Why would we choose reduction and sigmoidopexy of a redundant sigmoid volvulus instead of sigmoid resection in an elderly, high‑risk patient with viable bowel and significant comorbidities?

Why Reduction and Sigmoidopexy Was Chosen Over Resection

You likely chose reduction and sigmoidopexy instead of sigmoid resection because the patient was elderly with significant comorbidities making operative resection prohibitively high-risk, and the bowel was viable without signs of ischemia or perforation. 1

Primary Justification: Prohibitive Surgical Risk

The 2023 World Journal of Emergency Surgery guidelines explicitly state that non-resectional techniques like sigmoidopexy are reserved for patients in whom operative interventions present prohibitive risk (Grade 2C recommendation). 1 This applies specifically to:

• Elderly patients (often >80 years) who are unfit for major abdominal operations 1
• Patients with severe comorbidities that increase surgical mortality beyond acceptable levels 2
• High American Society of Anesthesiologists (ASA) physical status classification ≥3 or severely debilitated patients 3

Clinical Context Supporting Your Decision

Viable Bowel Status

• The bowel must be viable without signs of ischemia, necrosis, or perforation to justify non-resectional approach 1
• If peritonitis, ischemic bowel, or hemodynamic instability were present, emergency resection would be mandatory regardless of risk 1, 4

Immediate Mortality vs. Recurrence Risk Trade-off

• Emergency sigmoid resection carries 12-36% mortality in high-risk elderly patients 1
• Sigmoidopexy has lower immediate operative mortality but accepts a 29-36% recurrence rate 1
• In prohibitively high-risk patients, surviving the immediate episode takes priority over preventing future recurrence 1

Critical Caveats and Expected Outcomes

Recurrence Rates You Must Counsel About

• Sigmoidopexy has 29-36% recurrence rate compared to <6% after proper resection 1
• Mesosigmoidoplasty shows variable results: some series report only 2/126 recurrences, while others show 16-21% recurrence 1
• Simple detorsion alone is now discouraged due to 18-48% recurrence rate and 11-15% mortality 1

When This Decision Becomes Wrong

If the patient has concomitant megacolon, sigmoidopexy is insufficient and will result in 82% recurrence rate—these patients require subtotal colectomy even if high-risk. 1, 4 Intraoperative findings of dilated colon throughout (not just at the volvulus site) should have prompted more extensive resection. 1, 4

Alternative Minimally Invasive Options

If the patient was truly inoperable, percutaneous endoscopic colostomy (PEC) fixation could have been considered instead of open sigmoidopexy:

• PEC carries 10% major complication rate (peritonitis, tube migration, death) and 37% minor complication rate 1
• Colonoscopy-assisted sigmoidopexy using T-fasteners or anchor devices shows promising results in small series with no recurrence at 12-month follow-up 5, 3
• These endoscopic techniques avoid general anesthesia and laparotomy entirely 6, 5, 3

Post-Operative Surveillance Required

Close follow-up is mandatory because:

• Nearly half of recurrences occur within 3 months 4
• The patient should be counseled that if volvulus recurs and their medical condition improves, definitive sigmoid resection should be reconsidered 1, 4
• If megacolon is later identified, subtotal colectomy becomes necessary to prevent ongoing recurrences 1, 4

Bottom Line

Your decision was justified only if the patient's operative risk from sigmoid resection exceeded the combined risks of sigmoidopexy plus future recurrence. The 2023 guidelines support this approach as a weak recommendation (Grade 2C) based on low-quality evidence, acknowledging it as a compromise for patients who cannot tolerate standard resection. 1 However, this is explicitly a second-line strategy—sigmoid resection remains the gold standard whenever physiologically tolerable. 1, 4