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Frederick Salmon MRCS 1796 - 1868

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					SURGERY FOR VOLVULUS
    Who and When?
      Mr Graham Williams
  Consultant Colorectal Surgeon
         Wolverhampton
                SIGMOID VOLVULUS
                 Worldwide Incidence

      UK                       % of all intestinal obstruction
     USA
   Africa

     Iran

  Russia

    India
   Brazil

 Pakistan

            0     5       10        15       20       25         30
Ballantyne Dis Colon Rectum 1982
                   SIGMOID VOLVULUS
                 Average Age at Presentation

      UK

     USA
   Africa

     Iran

    Israel

    India
   Brazil

 Pakistan                                    Age in years

             0         20          40   60             80
Ballantyne Dis Colon Rectum 1982
  SITE OF VOLVULUS
                          Splenic
                          Flexure
         Transverse         1%
             3%




Ceacal
 33%
                      Sigmoid
                        63%
CAUSES OF VOLVULUS
•Chronic constipation
•Neuropsychotropic drugs
•Elderly population (care
 homes)
•Pregnancy
• High fibre diets
• Chagas disease
         VOLVULUS
          Diagnosis
• Sudden onset abdominal pain
• Previous history
• Distended, resonant abdomen
  –NB Tenderness and guarding
• Plain X-ray
  –Contrast study
    SIGMOID VOLVULUS
Issues to consider:
  •Simple or complicated
  •Underlying diagnosis
  •Acute management
  •Subsequent management
  •Resect or fix
   SIGMOID VOLVULUS
Colonic Infarction:
  •10% at presentation
  •Increasing pain
  •Tachycardia
  •Tenderness with guarding
  •Gas in wall on x-ray
  • Free gas
               SIGMOID VOLVULUS
                  Mortality Rates
                  African series                                   Western series
   70                                             40
%                                             %
   60                                             35

                                                  30
   50
                                                  25
   40
                                                  20
   30
                                                  15
   20
                                                  10
   10                                              5

    0                                              0
         Viable bowel       Gangrenous                 Emergency   Elective

Madiba & Thomson J Roy Coll Surg Edinb 2000
   SIGMOID VOLVULUS
Colonic Infarction:
  •Immediate resuscitation
  •Emergency laparotomy
  •Resection of infarcted
   segment
  •Ends out!
     TREATMENT OF SIGMOID
          VOLVULUS
Initial Management
         • Endoscopic decompression
         –Rigid ∑ + flatus tube
         –Flexible sigmoidoscopy
         –Colonoscopy
        SIGMOIDOSCOPIC
        DECOMPRESSION
• 1st Described by Bruusgard 1947
• Successful in 70-90% of cases
• Beware megacolon and pseudobstruction
• Correct position of patient
• Apron + incopads!
• Well lubricated tube with side holes
• Attach bag to tube first
• Flush tube
• Recurrence rate >80%
TREATMENT OF SIGMOID VOLVULUS
 Initial Management
      • Endoscopic decompression
       –Rigid ∑ + flatus tube
       –Flexible sigmoidoscopy
       –Colonoscopy
 Definitive Management
    • Laparotomy and Pexy
    • Laparotomy and resection
       –Colostomy
       –Primary anastomosis
    • Percutaneous Endoscopic Colostomy
    • Mesosigmoidoplasty
    • Laparoscopic resection
TREATMENT OF SIGMOID VOLVULUS

Factors to be considered in decision making:
       • Age of patient
          –Chronological & biological
       • Physical state
       • Co-morbidity
       • Mental state
       • Social circumstances
Local Resection
Pexy (fixation)
            SIGMOID VOLVULUS
            Resection vs Colopexy
               Welch & Anderson 1987                   Bagarini et al 1993
60                                         40
%                                      %
                                           35
50
                                           30
40
                                           25

30                                         20

                                           15
20
                                           10
10
                                            5

    0                                       0
        Resection      Colopexy                 Resection        Colopexy
            Mortality                               Recurrence
MEGACOLON & VOLVULUVS
              SIGMOID VOLVULUS
          Influence of Megacolon on Recurrence
         16
                                   Recurrent volvulus
         14
Number




         12

         10
                 15
          8                      10
          6

          4
                                        5
          2
                         2
          0
              Normal Caliber    Megacolon

   Chung et al Br J Surg 1999
SURGERY FOR SIGMOID VOLVULUS

Options in presence of megacolon:
       • Extended left hemi colectomy
       • Subtotal colectomy
          –Ileostomy
          –Ileo-rectal anastomosis
          –Caecorectal anastomosis
       SIGMOID VOLVULUS
Percutaneous Endoscopic Colostomy
  • 1st Described 1993
  • Daniels et al 2000, Br.J.Surg
     –14 patients, 53-99 years old
     –Two point fixation
     –Mean follow up 12 months
     –Recurrence in 3/8 after early removal
     –No recurerence in 5 where tube left in
Mesosigmoidoplasty for Volvulus

 •Broadens attachment of
 mesentery

 •No anastomosis
 •Difficult to perform with
 oedematous or thickened mesentery

 •Subrahmanyam (1992) Br J Surg
    –126 patients (60% emergency)
    –1 death
    –2 recurrences
    CAECAL VOLVULUS
• Involves caecum and ascending colon
• May resolve spontaneously
• High index of suspicion
• Laparotomy required
• Resection +/- stomas
• Caecopexy
• Caecostomy
                      SIGMOID VOLVULUS

          Simple                           ? Infarction


    ∑ decompression
                           ? Infarction


            Unsuccessful                           Urgent
                                                 Laparotomy
                            Unsuccessful
            Colonoscopy
                                           Viable         Dead Colon
  Successful


                        Fixation                  Resection
Elective Resection
                      Pex, Lap, PEC           Stoma / Anastomosis

				
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