589 d iseases of the c olon & r eCtum V olume 59: 7 (2016) key words

3. Sigmoid colectomy should be considered after resolu-

tion of the acute phase of sigmoid volvulus to prevent 

recurrent volvulus. Grade of Recommendation: Strong 

recommendation based on low-quality evidence, 1C.

of the variety of elective operative interventions that 

have been described for sigmoid volvulus, sigmoid col-

ectomy with colorectal anastomosis is the intervention 

that is most consistently effective at preventing recurrent 

episodes of volvulus.

7,11,14,15,18,50,55,74,77

 the entire length 

of the redundant colon should be removed so as to re-

duce the risk of postresection recurrent volvulus. stoma 

creation in the nonemergency setting is not usually re-

quired and should be considered on a case-by-case basis 

depending on the operative findings and unique circum-

stances of the patients. in patients with sigmoid volvulus 

and concurrent megacolon, subtotal colectomy has been 

shown to more effectively prevent recurrent volvulus 

when compared with sigmoid colectomy alone.

78–80

 in 

patients with sigmoid volvulus and viable, nonperforat-

ed bowel, sigmoid resection with colorectal anastomosis 

results in low morbidity and mortality in the range of 0% 

to 12%.

7,9,11,14,50,57

 Given the redundancy and mobility of 

the colon encountered in patients with sigmoid volvulus, 

resection can be performed via minilaparotomy or lapa-

roscopically, although the potential benefits of a laparo-

scopic approach in this setting are not clear.

50,74,75

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4. Nonresectional operative procedures, including detor-

sion alone, sigmoidoplasty, and mesosigmoidoplasty, 

are inferior to sigmoid colectomy for the prevention of 

recurrent volvulus. Weak recommendation based on 

low-quality evidence, 2C.

operative detorsion alone, detorsion with intraperitoneal 

or extraperitoneal fixation (sigmoidopexy), and tailoring 

of the sigmoid mesentery to broaden its base and prevent 

torsion (mesosigmoidopexy) are nonresectional techniques 

that have been described for the definitive treatment of 

sigmoid volvulus in patients with a viable colon. although 

recurrent volvulus after sigmoid resection is generally a 

rare event, recurrence after the nonresectional techniques 

is more variable.

5,7,18,50

 Bhatnagar and Sharma

81

 performed 

detorsion and extraperitoneal sigmoid colon fixation in a 

consecutive series of 84 patients in whom no recurrences 

were observed. in smaller series, recurrence after sigmoido-

pexy has been reported in the range of 29% to 36%.

14,55,61

 for 

mesosigmoidoplasty, subrahmanyam

82

 achieved excellent 

results in a series of 126 patients, with recurrent volvulus 

observed in only 2 patients. similarly, in a series of 15 cases 

reported by akgun,

83

 there were no episodes of recurrent 

volvulus after mesosigmoidoplasty. however, in the large 

series reported by oren et al

18

 and atamanalp,

50

 mesosig-

moidoplasty resulted in recurrent sigmoid volvulus in 21% 

and 16%. although there are only limited data on operative 

detorsion alone, with most evidence coming from older ret-

rospective studies, the associated morbidity is in the range 

of 30% to 35%, with mortality at 11% to 15%, and recur-

rent sigmoid volvulus at 18% to 48%, which had led many 

authors to discourage the use of this intervention.

18,50,56,57,84

5. Endoscopic fixation of the sigmoid colon may be con-

sidered in select patients in whom operative interven-

tions present a prohibitive risk. Grade of Recommen-

dation: Weak recommendation based on low-quality 

evidence, 2C.

sigmoid volvulus is often encountered in older patients, 

some of whom may be unfit for abdominal operations. for 

this subset of patients, a number of small case series have in-

vestigated advanced endoscopic techniques as a less invasive 

means to prevent recurrent sigmoid volvulus. the percuta-

neous endoscopic colostomy (PeC) technique is performed 

to fix the sigmoid colon to the anterior abdominal wall, re-

stricting its mobility, with the aim of preventing recurrent 

volvulus. fixation of the colon has been performed using 

t fasteners or by percutaneous tube colostomy placement 

with or without laparoscopic assistance.

14,85–90

 although 

the literature includes a few reports of small case series, 1 

relatively large study included 19 elderly patients with re-

current sigmoid volvulus who were judged unfit for defini-

tive surgical treatment.

85

 in that study, the PeC procedure 

was successfully performed in all of the patients, whereas 

major complications (including peritonitis, tube migra-

tion, and death) occurred in 2 patients (10%) and minor 

complications (eg, abdominal wall bleeding or infection) 

occurred in 7 patients (37%). there were 8 deaths from un-

related causes. of the 6 patients who underwent removal 

of the PeC tube(s), after 6 to 26 months of fixation, none 

experienced recurrent volvulus at a median follow-up of 35 

months. in another series of 14 patients, PeC maintained 

reduction of the volvulus in each of the 5 patients in whom 

it was left in place but in only 3 of 6 in whom the PeC was 

subsequently removed.

