Case PresentationCase Presentation

Georges E. Al Georges E. Al khourykhoury MDMDKings County Hospital CenterKings County Hospital Center11/19/200411/19/2004

Management of colonic Management of colonic VolvulusVolvulus

Georges E. Al Georges E. Al khourykhoury MDMD

Colonic Colonic VolvulusVolvulus

VolvulusVolvulus : : VolvereVolvere (to Twist ) = axial (to Twist ) = axial rotation of an organ around its pediclerotation of an organ around its pedicle..Mobile segments of the colon Mobile segments of the colon Infarction !! torsion of the vessels /closed Infarction !! torsion of the vessels /closed loop obstruction loop obstruction 1% to 4% of all cases of intestinal 1% to 4% of all cases of intestinal obstruction and 10% to 15% of colonic obstruction and 10% to 15% of colonic obstructions ( western countries)obstructions ( western countries)20% to 50% of all intestinal obstructions (In 20% to 50% of all intestinal obstructions (In Eastern Eastern Europe,AfricaEurope,Africa and Asia )and Asia )

Colonic Colonic VolvulusVolvulus

SplenicSplenic & 4% 35 & 4% 35 transversetransverse

CecalCecal 2020--40% 5040% 50

Sigmoid 60Sigmoid 60--80% 7080% 70

Location Incidence Mean Age (years)Location Incidence Mean Age (years)

Colonic Colonic VolvulusVolvuluspredisposing factorspredisposing factors

Anatomic predisposition and pathologic Anatomic predisposition and pathologic distention of the colon. distention of the colon. Colonic stasis with chronic distention and Colonic stasis with chronic distention and laxative abuse.laxative abuse.High fiber diet (African communities)High fiber diet (African communities)Pregnancy Pregnancy Ogilvie'sOgilvie's syndrome,Hirschprungsyndrome,Hirschprung’’ssMegacolonMegacolon ((chagaschagas’’ disease disease hypothyroidism,parkinsonhypothyroidism,parkinson,,…….).)

Sigmoid Sigmoid VolvulusVolvulus

In the US: pts of all ages with psychiatric or In the US: pts of all ages with psychiatric or neurologicneurologic disease and elderly pts with disease and elderly pts with debilitating diseases .debilitating diseases .The usual history is one of severe, chronic The usual history is one of severe, chronic constipation constipation Anatomically the sigmoid colon must be Anatomically the sigmoid colon must be disproportionately long compared with its disproportionately long compared with its mesenteric base mesenteric base

Sigmoid Sigmoid VolvulusVolvulus Clinical Clinical FeaturesFeatures

Early symptoms :intermittent cramping, Early symptoms :intermittent cramping, lower lower abdabd pain, and progressive pain, and progressive abdabddistention. distention. Later come N, V, dehydration, Later come N, V, dehydration, obstipationobstipation. . Similar episodes in the past that were Similar episodes in the past that were terminated spontaneously by the passage of terminated spontaneously by the passage of large amounts of flatus and stool.large amounts of flatus and stool.

Sigmoid Sigmoid VolvulusVolvulus Clinical Clinical FeaturesFeatures

Pts characteristically are seen late in the Pts characteristically are seen late in the course of their illnesscourse of their illnessDiffuse Diffuse abdabd tenderness ,distention tenderness ,distention tympanytympany. . Fever, Fever, abdabd tenderness,peritonitistenderness,peritonitis suggests suggests that strangulation is present. that strangulation is present. Perforation is unusual because the sigmoid Perforation is unusual because the sigmoid colon in older pts is usually thickened.colon in older pts is usually thickened.

Sigmoid Sigmoid VolvulusVolvulus Diagnostic Diagnostic StrategyStrategy

Institutionalized pt with an acute abdomen.Institutionalized pt with an acute abdomen.PlainPlain--film radiograph : film radiograph : ““bent inner tubebent inner tube””, , diagnosis 80%.diagnosis 80%.Barium Enema :twisted Barium Enema :twisted ““birdbird’’s beaks beak”” or or ““ace ace of spadesof spades””..CT scan : CT scan : mesocolonmesocolon ““whirl signwhirl sign””gangrene?.gangrene?.

