19
Colonic Volvulus
Michael D. Hellinger and Randolph M. Steinhagen
Introduction/Historical Perspective
Volvulus of the bowel refers to a twisting or torsion of the
intestine about its mesentery. The term volvulus, which may
involve any segment of the intestinal tract from stomach to rec-
tum, is a Latin word for twisted used by the Romans to signify
this condition.1 Volvulus of the colon usually occurs in the
sigmoid or cecum, but may involve any segment of colon. In
addition, synchronous volvulus of the sigmoid and cecum,2 or
sigmoid and ileum may occur.3 In the United States, volvulus
represents a rare cause of intestinal obstruction, encompassing
less than 5% of large bowel obstructions. However, worldwide
it is a much more common form of large bowel obstruction,
representing more than 50% of the cases in some countries.46
The first record of colonic volvulus is found in the Ebers
Papyrus from ancient Egypt. This record stated that either
volvulus would spontaneously reduce or the segment of bowel
would rot in his belly. The writings further document that if
this condition did not resolve, the patient should be prepared
for remedies to induce detorsion. As early as 1500 BC, there-
fore, it was recognized that detorsion was crucial for resolution
of this condition. Even in ancient times, a high fiber diet was
believed to be contributory to the development of volvulus. At
that time, treatment was directed at symptoms and relief of the
obstruction. External manipulation combined with purgatives
was the treatment of the times. Hippocrates advocated use of a
10-digit long suppository and air blown into the anus with a
metal workers bellows. This is perhaps the earliest predeces-
sor to todays sigmoidoscopic decompression.1,7
During subsequent years, reports concerning colonic
volvulus were infrequent. It was not until the 19th century,
when investigators began attempting to determine causes of
disease, that this entity was discussed further. Perhaps the fact
that volvulus was not recognized as a cause of colonic
obstruction was accounted for by the rarity of the diagnosis
before the 1800s. In 1872, Crise reported 12 cases, and in
1884 Treves reported 34 cases of colonic volvulus. In 1894,
Obalinski recognized regional variations in frequency of
volvulus.1,7,8
286
Throughout most of the 19th century, management was
nonoperative. Operative intervention was reserved for life-
threatening situations. High mortality rates for intestinal
operations in the face of obstruction were the reasons cited in
avoiding surgery. With advances in anesthesia and antisepsis,
surgical procedures were developed. In 1883, Atherton per-
formed the first successful operative detorsion of a sigmoid
volvulus in the United States. The next year, Treves recom-
mended colectomy for volvulus complicated by gangrene. By
1889, in fact, all of the surgical options for volvulus, includ-
ing detorsion, -pexy, and resection with or without stoma, had
been described.1,7
Early in the 20th century, with improvements in early diag-
nosis and rapid therapy, mortality rates began to decrease and
surgical therapy became the mainstay. Mortality rates
decreased from 30%60% to under 20%. Mortality for gan-
grenous bowel remained high (30%40%), reflecting a delay
in diagnosis and treatment. Moynihans statement in 1905
that a mortality of greater than 10% is the mortality of delay
had been confirmed in many series.1,7 Until the mid-20th cen-
tury, immediate surgical intervention was the standard of care.
In 1947, Bruusgaard, from Norway, challenged the routine
surgical approach, and reported a success rate of 86% for non-
operative reduction of sigmoid volvulus with proctoscopic
decompression and placement of a rectal tube.9 This paved the
way for todays therapeutic algorithms in the management of
colonic and specifically sigmoid volvulus.1,7 Finally, with wide-
spread use of flexible endoscopy, many authors have reported
successful detorsion and decompression of all forms of colonic
volvulus using the colonoscope or flexible sigmoidoscope.1015
Because of high recurrence rates, these endoscopic methods are
currently recommended as definitive treatment only for very
high-risk individuals who are too ill to undergo surgery, and as
a temporizing measure until eventual surgery under more con-
trolled conditions for all other patients.1,7,9,1416
The differential diagnosis of colonic volvulus encompasses
any cause of colonic distention. This includes all of the
mechanical as well as the nonobstructive causes. Mechanical
causes include colonic and extracolonic neoplasms, as well as
19. Colonic Volvulus 287

benign entities such as diverticulitis and inflammatory bowel

disease. Nonobstructive causes include colonic pseudo-
obstruction (Ogilvies syndrome), and various intraabdominal
processes that may result in an intestinal paralysis. In addi-
tion, Hirschsprungs disease must also be considered.5,6,17

Cecal Volvulus
Incidence and Epidemiology
Worldwide, cecal volvulus accounts for 40%60% of all
colonic volvuli. Originally described in 1837 by Rokitansky,
it remains, however, an uncommon cause of intestinal
obstruction. The worldwide incidence is estimated at 2.87.1
per million people per year. Most reported cases occur in
younger individuals with a predilection for females.1820 In a
review of the published literature between 1959 and 1989,
Rabinovici et al.19 found a mean age of 53 years and a female
to male ratio of 1.4:1.

Pathogenesis/Etiology
True cecal volvulus is actually an axial torsion of the cecum,
terminal ileum, and ascending colon about its mesentery
(Figure 19-1A). A variant, cecal bascule (Figure 19-1B), occurs
when the cecum folds anteriorly over the ascending colon with-
out an axial twist. This represents approximately 10% of cases
of cecal volvulus. Review of patient characteristics indicates
that there is a high rate of prior abdominal operations in
patients who subsequently develop cecal volvulus, and previ-
ous surgery has been considered to be a potential causative fac-
tor. A clear prerequisite is a mobile cecum and ascending colon.
