Management of Acute Sigmoid Volvulus
For acute sigmoid volvulus without signs of ischemia, perforation, or septic shock, perform immediate endoscopic decompression followed by mandatory definitive sigmoid resection during the same hospital admission. 1, 2
Initial Assessment and Risk Stratification
The critical first step is determining whether the patient requires immediate surgery or can undergo endoscopic decompression:
Signs Requiring Immediate Surgical Intervention:
- Septic shock on presentation 3, 1
- Clinical signs of bowel ischemia or perforation 3, 1
- Peritonitis on examination 3
Common pitfall: Absence of peritoneal signs does NOT rule out bowel ischemia—maintain high clinical suspicion. 4
Diagnostic Confirmation:
- Plain abdominal radiographs first-line: look for the "coffee bean sign" 3, 1
- Abdominal CT is the gold standard: reveals dilated colon with air/fluid level and the "whirl sign" (twisted colon and mesentery) 3, 1
Treatment Algorithm for Uncomplicated Cases
Step 1: Endoscopic Decompression
- Success rate: 70-91% 1, 2
- Complication rate: 2-4.7% 1
- This is first-line treatment for hemodynamically stable patients without peritonitis 1, 2
Step 2: Definitive Surgery During Same Admission
This is mandatory—do not discharge the patient after successful decompression alone. 1, 2
The evidence strongly supports this approach:
- Recurrence rate without surgery: 45-71% 1, 2, 4
- Elective surgery mortality: 5.9% 1
- Emergency surgery mortality: 12-40% 1, 5, 6
- Each recurrence increases risk of ischemia, perforation, and death 2
Research data reinforces this: one study showed 71.4% recurrence after decompression alone, with 36.4% mortality in the non-operative group vs. 6% mortality in the surgical group. 6 Another series demonstrated 60.9% recurrence rate and 17.6% emergency surgery mortality. 5
Exception to Mandatory Surgery:
Exclusively endoscopic therapy without subsequent surgery should only be reserved for patients with prohibitive surgical risk—meaning those who absolutely cannot tolerate any operation. 2 Even ASA grade 4 patients can undergo successful elective surgery with zero mortality in some series. 6
Surgical Management for Emergency Cases
When immediate surgery is required:
Surgical Options:
- Hartmann's procedure (sigmoid resection with end colostomy): preferred for hemodynamically unstable patients or those with significant comorbidities 1
- Sigmoid resection with primary anastomosis: can be performed in stable patients 3, 1
Technical Considerations:
- For infarcted bowel: resect WITHOUT detorsion and with minimal manipulation to prevent release of endotoxin, potassium, and bacteria 1
- Full oncological high ligation is NOT needed for benign sigmoid volvulus—ensure adequate vascular supply to remnant colon 1
- Emergency surgery mortality: 12-20% with surgical site infections being most common complication (42.86%) 1
Laparoscopic Approach:
May be suitable in select cases when performed by experienced surgeons, but benefits in emergency setting remain unclear compared to open approach. 1
Risk Factors for Mortality
Patients at highest risk requiring intensive monitoring:
- Age over 60 years 1, 2
- Shock on admission 1, 2
- History of previous volvulus episodes 1, 2
- Gangrenous bowel at presentation 6, 7
The presence of gangrenous bowel increases mortality to 11%. 7
Special Population: Pregnancy
For pregnant patients with sigmoid volvulus:
- Endoscopic detorsion is recommended but may be ineffective in third trimester due to uterine volume 3
- Multidisciplinary strategy depends on gestational age and fetal prognosis 3
- Definitive surgery can be performed from second trimester onward without significant fetal impact 3
- Maternal mortality: 6-12%; fetal mortality: 20-26% 3
Post-Decompression Monitoring
After successful endoscopic decompression, monitor for: