Role of Rigid Endoscopic Detorsion in the Management of Sigmoid Volvulus

Ngeno M, Ooko PB, Seno S, Oloo M, Topazian HM, White RE

Tenwek Hospital

Correspondence to: Dr. Mercy Ngeno, PO Box 39-20400, Bomet, Kenya. Email: mercycngeno@gmail.com

 

Abstract

Introduction: Sigmoid Volvulus (SV) is a common cause of bowel obstruction in Africa, affecting a relatively young and healthy population. There has been little research regarding the use of endoscopic detorsion in the management of SV from East Africa. The aim of this study was to determine the outcome of patients with SV managed by endoscopic detorsion at a single institution over a 9 year period. Methods: A retrospective review of all patients admitted with SV at Tenwek Hospital in Bomet, Kenya from January 2006 to October 2014 was done. Data were collected on demographics, clinical presentation, operative findings, management, and outcome. Results: There were 159 cases with a mean age of 41.1 years (range 15-87). Rigid endoscopic detorsion was attempted in 125 (79%) patients. The success, early recurrence, and mortality rate for rigid endoscopic detorsion was 79%, 6%, and 0% respectively. Eleven (13%, n=99) patients declined surgery after successful endoscopic detorsion, while 87 patients had semi-elective surgery, an average  of 3.5 days post detorsion. Sixty patients had emergency surgery, with gangrenous bowel noted in 43 (72%) cases. Patients undergoing emergency surgery had a higher morbidity rate (27% vs. 5%, p=0.0002), and a higher mortality rate (12% vs. 0, p=0.002) compared to those having semi-elective surgery due to the presence of gangrenous bowel. Conclusion: Rigid endoscopic detorsion is appropriate in the initial management of any stable patient with clinical and radiological features suggestive of sigmoid volvulus without features of peritonitis.

Keywords: Sigmoid Volvulus, Endoscopic Detorsion, Rigid Sigmoidoscopy, Outcomes.

Ann Afr Surg. 2015; 12(2): 85-8.

Introduction

Sigmoid volvulus (SV) is an abnormal twisting of the sigmoid colon on its mesentery, leading to luminal obstruction, and vascular occlusion (1). It occurs in the face of a redundant sigmoid colon with a narrow mesenteric attachment secondary to chronic constipation, irregular bowel habits or a bulky, high fiber diet (2,3). In many series from Africa, SV is a common cause of acute intestinal obstruction and the leading cause of large bowel obstruction (2,4-6).

Non-operative detorsion has been advocated for in the initial management of acute sigmoid volvulus in stable patients lacking features suggestive of bowel gangrene (7,8). Rigid or flexible colonoscopy allows for mechanical detorsion, decompression of massively distended proximal bowel, and assessment of bowel viability (1,7,9-11). SV commonly occurs 15-25 cm from the anal verge, thus easily accessible by rigid sigmoidoscopic examination and amenable to decompression (12). While flexible endoscopy has significant advantages over rigid sigmoidoscopy, the equipment and around the clock expertise required may be unavailable in many resource-limited settings (8-12).

There has been little literature from East Africa on the use of endoscopic detorsion in the management of SV. The purpose of this study was to determine the outcome of patients with SV managed by endoscopic detortion at Tenwek Hospital in, Bomet, Kenya.

 

Methods

A retrospective review of all patients admitted with a diagnosis of SV at Tenwek Hospital, in Bomet County, Kenya over a 9 year period (January 2006 to October 2014). Cases were defined as patients with a diagnosis of SV based on clinical, radiological (plain, upright abdominal X-rays), endoscopic and, at times, operative findings. Patients with ileo-sigmoid knotting or those without a clear diagnosis of SV at rigid sigmoidoscopy or laparotomy were excluded. Data were extracted on age, gender, presenting signs and symptoms, non-operative and operative procedures, operative findings, complications and outcome. Data were assessed using Fisher’s exact test and unpaired t test as appropriate. P-values less than or equal to 0.05 were accepted as significant.

All cases presenting with features of bowel obstruction had intravenous (IV) fluid resuscitation, correction of electrolyte imbalances where present, and administration of IV antibiotics as appropriate. Patients with suspected SV but without features of peritonitis (i.e. rebound tenderness, rigidity or guarding) had endoscopic detortion attempted using rigid sigmoidoscopy. If detortion was successful and no features of bowel ischemia noted, a rectal tube was inserted and secured using a 1.0 non-absorbable suture. Non-operative detorsion were carried out by surgical residents with close consultant supervision. Bowel prep was initiated within 12-24 hours after successful detortion if the patient’s vital signs remained stable, with no recurrence of symptoms or foul smelling bloody stool. A repeat plain abdominal X-ray was not routinely ordered after successful detorsion. Patients who had recurrence of symptoms due to a slipped flatus tube, but without features of peritonitis, underwent repeat rigid sigmoidoscopy. Semi-elective, open sigmoid resection and primary anastomosis were performed within 2-4 days of detorsion, unless the patient declined surgery.