A congenital component involves lack of fixation of the right
colon, which then assumes an intraabdominal position.4,1820 In
fact, a cadaver study revealed an 11% incidence of freely
mobile right colons, and a 26% incidence of cecal mobility suf-
ficient to allow folding. The authors concluded that 37% had
cecums mobile enough to allow for volvulus.4
However, because cecal volvulus is so rare, factors other
than cecal mobility must be involved. Prior abdominal sur-
gery with colonic mobilization, recent surgical manipulation,
adhesion formation, congenital bands, distal colonic obstruc-
tion, pregnancy, pelvic masses, extremes of exertion, and
hyperperistalsis have all been implicated.4,1820 During
abdominal surgery, excessive mobilization or manipulation of
the cecum and ascending colon or placement/withdrawal of
packs may precipitate postoperative volvulus.4 Previous
FIGURE 19-1. A Schematic illustration of a cecal volvulus.
reports of cecal volvulus reveal that 30%70% of patients had
B Schematic illustration of a cecal bascule.
undergone prior surgery.19,20 In the long term, an adhesive
band may act as a fulcrum for a previously mobilized ileum
and right colon to rotate axially. Displacement of the cecum
Clinical Presentation
by an enlarged uterus or pelvic mass may also promote volvu-
lus. In fact, several series report that 10% of patients with Symptoms and signs of cecal volvulus are that of small bowel
cecal volvulus are pregnant at the time of presentation.4,20 obstruction. The majority of patients present with abdominal
288 M.D. Hellinger and R.M. Steinhagen

pain, distention, constipation, nausea, and vomiting. Abdominal

distention is less marked than with more distal forms of
colonic volvulus. The presentation may be that of an acute
obstruction or one of an intermittent or recurrent pattern. In
the intermittent pattern, because duration of symptoms is
brief, diagnosis may be quite difficult. Acute volvulus results
in a closed loop cecal obstruction and distal small bowel
obstruction. This may progress to a more fulminant presenta-
tion when ischemia and gangrene develop. At that point, the
patient will present with peritoneal signs and systemic mani-
festations of an acute abdominal process. Before onset of gan-
grene, fever and leukocytosis are unreliable factors.1719,21

Diagnosis
The diagnosis is most often made on the basis of the combi-
nation of clinical presentation and plain abdominal films or
barium enema. Plain films may identify the classic coffee bean
deformity directed toward the left upper quadrant (Figure 19-
2A). If not, barium enema may reveal a birds beak or col-
umn cut-off sign in the right colon (Figure 19-2B).4,1719 In the
review by Rabinovici et al., 53% of cases were diagnosed pre-
operatively with clinical evaluation combined with radiologic
investigation. The diagnosis was suspected in 46% of plain
films, and barium enema was diagnostic in 88% of cases when
obtained. However, 47% were not diagnosed until laparo-
tomy.18 Although barium enema is of clear value when the
diagnosis is in question, in obvious cases, performance of this
study may needlessly delay surgical therapy. It therefore
should not be routinely used.4

Treatment/Outcome
Laparotomy remains the primary treatment modality for cecal
volvulus. Many patients are not diagnosed until exploration,
and nonoperative modalities have generally been unsuccessful.
However, both radiographic and endoscopic reduction have
been reported. Whereas radiographic attempts at reduction are
generally believed to carry a high risk of perforation, other
modalities have been used as temporizing measures.4,5,16,18
Percutaneous decompression via computed tomographic scan
guidance has been reported to be effective in decompressing a
massively dilated colon in otherwise inoperable candidates.22,23
Although significantly less efficacious than in the treatment
of distal volvulus, colonoscopic reduction of cecal volvulus
(Figure 19-3) has been reported with some success. Reasons
cited for limited use of this approach include difficulty tra-
versing the extent of unprepared bowel to reach the right
colon, difficulty performing the detorsion, the relative infre-
quency in which the diagnosis is made before laparotomy, and
the higher rate of ischemic changes in cecal volvulus than in
sigmoid volvulus. In fact, several authors have condemned FIGURE 19-2. A Plain abdominal X-ray of a cecal volvulus with
this approach as only unnecessarily delaying definitive surgi- a coffee bean deformity evident in the left upper quadrant. B
cal intervention and potentially placing the patient at risk for Barium enema study of a cecal volvulus revealing a birds beak
perforation. However, if successfully used, there may be a deformity.
19. Colonic Volvulus
FIGURE 19-3. Colonoscopic reduction of a cecal bascule.
relatively low rate of recurrence and the requirement for sub-
sequent surgery is debated.4,5,10,11,16,18,24,25
In general, the majority of individuals undergo surgical
intervention with a clear diagnosis of cecal volvulus, for com-
plete bowel obstruction, or for an acute surgical abdomen.