Sigmoid Sigmoid VolvulusVolvulus

Massively dilated colon with Massively dilated colon with a classic bent inner tube a classic bent inner tube appearance emanating from appearance emanating from the pelvis toward the RUQthe pelvis toward the RUQ

Sigmoid Sigmoid VolvulusVolvulus by BEby BE

The contrast agent stops The contrast agent stops abruptly at the narrowed abruptly at the narrowed point of torsion in the colon point of torsion in the colon 5% reduction.5% reduction.

Sigmoid Sigmoid VolvulusVolvulus

PathognomonicPathognomonic twisted twisted ““birdbird’’s beaks beak”” or or ““ace of ace of spadesspades”” deformitydeformity

Sigmoid Sigmoid VolvulusVolvulus: History: History

Papyrus Papyrus EbersEbers from ancient Egypt :from ancient Egypt :““if he does not evacuate it if he does not evacuate it for a twist in the bowel and if the phlegm does not find a way for a twist in the bowel and if the phlegm does not find a way out the it shall rot in the bellyout the it shall rot in the belly””Ancient Greece: purgatives were the first choice of treatmentAncient Greece: purgatives were the first choice of treatmentHippocrates :12 inch long suppository for relief of obstruction.Hippocrates :12 inch long suppository for relief of obstruction.1859 1859 MrMr Gay : Gay : ““with a a tube per rectum the bowel could be with a a tube per rectum the bowel could be relieved of its contents and rolling the body over the bowel relieved of its contents and rolling the body over the bowel would right itselfwould right itself””1883 Atherton : the first successful American operative 1883 Atherton : the first successful American operative detorsiondetorsion of the sigmoid of the sigmoid volvulusvolvulus1989 1989 SennSenn : : enyerotomyenyerotomy in all cases ,shortening of the in all cases ,shortening of the mesentery mesentery sigmoidoplexysigmoidoplexy, resection w primary , resection w primary anastomosisanastomosis1905 1905 MonihanMonihan ““anything over 10% mortality was the mortality anything over 10% mortality was the mortality of delayof delay””

Sigmoid Sigmoid volvulusvolvulus :1947 :1947 BruusgaardBruusgaard

””the treatment may be either non operative or the treatment may be either non operative or operative operative ““168 admissions of 91 pts ,non operative reduction 168 admissions of 91 pts ,non operative reduction was attempted 148 times with was attempted 148 times with proctoscopyproctoscopy and and rectal tube rectal tube succededsucceded 123 123 times.totaltimes.total mortality for mortality for 91 pts was only 14.2 %91 pts was only 14.2 %since since bruusgaardbruusgaard ‘‘ article the approach in the US article the approach in the US for sigmoid for sigmoid volvulusvolvulus has been to first attempt non has been to first attempt non operative reduction. operative reduction.

Sigmoid Sigmoid VolvulusVolvulus : : ManagementManagement

Relief of obstruction and the prevention of recurrent attacks. Relief of obstruction and the prevention of recurrent attacks. Studies from large referral centers 1970Studies from large referral centers 1970--1980s1980sDecompression with rigid or flexible endoscope is now Decompression with rigid or flexible endoscope is now considered the initial treatment of choice for pts without considered the initial treatment of choice for pts without evidence of intestinal ischemiaevidence of intestinal ischemiaSuccess is achieved in 60% to 95% of ptsSuccess is achieved in 60% to 95% of ptsMortality rate 2%. Mortality rate 2%. Recurrence rate 40% to 90%. Recurrence rate 40% to 90%. Mortality rates in the presence of gangrene are 25% to 80%.Mortality rates in the presence of gangrene are 25% to 80%.Spontaneous reductions : 2% of ptsSpontaneous reductions : 2% of pts

Sigmoid Sigmoid VolvulusVolvulus : : ManagementManagement

The rectal tube has to pass the point of The rectal tube has to pass the point of torsion (18 to 20 cm above the anus). torsion (18 to 20 cm above the anus). Erect and supine radiographs of the Erect and supine radiographs of the abdabd are are obtained to confirm the effectiveness of the obtained to confirm the effectiveness of the procedure and to procedure and to r/or/o pneumoperitoneumpneumoperitoneum..The rectal tube can be removed 48 to 72 The rectal tube can be removed 48 to 72 hours after reduction.hours after reduction.

