What is the management of sigmoid volvulus?

Management of Sigmoid Volvulus

For sigmoid volvulus management, the initial treatment should be urgent endoscopic decompression in uncomplicated cases, followed by definitive sigmoid resection during the same hospital admission to prevent recurrence and improve quality of life. 1

Initial Assessment and Diagnosis

• Sigmoid volvulus typically presents with symptoms ranging from non-specific abdominal pain to acute abdomen, predominantly affecting elderly patients (mean age 56-77 years) 1
• Diagnosis should be confirmed through:
  • Plain abdominal radiographs (first line) looking for the classical "coffee bean sign" 1
  • Abdominal CT (gold standard) showing dilated colon with air/fluid level and the "whirl sign" representing twisted colon and mesentery 1

Treatment Algorithm

For Patients with Septic Shock, Bowel Ischemia, or Perforation:

• Immediate surgical intervention is mandatory 1
• Surgical options include:
  • Resection with Hartmann's procedure (end colostomy) - preferred in hemodynamically unstable patients 1
  • Sigmoid resection with primary anastomosis - can be considered in stable patients with minimal contamination 1
• Avoid detorsion of gangrenous bowel intraoperatively to prevent release of endotoxins, potassium, and bacteria 1
• Mortality rate for emergency surgery is significant (12-20%) with surgical site infections being the most common complication (42.86%) 1

For Uncomplicated Sigmoid Volvulus:

1. First-line treatment: Endoscopic decompression 1

   • Success rate of 70-91% with complication rates of 2-4.7% in geriatric patients 1
   • Colonoscopic derotation converts an emergency into an elective procedure 1, 2
   • Post-decompression management should include:
     • Immediate fluid resuscitation 1
     • Broad-spectrum antibiotics to control bacterial translocation 1

2. After successful decompression:

   • Definitive sigmoid resection should be performed during the same hospital admission 1
   • Without resection, recurrence rates are extremely high (45-71%) 1, 3
   • Elective sigmoid resection has significantly lower mortality (5.9%) compared to emergency surgery (40%) 4

3. For high-risk patients unsuitable for definitive surgery:

   • Endoscopic fixation of the colon (percutaneous endoscopic colostomy) can be considered 1
   • However, recurrence remains a significant risk with non-operative management 5

Special Considerations

• Risk factors for mortality that require special attention:

  • Age over 60 years 1
  • Presence of shock on admission 1
  • History of previous volvulus episodes 1

• Laparoscopic approach:

  • Benefits in emergency setting remain unclear compared to open approach 1
  • May be suitable in select cases when performed by surgeons experienced with the technique 1

Pitfalls and Caveats

• Delay in treatment can lead to bowel ischemia, perforation, and significantly increased mortality 1, 6
• Recurrence after non-operative management alone is extremely high (>60%), emphasizing the need for definitive surgery 3, 5
• Endoscopic decompression should not be attempted if peritonitis or perforation is suspected 2
• Ischemia-reperfusion injury after derotation can aggravate intestinal dysfunction, requiring careful monitoring and supportive care 1