What are the indications for not performing a sigmoid resection in a patient with sigmoid volvulus?

Indications for NOT Resecting the Sigmoid Colon

Do not perform sigmoid resection only in patients with prohibitive surgical risk who cannot tolerate any operation, or in truly asymptomatic patients with incidentally discovered redundant sigmoid colon. 1

Absolute Contraindications to Sigmoid Resection

Prohibitive Surgical Risk

• Patients who are medically unfit for any surgical intervention represent the only true contraindication to sigmoid resection after sigmoid volvulus. 1
• In this highly select population, consider percutaneous endoscopic colostomy (PEC) for fixation, though this carries a 10% major complication rate and 37% minor complication rate. 1
• Even this alternative should be viewed as suboptimal—PEC is reserved only for patients who absolutely cannot tolerate any form of colectomy. 1

Asymptomatic Redundant Sigmoid Colon

• When colonic redundancy is discovered incidentally and remains completely asymptomatic, expectant management is appropriate with no prophylactic surgery indicated. 1
• This applies only to patients who have never experienced volvulus or related symptoms. 1

Critical Pitfall: Avoiding the "High-Risk" Label

The most dangerous clinical error is assuming elderly or comorbid patients are "too sick" for surgery after their first episode of sigmoid volvulus. The evidence strongly contradicts this assumption:

• In one series, 8 of 15 operatively managed patients were ASA grade 4, with zero postoperative mortality in this high-risk subgroup. 2
• Elective sigmoid resection carries only 0-12% morbidity and mortality. 1
• Mortality after conservative treatment alone ranges from 9-36%, with one series reporting 36.4% mortality in patients managed with colonoscopic decompression only. 1, 2
• Patients treated conservatively have significantly poorer long-term survival compared to those treated surgically (P = 0.036). 3

The Recurrence Argument Against Conservative Management

Recurrence rates after endoscopic decompression without resection are unacceptably high:

• Overall recurrence rate: 45-71% 1, 4
• 63% recur within just 3 months 1
• 71.4% recurrence rate in one surgical series 2
• In patients discharged after successful decompression without surgery, 61% experience recurrence at a median of 31 days, with 25% requiring emergent colectomy 4

Each recurrent episode carries escalating risk:

• All six deaths in one series occurred in patients with established gangrenous bowel 2
• Emergency surgery for recurrent volvulus carries 12-20% mortality compared to 5.9% for elective resection 4
• Maternal mortality in pregnant patients ranges from 6-12%, with fetal mortality of 20-26% 4

When Emergency Surgery Is Mandatory (Not a Contraindication)

These presentations require immediate sigmoid resection, not avoidance of surgery:

• Septic shock 4
• Clinical evidence of bowel ischemia or perforation 4
• Peritonitis 1, 4
• Hemodynamic instability 1

In unstable patients, perform Hartmann's procedure rather than primary anastomosis due to coagulopathy, acidosis, and hemodynamic compromise. 1 Emergency resection without anastomosis remains appropriate even when primary anastomosis is contraindicated. 5

Special Consideration: Concomitant Megacolon

• If megacolon is present alongside sigmoid volvulus, sigmoid resection alone is insufficient and contraindicated—these patients require subtotal colectomy. 1
• Recurrence rate is 82% when sigmoid colectomy alone is performed in patients with megacolon. 1
• This is not a contraindication to resection but rather an indication for more extensive resection. 1

Algorithm for Decision-Making

1. Is the redundant sigmoid completely asymptomatic and incidentally discovered?

   • Yes → No surgery indicated 1
   • No → Proceed to step 2

2. Has the patient experienced sigmoid volvulus (even once)?

   • Yes → Sigmoid resection is indicated during the same admission after endoscopic decompression 1, 4
   • No → Proceed to step 3

3. Can the patient tolerate ANY surgical procedure under general anesthesia?

   • Yes → Sigmoid resection is indicated (even ASA 4 patients tolerate elective resection well) 2
   • No → Consider PEC as last resort 1

The only patients who should not undergo sigmoid resection are those who have never had symptoms and those with truly prohibitive surgical risk who cannot survive any operation. All others benefit from definitive surgical management. 1, 2, 3