Sigmoid Sigmoid volvulusvolvulus

Sigmoid Sigmoid VolvulusVolvulus : : EndoscopyEndoscopy

Flexible Flexible fiberopticfiberoptic endoscopyendoscopy has facilitated has facilitated decompression of the dilated and friable decompression of the dilated and friable bowelbowelTotal colonoscopy permits evacuation of Total colonoscopy permits evacuation of bowel contents proximal to the site of the bowel contents proximal to the site of the volvulusvolvulus

Percentage of pts in whom sigmoid Percentage of pts in whom sigmoid volvulusvolvulus was successfully reduced was successfully reduced by non operative modalities in 19 American series totaling 596 pby non operative modalities in 19 American series totaling 596 ptsts

7070Total 70.0Total 70.0

2.32.3Spontaneous reductions Spontaneous reductions

0.20.2Colonoscopy Colonoscopy

40.140.1ProctoscopyProctoscopy and rectal tube and rectal tube

1919ProctoscopyProctoscopy

5.45.4Barium enemaBarium enema

33Enemas Enemas

Percentage Percentage Modality Modality

SURGICAL MANAGEMENT SURGICAL MANAGEMENT Acute Sigmoid Acute Sigmoid VolvulusVolvulus

Failed decompression, fever and Failed decompression, fever and leucocytosisleucocytosis,intestinal ,intestinal ischaemiaischaemia, perforation or peritonitis., perforation or peritonitis.Gangrenous colon in Gangrenous colon in industrialisedindustrialised countries countries <10%,25% in developing countries.<10%,25% in developing countries.Gangrenous colon requires immediate excision.Gangrenous colon requires immediate excision.Untwisting is not advised .Untwisting is not advised .Colostomy and mucous fistula or HartmannColostomy and mucous fistula or Hartmann’’s s procedure .procedure .Mortality:primaryMortality:primary anastomosis(0%anastomosis(0%--33%) 33%) v/sv/s( 0( 0--50% ) for colostomy. 50% ) for colostomy.

Outcome following emergency resection for sigmoid Outcome following emergency resection for sigmoid volulusvolulus in series detailing the presence of gangrenein series detailing the presence of gangrene

Average mortality Average mortality 5.95.9 38.038.0

People (1990) 50 0.0 People (1990) 50 0.0 4 75.04 75.0

DrapanasDrapanas (1961) 18 17.0 (1961) 18 17.0 5 60.05 60.0

Western SeriesWestern Series

UdezueUdezue (1990) 3 0.0(1990) 3 0.0 18.018.0

BagaraniBagarani (1993) 10 5.8(1993) 10 5.8 21.021.0

SroujiehSroujieh (1985) 20 10.0 (1985) 20 10.0 3 33.03 33.0

EjumuEjumu (1985) 21 4.8 (1985) 21 4.8 3 33.03 33.0

SchagenSchagen (1985) 116 1.7 (1985) 116 1.7 22 18.022 18.0

Shepherd (1969) 389 8.0 Shepherd (1969) 389 8.0 36 47.036 47.0

African SeriesAfrican Series

Number Mortality (%) Number Mortality Number Mortality (%) Number Mortality (%)(%)

Author (Year) Viable bowelAuthor (Year) Viable bowel Gangrenous bowelGangrenous bowel

Outcome following emergency and elective resection for Outcome following emergency and elective resection for sigmoid sigmoid volvulusvolvulus in series of more than 20 patients in series of more than 20 patients undergoing surgeryundergoing surgery

Average mortalityAverage mortality 31.031.0 8.08.0

BakBak (1986) 14 36.0 (1986) 14 36.0 18 5.618 5.6

BallantyneBallantyne (1982) 195 37.0 (1982) 195 37.0 129 8.5129 8.5

Arnold (1973) 25 44.0Arnold (1973) 25 44.0 74 15.074 15.0

Western SeriesWestern Series

MokoenaMokoena (1995) 27 30.0 (1995) 27 30.0 55 3.655 3.6

BagaraniBagarani (1993) 14 21.0 (1993) 14 21.0 17 5.817 5.8

SchagenSchagen (1985) (1985) 22 18.0 116 22 18.0 116 0.00.0

African SeriesAfrican Series

Number MortalitNumber Mortality (%) Number Mortality (%)y (%) Number Mortality (%)

