How should I manage an adult patient with acute sigmoid volvulus who is hemodynamically stable and shows no signs of peritonitis, perforation, or ischemia?

Management of Acute Sigmoid Volvulus in Hemodynamically Stable Patients

For a hemodynamically stable adult patient with acute sigmoid volvulus showing no signs of peritonitis, perforation, or ischemia, perform immediate endoscopic decompression followed by mandatory definitive sigmoid resection during the same hospital admission. 1, 2

Initial Endoscopic Decompression

• Endoscopic decompression is the first-line treatment for uncomplicated sigmoid volvulus, with success rates of 70-91% and low complication rates of 2-4.7%. 1, 2
• This approach is appropriate specifically because your patient is hemodynamically stable and lacks peritoneal signs, ischemia, or perforation. 1
• The procedure should be performed immediately upon diagnosis confirmation to relieve obstruction and prevent progression to ischemia. 2

Mandatory Definitive Surgery During Same Admission

After successful endoscopic decompression, you must proceed with elective sigmoid resection during the same hospitalization—this is not optional. 1, 2

Why Surgery Cannot Be Deferred:

• Without resection, recurrence rates are extremely high at 45-71%, and each recurrence increases the risk of ischemia, perforation, and mortality. 1, 2
• Elective sigmoid resection has significantly lower mortality (5.9%) compared to emergency surgery performed for recurrent volvulus (40%). 1
• The only exception to mandatory resection is patients with prohibitive surgical risk, in whom endoscopic therapy alone may be considered. 2

Surgical Approach for Your Stable Patient

• Sigmoid resection with primary anastomosis is the appropriate definitive operative option for hemodynamically stable patients without peritonitis, offering bowel continuity while avoiding a stoma. 1
• For benign conditions like sigmoid volvulus, a full oncological anterior resection with high ligation is not needed; the main consideration is ensuring adequate vascular supply to the remnant colon. 1
• Laparoscopic approach may be suitable if performed by experienced surgeons, though benefits in the emergency setting remain unclear compared to open approach. 1

Critical Pitfall to Avoid

The most common management error is performing successful endoscopic decompression and then discharging the patient without definitive surgery. This approach virtually guarantees recurrence with potentially catastrophic consequences. 1, 2 The patient must undergo sigmoid resection before hospital discharge, even though they are currently stable and decompressed. 1, 2

Risk Stratification for Your Patient

Monitor closely for factors associated with increased mortality, including:

• Age over 60 years 1, 2
• Development of shock 1, 2
• History of previous volvulus episodes 1

Post-Decompression Monitoring

• Watch for ischemia-reperfusion injury after derotation, which can aggravate intestinal dysfunction and requires careful monitoring and supportive care. 1
• Absence of peritoneal signs does not rule out bowel ischemia, so maintain vigilance during the interval between decompression and definitive surgery. 3