86

 at present, it appears that PeC 

may be a useful tool for the treatment of sigmoid volvu-

lus, but more studies are needed to assess its durability. for 

the time being, it should generally be reserved for patients 

in whom established operative interventions are judged to 

pose a prohibitive degree of risk.

Cecal Volvulus

1. Attempts at endoscopic reduction of cecal volvulus are 

generally not recommended. Grade of Recommendation: 

Strong recommendation base on low-quality evidence, 1C.

several retrospective studies include patients in whom 

endoscopic reduction of cecal volvulus was attempted. 

Pooled results from of studies published between 1978 

and 2012, including 34 patients in whom endoscopic 

reduction of cecal volvulus was attempted, demonstrat-

ed successful detorsion in 4 patients (12%).

10,15,19,48,91

 

in the most recent studies, by Renzulli et al in 2002

48

 

and swenson et al in 2012,

10

 endoscopic decompression 

was successful in 2 of 6 patients and 0 of 10 patients. in 

contradistinction to the management of sigmoid volvu-

lus, in which endoscopic decompression is an effective 

means of temporarily detorsing the colon, this tech-

nique is of limited value in cases of cecal volvulus.

10,15,33

 

With its low likelihood of success and its potential for 

causing injury to the volvulized colon, attempts at en-

doscopic reduction of cecal volvulus are generally not 

recommended.

17,23,33,45

2. In patients with cecal volvulus, resection is required in 

patients with nonviable or perforated bowel. Resection 

is also an appropriate first-line intervention for patients 

with viable bowel who are good operative candidates. 

Grade of Recommendation: Strong recommendation 

based on low-quality evidence, 1C.

nonviable or gangrenous cecum is present in 18% to 

44% of patients with cecal volvulus and has an associ-

ated mortality rate of 31% to 44%; a range that is 3- to 

4-fold higher compared with those patients with viable 

bowel.

7,13,16,17,20,21,91,92

 the bulk of the published litera-

ture on operative treatment of cecal volvulus that in-

cludes analysis of cases with viable and nonviable bowel 

comes from retrospective studies that were published 

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V

oGel et al: 

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olVulus anD 

P

seuDo-

o

BSTRUCTION

594

in the 1970s and 1980s.

7,17,91,92

 in the study by o’mara  

et al

17

 with 9 patients with cecal volvulus and gangrenous 

cecum, 7 underwent segmental resection with primary 

anastomosis, of which 2 (28%) died of septic complica-

tions. in contrast, the 7 patients with viable cecum who 

were treated with resection and primary anastomosis 

experienced postoperative morbidity at a rate equal to 

the nonviable cases (43%) but experienced no mortali-

ties. In a study by Ballantyne et al,

7

 there were 15 patients 

with cecal volvulus and gangrenous bowel, of whom 4 

(27%) underwent resection with ileostomy and 11 (73%) 

had resection with primary anastomosis. although the 

specific outcomes for the primary anastomosis group 

and the ostomy group were not reported, overall mor-

tality rates in patients with nonviable and viable cecum 

were 33% and 12%.

7

 anderson and Welch

37

 reported on  

69 patients with cecal volvulus, including 19 (27%) with 

a gangrenous cecum, of whom 12 underwent resection 

with primary anastomosis and 7 had resection with il-

eostomy and mucus fistula. in the 12 patients with a 

nonviable cecum, anastomotic leak and postoperative 

mortality occurred in 2 (17%) and 5 patients (42%). in 

comparison, 2 (29%) of 7 patients who underwent resec-

tion and ileostomy died after surgery.

37

 in the 14 patients 

with viable cecum who underwent resection with pri-

mary anastomosis, 1 patient developed an anastomotic 

leak and 3 (21%) died. in a closer look at the patients 

with gangrenous cecum, anderson and Welch

37

 noted 

that death after resection and primary anastomosis oc-

curred only in patients with extensive gangrene or perfo-

ration, whereas there were no deaths after resection and 

primary anastomosis in patients with “patchy gangrene.” 

in the most recent retrospective study, by swenson et al,

10

 

of 53 patients with cecal volvulus, operative treatment 

was performed in 52, including resection in 44 patients 

(85%), with overall postoperative morbidity in 17% and 

no mortality.

to summarize, the data presented here come largely 

from retrospective studies of cecal volvulus published 

>20 years ago. the results of these studies indicate the 

following: 1) cecal resection is the most consistently ef-

fective means of preventing recurrent volvulus

7,17,20,21,23,45

; 

2) nonviable bowel is a meaningful predictor of mortality 

in patients with cecal volvulus and resection is required 

in these patients.