Author (Year) Emergency Author (Year) Emergency ElectiveElective

Elective Surgery for Decompressed Elective Surgery for Decompressed

Sigmoid Sigmoid VolvulusVolvulus

ResectionalResectional or nonor non--resectionalresectional ????Traditional opinion is that resection of at Traditional opinion is that resection of at least the sigmoid colon is mandatory .least the sigmoid colon is mandatory .If associated with If associated with megacolon,totalmegacolon,totalcolectomycolectomy or subtotal or subtotal colectomycolectomy is advised.is advised.Subtotal Subtotal colectomycolectomy when when dysmotilitydysmotility has has been demonstrated preoperatively to been demonstrated preoperatively to involve the entire colon. involve the entire colon. Mortality of 21% Mortality of 21% Recurrence of 1.2%.Recurrence of 1.2%.

Laparoscopic Resection Laparoscopic Resection

Laparoscopic resection of the sigmoid colon Laparoscopic resection of the sigmoid colon for decompressed sigmoid for decompressed sigmoid volvulusvolvulus may be may be a useful alternative in high risk patients or in a useful alternative in high risk patients or in the elderly who may not tolerate the elderly who may not tolerate conventional colonic surgery. conventional colonic surgery.

ColopexyColopexy

Advantage of not requiring resection of the Advantage of not requiring resection of the sigmoid colon, not requiring bowel sigmoid colon, not requiring bowel preparation. preparation. Mortality is 11% Mortality is 11% Recurrence is 22%. Recurrence is 22%. PercutaneousPercutaneous endoscopicendoscopic colopexycolopexy using using PEG KitPEG Kit

Series on management of viable bowel in sigmoid Series on management of viable bowel in sigmoid volvulusvolvulus detailing resection and detailing resection and colopexycolopexy

AverageAverage 21.0 021.0 0 11.0 21.511.0 21.5

BagariniBagarini (1993) 16.0 0 (1993) 16.0 0 0.8 28.50.8 28.5

SalimSalim (1991) 13.0 0 (1991) 13.0 0 0.0 0.0 0.00.0

Hines (1967) 5 0Hines (1967) 5 0

Welch (1987) 52 0 Welch (1987) 52 0 17.0 36.017.0 36.0

Mortality (%) Recurrence (%) MorMortality (%) Recurrence (%) Mortality(%) Recurrence (%)tality(%) Recurrence (%)

Author (Year) Resection Author (Year) Resection ColopexyColopexy

MesosigmoidoplastyMesosigmoidoplasty

First described by First described by TiwaryTiwary and Prasad in 1976and Prasad in 1976Broadening the base of the Broadening the base of the mesosigmoidmesosigmoid and reduction of its and reduction of its lengthlengthSimple operation ,low rate of operative morbidity and Simple operation ,low rate of operative morbidity and mortality.mortality.No likelihood of No likelihood of anastomoticanastomotic leakage and sepsis. leakage and sepsis. Undue postUndue post--operative constipation is not a problem operative constipation is not a problem SubrahmanyamSubrahmanyam’’ss series of 126 pts with an average series of 126 pts with an average f/uf/u of 8.2 of 8.2 years, and a recurrence rate of 1.6% and no mortality.years, and a recurrence rate of 1.6% and no mortality.The lack of verification of The lack of verification of SubrahmanyamSubrahmanyam’’ss results in other results in other surgeonssurgeons’’ hands counts against its routine use. hands counts against its routine use.

MesosigmoidoplastyMesosigmoidoplasty

ExtraperitonealizationExtraperitonealization for for Sigmoid Sigmoid VolvulusVolvulus

Recurrence free cure of sigmoid Recurrence free cure of sigmoid volvulusvolvulusperformed since 1968performed since 1968There is not enough freedom for the There is not enough freedom for the sigmoid colon to undergo torsion in the sigmoid colon to undergo torsion in the restricted space.restricted space.Minimal Minimal complications,hascomplications,has low morbidity and low morbidity and mortality rate mortality rate Suitable for elective and emergency Suitable for elective and emergency situationssituations

ExtraperitonealizationExtraperitonealization: Cumulative Experience: Cumulative Experience