Obviously, in the face of gangrenous or ischemic bowel,
resection is mandatory. When viable bowel is encountered,
although resection is the preferred option, other alternatives
exist. These include detorsion alone or combined with
some fixation procedure. Fixation options include cecopexy
and/or cecostomy. Appendicostomy has also been
reported.4,5,18,19,25,26
Generally, fixation is accomplished by cecopexy and/or
cecostomy. Cecopexy is performed by elevating a lateral peri-
toneal flap along the entire length of the ascending colon, and
suturing the flap to the serosa of the anterior colonic wall,
thereby placing the ascending colon in a partially retroperi-
toneal location, and eliminating the excess mobility (Figure
19-4). An advantage of tube cecostomy is that it not only
anchors the cecum, but also provides a vent for the distended
colon. Cecostomy is relatively simple to perform, and after
removal of the tube, spontaneous closure is common.4,5,18,25 In
a review of the literature, Rabinovici et al.19 found that detor-
sion, cecopexy, and cecostomy all carry similar recurrence
rates of 12%14%. Interestingly, they also noted a mortality
for cecostomy triple that of either cecopexy or detorsion (32%
289
FIGURE 19-4. Colopexy and cecostomy for cecal volvulus.
versus 10% and 13%, respectively). Other authors have
reported recurrence rates ranging from 0% to 30%.4,5,18,25
Resection, however, carries virtually no risk of recurrence
and is not associated with a higher rate of postoperative com-
plications when compared with cecopexy alone.18,25 After
resection, primary anastomosis can usually be safely per-
formed. However, in the face of gangrenous bowel, end
ileostomy may be a safer procedure. The ultimate decision
regarding intestinal anastomosis is one made at the time of sur-
gery, taking into account degree of contamination, and the
patients overall status.4,5,18,19,25,26 Overall mortality is inde-
pendent of the procedure chosen, rather it is related to whether
or not the surgery is elective or emergent and the presence or
absence of gangrene. Literature documents no mortality in the
elective situation. If viable bowel is found at the time of an
emergency operation, mortality ranges from 7% to 15%. This
increases to 33%41% in the face of gangrenous bowel.4,18,25
Transverse Colon Volvulus
Incidence and Epidemiology
Volvulus of the transverse colon is an exceptionally rare find-
ing. It is estimated to represent from 1% to 4% of all forms of
colonic volvulus. However, in Eastern and Scandinavian
290 M.D. Hellinger and R.M. Steinhagen

countries, it may comprise 30%40% of cases. This form of recurrence, and may therefore be best reserved for those high-
volvulus tends to occur more often in the young, with most risk individuals who show no signs of compromised
series showing a peak incidence in the second through fourth bowel.12,14,18 However, colonoscopy may serve to confirm
decades of life. There is a two- to threefold female predomi- intestinal viability and allow for a less emergent definitive
nance.4,18,20,2729 procedure to be performed.30
Operative procedures include detorsion with or without
colopexy, and resection. Most authors recommend either seg-
Pathogenesis/Etiology mental transverse colectomy or extended right colectomy as
Although anatomic factors are key to the development of definitive treatment. Clearly, in the presence of nonviable
transverse colon volvulus, physiologic, rather than congenital, bowel, resection is mandatory.12,14,18,3032 As in cecal volvu-
factors seem to have a crucial role in the development. These lus, the decision regarding primary anastomosis versus diver-
patients frequently have a history of chronic constipation sion is made during surgery, taking into account the severity
and/or laxative abuse, previous abdominal surgery, a diet high of the disease process and the patients overall condition.
in fiber, recurrent distal obstruction, and institutionalization. When viable bowel is encountered, several different
There are also reports, however, of an association with malro- colopexy procedures have been reported. These include
tation, Hirschsprungs disease, and Chilaiditis syndrome. suture of the greater omentum, transverse mesocolon, or
Finally, adhesive bands, frequently reported in these patients, transverse colon itself to the anterior abdominal wall and/or
may act as a fulcrum around which the bowel can twist. pelvis,18,30,32 and the U colopexy reported by Mortensen.31 In
Specific factors that may increase the risk of occurrence are a this procedure, after reduction and needle decompression of
redundant or elongated transverse colon with narrow mesen- the volvulus, the redundant U-shaped loop of transverse
teric attachments, narrowed distance between the flexures, colon is sutured to the adjacent limbs of ascending and
and an absence or paucity of fixation of the mesentery. These descending colon (Figure 19-5).
factors increase the likelihood of an axial rotation of the trans- Recurrence from either detorsion or colopexy has been
verse colon about its mesentery.4,18,20,2731 reported to range from 30% to 75%, whereas resection elim-
inates virtually all risk of recurrence.25,32 Mortality, however,
Clinical Presentation
Transverse colon volvulus presents as a large bowel obstruc-
tion. Presentation may be as a subacute recurring process or
may take a more fulminant course. The subacute form is asso-
ciated with repetitive episodes, each with gradual onset.
Although associated with significant abdominal distension,
pain is mild to moderate, and vomiting is usually absent. Up
to 50% of patients admit to previous episodes. The fulminant
form is associated with less distension, but marked pain and
vomiting. Clinical deterioration is rapid in these
cases.4,17,2729,31
Although diagnosis may be suspected on clinical presenta-
tion, plain films are rarely diagnostic. The diagnosis is there-
fore usually made at the time of exploration. Plain films may
reveal a distended proximal colon with decompressed distal
bowel and two distinct air-fluid levels representing two limbs
of the volvulized transverse colon. This has been described as
a bent inner-tube appearance with the apex pointing inferi-
orly. Barium contrast studies, if performed, will demonstrate
a birds beak deformity at the distal transverse colon.
