Management of Acute Large Bowel Obstruction Due to Sigmoid Volvulus After Failed Sigmoidoscopy
Laparoscopic anterior resection of the rectum is not the indicated procedure for acute large bowel obstruction due to sigmoid volvulus after failed sigmoidoscopy one month ago. Instead, sigmoid colectomy (not anterior resection) should be performed as definitive treatment to prevent recurrence.
Optimal Management Approach
Initial Assessment
- Evaluate for signs of intestinal ischemia, perforation, or peritonitis which would require immediate surgery
- Review previous sigmoidoscopy findings and reason for failure
- Assess patient's overall clinical condition and comorbidities
Treatment Algorithm
For patients without signs of ischemia/perforation:
- Attempt endoscopic decompression with flexible colonoscopy (not rigid sigmoidoscopy)
- Success rate of endoscopic decompression: 60-95% 1
- Leave decompression tube in place after successful detorsion
If endoscopic decompression is successful:
- Proceed with definitive sigmoid colectomy during the same admission
- High recurrence rate (43-75%) without definitive surgery 1
If endoscopic decompression fails or ischemia/perforation is present:
- Urgent sigmoid resection is indicated 1
Surgical Options
Preferred approach:
- Sigmoid colectomy with primary anastomosis (not anterior resection)
- The entire redundant sigmoid colon should be removed 1
Alternative approaches based on patient condition:
- Hartmann procedure (sigmoid resection with end colostomy) for unstable patients or those with peritonitis
- Laparoscopic approach can be considered in select cases by experienced surgeons
Evidence Analysis
The guidelines clearly state that "the role of laparoscopic surgery for volvulus is limited: the absence of fixation of the sigmoid colon and its excessive length often make laparoscopic exposure and dissection difficult" 1. This challenges the appropriateness of laparoscopic anterior resection in this case.
Importantly, anterior resection of the rectum is not the appropriate procedure for sigmoid volvulus. The 2023 WSES guidelines specifically recommend sigmoid colectomy as the definitive treatment 1. Anterior resection would unnecessarily remove rectal tissue when the pathology is limited to the sigmoid colon.
Recent evidence shows a high recurrence rate following non-operative management of acute sigmoid volvulus, with cumulative increase in morbidity and mortality with subsequent episodes 2. After failed sigmoidoscopy one month ago, the patient is at high risk for recurrence and complications.
Important Considerations
- Timing: Definitive surgery should be performed as early as possible, even during the index admission 1
- Extent of resection: The entire redundant sigmoid colon should be removed, but a full oncological anterior resection is not typically needed for this benign pathology 1
- Non-resectional procedures (detorsion, sigmoidopexy, mesosigmoidoplasty) are inferior to sigmoid colectomy and should be avoided 1
- Recurrence risk: Without definitive surgery, recurrence rates are 43-75% 1, with each recurrence carrying increased risk of ischemia or perforation
Pitfalls to Avoid
- Delaying definitive treatment: Recurrence after endoscopic decompression alone is up to 86% 3
- Choosing anterior resection: This removes more tissue than necessary and is not the standard procedure for sigmoid volvulus
- Relying on non-resectional procedures: These have higher recurrence rates compared to sigmoid colectomy
- Underestimating recurrence risk: Each recurrent episode increases the risk of complications including ischemia and perforation
In conclusion, the patient should undergo sigmoid colectomy rather than laparoscopic anterior resection of the rectum, as this is the established definitive treatment for sigmoid volvulus with the lowest recurrence rate and best outcomes for morbidity and mortality.