003.13.1106106130130Total Total

004.54.510101111AvisarAvisar

003.23.273738888KhanaKhana

002.42.423233131BhatnagarBhatnagar

recurrencerecurrencef/y(yf/y(y))Pts in Pts in f/uf/unnAuthorAuthor

ExtraperitonealizationExtraperitonealization for for Sigmoid Sigmoid VolvulusVolvulus

ExtraperitonealizationExtraperitonealization for for Sigmoid Sigmoid VolvulusVolvulus

CecalCecal volvulusvolvulus

First noted by First noted by HiladenusHiladenus in the 16th century and in the 16th century and reviewdreviewd by by rokitanskyrokitansky in 1837in 18371% of all intestinal obstruction 1% of all intestinal obstruction 18 to 44% of all colonic 18 to 44% of all colonic volvulusvolvulus..The incidence of 7.1 per million people per yearThe incidence of 7.1 per million people per yearThe age and sex distribution of these patients have The age and sex distribution of these patients have changed over the years and shifted toward older changed over the years and shifted toward older patients (mean, 53 years) and female patients (mean, 53 years) and female predominance (predominance (female:malefemale:male ratio, 1.4:1).ratio, 1.4:1).

CecalCecal VolvulusVolvulus

Abnormal mobility of the Abnormal mobility of the cecumcecum that results from improper that results from improper developmental fusion of the mesentery of the developmental fusion of the mesentery of the cecumcecum and the and the ascending colon with the posterior parietal peritoneum in the ascending colon with the posterior parietal peritoneum in the right gutter.right gutter.11.2% of the population has a 11.2% of the population has a cecumcecum sufficiently mobile to sufficiently mobile to allow the development of torsion (allow the development of torsion (dissection of adult male cadavers dissection of adult male cadavers by by WolferWolfer et al northwestern university medical school ).et al northwestern university medical school ).400 times as common as the clinical incidence.400 times as common as the clinical incidence.DonhauserDonhauser and Atwell in a 1949 autopsy study found the and Atwell in a 1949 autopsy study found the cecumcecum to be sufficiently mobile in 25.6 % of cases to allow to be sufficiently mobile in 25.6 % of cases to allow cecalcecal bascule to occur .bascule to occur .Incidence of previous abdominal surgery ,adhesions..Incidence of previous abdominal surgery ,adhesions..Marathon runners ( congenital Marathon runners ( congenital hypofixationhypofixation coupled with a coupled with a thin and flexible mesentery )thin and flexible mesentery )

CecalCecal VolvulusVolvulus

Rotation of the Rotation of the hypermobilehypermobilececumcecum, usually 360 degrees , usually 360 degrees around the mesenteric around the mesenteric pedicle of the pedicle of the ileocecalileocecalartery, produces a closedartery, produces a closed--loop obstruction loop obstruction axial axial ileocolicileocolic volvulusvolvulus 90% 90% of the cases : the torsion is of the cases : the torsion is usually counterclockwise usually counterclockwise rotation in an oblique rotation in an oblique fashion alsofashion alsodisplacing the displacing the ileum.ileum.

CecalCecal VolvulusVolvulus

The clinical signs and symptoms are not The clinical signs and symptoms are not specific : specific : Generalized Generalized abdabd pain 90% pain 90% AbdAbd distention 80 %distention 80 %Constipation or Constipation or obstipationobstipation 60 %60 %Vomiting 28 %Vomiting 28 %The diagnosis is rarely made on the clinical The diagnosis is rarely made on the clinical grounds alone .grounds alone .The The radiologicradiologic diagnosis can be made with diagnosis can be made with confidence in 90% of casesconfidence in 90% of cases

CecalCecal VolvulusVolvulus : Plain film: Plain film

Dilated Dilated cecumcecum located located anywhere in the anywhere in the abdabd, , usually found in the usually found in the epigastriumepigastrium or LUQ,or LUQ,KidneyKidney--bean shapebean shapeThe terminal ileum The terminal ileum may be air filled and may be air filled and visualized in an visualized in an abnormal position to abnormal position to the right of the the right of the distended distended cecumcecum..

CecalCecal VolvulusVolvulus :Plain film:Plain film

A single fluid level A single fluid level my be seen in the my be seen in the dilated dilated cecumcecumwhich may be seen which may be seen located anywhere in located anywhere in the the abdabd

CecalCecal VolvulusVolvulus :BE:BE

Contrast column may flow to Contrast column may flow to the right the right colon,demonstratingcolon,demonstratingthe spiraling mucosal folds of the spiraling mucosal folds of the the twist,ortwist,or stop in a tapered stop in a tapered beak like configuration.beak like configuration.Accuracy (88 %)Accuracy (88 %)Minimal complications. Minimal complications.

