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

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

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

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

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

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

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

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

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

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

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

17. 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%

20. 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

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

22. Local Resection

23. Pexy (fixation)

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

25. MEGACOLON & VOLVULUVS

26. Normal CaliberMegacolon Number SIGMOID VOLVULUS Influence of Megacolon on Recurrence 15 10 Recurrent volvulus Chung et al Br J Surg 1999 2 5

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

31. 1 st Described 1993 Daniels et al 2000, Br.J.Surg – 14 patients, 53-99 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

32. 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

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

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