treatment, concomittant diseases, postoperative
Table I
Clinical features of the patients
Clinical features
Acute abdominal pain
Abdominal distension
Abdominal rigidity and tenderness
Nausea and vomiting
Constipation
Bloody mucoid discharge per rectum
Number (%)
32 (100)
30 (94)
32 (100)
10 (31)
30 (94)
2 (6%)
Sigmoid Volvulus
367
Table II
Results according to the types of surgery
Types of surgery
Number of patients
Concomittant diseases
Hypertension
Ischaemic heart disease
Diabetes mellitus
Alzheimers disease
Benign prostatic hypertrophy
Hyperthyroidism
Pulmonary disease
Postop. complication
Pulmonary atelectasis
Intestinal complication
Obstruction due to adhesions
Internal hernia
Wound infection
Mortality
Recurrences
DHS (days)
Mean SD
Resection &
anastomosis
(%)
Resection &
colostomy
(%)
Operative
detorsion &
sigmoid
plication (%)
Total
(%)
9 (28)
4 (44)*
2
4
0
16 (50)
14 (87)*
8
7
4
7 (22)
5 (71)
2
5
0
1
32 (100)
23 (72)
12 (37)
16 (50)
4 (12)
1 (3)
2 (6)
1 (3)
6 (19)
9 (28)
4 (12)
2 (6)
2
1
2
2 (22)
2 (12)
2 (29)
1 (6)
2 (12)
1 (6)
10.89 4.17
15.63 14.15
1 (14)
2 (29)
9.86 1.35
1 (3)
2 (6)
2 (6)
2 (6)
References
1. Harding Rains A. J., Mann J. V. (eds). BAILY & LOVEs short practice of surgery. 20th ed. H.K. Lewis, London, UK 1988, 1175.
2. JOHNSON L. P. Recent experience with sigmoid volvulus in
Ethiopia : its incidence and management by primary resection.
Ethiop Med J, 1965, 4 : 197-204.
3. ASBUN H. I., CASTELLANOS H., BALDERRAMA B. et al. Sigmoid
volvulus in the high-altitude of the Andes review of 230 cases.
Dis Colon Rectum, 1992, 35 : 350-3.
4. BALLANTYNE G. H. Review of sigmoid volvulus : clinical patterns
and pathogenesis. Dis Colon Rectum, 1982, 25 : 823-30.
5. WILK P. J., ROSS M. Sigmoid volvulus in an 11-year-old girl. Am J
Dis Child, 1974, 127 : 400-2.
6. KUZU M. A., ASLAR A. K., SORAN A., POLAT A., TOPCU O., HENGIRMEN S. Emergent resection for acute sigmoid volvulus - Results of
106 consecutive cases. Dis Colon Rectum, 2002, 45 : 1085-90.
7. DULGER M., CANTURK N. Z., UTKAN N. Z., GONULLU N. N.
Management of sigmoid colon volvulus. Hepatogastroenteroly,
2000, 47 : 1280-3.
8. AKGUN Y. Mesosigmoplasty as a definitive operation in treatment
of acute sigmoid volvulus. Dis Colon Rectum, 1996, 39 : 579-81.
9. PINEDO G., KIRBERG A. Percutaneous endoscopic sigmoidopexy in
sigmoid volvulus with T-fasteners Report of two cases. Dis
Colon Rectum, 2001, 44 : 1867-9.
10. CHOI D., CARTER R. Endoscopic sigmoidopexy : a safer way to
treat sigmoid volvulus ? J R Coll Surg Edinb, 1998, 43 : 64-5.
11. CHUNG C. C., KWOK S. P. Y., LEUNG K. L., KWONG K. H., LAU W. Y.,
LI A. K. C. Laparoscopy-assisted sigmoid colectomy for volvulus.
Surg Laparosc Endosc, 1997, 7 : 423-5.
12. BHATNAGAr B. N. S. Prevention of recurrence of sigmoid colon
volvulus : a new approach. A preliminary report. J R Coll Surg
Edinb, 1970, 15 : 49-52.
13. ELI A., HARRY B. A., OMRI Z. L. Elective Extraperitonealization for
Sigmoid volvulus : An Effective and Safe Alternative. J Am Coll
Surg, 1997, 185 : 580-3.
14. SUBRAHMANYAM M. Mesosigmoplasty as a definitive operation for
sigmoid volvulus. Br J Surg, 1992, 79 : 683-4.
N. Agaoglu et al.
368
15. AJAY K. K., MAHENDRA K. M., KUNDAN K. Extraperitonealization
for sigmoid volvulus : a reappraisal. Aust N Z J Surg, 1995, 65 :
496-8.
16. SONIA S., CARLOS A. A., NILSON S., CARLOS M., LEONARD S.
Sigmoid volvulus in children and adolescents. J Am Coll Surg,
2000, 190 : 717-23.
17. HINES J. R., GEURKINK R. E., BASS R. T. Recurrence and mortality
rates in sigmoid volvulus. Surg Gynecol Obstet, 1967, 124 : 56770.
18. WELCH G. H., ANDERSON J. R. Acute volvulus of the sigmoid
colon. World J Surg, 1987, 11 : 258-62.
19. GIBNEY E. J. Volvulus of the sigmoid colon. Surg Gynecol Obstet,
1991, 173 : 243-55.
20. RENZULLI P., MAURER C. A., NETZER P., BUCHLER M. W.
Preoperative colonoscopic derotation is beneficial in acute colonic
volvulus. Digest Surg, 2002, 19 : 223-9.
21. MANGIANTE E. C., CROCE M. A., FABIAN T. C. et al. Sigmoid volvulus. A four decade experience. Am Surg, 1989, 55 : 41-4.
22. BAK M. P., BOLEY S. J. Sigmoid volvulus in elderly patients. Am J
Surg, 1986, 15 : 71-5.
23. TOURE C. T., DIENG M., MBAYE M. et al. Rsultats de la colectomie
en urgence dans le traitement du volvulus du colon au centre
hospitalier universitaire (CHU) de Dakar. Ann Chir, 2003, 128 :
98-101.
N. Agaoglu (Nadhim A. Mustafa)
K.T.. Lojmanlar 36/4
TUR-61080 Trabzon Turkey
Tel.
: +90 462 3775634
Fax
: +90 462 3250518
E-mail
: nagaoglu@meds.ktu.edu.tr