CecalCecal VolvulusVolvulus : : ManagementManagement

There is no role for There is no role for nonoperativenonoperativemanagement. management. Closed loop obstruction that involves Closed loop obstruction that involves variable lengths of small intestine!!variable lengths of small intestine!!Surgery becomes urgent as soon as the Surgery becomes urgent as soon as the diagnosis of a diagnosis of a cecalcecal volvulusvolvulus is is established. established. NonoperativeNonoperative decompression by decompression by colonoscopy has been reportedcolonoscopy has been reported

CecalCecal volvulusvolvulus :Management:Management

At At laparotomylaparotomy determination of the viability of the bowel is determination of the viability of the bowel is the initial step in the management.the initial step in the management.The proportion of pts who present with a gangrenous The proportion of pts who present with a gangrenous cecumcecumvaries from 23 to 100%varies from 23 to 100%Nonviable bowel requires immediate excision of the involved Nonviable bowel requires immediate excision of the involved loop which can be achieved by right loop which can be achieved by right hemicolectomyhemicolectomy..Untwisting under these circumstances is not Untwisting under these circumstances is not advised,becauseadvised,becauseit has been shown to result in irreversible septic shock.it has been shown to result in irreversible septic shock.Primary Primary anastomosisanastomosis vsvs ileostomyileostomy must be based on the ptmust be based on the pt’’s s conditionconditionIleostomyIleostomy and mucus fistula remain an optionand mucus fistula remain an option

CecalCecal Volvulus:ManagementVolvulus:Management

When the bowel is viable operative When the bowel is viable operative detorsiondetorsion is the first step.is the first step.DetorsionDetorsion alone is not recommended, high alone is not recommended, high recurrence rates 20recurrence rates 20--75% .75% .Additional procedure to limit recurrence: Additional procedure to limit recurrence: resectionalresectional or non or non resectionalresectional..Resection: Right Resection: Right hemicolectomyhemicolectomy followed by followed by primary primary anastomosisanastomosis..

CecalCecal VolvulusVolvulus :Management:Management

Non Non resectionalresectional procedures : procedures : cecopexycecopexy and and cecostomycecostomyCecopexyCecopexy : anchoring the right colon to the : anchoring the right colon to the parietal peritoneum prevent recurrence by parietal peritoneum prevent recurrence by eliminating prerequisite eliminating prerequisite hypermobilityhypermobility..The average recurrence is 16% ( 0%The average recurrence is 16% ( 0%--40% )40% )Safe procedure , low mortality (0% to 18%) .Safe procedure , low mortality (0% to 18%) .Laparoscopic Laparoscopic cecopexycecopexy has been reported with no has been reported with no recurrence after followrecurrence after follow--up.up.

CecalCecal volvulusvolvulus

CecostomyCecostomy : placement : placement cecostomycecostomy tube through a small tube through a small incision on the incision on the cecalcecal wall bringing the wall bringing the cecumcecum to the anterior to the anterior abdominal wall and bringing the tube through a small incision abdominal wall and bringing the tube through a small incision to the skin.to the skin.Advantage : decompressing the distended segment.Advantage : decompressing the distended segment.Threatening complications : Threatening complications : gangrene,cecalgangrene,cecalnecrosis,intraperitonealnecrosis,intraperitoneal leakage,fistulaleakage,fistulaRecurrence of 2 to 14 % .Recurrence of 2 to 14 % .Mortality rates 0 to 40 % Mortality rates 0 to 40 % CecostomyCecostomy and and cecopexycecopexy are advised in cases where the are advised in cases where the cecalcecalwall is healthy and of normal thickness.wall is healthy and of normal thickness.Combined Combined cecopexycecopexy and and cecostomycecostomy has been performed with has been performed with no recurrence and no mortality ,7 cases reported.no recurrence and no mortality ,7 cases reported.