However, awaiting these studies only leads to a delay in defin-
itive management.4,17,2730

Treatment/Outcome
Although successful endoscopic decompression has been
reported, surgical intervention is the recommended treatment
modality. Based on literature from surgical detorsion, it is
assumed that endoscopic treatment will lead to a high rate of FIGURE 19-5. Parallel coloplasty as described by Mortensen.31
19. Colonic Volvulus
from resection has been reported to be as high as 33%. This
is primarily in the setting of gangrene or perforation.18,27 In
these cases, mortality may be decreased by construction
of an end stoma or extended resection with ileocolic anasto-
mosis.30
Splenic Flexure Volvulus
Incidence and Epidemiology
Having been described in fewer than 50 patients in the
English literature, volvulus of the splenic flexure of the colon
is the rarest form of colonic volvulus. It is estimated to repre-
sent 1%2% of all cases of colonic volvulus. It seems to be
more common in women and occurs at a younger age than
cecal or sigmoid volvulus.4,13,25,33,34
Pathogenesis/Etiology
The infrequency of this form of volvulus is believed to be the
result of multiple attachments of the splenic flexure, and the
retroperitoneal position of the descending colon. Three liga-
ments, the gastrocolic, splenocolic, and phrenocolic, are
responsible for fixation of the splenic flexure. Congenital
absence, laxity, or iatrogenic disruption of these ligaments
may lead to excessive mobility of the splenic flexure. In
addition, an intraperitoneal descending colon and adhesive
bands from previous surgery may further predispose to the
development of this form of volvulus. In fact, up to two-
thirds of patients have had prior abdominal surgery. Finally,
it has been speculated that chronic constipation may lead to
redundancy of the colon and elongation of the mesentery.
This may possibly create laxity of the ligamentous attach-
ments.4,13,25,33,34
Clinical Presentation
As in transverse colon volvulus, the presentation may be
acute and fulminant, or a more chronic or subacute event.
Many patients have a history of severe chronic constipation,
with longstanding laxative abuse. At presentation, the major-
ity of patients have significant abdominal distention and pain.
Although nausea and vomiting are common, obstipation is
rare. Very few patients present with strangulation, gangrene,
or findings of an acute surgical abdomen.4,33,34
Four features have been described radiographically that
may suggest splenic flexure volvulus. They are: 1) a markedly
dilated air-filled colon with an abrupt termination at the
splenic flexure; 2) two widely spaced air-fluid levels, one in
the cecum and the other in the transverse colon; 3) an empty
descending and sigmoid colon; and 4) a birds beak obstruc-
tion at the splenic flexure on contrast enema examination
(Figure 19-6). An additional sign is a crescenteric gas shadow
in the left upper quadrant of the abdomen.13,33
291
FIGURE 19-6. Barium enema study of a chronic splenic flexure volvu-
lus. Arrows indicate the point of rotation and birds beak deformity.
Treatment/Outcome
Although colonoscopic and fluoroscopic decompression have
been reported, most reports have identified surgery as the pri-
mary mode of management. Surgical options include resec-
tion with or without stoma formation, or detorsion with or
without colopexy. Segmental resection may be considered;
however, the majority of these patients will have an associated
redundant, dilated colon and a history of chronic constipation.
Therefore, these patients may be better served by undergoing
an extended resection with an ileosigmoid or ileorectal anas-
tomosis. Stomas should be reserved for cases involving gan-
grenous bowel with perforation and peritoneal contamination,
or for other high-risk cases.4,13,25,34
No mortality has been reported with either form of surgical
management. The complication rate, excluding recurrence, is
in the range of 10%. Resection carries a 0% recurrence rate.
However, the recurrence rate after detorsion alone, whether
performed surgically, endoscopically, or fluoroscopically, is
approximately 20%25%. As a result of these high recurrence
rates, nonoperative decompression/detorsion should be
reserved for extremely high-risk patients who are not candi-
dates for surgical intervention, or as a temporizing measure
before a semi-elective definitive resection.4,13,34
Sigmoid Volvulus
Incidence and Epidemiology
Although it is the most common form of volvulus seen,
volvulus of the sigmoid colon is not very common in the
United States and Western Europe, accounting for less than
10% of all cases of large bowel obstruction.5,6,19,35 In some
regions of Asia, Africa, and other less-developed portions of
the world, however, the situation is significantly different. In
these areas, sigmoid volvulus accounts for 20%50% of the
292
cases of intestinal obstruction. Overall, there is a substantial
male predominance, especially in developing nations.
However, sigmoid volvulus is the most common cause of
intestinal obstruction in pregnancy, accounting for nearly
45% of all intestinal obstructions in this group of
women.3,4,5,19 The reasons for geographic differences in inci-
dence are thought to be primarily related to diet. In the West,
relatively lower amounts of fiber are consumed, resulting in a
much higher incidence of colorectal cancer and diverticular
disease, which are the more common etiologies for colonic
obstruction in these areas. In less-developed regions of Asia
and Africa, extremely high fiber diets result in significantly
elongated colons, and lead to development of sigmoid volvulus,
in relatively young patients.
Pathogenesis/Etiology
Any condition that results in an elongated colon predisposes
to the development of volvulus. In order for volvulus of any
part of the intestinal tract to occur, there must be a long redun-
dant, mobile segment, with a relatively narrow mesenteric
attachment, such that the sites of fixation at each end are rel-
atively close together. The sigmoid colon is the ideal location
for this configuration: the sigmoid can be extremely redun-
dant and mobile and the sites of fixation at the descending-
sigmoid junction and the rectosigmoid junction are often in
close proximity to each other.3,19
Although a single etiology has not been identified, several
theories do exist. In 1849, in his Manual of Pathological
Anatomy, Von Rokitansky proposed that the primary
causative factor was a congenital or acquired long, loose,
and floppy mesentery. Thirty-five years later, in his text of
intestinal obstruction, Treves indicated that the loop in sig-
moid volvulus must be of considerable length, the meso-
colon must be long and very narrow at its parietal attachment,
so that two ends of the loop may be brought as close together
as possible.3
In the West, the typical patient with sigmoid volvulus is an
elderly institutionalized male, often receiving psychotropic
medications, who is usually extremely constipated. Other fac-
tors that have been implicated are laxative abuse, previous
abdominal surgery, and diabetes.3,5,18 In other parts of the
world, the patients are significantly younger.24,36,37
Megacolon from any etiology, but especially Hirschsprungs
disease or Chagas disease, predisposes to volvulus.3,8,19
Gross features of the sigmoid colon include progressive
widening and eventual loss of taenia coli, absence of appen-
dices epiploicae, and a thickened narrowed fibrous mesentery.