7,17,20,21,23,57,92

; and 3) whether resection 

with primary anastomosis or resection with ileostomy, 

with or without mucus fistula, should be performed in 

cases with nonviable bowel is a delicate point. the data 

from anderson and Welch,

37

 o’mara et al,

17

 and Ballan-

tyne et al

7

 support the use of resection and anastomosis 

in select patients with cecal volvulus and nonviable bow-

el. alternatively, in patients with cecal perforation, ex-

tensive gangrene, or peritonitis, resection with ileostomy 

(and occasionally mucus fistula) may be preferable.

17,37

3. For cecal volvulus with viable bowel, nonresectional 

operative procedures may be a suitable alternative to re-

section. Grade of Recommendation: Weak recommenda-

tion based on low-quality evidence, 2C.

in cases of cecal volvulus with viable bowel, the options 

for operative treatment include detorsion alone, detorsion 

with suture fixation to the abdominal wall (cecopexy), ce-

costomy, and segmental resection of the cecum. for each 

intervention, the risks of postoperative morbidity and 

mortality should be weighed against the risk of recurrent 

cecal volvulus. in the review by Rabinovici et al,

20

 there 

were 561 patients with cecal volvulus for whom cecopexy, 

detorsion alone, resection, or cecostomy was performed 

in 32%, 25%, 25%, and 16%. Patients who underwent ce-

copexy or detorsion alone had the low rates of abdomi-

nal and wound complications (15% and 15%), mortality 

(10% and 13%), and recurrent volvulus (13% and 12%).

20

 

alternatively, resection resulted in abdominal or wound 

morbidity in 29% and mortality in 22% but no episodes 

of recurrent volvulus. the worst outcomes were associated 

with cecostomy, which resulted in morbidity, mortality, 

and recurrence in 52%, 32%, and 14%.

20

 in the review of 

case series published between 1972 and 1986 by tejler and 

Jiborn,

21

 detorsion alone, cecopexy, cecostomy, and resec-

tion resulted in death in 13%, 5%, 10%, and 8% and re-

current volvulus in 13% 13%, 1%, and 0% of patients.

single-center studies in which patients with nonviable 

bowel were distinguished from those with viable bowel in-

dicated a low rate of mortality, with 0 or near-0 incidence 

of recurrent volvulus after resection of viable bowel, but 

were more variable in terms of morbidity, mortality, and 

recurrence after the nonresectional procedures.

7,10,13,15,17,37

 

o’mara et al

17

 reported on 41 patients with cecal volvulus 

and viable bowel, for whom cecostomy, resection, operative 

detorsion only, or cecopexy was performed in 4, 7, 12, and 

18 patients and for whom postoperative complications oc-

curred in 3 (75%), 3 (43%), 5 (52%), and 3 patients (17%). 

in the patients who underwent cecostomy, resection, opera-

tive detorsion only, or cecopexy, postoperative mortality oc-

curred in25%, 0%, 17%, and 0% (7% total). With long-term 

follow-up, none of the 44 surviving patients in the series 

by o’mara et al

17

 were diagnosed with recurrent volvulus. 

Without separating cases with viable and nonviable bowels, 

Ballantyne et al

7

 noted mortality for detorsion, cecostomy, 

cecopexy, resection with primary anastomosis, and resec-

tion with ileostomy of 27%, 0, 8%, 14%, and 25% and over-

all mortality with viable and nonviable bowel of 11% and 

33%. similar to o’mara et al

17

, Ballantyne et al

7

 also noted 

0 recurrences after cecostomy and cecopexy and only 1 re-

currence in 11 patients treated with detorsion alone. ander-

son and Welch

37

 reported on 18 cecopexy and 14 cecostomy 

cases, of which there was 1 death in each group and recur-

rent volvulus in 3 of 18 and 0 of 14. the 1 patient who had 

detorsion alone developed recurrent volvulus.

37

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although it is clear that resection is required for non-

viable or perforated bowel, limitations in the available 

data make it impossible to advocate the best operation for 

patients with cecal volvulus and viable bowel. Resection 

of viable bowel has the advantage of effectively prevent-

ing recurrent volvulus with 0 or near-0 mortality but the 

disadvantage of increased postoperative morbidity com-

pared with the nonresectional procedures.

13,15,17,20,21,23

 the 

effectiveness of cecopexy is more variable than that of re-

section but may result in a lower rate of procedure-related 

morbidity compared with resection.