 

Emergent explorative laparotomy was undertaken in patients with features of peritonitis on physical exam, strong consideration of other diagnosis apart from SV, after unsuccessful endoscopic detortion, or when features suggestive of bowel ischemia (dark mucosa and/or foul smelling bloody stool) were noted at detorsion. A primary anastomosis was performed after resection of viable or gangrenous sigmoid colon if the patient was stable, the resected bowel edges were well vascularized, there was no fecal peritonitis, and a tension free anastomosis could be achieved. On-table lavage was not performed in any patient.

 

Results

There were 159 cases during the study period comprising of 143 (90%) males and 16 (10%) females. The mean age was 41.1 years (range 15-87) with the majority (70%) of patients aged 50 years and below (Table 1). The mean duration of symptoms was 2.7 days (range 6 hours-14 days). The most common signs and symptoms were abdominal distension (150, 94%), abdominal pain (143, 90%), abdominal tenderness (116, 73%), constipation (110, 69%), vomiting (102, 64%), empty rectal vault on digital exam (74, 47%), and peritonitis (28, 18%).

 

Rigid endoscopic detorsion was attempted in 125 (79%) patients who had clinical and radiologic features consistent with SV without features of peritonitis on physical exam, and was successful in 99 (79%) patients (Figure 1). Early SV recurrence was noted in 6 (6%) of these patients 1-2 days after detorsion due to a slipped flatus tube. Repeat rigid endoscopic detorsion was successful in all six cases. Of the 99 patients who had successful endoscopic detorsion, 87 (88%) had surgery, 11 (13%) declined surgery, and one, a 16 year-old female, had a rectal biopsy to evaluate for hirschprung’s disease. The mean duration between successful rigid endoscopic detorsion and surgery was 3.5 days (range 1-7).At operation, a viable and redundant sigmoid colon was noted in all 87 patients. Resection and primary anastomosis was performed in 85 patients, resection and Hartman’s colostomy in one patient (due to inability to achieve a tension free anastomosis in a patient with significant malnutrition), and sigmoidopexy in one patient. Morbidities following semi-elective surgery were noted in 5 (5%) patients including 4 cases of surgical site infection and one case of anastomotic leak. No mortalities occurred among this group.

 

 

Emergency surgery was undertaken in patients who had unsuccessful endoscopic detorsion (15), features suggestive of bowel gangrene at endoscopy (ischemic mucosa in 2, bloody, and foul smelling stools in 9), peritonitis (28) at presentation, or strong consideration of other diagnosis apart from SV (6). At laparotomy, 43 (72%) patients in this group had gangrenous bowel (Table 2). The incidence of bowel gangrene in patients with peritonitis at 89% was much higher than those without peritonitis who had unsuccessful rigid endoscopic detorsion at 33% (p=0.0003). Resection and primary anastomosis was performed in 39 cases with viable or gangrenous bowel, and a colostomy fashioned after resection of gangrenous bowel in 21 cases . Morbidities, in this group, were noted in 16 (27%) patients, with surgical site infection (11, 18%) being the most common complication . There were no case of anastomotic leak. Seven (11.6%) patients died (four with a colostomy after resection of gangrenous bowel, two after primary resection and anastomosis (PRA) of gangrenous bowel and one after PRA of viable bowel). Causes of death included severe sepsis (4), pulmonary embolism (2), and severe pneumonia

 

(1). The mortality rate in this group, based on bowel status, was 5.9% in patients with viable bowel and 14% in patients with gangrenous bowel (P=0.7).

 

The overall morbidity rate, mortality rate and mean length of stay for all cases were 13%, 4% and 8.7 days (range 2-26) respectively. Patients who had emergency surgery had a higher morbidity rate (27% vs. 5%, p=0.0002), higher mortality rate (12% vs. 0, p=0.002) and a similar duration of stay (8.5 days vs. 9.3 days, p= 0.2) compared to patients undergoing semi-elective surgery due to the presence of gangrenous bowel.

Discussion

The management of SV involves appropriate correction of electrolyte and fluid imbalances, differentiation of strangulated from viable bowel, relief of bowel obstruction and prevention of recurrent attacks (12). While