Abstract

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original paper
Sigmoid volvulus: a 10-year-audit
Sigmoid volvulus: a 10-year-audit
S Connolly, AE Brannigan, E Heffernan, JMP Hyland
Centre for Colorectal Disease, St Vincent’s University Hospital, Dublin, Ireland
Abstract
Background Chronic constipation in elderly, institutionalised patients is the leading cause of sigmoid volvulus in the
developed world. Endoscopic deflation is associated with a 90% recurrence rate and a 35% mortality rate.
Aims To review a 10-year experience of sigmoid volvulus and encourage more aggressive primary treatment.
Methods A retrospective study was performed on 16 patients with sigmoid volvulus from 1992 to 1999. Patients
were identified using the hospital inpatient enquiry (HIPE) data system. Demographics, clinical course, intervention,
complications and outcome were recorded.
Results The male:female ratio was 5:3 and mean age was 78 years (range 39-92). Fifty per cent had at least one
risk factor: Parkinson’s disease (n=3); multiple sclerosis (n=1); Alzheimer’s disease (n=1); and hypokalaemia (n=3).
Thirty-seven per cent were managed conservatively and 63% required surgical intervention. Mean time to surgery
was 2.4 days. Operations performed were sigmoid colectomy (45%), Hartmann’s procedure (33%) and total
colectomy (22%). There was one post-operative death from myocardial ischaemia. Mean duration of admission was
21 days.
Conclusions Endoscopic deflation of a sigmoid volvulus facilitates optimisation of cardiopulmonary co-morbidity in a highrisk group of patients. It converts an emergent to an elective procedure and minimises operative morbidity as a result.
Introduction
Sigmoid volvulus secondary to high dietary fibre is the most
common cause of large bowel obstruction in the developing
world,1 while chronic constipation among elderly,
institutionalised patients is the leading cause of sigmoid
volvulus in the developed world.2 Historically, the management
of this condition has been conservative with surgical
intervention reserved for patients failing endoscopic
decompression. This largely reflected a mortality rate of
approximately 15-30% among patients undergoing emergency
laparotomy. Newer, less invasive techniques such as
sigmoidopexy have been described but are not universally
applied.3 We reviewed the management and outcome of
patients presenting to one Irish institution with volvulus of the
sigmoid colon over a 10-year period.
Patients and methods
Patients with a diagnosis of sigmoid volvulus were identified
retrospectively using the HIPE system. All charts were analysed and
data collected. Sixteen patients presented with previously undiagnosed
sigmoid volvulus. The male:female sex ratio was 10:6 and the mean age
was 78 years (range 39-92). Ten patients (66%) were resident in nursing
homes, 3 (20%) lived alone and 2 (13%) lived in a family setting. Fifty
per cent of patients had risk factors documented at the time of
presentation. Three patients (19%) had Parkinsonism, one (6%) had
multiple sclerosis and was on anticholinergic medication and one (6%)
had Alzheimer’s disease. Three patients (19%) were hypokalaemic at
presentation and one patient (6%) had a history of chronic constipation.
Results
Management
All 16 patients had clinical findings consistent with large bowel
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obstruction and suggestive of sigmoid volvulus. Patients
and/or carers typically reported constipation, abdominal
distension and colicky abdominal pain. All patients had an
abdominal radiograph at the time of admission and, in four
cases, a gastrograffin enema was performed. All 16 patients
were catheterised and resuscitated with intravenous fluids.
Ten patients underwent surgical intervention at a mean of
2.4 days and the diagnosis was confirmed intraoperatively. Of
these 10 patients, four underwent an initial attempt at
endoscopic decompression. This failed in three patients and in
the case of the fourth patient initial success was followed by a
recurrent volvulus requiring surgical intervention 15 days later.
Antibiotic prophylaxis was administered at anaesthetic
induction and at laparotomy the volvulus was reversed and the
diseased segment resected with primary anastomosis in 66% of
patients; sigmoid colectomy 45%, subtotal colectomy 22% and
a Hartmann’s procedure was performed in the remaining 33%
of patients. Subsequent histology supported the diagnosis of
volvulus.
Outcome
Eighty per cent of patients were admitted to the intensive care
unit postoperatively for a mean of 1.8 days. There was one perioperative death secondary to a myocardial infarction on the
first post-operative day. Patients were discharged from hospital
after a mean of 21 days. The mean follow-up is two years and
there has been no evidence of recurrent disease in the
surgically-treated group of patients.
Discussion
The elderly population is expected to grow in both absolute
numbers and as a percentage of the overall population and
6.5% of the population will be over 80 years of age by 2010.4
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S Connolly et al
Sigmoid volvulus is the third most common cause of large
bowel obstruction and, in the Western world, generally occurs
in elderly, institutionalised patients. Initial conservative
treatment is associated with a recurrence rate of 45-90%.
Recurrent volvulus requires surgical intervention and is
associated with significant morbidity as it is often associated
with a need for emergency surgery.
The independent influence of age on surgical morbidity and
mortality is controversial. Both generally increase with age but
whether this is due to specific anaesthetic and surgical risks or
reflects co-morbidity is difficult to determine. The timing of
surgical intervention is critical among the elderly, as mortality
for emergent procedures is significantly higher than for the
same operation done on an elective basis.5
Historically, sigmoid volvulus was treated conservatively by
sigmoidoscopic decompression, which is associated with a
recurrence rate of up to 90%. Emergency operative mortality
was historically reported at up to 35%.6 Over the last 10 years,
the impact of aggressive resuscitation, correction of reversible
medical problems combined with advances in anaesthesia have
improved patient outcome. The conversion of an emergency
procedure to an elective one has reduced the operative
mortality rate to as low as 5%.7
Current literature suggests that elderly patients presenting
with sigmoid volvulus should be aggressively resuscitated and
undergo sigmoid endoscopic deflation, which allows correction
of reversible cardiopulmonary conditions. Once medically
optimised, patients who are fit for surgical correction may have
a better outcome with elective surgery than with recurrent
volvulus treated nonoperatively.7-9 Patients presenting with
evidence of non-viable bowel confirmed at laparotomy have a
poorer prognosis; however, in such cases, surgical resection
with formation of a stoma may carry a better prognosis than
primary anastomosis.10 In the absence of endoscopic evidence
of necrosis and in the presence of healthy bowel at laparotomy,
resection and primary anastomosis is preferable.11
Minimally invasive techniques such as endoscopic
sigmoidopexy and laparoscopic-assisted sigmoidectomy have
been reported in the literature and appear to be associated with
minimal morbidity (although this is based on case reports only
and has not been the subject of a randomised trial).3,12
With an ever-increasing geriatric population, the problem of
Irish Journal of Medical Science • Volume 171 • Number 4
sigmoid volvulus is likely to become more common in the
future. Advances in the anaesthetic management of elderly
patients coupled with a mortality rate of up to 21% associated
with recurrent sigmoid volvulus following conservative
treatment may enhance the alternative option of definitive
initial treatment of this condition following resuscitation.7
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Correspondence to: Mr John Hyland, Tel: (01) 269 5033; fax: (01)
269 7949; email: [email protected]
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