Volvulus Colorectal Conference



Yüklə 446 b.
tarix01.05.2017
ölçüsü446 b.


Volvulus


Volvulus

  • Obstruction caused by twisting of the intestines more than 180 degrees about the axis of the mesentery

  • 1-5% of large bowel obstructions

    • Sigmoid ~ 65%
    • Cecum ~25%
    • Transverse colon ~4%
    • Splenic Flexure


Sigmoid Volvulus

  • Worldwide - up to 50% of obstruction

    • India, Africa, E. Europe
  • More commonly seen in elderly patients in western societies

  • Redundant colon, mesocolon narrowed, twisting at mesentery

  • Risk factors

    • Chronic constipation
    • Psychiatric problems
    • Non-western societies
      • high residue diet


Presentation

  • Hx: Abdominal pain, distension, no flatus or bowel movements

  • Exam: tympanitic abdomen, distension, mild tenderness, palpable mass



Sigmoid volvulus

  • “bent inner tube” appearance

  • Dilated sigmoid loop with limbs pointing towards the RLQ



Sigmoid volvulus

  • “Coffee bean” appearance with the two twisted loops with a central doubled wall component



Barium Enema

  • Contraindicated in patients with free air on AXR, clinical signs of peritonitis, or suspicion for necrosed bowel

  • Bird’s beak

  • Can decompress



Management of choice

  • Endoscopic decompression

    • Rigid or flexible proctosigmoidoscope inserted into rectum
    • Gush of air/feces --> successful decompression
    • Rectal tube
    • Successful in 85-90% of cases
    • Recurrence rate >60%
    • Decreased risk for bowel necrosis if treated early
      • Colon ischemia, perforation
    • Elective resection


Operative management for sigmoid volvulus

  • Elective resection

    • Same admission
  • Emergent laparotomy

    • Operation depends on viability of the bowel
      • Resection and anastomosis
      • Hartmann resection
      • Exteriorization resection
      • Detorsion
      • Detorsion with colopexy
      • Percutaneous colostomy
      • Percutaneous sigmoidpexy


Delayed resection with primary anastomosis

  • Delayed resection with primary anastomosis

    • Mortality rate 8%
  • Operative mortality related to viability of bowel



Cecal Volvulus

  • Less common than sigmoid volvulus

  • Parietal peritoneum fails to connect with the cecum and right colon

    • Present in about 10% of population
  • Increased mobility of bowel, resulting in it folding on its axis or upward

  • Torsion occurs proximal to cecum

  • Risk factors:

    • Distal obstruction, pregnancy, adhesions, congenital bands, prolonged constipation, meteorism (air in intestines) that occurs with non-pressurized air travel


Hx: abdominal pain, colicky

  • Hx: abdominal pain, colicky

    • Distention
  • Axial torsion type

    • Twist 180-360 degrees on longitudinal axis of ascending colon (distal ileum and ascending colon)
    • Associated with bowel compromise, ischemia, and perforation
  • Cecal bascule



X-rays

  • “comma” shaped

  • Convexity toward right and downward

  • BE - risk of perforation with getting air/contrast to right colon



Management

  • Decompression with colonoscope

    • Less successful than with sigmoid volvulus
  • Emergent operation if signs of vascular compromise



Operative management for cecal volvulus

  • Detorsion ± appendectomy

  • Cecopexy/Laparoscopic cecopexy

    • Suture R colon to lateral paracolic gutter or use lateral peritoneal flap
  • Cecostomy

  • Resection

    • Right colectomy with primary anastomosis


Results

  • Detorsion ± appendectomy

    • High rate of recurrence (not commonly done anymore)
  • Cecopexy

    • Do not need to have prepped bowel
    • Recurrence 25%
  • Cecostomy ± cecopexy

    • Combined procedure more effective in preventing recurrence
  • Resection

    • Primary anastomosis unless peritoneal contamination is present


Transverse colon volvulus

  • Less common area for volvulus(4%)

  • Associated with mobile right colon, distal obstruction, chronic constipation, congenital malrotation of the midgut

  • Usually not diagnosed preoperatively

  • No characteristic radiological findings except colonic dilatation

  • Resection of transverse colon

    • High rate of recurrence if treated with detorsion alone



Yüklə 446 b.

Dostları ilə paylaş:




Verilənlər bazası müəlliflik hüququ ilə müdafiə olunur ©azkurs.org 2020
rəhbərliyinə müraciət

    Ana səhifə