Operative Management and Outcomes of Patients with Sigmoid Volvulus at a Tertiary Public Hospital in Malawi 

Ephraim Bitilinyu-Bangoh1, Fatsani Mwale1, Loveness Ulunji Chawinga1, Gift Mulima2

1. College of Medicine, University of Malawi, Chichiri, Blantyre 3, Malawi.                                                    

2. Kamuzu Central Hospital, Lilongwe, Malawi              

Correspondence to: Dr. Gift Mulima; Email: gmulima@gmail.com

Received: 20th August 2020; Revised: 16th April 2021; Accepted: 21st April 2021; Available online: 19th May 2021

Abstract

Background: Sigmoid Volvulus (SV) is a common cause of acute bowel obstruction in Malawi. We aimed to describe the surgical management of SV and its outcomes at Kamuzu Central Hospital, Lilongwe, Malawi. Methods: We retrospectively reviewed records from January 2019 to December 2019 of all SV patients, aged 18 years and above. Data extracted included age, sex, admission date, surgery date, bowel viability at time of surgery, procedure done, suspected anastomotic leakage, length of hospital stay and mortality. The data was analyzed using STATA 14.0. Results: There were more males (n= 59, 81.9 %) than females. The median (IQR) age was 50.5 (38-60) years. A viable sigmoid colon was present in 61 (84.7%) patients. The commonest procedures done were sigmoid resection and primary anastomosis (RPA) (59.7%, n=43) and Hartmann’s procedure (HP) (36.1%, n=26). The median length of hospital stay was 5 days in HP, 7 days in RPA and longest in mesosigmoidopexy (10 days). Suspected anastomotic leakage occurred in 2(4.7%) patients. The overall mortality was 6.9% with all deaths occurring in RPA patients. Conclusion: Mortality is high in SV patients who undergo RPA. We recommend Hartmann’s procedure in cases where the bowel has significant oedema or is gangrenous.

Keywords: sigmoid volvulus, resection and primary anastomosis, Hartmann's procedure, mesosigmoidopexy.


Ann Afr Surg. 2021 ; 18(3): 176-179 
DOI: http://dx.doi.org/10.4314/aas.v18i3.9
Conflicts of Interest: None
Funding: College of Medicine, University of Malawi, Student Research grants
© 2021 Author. This work is licensed under the Creative Commons Attribution 4.0 International License 

Introduction

Sigmoid volvulus (SV) is a life-threatening condition affecting more males than females in ratios ranging from 2:1 to 10:1 (1–3). It is more common in Eastern Europe, India and Africa, which account for 50% of all cases of intestinal obstruction (4). The mortality rate associated with SV is high, estimated in some series to be around 20% depending on treatment modality and case severity (5).
The precise etiology of SV remains speculative, and several etiological factors have been suggested including chronic constipation, a high fiber diet, bowel habits, high altitude, and enemas containing ginger, pepper and herbal extracts (3, 4, 6). Classically, patients present with a triad of abdominal pain, constipation, and abdominal distention. An abdominal radiograph may reveal findings typical of volvulus; the coffee-bean sign, an inverted U-shape between the twisting and distending of the sigmoid colon and mesenteric axis in at least 60% of cases (2, 3).
Initial treatment of SV involves sigmoidoscopy with decompression and detorsion, with or without placement of a rectal tube. The success rate for sigmoidoscopic decompression can be between 60 and 81% (2, 7, 8). There are several surgical options that are considered to be acceptable treatment for SV including resection and primary anastomosis (RPA), Hartmann’s procedure (HP), and mesosigmoidopexy depending on settings and resource availability (5).
In our study, we report our experience in the operative management and outcomes of SV patients at the Kamuzu Central Hospital (KCH), Lilongwe, Malawi. The hospital has a 1200 bed capacity and is the only tertiary and public referral hospital for the central region of the country (9)


Methods

We reviewed the admission and theater records of all patients with a diagnosis SV seen from January 1st 2019 to 31st December 2019 aged 18 years and above. These were patients who had emergency surgery after failed decompression with rigid sigmoidoscopy, or decompression was not attempted at all, and those who had elective surgery after successful decompression and who were operated on within the same admission time period. Patients who were managed conservatively and those who had ileosigmoid knotting as a finding at surgery were excluded from the study. The primary outcome of the study was mortality.
The collected data were de-identified and the investigators had no access to the patient identifiers, that is, name and address. Variables of interest extracted from the records were age, sex, admission date, surgery date, sigmoid colon condition at time of surgery, that is, viable versus gangrenous (non-viable), and the ultimate procedure that was done during operation, that is, RPA or HP. The preoperative duration, defined as time (days) between admission to surgery, was calculated from the admission and surgery dates. Furthermore, we recorded suspected anastomotic leakage (SAL) as a complication in those who had RPA. Anastomotic leakage (AL) was suspected if observation of fecal material at the incision site or development of peritonitis was documented in the patient’s file. The length of hospital stay (LOS) was also recorded.
Collected data were entered into Microsoft Excel 2016 MSO (16.0.4266.1001) and kept on a password protected computer. Analysis was done using STATA 14.0 (StataCorp, College Station, TX, USA). Descriptive statistics were used to determine rates of variables of interest. We set alpha at 0.05. Fischer’s exact test was used to describe the association between bowel viability and mortality among patients who had RPA.
Ethical consideration
The study was approved by the College of Medicine Research and Ethics Committee (COMREC), approval number U.06/19/2702, and the KCH Research Committee.

Results