The scarring forms patches and bands coined shrinking
mesosigmoiditis by Brusgaard, and is believed to be the
result of previous episodes of volvulus.9,19,38 The rotation may
be either clockwise or counterclockwise. Once the rotation
has reached 360 degrees, a closed loop obstruction occurs.
Hyperperistalsis and fluid secretion into the closed loop add
to increased pressure and tension. Eventually, as blood flow is
M.D. Hellinger and R.M. Steinhagen
compromised, ischemia and necrosis develop. Additionally,
the diminished blood flow may lead to arterial and venous
thrombosis. Three patterns of necrosis have been described:
1) at the neck of the volvulus, 2) any location within the
closed loop, and 3) in the proximal descending colon or dis-
tal rectum because of retrograde mesenteric thrombosis.
Because the sigmoid loop is usually chronically thickened, it
is unlikely for a perforation to occur in this location. In the
face of a competent ileocecal valve, perforation is more com-
mon in the cecum.39
Clinical Presentation
As previously described, the patient is typically a male nurs-
ing home resident, on psychotropic medications, with a his-
tory of chronic constipation. These patients may not complain
of pain, but rather a caregiver notices an extremely long inter-
val between bowel movements, associated with significant
abdominal distension. In younger patients, constipation, dis-
tension, and abdominal pain are the predominant symptoms.38
Before arrival at the hospital, the patient may have been given
enemas or laxatives, without relief. This therapy may have, in
fact, made the distension worse. There is often significant
delay between onset and evaluation.40,41 It has been reported
that 40%60% of patients will give a history of having had
similar episodes.4,38
On presentation, the distension is often dramatic. Unlike
the patient with fecal impaction, the rectal ampulla is empty.
Plain abdominal films typically show massive colonic disten-
sion, with or without small bowel dilatation (depending on the
competence of the ileocecal valve). The very large sigmoid
loop will be orientated toward the right upper quadrant. The
adjacent walls of the sigmoid will appear to be thickened,
arising out of the left lower quadrant, giving the classical
bent inner tube sign (Figure 19-7A).38 In the majority of
cases, plain radiographs are sufficient to establish the diagno-
sis.40 In fact, plain abdominal X-rays alone are diagnostic in
60%75% of cases.39,42 However, the massive distension may,
occasionally, make the diagnosis difficult to establish with
certainty. In those cases, a contrast enema should be obtained.
This study will show the obstruction at the rectosigmoid junc-
tion, with the classical birds beak configuration (Figure 19-
7B).5,39 The addition of barium enema to the plain abdominal
X-rays may increase the diagnostic yield to near 100%.42
The major diagnosis from which sigmoid volvulus must be
distinguished is colonic obstruction caused by neoplasm.
Usually the abdominal X-rays can distinguish one from the
other; however, in the presence of truly massive distension,
differentiation may be difficult. At the time of attempted sig-
moidoscopic detorsion, the obstructing neoplasm will hope-
fully be visualized and the true diagnosis will be apparent.
The other condition that may cause clinical confusion is
colonic megacolon associated with abnormal colonic motility.
This condition also presents in elderly, constipated nursing
home patients. The X-rays can look remarkably similar.
19. Colonic Volvulus
FIGURE 19-7. A Plain abdominal X-ray of a sigmoid volvulus indicating the bent inner tube sign. B Barium enema study of a sigmoid
volvulus indicating the birds beak deformity and complete obstruction to retrograde flow of contrast.
Because rectal tube decompression will generally rapidly and
successfully relieve the distension associated with this form
of megacolon, distinction from volvulus can be difficult. It is
important to make the distinction, however, because this con-
dition is also associated with a high incidence of recurrence,
but will not be successfully treated by sigmoid resection. In
one series, a 37% incidence of recurrent volvulus was seen
after sigmoid resection and anastomosis. However, virtually
all of these patients had megacolon-associated abnormal
colonic motility.43
Treatment/Outcome
The patient with sigmoid colon volvulus should be hydrated
and resuscitated. Since 1947, when Bruusgaard9 reported a
90% success rate with sigmoidoscopic detorsion, the main-
stay of emergency therapy has generally been detorsion and
decompression. Detorsion of sigmoid volvulus has been
described using several techniques, including rigid proc-
toscopy, flexible sigmoidoscopy or colonoscopy, blind
293
passage of a rectal tube, and use of a column of barium dur-
ing barium enema examination.7,9,10,14,15,24 Successful decom-
pression using one of these techniques is generally reported in
the range of 70%80%.18,3941,44
A significant concern is that the sigmoid may already be
gangrenous. Several authors in Asia and Africa have noted an
incidence of gangrene approaching 50%, as well as a signifi-
cant incidence of double volvulus (ileosigmoid knotting)
rarely seen in the West, and have therefore recommended
emergency laparotomy without attempts at detorsion.36,37,4547
If ischemic mucosa is visualized, attempts at detorsion should
be immediately abandoned and operative intervention should
be undertaken emergently. For this reason, we strongly rec-
ommend using only those detorsion techniques that visualize
the mucosa before detorsion. Attempts at detorsion via blind
passage of a rectal tube should be avoided. Attempted detor-
sion of nonviable bowel will lead to a high incidence of per-
foration and peritonitis. The presence of nonviabilty should
be suspected by the presence of signs and symptoms of
compromised bowel and/or systemic sepsis, such as fever,
294
leukocytosis, and especially localized tenderness over the sig-
moid loop. If these are present, decompression should not
even be attempted. The patient should be taken for emergent
surgery. In approximately 25% of cases, the site of the twist
will be more proximal than can be reached with a rigid proc-
toscope.14 Use of flexible scopes can obviate this problem.
