Colonic Volvulus

Question 1

Most Common form

Answer 1

Sigmoid volvulus

50% to 90% of all cases.

Question 2

RF

Answer 2

2: 1 male predominance
increasing age
> seventh decade of life or beyond
diet
race
diabetes
pregnancy
constipation/ dysmotility
Institutionalized patients
psychiatric and neurologic disorders

Question 3

Diagnosis relies upon radiographic findings

Answer 3

“bent inner tube” or “omega loop,”

If plain films are nondiagnostic
> Do (CT) > mesenteric whirl and paucity of rectal gas

Question 4

Initial Management in Stable PT

Answer 4

If no evidence of colonic ischemia > fever or peritonitis

• endoscopic detorsion By rigid proctoscope or a flexible endoscope.

Rigid proctoscopy > only in the setting of a lack of access to standard flexible endoscopy
higher risk of perforation and does not visually inspect colonic mucosa.

Question 5

Classic appearance in Scope and What to do

Answer 5

• classic “pinwheel” appearance at the point of torsion
• scope should be passed through the torsed segment.
• Rates of successful endoscopic detorsion 55% to 94%.
• After detorsion, Leave a soft red-rubber catheter in the colon to allow for continued decompression and prevention of a short-term recurrence

Question 6

Recurrence after Endoscopic detorsion sigmoid

Answer 6

85-90%

Question 7

Operations Options

Answer 7

• Current gold standard approach for the prevention of recurrent sigmoid volvulus is sigmoid colon resection with primary anastomosis.

Other Options if severe colonic edema is encountered:
- Resection with end colostomy and Hartmann’s pouch
- primary anastomosis with diverting loop ileostomy

Question 8

When Should the procedure take place ?

Answer 8

Within the index admission

Question 9

specific setting in which recurrence rates remain high after sigmoidectomy

Answer 9

• Megacolon
• Recurrence > greater than 80%
• Consideration may be given to subtotal colectomy.

Question 10

When to Consider Emergency Operation

Answer 10

• Signs of ischemia, perforation, sepsis, or evidence of shock
• Fail attempted endoscopic detorsion.

IV Fluids , Cross Match, Abx , OT

Question 11

Intraop Considerations

Answer 11

• Compromised bowel should not undergo detorsion before resection
• In the setting of perforation, copious irrigation of the abdomen

Question 12

Things to put in Mind intraop that affect your decision

Answer 12

• Proximal bowel dilatation
• fecal contamination
• presence of ongoing hemodynamic abnormalities
• nutritional
• functional
• frailty status

Question 13

Why they do detorsion then Prevention surgery ?

Answer 13

Surgical resection in the emergent setting is associated with higher rates of mortality.

Question 14

Cecal Volvulus

Answer 14

The second most frequent type

10% to 40% of colonic volvulus

Question 15

Types

Answer 15

two types of volvuli that can occur in the cecum.

• The most common > axial twisting of the cecum and accounts for up to 90% of cases.
  cecum rotates around its long axis forming a clockwise twist, leaving the cecum in the right lower quadrant.
• The less common type is not a true volvulus
  folding of the cecum upon itself directed toward the hepatic flexure, known as a bascule.
  Overall this accounts for only 10% of reported cases.

Question 16

RF

Answer 16

mobile cecum
chronic constipation
psychiatric illness
high fiber diet
chronic laxative use
pregnancy
prior abdominal surgeries
female predominance of 1.4: 1.

Question 17

Diagnosis

Answer 17

Plain films > classic “coffee bean” sign pointing to the left upper quadrant
paucity of rectal gas.

CT scan > assessing bowel for ischemia or signs of impending ischemia.
Intestinal thickening
hypoenhancement of the bowel wall
pneumatosis
abdominal free fluid

Question 18

When To go for Emergency Sx

Answer 18

• signs of cecal ischemia, perforation, or shock
• aggressive fluid resuscitation
• administration of broad-spectrum antibiotics
• proceed to the operating room for emergent intervention.

Question 19

What Sx to Do

Answer 19

• ileocolic resection or right hemicolectomy
• Primary anastomosis Depending on :
  hemodynamics
  comorbidities
  fecal contamination
  local inflammatory changes.

Question 20

If patient is Stabe, no Shock, Abdomen Good

Answer 20

• surgical intervention remains urgent in nature.
• endoscopic reduction is not recommend
• 30% success rate and may lead to perforation.

Question 21

Intraop You should do what ?

Answer 21

• assessment of bowel viability
• necrosis of the cecum is a common finding
  > resection with consideration of primary anastomosis.
• If no necrosis > right hemicolectomy or ileocolic resection with a side-to-side stapled anastomosis is typically performed.

Question 22

What about nonresection techniques

Answer 22

• Detorsion with or without cecostomy and cecopexy
• not recommended
• high recurrence rates
• high morbidity and mortality.

Both cecostomy and cecopexy are reserved for patients who are poor resection candidates due to comorbid conditions or physiologic status.

• It is important to assess the quality of the bowel wall
• The fragile or edematous tissue > poor candidate for holding suture > lead to complications > leak and failure of apposition to the abdominal wall or retroperitoneum.

Question 23

Other Types of Volvulus

Answer 23

Transverse colon and splenic flexure volvuli
2% to 5% of all colonic volvulus cases.
occur in a younger patient population
increased incidence in women.

Question 24

Signs on imaging

Answer 24

• Diagnosis is rarely made by using plain films alone.
• Splenic flexure volvulus i> “coffee bean” sign in the left upper quadrant on abdominal x-ray.
• volvulus of the transverse colon can be characterized by an “inverted coffee bean” sign.

Question 25

Treatment of these rare types

Answer 25

No Endoscopy asses Bowel Viability Noncompromised bowel may be detorsed before resection. Options: extended right hemicolectomy segmental resection primary anastomosis Vs End Colostomy

Question 26

Very Rare volvulus

Answer 26

- ileosigmoid knotting Type 1 MC portion of ileum encircles the sigmoid colon. Type 2 wrapping of the sigmoid colon around a loop of ileum. Type 3 ileocecal segment wrapping around the sigmoid colon.

Question 27

Diagnosis

Answer 27

- Diagnosis can be challenging - Dilated loops of small bowel distended sigmoid loop. CT > whirling of the ileal and sigmoid mesentery with associated medial deviation of the cecum and left colon.

Question 28

Can be confused with Sigmoid volvulus

Answer 28

- Ileosigmoid knotting may be confused for sigmoid volvulus on imaging prompting attempted endoscopic decompression - In these cases, endoscopic decompression will fail due to the wrapping of the mesentery, further raising the suspicion for ileosigmoid knotting.