Surgery for volvulus who and When? Mr Graham Williams



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SURGERY FOR VOLVULUS Who and When?




SIGMOID VOLVULUS Worldwide Incidence



SIGMOID VOLVULUS Average Age at Presentation



SITE OF VOLVULUS



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

  • Simple or complicated

  • Underlying diagnosis

  • Acute management

  • Subsequent management

  • Resect or fix





SIGMOID VOLVULUS

  • 10% at presentation

  • Increasing pain

  • Tachycardia

  • Tenderness with guarding

  • Gas in wall on x-ray

  • Free gas



SIGMOID VOLVULUS Mortality Rates



SIGMOID VOLVULUS

  • Immediate resuscitation

  • Emergency laparotomy

  • Resection of infarcted segment

  • Ends out!



TREATMENT OF SIGMOID VOLVULUS

  • 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

  • Endoscopic decompression

    • Rigid ∑ + flatus tube
    • Flexible sigmoidoscopy
    • Colonoscopy
  • Laparotomy and Pexy

  • Laparotomy and resection

    • Colostomy
    • Primary anastomosis
  • Percutaneous Endoscopic Colostomy

  • Mesosigmoidoplasty

  • Laparoscopic resection



TREATMENT OF SIGMOID VOLVULUS

  • Age of patient

    • Chronological & biological
  • Physical state

  • Co-morbidity

  • Mental state

  • Social circumstances







SIGMOID VOLVULUS Resection vs Colopexy





SIGMOID VOLVULUS Influence of Megacolon on Recurrence







SURGERY FOR SIGMOID VOLVULUS

  • Extended left hemi colectomy

  • Subtotal colectomy

    • Ileostomy
    • Ileo-rectal anastomosis
    • Caecorectal anastomosis




SIGMOID VOLVULUS

  • 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




CAECAL VOLVULUS

  • Involves caecum and ascending colon

  • May resolve spontaneously

  • High index of suspicion

  • Laparotomy required

  • Resection +/- stomas

  • Caecopexy

  • Caecostomy







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