What is the recommended management for a patient with Caecal volvulus (caecal twisting) who has undergone spontaneous detorsion (untwisting)?

Management of Cecal Volvulus After Spontaneous Detorsion

Exploration and resection is the recommended management for a patient with cecal volvulus who has undergone spontaneous detorsion, as this approach has the lowest recurrence rates and best outcomes for morbidity and mortality. 1, 2

Rationale for Surgical Management

Cecal volvulus represents approximately 30% of all colonic volvulus cases and requires definitive surgical management even after spontaneous detorsion due to:

• High recurrence rates (45-71%) after conservative management 2
• Risk of subsequent ischemia, gangrene, and perforation if recurrence occurs
• Potential for closed-loop obstruction and small bowel ischemia 3

Management Algorithm

1. Initial Assessment

   • Confirm complete detorsion via imaging (CT scan)
   • Assess for signs of bowel compromise (tenderness, peritonitis)
   • Evaluate patient's surgical fitness

2. Definitive Management Options

   • First-line: Resection with primary anastomosis (ileocolic anastomosis)

     • Lowest recurrence rate
     • Recommended by World Journal of Emergency Surgery guidelines 1, 2
     • Mortality and morbidity rates in elective setting are low (0-12%)

   • Second-line: Exploration with fixation (cecopexy)

     • Consider only in high-risk surgical patients
     • Higher recurrence rates (16-48%) compared to resection 1, 2
     • May be performed laparoscopically in select cases 4

   • Not recommended: Observation or conservative management

     • Associated with unacceptably high recurrence rates
     • Detorsion alone results in 18-48% recurrence 1
     • Conservative management should be avoided due to risk of life-threatening complications

Special Considerations

• Timing of Surgery: Perform definitive surgery during the same hospitalization, even after successful spontaneous detorsion 2

• Surgical Approach: Laparoscopic approach may be considered if surgeon expertise allows 2

• Extent of Resection: The entire redundant and mobile cecum should be removed to prevent recurrence

• Comorbidities: In extremely high-risk patients where resection poses prohibitive risk, cecopexy may be considered as a compromise, understanding the higher recurrence risk 5

Pitfalls to Avoid

• Delaying definitive treatment: Even with successful spontaneous detorsion, definitive surgical management should not be delayed or deferred

• Simple detorsion without fixation: This approach has been abandoned due to high recurrence rates

• Discharge without intervention: This would expose the patient to high risk of recurrence with potentially worse outcomes including bowel ischemia and perforation

• Underestimating the risk of recurrence: The mobile cecum that allowed initial volvulus remains a risk factor if not addressed surgically

By following these recommendations, the risk of recurrence and associated complications can be minimized, improving long-term patient outcomes.