What are the indications for sigmoidectomy?

Indications for Sigmoidectomy

Sigmoidectomy is indicated for sigmoid volvulus (both emergently when ischemia/perforation is present and electively after successful endoscopic decompression), complicated diverticular disease (including stricture, fistula, or recurrent episodes in high-risk patients), sigmoid cancer, and recurrent diverticular bleeding. 1, 2

Emergency Indications

Sigmoid Volvulus with Complications

• Proceed directly to urgent sigmoid resection when bowel ischemia, perforation, peritonitis, or septic shock is present on admission (occurs in 5-25% of sigmoid volvulus cases). 1, 2
• Resect infarcted bowel without detorsion and with minimal manipulation to prevent endotoxin, potassium, and bacterial release into circulation. 1, 2
• Emergency surgery carries 12-20% mortality with surgical site infections being the most common complication (42.86%). 2
• Hartmann procedure (end colostomy) is preferred over primary anastomosis in hemodynamically unstable patients, those with non-viable colon, peritonitis, or significant comorbidities. 1, 3

Failed Endoscopic Decompression

• When flexible colonoscopic detorsion is unsuccessful (occurs in 9-24% of attempts), proceed to urgent sigmoid resection. 1, 2
• Abort endoscopy immediately if advanced mucosal ischemia or impending perforation is discovered during the procedure. 1, 2

Elective Indications After Sigmoid Volvulus

Post-Decompression Definitive Surgery

• Perform sigmoid colectomy during the same hospital admission after successful endoscopic decompression—this is critical. 2, 4
• Without resection, recurrence rates reach 45-71% overall (61% at median 31 days, with 63% recurring within 3 months). 2, 4
• Elective sigmoid resection has dramatically lower mortality (5.9%) compared to emergency surgery (40%). 2
• Remove the entire length of redundant sigmoid colon to minimize recurrence risk. 2, 4
• Primary anastomosis without stoma is typically feasible in the non-emergency elective setting. 2, 4

Common pitfall: Discharging patients after successful endoscopic decompression without definitive surgery results in 61% recurrence, with 25% requiring emergent colectomy. 2

Recurrent Volvulus with Megacolon

• When volvulus recurs after prior sigmoidectomy, this indicates unrecognized megacolon—perform subtotal colectomy (not repeat sigmoidectomy). 4
• Sigmoid colectomy alone in patients with megacolon has an 82% recurrence rate. 4
• Subtotal colectomy (terminal ileum to rectosigmoid junction) shows zero recurrence in available series. 4

Diverticular Disease Indications

Absolute Indications

• Sigmoid stricture preventing complete colonoscopy (12.5% harbor occult adenocarcinoma; surgery allows lymph node clearance). 5
• Colovesical or other fistulas from diverticular disease. 2, 6
• Recurrent diverticular bleeding refractory to endoscopic management. 2, 6
• Stenosis with obstructive symptoms. 2, 6

High-Risk Patient Populations

• Patients on immunosuppression therapy, those with chronic renal failure, or collagen-vascular diseases have a 5-fold increased risk (36% vs 7%) of perforation in recurrent episodes. 6
• Elective sigmoidectomy is justified in these high-risk patients after even one conservatively treated episode of diverticulitis. 6

Important nuance: The outdated "two-episode rule" for elective surgery has been abandoned because 80% of patients requiring acute surgery present with complications at their first episode. 6

Relative Indications

• Recurrent attacks of diverticulitis with persistent complaints despite conservative management (accounts for 36% of elective cases). 6
• Persistent abscesses not amenable to percutaneous drainage. 6

Malignancy Indications

Sigmoid Cancer

• Left hemicolectomy is the standard oncologic resection for sigmoid cancer, providing adequate lymph node clearance. 7
• Sigmoidectomy alone may be acceptable only in highly selected cases: residual microscopic cancer after complete endoscopic polypectomy with negative sentinel lymph nodes. 7
• When sigmoid cancer is accidentally associated with sigmoid diverticulitis, extend resection to left hemicolectomy. 7

Procedures to Avoid

• Do not perform sigmoidopexy, mesosigmoidoplasty, or detorsion alone for sigmoid volvulus—these carry 16-36% recurrence rates. 2, 4
• Endoscopic fixation techniques (percutaneous endoscopic colopexy) should be reserved only for patients with truly prohibitive surgical risk, as they carry 10% major complication rates and 37% minor complication rates. 2, 4

Special Populations

Pregnant Patients with Sigmoid Volvulus

• Endoscopic detorsion is preferred initially, though efficacy is limited in the third trimester. 2
• Definitive surgical resection can be safely performed from the second trimester onward. 2
• Maternal mortality is 6-12%; fetal mortality is 20-26%. 2
• Require multidisciplinary care involving surgery, obstetrics, and neonatology. 2

Asymptomatic Redundant Sigmoid

• No prophylactic surgery is indicated for incidentally discovered asymptomatic redundant sigmoid colon. 4
• Expectant management is the standard approach. 4