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Volvulus Lesley Hunt Northern General Hospital Sheffield

Volvulus Lesley Hunt Northern General Hospital Sheffield. Colonic Volvulus. Incidence 1.7 per 100 000 in UK Wide geographical variation Elderly psychiatric institutionalised patients Mortality 7-30% per episode. Dilemma ? why. No randomised trials

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Volvulus Lesley Hunt Northern General Hospital Sheffield

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  1. Volvulus Lesley Hunt Northern General Hospital Sheffield

  2. Colonic Volvulus • Incidence 1.7 per 100 000 in UK • Wide geographical variation • Elderly psychiatric institutionalised patients • Mortality 7-30% per episode

  3. Dilemma ? why • No randomised trials • No controlled trials • No prospective audits • Small retrospective studies • Few up to date studies

  4. Management options • Non operative decompression • Surgical resection • Colopexy procedures • Percutaneous endoscopic colostomy (PEC) • No treatment

  5. Non operative decompression • Widely accepted • Rigid sigmoidoscope or colonoscope • 90% successful • 5-8% mortality • 22-90% recurrence

  6. Surgery (1) Non viable bowel • Resection (Hartmanns) • Mortality 0-75%

  7. Surgery (2) Viable bowel • Early surgery • Mortality (elective) 0-15% • Choice of operation/survival • ? Laparoscopic

  8. Surgery (3) Sigmoid colectomy • Good results in able bodied • Sigmoid colectomy + anastomosis 37% recurrence • Sigmoid colectomy + stoma 20% recurrence • Associated mega colon 82% recurrence • Mortality 0-15%

  9. Surgery (4) Non resection • Mesocoloplasty: mortality 40% recurrence 27% • Colopexy: mortality 11% recurrence 21% • Tube sigmoidostomy: mortality 0% recurrence 0%

  10. Percutaneous endoscopic colostomy (PEC) • Simpson et al BJS 2000 • 14 patients • No deaths • Tube removed 8 (3 recurred) • Tube in situ 5 (0 recurred)

  11. PEC

  12. PEC (Sheffield) • In Sheffield 11 date (Dr Mark McAlindon) • 2 leaks • 1 patient washout and PEC retained later converted to stoma • 1 patient ITU emergency colostomy

  13. Ceacal volvulus • Colonoscopic de-rotation: high failure rate + delays operation • Ceacostomy, Caecopexy or Right hemicolectomy • Similar mortality (9 and 4.5%) • 30% recurrence after ceacopexy • 0% recurrence after tube ceacostomy

  14. ? No Treatment • Northern Chapter of ACPGBI • Scenario: elderly demented patient with sigmoid volvulus • 65% no surgery • 26% no colonoscopic decompression

  15. Sigmoid volvulus (unfit patient) Viable bowel Yes No Non operative de-rotation Could possibly survive surgery Successful Yes Unsuccessful Patient/family wish surgery Could possibly survive surgery No Patient/family wish intervention TLC Hartmann’s procedure Yes Yes Yes No Patient/family wish surgery PEC Recurrent episodes Expectant policy Operative de-rotation and fixation

  16. Sigmoid volvulus (fit patient) Viable bowel Yes No Non operative Decompression Hartmann’s Procedure Successful Unsuccessful No Viable bowel Urgent Surgery Emergency surgery Yes Evidence of mega colon No evidence of mega colon Sigmoid colectomy Subtotal colectomy

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