The major complication associated with attempted detorsion
is inadvertent perforation. This is more likely in the presence
of gangrene, but can occur with viable bowel as well.
Once decompression has been accomplished, there is usu-
ally forceful evacuation of flatus and stool (frequently all over
the clothes and shoes of an unsuspecting novice) and visible
deflation of the patients abdominal distension. A rectal tube
should then be gently inserted into the colon to a point prox-
imal to the site of the twist (which is usually within 20 cm of
the anus). The tube should then be fixed in place, to allow
continued decompression and prevention of recurrence. A
plain abdominal film should be obtained to document decom-
pression and the patient should be admitted to the hospital.
Successful detorsion provides the advantage of converting a
surgical emergency to an elective situation.
Over the next several days, bowel function is likely to
return to normal. Medical conditions (cardiac, pulmonary,
renal, etc.) should be addressed, electrolyte abnormalities
should be corrected, and the patients condition optimized.
Colonoscopy, to rule out a proximal lesion, should be per-
formed, and then a decision must be made. The rectal tube
can be safely removed and the patient could be discharged
from the hospital; however, it is well established that the rate
of recurrent sigmoid volvulus is in excess of 25%.48,49 In fact,
most authors document a recurrence rate of greater than 50%,
and some report recurrences as high as 80%90%.18,21
However, one report notes that 15 of 29 patients (52%) with
sigmoid volvulus never required surgery. Twenty-three of 26
successfully decompressed patients were observed. Twelve
recurred, six of whom were again decompressed and
observed. Four of these patients had no further recurrence.
Whereas none of the conservatively treated patients devel-
oped a complication, 43% of the surgical patients died.35 The
overall condition of the patient, the ease with which the
volvulus was untwisted, and whether or not there were previ-
ous episodes of volvulus, are all factors that must be consid-
ered in the decision to perform definitive surgery.
The standard elective surgical procedure is sigmoid resec-
tion with primary anastomosis; however, a number of nonre-
sective techniques have been described, including nonsurgical
endoscopic sigmoidopexy with or without tube fixation,17,50,51
extraperitoneal sigmoidopexy,52 sigmoidopexy to the trans-
verse colon and/or the parieties,17 mesosigmoplasty,53,54
colopexy with banding,55 mesenteric fixation,7 and laparo-
scopic fixation.56 Although several authors have reported
excellent results using pexy without resection,5254 others
have reported recurrence rates in excess of 25%.38 Whereas
recurrence after resection approaches zero, resection with
anastomosis was historically accompanied by relatively
M.D. Hellinger and R.M. Steinhagen
substantial morbidity and mortality,42 prompting a number of
investigators to seek less risky alternatives.
Bhatnagar and Sharma52 reported a series of 84 patients
treated by sigmoidopexy with extraperitonealization. They
reported a mortality of 9%. Patients were followed for a mean
of 6.7 years with no evidence of recurrence (48 patients were
followed for more than 5 years). Salim,55 however, reported
on a technique of percutaneous deflation, followed by tube
detorsion and decompression, and finally intraperitoneal sig-
moidopexy. He conducted a prospective, randomized trial of
this nonresectional technique compared with resection and
primary anastomosis. Of the initial 21 patients randomized to
the decompression followed by surgical arm, six required
emergency surgery. The remaining 15 were able to undergo
an elective resection. Of note, he reported no recurrences and
a mortality of 0% in the colopexy group as opposed to 13% in
the group undergoing resection.55
Finally, the technique of mesosigmoidoplasty deserves dis-
cussion. This procedure is performed by incising the elon-
gated sigmoid mesentery vertically along its axis. Peritoneal
flaps are then created which are then approximated trans-
versely (Figure 19-8). This procedure thereby creates a short-
ened, broad mesentery precluding future bowel rotation.
Although one author has reported a recurrence of 28%, most
report recurrences of less than 2%. Mortality ranges from 0%
to 7%.53,54
Modern surgical and anesthetic techniques, including the
use of surgical staplers, have reduced operative complications
substantially. Resection with anastomosis, therefore, should
currently be considered the standard of care for elective cases.
However, in circumstances in which continence is an issue, an
end stoma may be a better alternative. Colostomy via a
FIGURE 19-8. Mesosigmoidoplasty. A A longitudinal peritoneal inci-
sion is made in the elongated, narrow mesentery. B The incision is
then closed transversely, broadening the mesenteric base and short-
ening the height of the sigmoid loop.