Outcome of Resection in pts with Outcome of Resection in pts with cecalcecal volvulusvolvulus

Tuech1996Tuech1996 22 9 10 22 9 10 00 12 12 1717

Gupta1993Gupta1993 11 18 2 11 18 2 00 9 9 1717

Hiltunen1992 Hiltunen1992 11 9 2 11 9 2 00 9 9 99

Geer1991Geer1991 11 0 ns 11 0 ns nsns

After 1990After 1990

PahlmanPahlman 19891989 17 24 14 17 24 14 44 3 3 6060

Anderson 1986Anderson 1986 33 32 14 33 32 14 2121 19 19 3737

BallantyneBallantyne 19851985 39 17 24 39 17 24 1212 15 15 3333

Before 1990Before 1990

Author n Overall Author n Overall mortaltymortalty % n Viable mortality n Nonviable mortality% n Viable mortality n Nonviable mortality

CecalCecal VolvulusVolvulus

Conclusion:Conclusion:Emergency operation is more the Emergency operation is more the rule,becauserule,because nonoperativenonoperative decompression is decompression is not usually possiblenot usually possibleResection and Resection and anastomosisanastomosis is the favored is the favored option for both gangrenous and viable option for both gangrenous and viable bowel bowel CecostomyCecostomy and and cecopexycecopexy seem poorer seem poorer alternatives although they have a role to alternatives although they have a role to play in unstable high risk pts.play in unstable high risk pts.

CecalCecal basculebascule

Bascule :( French seesaw) describes a type of Bascule :( French seesaw) describes a type of balanced drawbridgebalanced drawbridgeThe redundant mesentery or the The redundant mesentery or the hypofixationhypofixation ,in ,in combination with massive distention allows the combination with massive distention allows the cecumcecum to fold on itself.to fold on itself.Subsequently adhesions form between the anterior Subsequently adhesions form between the anterior abdabd wall of the wall of the cecumcecum and ascending colon and ascending colon resulting in resulting in basculationbasculation..The presence of previous The presence of previous abdabd surgery especially surgery especially appendectomy,isappendectomy,is more often associated with more often associated with cecalcecalbascule.bascule.

CecalCecal basculebascule

The The cecumcecum rotates in a rotates in a horizontal plane horizontal plane anteriorlyanteriorlyupward with the obstruction at upward with the obstruction at the point of folding.the point of folding.

CecalCecal BasculeBascule

Massively dilated Massively dilated cecumcecum extending extending from the right lower abdomen from the right lower abdomen across the midline toward the left across the midline toward the left side. side. Neither the typical coffeeNeither the typical coffee--bean bean sign associated with sign associated with cecalcecal volvulusvolvulusnor the birdnor the bird’’s beak sign of sigmoid s beak sign of sigmoid volvulusvolvulus are present because there are present because there is no axial torsion of the bowel.is no axial torsion of the bowel.

Transverse colon Transverse colon volvulusvolvulus

It was first reported 1n 1932 by It was first reported 1n 1932 by kalliokallio1 to 4 % of colonic 1 to 4 % of colonic volvulusvolvulusYounger population in their fourth decadeYounger population in their fourth decadeTwofold female predominanceTwofold female predominancePrevious Previous abdabd surgery and a history of chronic surgery and a history of chronic constipationconstipationPreoperative diagnosis is difficultPreoperative diagnosis is difficultRedundant transverse colon segment is noted at Redundant transverse colon segment is noted at surgerysurgeryColonoscopicColonoscopic decompressions have been reporteddecompressions have been reportedOperative strategy : resection or some form of Operative strategy : resection or some form of colopexycolopexy, to the abdominal wall and /or pelvis., to the abdominal wall and /or pelvis.

SplenicSplenic flexure flexure volvulusvolvulus

The least common site of The least common site of volvulusvolvulus1 % in published American series1 % in published American seriesCongenital absence of any of the ligaments or Congenital absence of any of the ligaments or injury to them during abdominal surgery predispose injury to them during abdominal surgery predispose the pt to the pt to volvulusvolvulus..Complete absence of all three ligaments was Complete absence of all three ligaments was reported in two ptsreported in two ptsFixation or resection of the Fixation or resection of the splenicsplenic flexureflexureColopexyColopexy of the of the splenicsplenic flexure has not been flexure has not been reportedreportedSplenicSplenic flexure colostomy which provided flexure colostomy which provided decompression and fixationdecompression and fixation