What is the treatment for volvulus?

Treatment of Volvulus

For volvulus, the optimal treatment is endoscopic detorsion as first-line management for uncomplicated cases, followed by definitive sigmoid resection during the same admission to prevent recurrence. 1

Initial Management Based on Volvulus Type

Sigmoid Volvulus

• First-line treatment: Endoscopic detorsion/decompression

  • Success rates: 70-91% for initial decompression 1
  • Low complication rates: 2-4.7% 1
  • Contraindicated in cases of suspected bowel ischemia, perforation, or peritonitis

• Urgent surgical intervention is required when:

  • Endoscopic detorsion fails
  • Signs of bowel ischemia, perforation, or peritonitis are present
  • Patient presents with shock 2

Cecal Volvulus

• Endoscopy has no role in cecal volvulus
• Right hemicolectomy is the only treatment option 2

Definitive Management

For Sigmoid Volvulus

• After successful endoscopic decompression:

  • Sigmoid colectomy with primary anastomosis should be performed during the same admission 2, 1
  • Delaying definitive surgery leads to high recurrence rates (45-71%) 2

• Surgical options:

  1. Sigmoid resection with primary anastomosis (preferred for stable patients)
  2. Hartmann procedure (sigmoid resection with end colostomy) for:
     • Hemodynamically unstable patients
     • Patients with significant comorbidities
     • Cases with peritonitis or bowel perforation 2

Special Considerations

• For patients with megacolon: Subtotal colectomy is recommended rather than limited sigmoid resection (recurrence rates: 82% with limited resection vs. 0% with subtotal colectomy) 1

• For high-risk patients unfit for surgery: Percutaneous endoscopic colostomy (PEC) may be considered, though complications occur in up to 47% of cases 1

Surgical Approach

• Open surgery is most common for emergency cases
• Laparoscopic approach may be suitable in select cases by experienced surgeons, though evidence shows:
  • Potentially higher anastomotic leak rates
  • Similar overall postoperative morbidity 2
  • Limited role due to technical challenges with the redundant sigmoid colon 2

Outcomes and Prognosis

• Mortality rates:

  • Emergency surgery: 17.6-24% 3, 4
  • Elective surgery: 0-6% 3, 4
  • Conservative management alone: 12% during index admission 4

• Recurrence rates:

  • After endoscopic management alone: 57-61% 1, 5
  • After definitive surgical management: Significantly lower

Common Pitfalls to Avoid

1. Delaying diagnosis - increases risk of ischemia, necrosis, and mortality 1
2. Overreliance on conservative management without definitive surgery - leads to high recurrence rates 1
3. Attempting endoscopic decompression in cecal volvulus - ineffective and wastes valuable time 2
4. Inadequate extent of resection in patients with megacolon - results in high recurrence rates 1
5. Manipulating or detorsing ischemic/necrotic bowel - can release endotoxins and bacteria into circulation 2

The treatment algorithm should be guided by the patient's clinical condition, the location of the volvulus, and the presence of complications such as ischemia or perforation. Prompt diagnosis and appropriate management are essential to reduce morbidity and mortality.