What is the best course of treatment for a patient with recurrent volvulus after undergoing a sigmoidectomy (removal of the sigmoid colon)?

Recurrent Volvulus After Sigmoidectomy

For a patient with recurrent volvulus after sigmoidectomy, you must perform subtotal colectomy because the initial sigmoid resection was inadequate—this patient has underlying megacolon that was either missed or inadequately addressed at the first operation. 1

Understanding Why Recurrence Occurred

The critical issue here is that recurrence after sigmoidectomy indicates concomitant megacolon was present but not recognized or treated appropriately during the initial surgery. 1

• Recurrence rates after proper sigmoid colectomy should be minimal when the entire redundant segment is removed 1
• When volvulus recurs after sigmoidectomy, it typically involves the remaining redundant colonic segments (descending colon, transverse colon) that are also dilated and dysfunctional 1, 2
• Studies show that patients with megacolon who undergo sigmoid colectomy alone have an 82% recurrence rate, compared to only 6% in those without megacolon 1
• The overall recurrence rate in one series was 36%, with the major variable being the degree of colonic involvement beyond the sigmoid 1

Definitive Treatment Algorithm

Step 1: Immediate Management of the Acute Episode

• If the patient presents with acute recurrent volvulus without peritonitis or ischemia, attempt endoscopic decompression first 3
• If there are signs of peritonitis, ischemia, or hemodynamic instability, proceed directly to emergency laparotomy 3

Step 2: Surgical Planning During Same Admission

Once decompressed, you must plan for subtotal colectomy during the same hospital admission—do not discharge the patient without definitive surgery. 1, 3

• The World Journal of Emergency Surgery provides a strong recommendation (Grade 1C) that patients with concomitant megacolon and sigmoid volvulus require subtotal colectomy 1
• Sigmoid colectomy alone is explicitly stated as insufficient because volvulus will recur in the remnant segments 1
• In patients with megacolon treated by subtotal colectomy, no recurrences were documented in the available series 1

Step 3: Extent of Resection

Perform subtotal colectomy with ileorectal or ileosigmoid anastomosis (if any viable sigmoid remains). 1

• Remove all redundant and dilated colon—this typically means resection from the terminal ileum to the rectosigmoid junction 1
• Intraoperative findings of dilated colon throughout (not just at the volvulus site) confirm the need for extended resection 1
• A capacious rectum on digital examination preoperatively is a clinical clue that megacolon is present 1

Step 4: Technical Considerations

• The choice between laparotomy and laparoscopy depends on surgeon expertise and the patient's condition 1, 3
• In the elective/semi-elective setting after successful decompression, primary anastomosis can typically be performed safely 3
• Stoma creation is generally not required in the non-emergency setting 1, 3
• If operating emergently on an unstable patient with ischemic bowel, perform Hartmann's procedure rather than primary anastomosis 3

Critical Pitfalls to Avoid

The most dangerous mistake is repeating the same inadequate operation (another sigmoid colectomy). 1

• Do not perform another limited sigmoid resection—this will fail again 1
• Do not consider non-resectional procedures like sigmoidopexy or mesosigmoidoplasty, which have recurrence rates of 16-36% even in first-time volvulus 1
• Do not discharge the patient after endoscopic decompression without surgery—the recurrence rate is 71% and mortality with recurrent gangrenous volvulus is 36-40% 4, 5, 6
• Do not be falsely reassured by the patient's age or comorbidities—even ASA grade 4 patients can undergo successful elective surgery with 0% mortality, compared to 40% mortality with emergency surgery for recurrent gangrenous volvulus 6

Special Consideration: Patients Unfit for Surgery

• Only if the patient has truly prohibitive surgical risk should you consider percutaneous endoscopic colostomy (PEC) for fixation 1
• PEC carries a 10% major complication rate and 37% minor complication rate 1
• This is a temporizing measure, not definitive treatment, and should be reserved for patients who absolutely cannot tolerate subtotal colectomy 1

Evidence Quality Note

The 2023 World Journal of Emergency Surgery consensus guidelines provide the most authoritative and recent guidance on this specific scenario, explicitly stating that subtotal colectomy is required for recurrent volvulus in the setting of megacolon (which is what recurrence after sigmoidectomy indicates). 1 This is supported by older research data showing 82% recurrence with limited resection versus 0% with subtotal colectomy in megacolon patients. 1, 4, 2