What is the management of cecal volvulus?

Management of Cecal Volvulus

Right hemicolectomy is the definitive treatment for cecal volvulus as endoscopic approaches have no role and surgery is the only viable option for this condition. 1

Diagnosis

• Cecal volvulus accounts for approximately 30% of all colonic volvulus cases and presents as an axial twist of the cecum, ascending colon, and terminal ileum around the mesenteric pedicle 2, 3
• Diagnosis should be confirmed through:
  • Plain abdominal radiographs as first-line imaging, which may show dilated gas-filled segment of the colon 1, 2
  • Abdominal CT scan (gold standard) showing the characteristic "whirl sign" representing twisted colon and mesentery 1
• Predisposing factors include chronic constipation, high-fiber diet, frequent use of laxatives, and dolicho-colon (elongated colon on a narrow mesenteric base) 1

Treatment Algorithm

Emergency Presentation

• For patients with septic shock, bowel ischemia, or perforation, immediate surgical intervention is mandatory 1, 2
• Unlike sigmoid volvulus, endoscopic decompression has no role in cecal volvulus management 1
• Surgical options include:
  • Right hemicolectomy (definitive treatment) with primary anastomosis when bowel is viable 1, 2
  • Right hemicolectomy with end ileostomy in cases of perforation or significant bowel compromise 2

Surgical Considerations

• Delay in diagnosis and treatment can lead to intestinal necrosis or perforation, with mortality rates ranging from 10-40% depending on bowel viability 2
• Simple detorsion without resection may be considered in high-risk patients without gangrene, but has high recurrence rates 4
• Cecopexy (fixation of the cecum to the abdominal wall) may be considered in select cases, particularly in high-risk patients, but right hemicolectomy remains the preferred definitive treatment 5
• Laparoscopic approach may be suitable in select cases when performed by surgeons experienced with the technique 5

Pitfalls and Caveats

• Due to the rarity of cecal volvulus (responsible for only 1-1.5% of all intestinal obstructions in adults), it is often not considered in the differential diagnosis, leading to delays in treatment 2, 6
• The clinical presentation can be highly variable, further complicating timely diagnosis 2
• Despite advances in medical imaging, preoperative diagnosis remains challenging, with many cases diagnosed only at laparotomy 2
• Mortality is significantly increased with delayed diagnosis and intervention, particularly in elderly patients 2
• Ischemia-reperfusion injury after detorsion can aggravate intestinal dysfunction, requiring careful monitoring and supportive care 7