SURGERY FOR VOLVULUS Who and When?

1. SURGERY FOR VOLVULUSWho and When? Mr Graham Williams Consultant Colorectal Surgeon Wolverhampton

3. SIGMOID VOLVULUSWorldwide Incidence % of all intestinal obstruction Ballantyne Dis Colon Rectum 1982

4. SIGMOID VOLVULUSAverage Age at Presentation Age in years Ballantyne Dis Colon Rectum 1982

5. SITE OF VOLVULUS Splenic Flexure 1% Transverse 3% Ceacal 33% Sigmoid 63%

6. CAUSES OF VOLVULUS • Chronic constipation • Neuropsychotropic drugs • Elderly population (care homes) • Pregnancy • High fibre diets • Chagas disease

7. VOLVULUSDiagnosis • Sudden onset abdominal pain • Previous history • Distended, resonant abdomen • NB Tenderness and guarding • Plain X-ray • Contrast study

11. SIGMOID VOLVULUS Issues to consider: • Simple or complicated • Underlying diagnosis • Acute management • Subsequent management • Resect or fix

13. SIGMOID VOLVULUS Colonic Infarction: • 10% at presentation • Increasing pain • Tachycardia • Tenderness with guarding • Gas in wall on x-ray • Free gas

14. SIGMOID VOLVULUSMortality Rates Western series African series % % Viable bowel Gangrenous Emergency Elective Madiba & Thomson J Roy Coll Surg Edinb 2000

15. SIGMOID VOLVULUS Colonic Infarction: • Immediate resuscitation • Emergency laparotomy • Resection of infarcted segment • Ends out!

16. TREATMENT OF SIGMOID VOLVULUS Initial Management • Endoscopic decompression • Rigid ∑ + flatus tube • Flexible sigmoidoscopy • Colonoscopy

17. 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%

20. TREATMENT OF SIGMOID VOLVULUS Initial Management • Endoscopic decompression • Rigid ∑ + flatus tube • Flexible sigmoidoscopy • Colonoscopy • Laparotomy and Pexy • Laparotomy and resection • Colostomy • Primary anastomosis • Percutaneous Endoscopic Colostomy • Mesosigmoidoplasty • Laparoscopic resection Definitive Management

21. TREATMENT OF SIGMOID VOLVULUS Factors to be considered in decision making: • Age of patient • Chronological & biological • Physical state • Co-morbidity • Mental state • Social circumstances

22. Local Resection

23. Pexy (fixation)

24. SIGMOID VOLVULUSResection vs Colopexy Welch & Anderson 1987 Bagarini et al 1993 % % Resection Colopexy Resection Colopexy Mortality Recurrence

25. MEGACOLON & VOLVULUVS

26. SIGMOID VOLVULUSInfluence of Megacolon on Recurrence Recurrent volvulus Number 15 10 5 2 Normal Caliber Megacolon Chung et al Br J Surg 1999

29. SURGERY FOR SIGMOID VOLVULUS Options in presence of megacolon: • Extended left hemi colectomy • Subtotal colectomy • Ileostomy • Ileo-rectal anastomosis • Caecorectal anastomosis

31. SIGMOID VOLVULUS Percutaneous Endoscopic Colostomy • 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

32. Mesosigmoidoplasty for Volvulus • Broadens attachment of mesentery • No anastomosis • Difficult to perform with oedematous or thickened mesentery • Subrahmanyam (1992) Br J Surg • 126 patients (60% emergency) • 1 death • 2 recurrences

33. CAECAL VOLVULUS • Involves caecum and ascending colon • May resolve spontaneously • High index of suspicion • Laparotomy required • Resection +/- stomas • Caecopexy • Caecostomy

34. Simple ? Infarction SIGMOID VOLVULUS ∑ decompression ? Infarction Unsuccessful Urgent Laparotomy Unsuccessful Colonoscopy Viable Dead Colon Successful Resection Stoma / Anastomosis Fixation Pex, Lap, PEC Elective Resection