7,17,20,21,37

 Cecostomy is 

another effective operative intervention, with low rates of 

recurrent volvulus, but it has a relatively high incidence of 

morbidity and adds potential new challenges that relate to 

the ostomy.

15,17,20,21,23

 Reports on the use of operative de-

torsion alone for cecal volvulus indicate a low incidence of 

recurrent volvulus (0%–13%) but a high rate of mortality 

(13%–33%) that, when coupled with concerns about the 

failure of detorsion alone to correct the underlying pathol-

ogy of cecal volvulus, has led some authors to suggest that 

this procedure should be abandoned.

7,17,20,21

 ultimately, 

with more than 1 appropriate operative intervention for 

cecal volvulus with viable bowel, a decision on the most 

appropriate intervention should be individualized, with 

consideration of both the condition of the patient and the 

bowel.

45

 laparoscopic techniques to achieve reduction, 

fixation, or resection of the cecum are an acceptable alter-

native to laparotomy for hemodynamically stable patients 

under the care of surgeons with suitable experience.

74,76,93

 

the treatment recommendations for patients with cecal 

bascule are similar to those discussed for patients with the 

more common form of organoaxial cecal volvulus.

20

Acute Colonic Pseudo-Obstruction

1. Initial evaluation should include a focused history 

and physical examination, complete blood count, serum 

electrolytes, renal function assessment, and diagnostic 

imaging. Grade of recommendation: Strong recommen-

dation, based on low- or very-low-quality evidence, 1C.

aCPo is a condition that most often affects older, hospi-

talized, or institutionalized patients with severe comorbid 

conditions or infection or those recovering from surgery 

or traumatic injury.

28,30–34

 abdominal pain, nausea and 

vomiting, abdominal distension, and dilation of the as-

cending and transverse colons on abdominal radiographs 

are typical findings but are nonspecific for aCPo.

26,28,94

 

the frequent presence of comorbid conditions in patients 

with aCPo, along with the possibility of electrolyte de-

rangement and acute renal insufficiency secondary to de-

hydration, warrants the inclusion of routine blood testing 

during the initial evaluation of patients with suspected 

colonic aCPo. to accurately diagnose aCPo, clinicians 

should exclude the presence of a mechanical large-bowel 

obstruction and should consider other conditions that 

result in colon dilation. abdominal Ct or water-soluble 

contrast enema can reliably distinguish aCPo from a me-

chanical large-bowel obstruction.

95–98

 endoscopic evalua-

tion of the colon may also be effective in distinguishing 

aCPo from large-bowel obstruction but is generally not 

recommended for diagnostic purposes in this setting be-

cause of its invasive nature and associated risks.

24,33,99

 al-

though most patients with aCPo have a nonemergent 

presentation, ischemia or perforation of the colon is re-

ported in 3% to 15% of cases with associated mortality 

in <50%.

26,30,100–102

 fever, leukocytosis, abdominal tender-

ness, and cecum dilation >12 cm, are factors that may be 

indicative of colon ischemia or perforation in aCPo.

28,30,100

2. Initial treatment of ACPO is supportive and focused on 

the elimination or correction of conditions that predis-

pose to ACPO or prolong its course. Grade of Recommen-

dation: Strong recommendation based on low-quality 

evidence, 1C.

first-line therapy for patients with aCPo without clini-

cal or radiologic evidence of colon ischemia or perforation 

and cecal diameter <12 cm is noninvasive and typically 

includes correction of serum electrolyte abnormalities, 

fluid resuscitation, avoidance or minimization of narcot-

ics and anticholinergic medications, identification and 

treatment of concomitant infection, bowel rest, ambula-

tion, knee-chest or prone positioning to promote flatus, 

and the insertion of nasogastric and rectal tubes to fa-

cilitate intestinal decompression.

26,28,33,103–105

 oral osmotic 

and stimulant laxatives should be avoided in patients with 

aCPo because they may worsen dilation of the colon 

via gas production and propulsion of gas into an already 

dilated colon.

26,28

 With nonoperative treatment, serial 

physical examinations and repeat abdominal radiographs 

facilitate continuous reassessment. Clinical signs of isch-

emia include increased pain, fever, abdominal tenderness, 

and leukocytosis.

30

 in a series of 400 patients with aCPo, 

including 221 patients with documented radiographic ce-

cal diameter, ischemia or perforation occurred in 0%, 7%, 

and 23% of patients with cecal diameters <12 cm, 12 to 

14 cm, and >14 cm.

30

 if serial examinations and abdominal 

radiographs do not suggest colon ischemia, perforation, 

or impending perforation, a nonoperative or “conserva-

tive course” of therapy should generally be continued for 

up to a few days, with the expectation that it will lead to 

resolution of aCPo in 70% to 90% of patients.

30,33,102–105