What is the management of sigmoid volvulus?

Management of Sigmoid Volvulus

The definitive management of sigmoid volvulus involves initial endoscopic decompression followed by elective sigmoid resection during the same hospital admission to prevent recurrence, unless signs of peritonitis, bowel ischemia, or perforation are present, which require immediate surgical intervention. 1

Initial Assessment and Diagnosis

• Sigmoid volvulus typically presents with the classic triad of abdominal pain, constipation, and abdominal distension, with vomiting appearing as a late sign 2
• Physical examination often reveals pronounced asymmetric abdominal distension, diminished bowel sounds, and an empty rectum on digital examination 2
• Diagnosis should be confirmed through plain abdominal radiographs (first line) looking for the "coffee bean sign" and abdominal CT (gold standard) showing the "whirl sign" representing twisted colon and mesentery 1
• Warning signs of complications include peritonitis or shock, suggesting colonic necrosis or perforation, though absence of peritoneal signs does not rule out bowel ischemia 2

Treatment Algorithm

For Uncomplicated Sigmoid Volvulus:

1. Initial Management:

   • Endoscopic decompression via sigmoidoscopy with rectal tube placement is the first-line treatment with success rates of 70-91% 1, 3
   • This approach has shown an overall efficacy of 87.5% in successfully reducing the volvulus 4
   • The rectal tube should be left in place after successful decompression to prevent immediate recurrence 5

2. Definitive Management:

   • After successful decompression, definitive sigmoid resection should be performed during the same hospital admission 1
   • Elective sigmoid resection has significantly lower mortality (5.9%) compared to emergency surgery (40%) 1
   • Without definitive surgical management, recurrence rates are extremely high (45-71%) 1, 2

For Complicated Sigmoid Volvulus:

• Immediate surgical intervention is mandatory for patients with:

  • Septic shock
  • Bowel ischemia
  • Perforation 1

• Surgical options include:

  • Resection with Hartmann's procedure (34.3% of emergency cases in one study) 5
  • Sigmoid resection with primary anastomosis (29.1% of cases) 5
  • Laparotomy with detorsion (27.01% of cases) 5
  • Mikulicz procedure (6.6% of cases) 5

Outcomes and Prognosis

• Mortality rate for emergency surgery is significant (12-20%) with surgical site infections being the most common complication (42.86%) 1
• Risk factors for mortality include age over 60 years, presence of shock on admission, and history of previous volvulus episodes 1
• In one study, the overall mortality rate was 9.8%, highlighting the serious nature of this condition 5
• Recurrence after successful endoscopic decompression without definitive surgery is reported in approximately 57% of cases 4

Special Considerations

• Laparoscopic approach may be suitable in select cases when performed by experienced surgeons, though benefits in emergency settings remain unclear compared to open approach 1
• Elderly and institutionalized individuals taking psychotropic medications that cause chronic constipation are at higher risk in Western countries 2
• Ischemia-reperfusion injury after derotation can aggravate intestinal dysfunction, requiring careful monitoring and supportive care 1
• While sigmoid volvulus is rare in children, the management principles remain similar, with endoscopic decompression followed by elective surgery 6