19. Colonic Volvulus
minimal left lower quadrant incision has been suggested for
debilitated patients, too sick to undergo formal laparotomy.57
Laparoscopic techniques have also been applied,5860 but in
general, because the redundant distended colon obscures the
working space and the incision required to deliver the speci-
men is also large enough to exteriorize the redundant sigmoid
colon and perform an adequate resection and anastomosis,
there is little to be gained by the use of laparoscopy.60 In fact,
the entire resection and anastomosis can often be performed
via a limited left lower quadrant muscle splitting incision, a
very small midline incision, or via a Pfannenstiel incision.
If decompression is not possible, if the patient has signs
and symptoms of peritonitis or colonic ischemia, or if gan-
grenous mucosa is visualized during attempted decompres-
sion, the situation becomes a surgical emergency. The patient
should be rehydrated, electrolyte abnormalities and anemia
should be corrected, the patient should be given intravenous
antibiotics, and emergency surgery should be undertaken. The
patient should be explored via a midline laparotomy, the
volvulus should be manually reduced if the bowel is viable,
and the redundant, twisted sigmoid should be resected.
However, when gangrenous bowel is encountered during
laparotomy, detorsion should not be performed. Accumulated
toxins and bacteria may be released into the circulation,
resulting in sepsis and cardiovascular collapse. Maintenance
of the volvulus is therefore paramount as one obtains early
vascular control. Inspection of the proximal colon must be
performed, because in the face of a competent ileocecal valve,
the closed loop obstruction produces rapid cecal ischemia and
perforation.21,38 Obviously, avoidance of fecal contamination
is paramount. With the use of 90-mm linear staplers, even
though the bowel proximal to the volvulus may be enor-
mously dilated, resection without spillage is usually possible.
Generally, an anastomosis should be avoided if the proximal
colon is massively dilated and loaded with feces. Some
authors have applied the technique of intraoperative colonic
lavage to facilitate primary anastomosis.61 In most cases, the
proximal sigmoid should be exteriorized as an end-sigmoid
colostomy; the distal end can be treated with a Hartmann-type
closure, or a mucus fistula. A single prospective, randomized
trial comparing primary anastomosis to the Hartmanns pro-
cedure in 14 patients with gangrenous bowel, revealed a 50%
anastomotic leak rate. In addition, mortality was more than
double in those patients in whom an anastomosis was per-
formed (33% versus 13%).36 Although the colostomy can
generally easily be reversed in an elective manner, it must be
recognized that because of the age and infirmity of many
of these patients, in actual practice, the colostomy is often
permanent.
Overall mortality rates for the treatment of sigmoid volvu-
lus range from 14% to 45%. Emergency surgery without pre-
operative detorsion is associated with mortality rates of
20%45%. If nonviable bowel is encountered, these rates may
exceed 50%. In fact, several studies report mortality of
60%80% in these cases.9,17,21,35,36,3841,62 Elective surgery,
295
after detorsion, is currently associated with mortality rates
below 10%, despite the fact that these are generally patients
with multiple comorbidities. However, older data reveal this
mortality was as high as 25%.7,9,17,21,35,36,3841,62
Paradoxically, outcomes in developed nations tend to be far
worse than those in developing countries. This is presumed to
be attributable to the older age and presence of significant
comorbidities of the patients in the Western nations.4,38
Ballantyne,42 in a review of 67 series of sigmoid volvulus
worldwide before 1981, compared mortality of nongan-
grenous and gangrenous bowel in the United States as com-
pared with the rest of the world. He noted that the overall
mortality in the United States was 25% and internationally
18%. When gangrenous bowel was present, the United States
mortality further exceeded the international rate (80% versus
48%). However, for the nongangrenous, elective procedures,
the United States mortality was somewhat less than the world-
wide rate (10.6% versus 12.6%).
It has been suggested that a nonresectional approach may be
safer in these ill patients. However, nonoperative decompres-
sion alone carries 0%12% mortality. This may be related to
attempted detorsion in the presence of ischemic bowel.
Finally, operative detorsion with or without pexy carries a sim-
ilar mortality to elective resection and anastomosis (8%14%).
Therefore, one must consider the overall risk of recurrence as
well as the risk of mortality. As expected, any nonresectional
procedure carries a substantial risk of recurrence. For decom-
pression alone it ranges from 25% to 70%, whereas detorsion,
with or without pexy, has been associated with recurrence rates
of 23%40%. Most authors indicate that the risk of recurrence
after resection approaches zero; it has been reported to be as
high as 5% in some series.17,9,21,35,36,3841,62 This is usually
attributed to concomitant megacolon and/or megarectum.48
The only prospective randomized trial comparing elective
resection and primary anastomosis with mesosigmoidoplasty
confirms these findings. None of the resected patients and 29%
of the plastied patients experienced recurrence. However, there
was no mortality in the plasty group as compared with 10% in
the resection group.36
Ileosigmoid Knotting
Incidence and Epidemiology
Ileosigmoid knotting, also called compound volvulus, is a
rare form of volvulus uncommon in the West. It is, however,
comparatively more common in certain areas of Africa, Asia,
and the Middle East. In particular, large series are reported
from Turkey, Russia, Scandinavia, Uganda, and India. It is
more common in males than females, and presents at a
younger age than sigmoid volvulus. In fact, it has rarely been
reported in individuals older than 50 years of age.3,6367
The geographic distribution corresponds with regions of
the world where diets high in bulk and carbohydrates are
296
consumed with large volumes of liquid. The incidence is
highest in groups in which one single large meal is consumed
daily. It has been reported to peak in the followers of Islam
during Ramzan when a single large meal is consumed at sun-
set after a full days fast.3,6367
Pathogenesis/Etiology
Theories of the pathogenesis of ileosigmoid knotting focus on
a large volume diet high in bulk and carbohydrates, associated
with large volumes of concomitant liquid ingestion. This may
lead to an elongated abnormally mobile small intestinal
mesentery, in addition to a long narrow pedicled sigmoid
mesentery. The simultaneous consumption of a large meal
combined with a large volume of fluid may then initiate an
acute knot formation. As the bolus empties into the jejunum,
the bowel becomes hyperperistaltic, and the weight acts to
pull it into the left paracolic gutter. The empty distal loops of
small bowel are then displaced around a narrow-based sig-
moid. Continued peristalsis leads to further rotation of the
loop, internal herniation, and knot formation (Figure 19-9).
