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Acta chir belg, 2005, 105, 365-368

Surgical Treatment of the Sigmoid Volvulus


N. Agaoglu (N. A. Mustafa)*, Y. Ycel, S. Trkylmaz
*Department of General Surgery, Karadeniz Technical University, Faculty of Medicine, Trabzon, Turkey.

Key words. Volvulus (surgery) ; sigmoid colon.


Abstract. Sigmoid volvulus is not an uncommon cause of intestinal obstruction. The purpose of this study is to evaluate the clinical features and surgical treatment methods in patients with sigmoid volvulus. Thirty-two patients operated
on between January 1991 and October 2002 were reviewed retrospectively. The demographic data of the patients,
clinical features, preoperative radiological and operative findings, type of surgical procedure performed, postoperative
complications, mortality and duration of hospital stay (DHS) after surgery were reviewed.
There were 21 male (66%), 11 female patients (34%) and their age ranged from 61 to 87 years with a median of 73.5
8.38 years. Most frequent clinical features were abdominal pain, distension and constipation. The correct preoperative diagnosis was made in 44% (14/32) of cases. Surgical treatment consisted of sigmoidectomy with primary anastomosis (R&A) (n = 9, 28%), sigmoidectomy with colostomy (R&C) (n = 16, 50%), and detorsion with sigmoidopexy
(D&P) (n = 7, 22%). Concomittant diseases were more frequent in R&C group (n = 14, 87%) and this was statistically
significant as compared to R&A (n = 4, 44%) (P = 0.03). Postoperative complication rate in R&C group was more
frequent and DHS longer but the difference between treatment groups was not significant statistically. Two recurrences
were observed in D&P group. Sigmoidectomy should be the basic principle in management of sigmoid volvulus and
primary anastomosis can be performed safely in selected patients without increasing morbidity and DHS.

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).

Various surgical procedures have been advocated for


sigmoid volvulus such as sigmoidectomy with primary
anastomosis, sigmoidectomy with Hartmanns or PaulMikulicz colostomies, mesosigmoidoplasty, percutaneous endoscopic or open sigmoidopexy, tube sigmoid
colostomy, laparoscopy-assisted sigmoid colectomy,
and extraperitonealization of sigmoid colon (6-12). In
this retrospective study, we evaluated the clinical features, the predisposing factors, the surgical treatment
methods and the main postoperative complications of
patients with sigmoid volvulus.
Material and methods
Thirty-two patients with sigmoid volvulus admitted to
the Department of General Surgery of Karadeniz
Technical University-Faculty of Medicine between
January 1991 and October 2002 were reviewed retrospectively. The records of age, gender, main symptoms
and duration, physical examination findings, preoperative radiological and operative findings, type of surgical
procedure performed, postoperative complications, mortality and duration of hospital stay (DHS) after surgery
were reviewed for all patients (DHS for closure of the
colostomy was not included). All patients without signs
of peritonitis and perforation and those who were
relieved with a trial of conservative treatment by sigmoidoscopy and passage of rectal tube were operated on

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%)

complications, and DHS of the patients are shown in


Table II. The mortality, one from R&C group at the 4th
postoperative day and the other from D&P group at the
1st postoperative day, were due to severe coronary artery
disease with extensive myocardial infarction. The mean
follow-up periods were 26.72 17.73 months (range 682 months). During this period, one recurrent volvulus
was treated by sigmoidectomy with primary anastomosis, and the other by sigmoidectomy with Hartmanns
colostomy.
Discussion
Various surgical procedures have been adopted for the
management of nongangrenous sigmoid volvulus such
as mesosigmoidoplasty and extraperitonealization of the
sigmoid colon in an attempt to prevent recurrence without subjecting the patients to the risk of resection and
anastamosis (8, 12-15). Open or percutaneous endoscopic sigmoidopexy, tube sigmoid colostomy, and
laparoscopy-assisted sigmoid colectomy are other surgical procedures performed in patients with sigmoid
volvulus (9-11). Most authors agree that the definitive
treatment of sigmoid volvulus is sigmoidectomy with or
without anastomosis (6-7, 16). However resection with
primary anastomosis in emergency situations, when the
general condition of the patient is suboptimal and bowel
not prepared, carries an unacceptably high complication
rate (15). As a result, elective resection of the sigmoid
colon has frequently been advised (4, 17-19). Endoscopic deflation and rectal tube application in the absence
of clinical, laboratory or radiological signs of bowel
necrosis or perforation allows stabilization of the patient
and converts an emergent colon surgery to an elective
procedure. In the present study sigmoidoscopic reduction of the sigmoid volvulus was successful in 6 (19%)
patients. However this reduction is not a definitive treatment and carries a high recurrence rate (40-90%) (4, 17).
Consequently elective resection or sigmoidopexy of the
redundant sigmoid colon during the same hospitalization has been advocated (7, 10, 20). In this study, resection of the sigmoid colon with primary anastomosis (n =
9, 28%) was the preferred surgical treatment of sigmoid
volvulus in thick-walled megacolon without any general
or local factors that might jeopardize the healing process
in colonic anastomosis (e.g. hypoproteinaemia, gangrenous colon, generalized peritonitis, and faecal loading of the colon). Otherwise sigmoidectomy with
colostomy (n = 16, 50%) either Hartmanns or PaulMikulicz procedures was carried out for devitalized
colon. Detorsion and sigmoidopexy (n = 7, 22%) were
performed in the absence of ischaemia or necrosis of the
sigmoid colon with poor general condition of the
patients requiring a duration of the operation as short as
possible.

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)

* : The difference between two groups was statistically significant (P = 0.03).

Sigmoid resection, whether urgent or elective, is


associated with a relatively high mortality rate (10, 21,
22). In the present study there were two deaths (6%),
one in each R&C and D&P groups. This contrasts with
findings from Africa in which the mortality rate was
higher after colectomy with primary anastomosis than
after colectomy with temporary colostomy followed by
secondary anastomosis in the emergency management
of the colon volvulus (23). The main drawback of detorsion-sigmoidopexy of the sigmoid volvulus is recurrence of the disease. In the present study two (29%) of
the patients treated with detorsion-sigmoidopexy had a
recurrent episode of volvulus during the follow-up period. One of the recurrent volvulus was treated with sigmoidectomy and primary anastomosis and the other
with sigmoidectomy and Hartmanns colostomy.
This study suggests that detorsion and sigmoidopexy
carry a high risk of recurrence of the volvulus and that
the most advisable surgical treatment of the disease is
resection of the redundant sigmoid colon. The continuity of the bowel can be restored safely by primary
colonic anastomosis without increasing the rate of postoperative complications and DHS. This surgical procedure should be attempted in selected patients without
generalized peritonitis from gangrenous or perforation
of the sigmoid colon volvulus. Otherwise resection of
the sigmoid colon with temporary colostomy procedures
is the most convenient alternative surgical procedure in
unsuitable conditions.

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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

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