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.
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.
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%
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.
iseases of the
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.
Bhatnagar and Sharma
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%.
observed in only 2 patients. similarly, in a series of 15 cases
reported by akgun,
there were no episodes of recurrent
series reported by oren et al
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.
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.
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.
in that study, the PeC procedure
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
at present, it appears that PeC
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.
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%).
in the most recent studies, by Renzulli et al in 2002
and swenson et al in 2012,
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.
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
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
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
oGel et al:
in the 1970s and 1980s.
in the study by o’mara
with 9 patients with cecal volvulus and gangrenous
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,
there were 15 patients
(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%.
anderson and Welch
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.
in the 14 patients
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
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,
was performed in 52, including resection in 44 patients
(85%), with overall postoperative morbidity in 17% and
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
2) nonviable bowel is a meaningful predictor of mortality
in these patients.
; 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,
o’mara et al,
tyne et al
support the use of resection and anastomosis
el. alternatively, in patients with cecal perforation, ex-
tensive gangrene, or peritonitis, resection with ileostomy
(and occasionally mucus fistula) may be preferable.
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,
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%).
alternatively, resection resulted in abdominal or wound
of recurrent volvulus. the worst outcomes were associated
with cecostomy, which resulted in morbidity, mortality,
and recurrence in 52%, 32%, and 14%.
in the review of
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.
o’mara et al
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
were diagnosed with recurrent volvulus.
Ballantyne et al
noted mortality for detorsion, cecostomy,
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
, Ballantyne et al
0 recurrences after cecostomy and cecopexy and only 1 re-
currence in 11 patients treated with detorsion alone. ander-
son and Welch
reported on 18 cecopexy and 14 cecostomy
rent volvulus in 3 of 18 and 0 of 14. the 1 patient who had
detorsion alone developed recurrent volvulus.
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.
effectiveness of cecopexy is more variable than that of re-
morbidity compared with resection.
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
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.
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
laparoscopic techniques to achieve reduction,
native to laparotomy for hemodynamically stable patients
under the care of surgeons with suitable experience.
the treatment recommendations for patients with cecal
bascule are similar to those discussed for patients with the
more common form of organoaxial cecal volvulus.
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.
vomiting, abdominal distension, and dilation of the as-
cending and transverse colons on abdominal radiographs
are typical findings but are nonspecific for aCPo.
the frequent presence of comorbid conditions in patients
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.
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.
presentation, ischemia or perforation of the colon is re-
ported in 3% to 15% of cases with associated mortality
fever, leukocytosis, abdominal tender-
ness, and cecum dilation >12 cm, are factors that may be
indicative of colon ischemia or perforation in aCPo.
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
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.
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
physical examinations and repeat abdominal radiographs
facilitate continuous reassessment. Clinical signs of isch-
emia include increased pain, fever, abdominal tenderness,
in a series of 400 patients with aCPo,
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.
if serial examinations and abdominal
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.