The fact that this entity usually occurs in the early morning
hours lends further credence to the theory that dietary and
dining habits of certain populations are causative.3,6367
FIGURE 19-9. Ileosigmoid knotting: these schematic illustrations indicate the four forms of knotting. The active ileum may rotate around the
sigmoid colon in either a clockwise A or counterclockwise B direction. Much more infrequently, the sigmoid colon may act as the active
loop and rotate in either a clockwise C or counterclockwise D direction around the ileum.
M.D. Hellinger and R.M. Steinhagen
Alver et al.,64 in a review of 68 cases, described four dif-
ferent patterns of ileosigmoid knot formation which differen-
tiate between an active or passive segment of bowel and the
direction of rotation. Usually, the ileum is the active compo-
nent and wraps around the sigmoid in either a clockwise or
counterclockwise manner. Alternatively, the sigmoid may
wrap around a passive segment of ileum, either clockwise or
counterclockwise.
Clinical Presentation
The presentation of ileosigmoid knotting is one of acute
onset, often with a fulminant course. There is a dramatic
absence of prior similar attacks that are frequently seen in
other forms of volvulus. Patients usually present in shock
with signs of an intraabdominal catastrophe. The patient may
complain of severe colicky abdominal pain, which begins in
the periumbilical region. Nausea and vomiting, as well as dis-
tension, are early findings. At surgery, gangrenous intestine is
found in 70%100% of cases. As the result of the severity of
the condition at presentation, acidosis, hypovolemia, oliguria,
hypotension, and tachycardia are common findings.3,6367
Preoperative diagnosis is extremely difficult because of the
confusing nature of the presentation and unfamiliarity with
19. Colonic Volvulus
this entity. Clinically, the patients condition presents as a
small bowel obstruction, but radiographic evaluation is more
consistent with a large intestinal obstruction. In fact, X-rays
are often atypical, and the diagnosis is correctly made in
fewer than 20% of patients preoperatively. However, several
characteristic radiographic features of ileosigmoid knotting
have been identified. These include a double obstruction, with
an obstructed distended sigmoid loop pulled to the right and a
proximal small bowel obstruction on the left. A diagnostic
triad has been proposed consisting of a clinical small bowel
obstruction, a radiographic large bowel obstruction, and the
inability to pass a sigmoidoscope to decompress a suspected
sigmoid volvulus.3,6467
Treatment/Outcome
Because of the high incidence of ischemia and gangrene at the
time of presentation, after an initial period of rapid resuscita-
tion and antibiotic administration, patients should be taken for
emergent abdominal exploration. Controversy clearly exists
regarding the preferred surgical approach. Treatment recom-
mendations have ranged from simple detorsion to double
resection. Because of the high likelihood of gangrenous
bowel, most authors advocate en bloc resection of both seg-
ments of intestine without attempts to untwist the bowel.
They state that untying the knot may be time consuming, dif-
ficult, hazardous, and may lead to systemic release of endo-
toxin and propagation of shock. Finally, perforation may
ensue, leading to peritoneal contamination.3,6366 However,
others have recommended detorsion if one or both segments
of bowel are thought to be viable. Deflation of the torsed seg-
ments had been shown to assist in untying the knot and dimin-
ishing the risk of rupture. There are conflicting data on
recurrence after detorsion alone.3,6366 Some authors advise
resection of the sigmoid in all cases because of the possibility
of recurrent knotting or eventual sigmoid volvulus.62,6466
Although most perform a primary ileoileal or ileocolic
anastomosis in patients with gangrenous small bowel, a
Hartmanns procedure is usually performed when the sigmoid
is found to be nonviable. When the sigmoid is viable, despite
the lack of bowel preparation, some authors have reported
safe colorectal anastomoses. Because of the risk of inferior
mesenteric artery or superior rectal artery thrombosis, most
authors also advocate resection of the sigmoid well past the
areas of twisting and/or gangrene to ensure adequate blood
supply.3,6367
Overall surgical mortality generally ranges from 30% to
50%. One review of seven patients reported no mortality,
despite finding gangrenous colon in all seven patients, and
gangrenous ileum in three.6367 Mortality for nongangrenous
bowel is generally less than that for gangrenous bowel.
Reports range from 10% to 30% for nongangrenous intestine,
and 40% to 50% for gangrenous bowel.3,6466 Alver et al.,64
however, noted a paradoxic relationship between duration of
symptoms and mortality. Those patients who presented within
297
24 hours had a mortality of 42%, whereas those that presented
later had a much lower mortality rate of 20%. Additionally, he
noted that the rate of gangrene was 91% in the early presen-
ters but only 57% in the late presenters. This reflects the more
rapid fulminant course of the patients that present earlier.64 In
addition, when extensive gangrene of the small bowel is
found, leaving the patient with less than 60 cm of residual
bowel, mortality has been shown to be 100%.64
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