SURGERY FOR VOLVULUS Who and When? Mr Graham Williams Consultant Colorectal Surgeon Wolverhampton

SIGMOID VOLVULUS Worldwide Incidence % of all intestinal obstruction Ballantyne Dis Colon Rectum 1982

SIGMOID VOLVULUS Average Age at Presentation Age in years Ballantyne Dis Colon Rectum 1982

SITE OF VOLVULUS Ceacal 33% Transverse 3% Splenic Flexure 1% Sigmoid 63%

CAUSES OF VOLVULUS Chronic constipation Neuropsychotropic drugs Elderly population (care homes) Pregnancy High fibre diets Chagas disease

VOLVULUS Diagnosis Sudden onset abdominal pain Previous history Distended, resonant abdomen – NB Tenderness and guarding Plain X-ray – Contrast study

SIGMOID VOLVULUS Simple or complicated Underlying diagnosis Acute management Subsequent management Resect or fix Issues to consider:

SIGMOID VOLVULUS 10% at presentation Increasing pain Tachycardia Tenderness with guarding Gas in wall on x-ray Free gas Colonic Infarction:

Viable bowelEmergencyGangrenousElective % % African series SIGMOID VOLVULUS Mortality Rates Western series Madiba & Thomson J Roy Coll Surg Edinb 2000

SIGMOID VOLVULUS Immediate resuscitation Emergency laparotomy Resection of infarcted segment Ends out! Colonic Infarction:

TREATMENT OF SIGMOID VOLVULUS Endoscopic decompression – Rigid ∑ + flatus tube – Flexible sigmoidoscopy – Colonoscopy Initial Management

SIGMOIDOSCOPIC DECOMPRESSION 1 st Described by Bruusgard 1947 Successful in 70-90% of cases Beware megacolon and pseudobstruction Correct position of patient Apron + incopads! Well lubricated tube with side holes Attach bag to tube first Flush tube Recurrence rate >80%

TREATMENT OF SIGMOID VOLVULUS Endoscopic decompression – Rigid ∑ + flatus tube – Flexible sigmoidoscopy – Colonoscopy Laparotomy and Pexy Laparotomy and resection – Colostomy – Primary anastomosis Percutaneous Endoscopic Colostomy Mesosigmoidoplasty Laparoscopic resection Initial Management Definitive Management

Age of patient – Chronological & biological Physical state Co-morbidity Mental state Social circumstances TREATMENT OF SIGMOID VOLVULUS Factors to be considered in decision making:

Local Resection

Pexy (fixation)

Resection Colopexy MortalityRecurrence % % Welch & Anderson 1987Bagarini et al 1993 SIGMOID VOLVULUS Resection vs Colopexy

MEGACOLON & VOLVULUVS

Normal CaliberMegacolon Number SIGMOID VOLVULUS Influence of Megacolon on Recurrence Recurrent volvulus Chung et al Br J Surg

Extended left hemi colectomy Subtotal colectomy – Ileostomy – Ileo-rectal anastomosis – Caecorectal anastomosis SURGERY FOR SIGMOID VOLVULUS Options in presence of megacolon:

1 st Described 1993 Daniels et al 2000, Br.J.Surg – 14 patients, years old – Two point fixation – Mean follow up 12 months – Recurrence in 3/8 after early removal – No recurerence in 5 where tube left in SIGMOID VOLVULUS Percutaneous Endoscopic Colostomy

Mesosigmoidoplasty for Volvulus Broadens attachment of mesentery No anastomosis Difficult to perform with oedematous or thickened mesentery Subrahmanyam (1992) Br J Surg – 126 patients (60% emergency) – 1 death – 2 recurrences

Involves caecum and ascending colon May resolve spontaneously High index of suspicion Laparotomy required Resection +/- stomas Caecopexy Caecostomy CAECAL VOLVULUS

SIGMOID VOLVULUS Simple? Infarction Successful Urgent Laparotomy ∑ decompression ? Infarction Colonoscopy Unsuccessful Dead ColonViable Fixation Pex, Lap, PEC Elective Resection Resection Stoma / Anastomosis