What is the management and treatment of volvulus?

Management and Treatment of Volvulus

The optimal treatment of volvulus depends on the patient's initial presentation, with endoscopic decompression as first-line treatment for uncomplicated cases and urgent surgery for patients with septic shock, bowel ischemia, or perforation. 1, 2

Initial Assessment and Diagnosis

• Diagnosis should be confirmed through plain abdominal radiographs (first line) looking for the classical "coffee bean sign" and abdominal CT (gold standard) showing dilated colon with air/fluid level and the "whirl sign" 1, 2
• Urgent radiology is critical for diagnosis, with abdominal CT being the gold standard for detecting the "whirl sign" representing twisted colon and mesentery 1
• Sigmoid volvulus is the most common form, followed by cecal volvulus, with different management approaches for each location 3

Treatment Algorithm

For Uncomplicated Volvulus:

• First-line treatment is endoscopic decompression with a success rate of 70-91% and complication rates of 2-4.7% in geriatric patients 1, 2
• Flexible endoscopy is preferred over rigid endoscopy due to superior diagnostic performance and lower perforation rates 1
• After successful decompression, a flatus tube should be left in place to maintain reduction and allow continued colonic decompression 1
• Definitive sigmoid resection should be performed during the same hospital admission to prevent recurrence, as recurrence rates without resection are extremely high (45-71%) 1, 2
• Elective sigmoid resection has significantly lower mortality (5.9%) compared to emergency surgery (40%) 2

For Complicated Volvulus (ischemia, perforation, or failed decompression):

• Immediate surgical intervention is mandatory for patients with septic shock, bowel ischemia, or perforation 1, 2
• Intraoperatively, resection of infarcted bowel should be performed without detorsion and with minimal manipulation to prevent release of endotoxin and bacteria 1
• Surgical options include:
  • Hartmann's procedure (sigmoid resection with end colostomy) - commonly used for non-viable colon or peritonitis 1
  • Sigmoid resection with primary anastomosis - may be appropriate in selected stable patients 1

Special Considerations

• Risk factors for mortality include age over 60 years, presence of shock on admission, and history of previous volvulus episodes 1, 2
• Emergency surgery is associated with significant mortality (12-20%) with surgical site infections being the most common complication (42.86%) 1, 2
• Non-resectional procedures (detorsion, sigmoidoplasty, mesosigmoidoplasty) are inferior to sigmoid colectomy for prevention of recurrent volvulus and should be avoided 1
• After derotation, ischemia-reperfusion injury can aggravate intestinal dysfunction, requiring fluid resuscitation and broad-spectrum antibiotics 1
• Laparoscopic approach may be suitable in select cases when performed by experienced surgeons, though benefits in emergency settings remain unclear 1, 2

Pitfalls and Caveats

• Endoscopic decompression should be aborted if advanced mucosal ischemia, perforation, or impending perforation is discovered during the procedure 1
• Without definitive surgical resection after successful decompression, recurrence rates are extremely high (up to 86%), with each recurrence increasing the risk of complications 4, 5
• In high-risk patients who cannot undergo definitive surgery, percutaneous endoscopic colostomy can be considered as an alternative 1
• The decision between primary anastomosis and end colostomy should consider the patient's hemodynamic stability, presence of peritonitis, and comorbidities 1