Colopexy as a treatment option for the management of acute transverse colon volvulus: A case report

Abstract

Transverse colon volvulus is an uncommon acute surgical presentation associated with a higher rate of mortality than volvulae at other locations along the colon. Surgical resection or correction is the only treatment, and various methods have been described in case report literature to relieve the volvulus and prevent recurrence.
We present the case of a 25-year-old Caucasian woman who was admitted with a three-day history of abdominal pain, absolute constipation and abdominal distension. Subsequent radiographic and computed tomography imaging revealed right-sided colonic dilatation suggestive of a volvulus. An emergency laparotomy was performed during which the dilated proximal bowel was decompressed and colopexy executed by using the greater omentum to fix the transverse colon at the hepatic and splenic flexures.
Volvulus of the transverse colon is rare but must form part of the clinician's differential diagnosis when encountering a patient with suspected bowel obstruction, especially in younger patients with no previous surgical history. Laparotomy is the treatment of choice and the technique of using the greater omentum as a fixing point for redundant bowel to the lateral abdominal wall is an option that may be considered especially when the bowel appears viable.

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C A S E R E P O R T Open Access
Colopexy as a treatment option for the
management of acute transverse colon
volvulus: a case report
Mark J Sage
*
, Jenan Younis, Katie E Schwab and Keith A Galbraith
Abstract
Introduction: Transverse colon volvulus is an uncommon acute surgical presentation associated with a higher rate
of mortality than volvulae at other locations along the colon. Surgical resection or correction is the only treatment,
and various methods have been described in case report literature to relieve the volvulus and prevent recurrence.
Case presentation: We present the case of a 25-year-old Caucasian woman who was admitted with a three-day
history of abdominal pain, absolute constipation and abdominal distension. Subsequent radiographic and
computed tomography imaging revealed right-sided colonic dilatation suggestive of a volvulus. An emergency
laparotomy was performed during which the dilated proximal bowel was decompressed and colopexy executed by
using the greater omentum to fix the transverse colon at the hepatic and splenic flexures.
Conclusions: Volvulus of the transverse colon is rare but must form part of the clinician's differential diagnosis
when encountering a patient with suspected bowel obstruction, especially in younger patients with no previous
surgical history. Laparotomy is the treatment of choice and the technique of using the greater omentum as a fixing
point for redundant bowel to the lateral abdominal wall is an option that may be considered especially when the
bowel appears viable.
Introduction
Transverse colon volvulus, first reported by Kallio [1] in
1932, is a rare cause of large bowel obstruction but is
associated with a greater mortality than the more com-
mon sigmoid or caecal volvulae. Several surgical options
to prevent recurrence have been described in the literature
but we believe this is the first case where the greater
omentum has been used as a fixation point for the trans-
verse colon.
Case presentation
A 25-year-old Caucasian woman presented to our emer-
gency department with a three-day history of abdominal
pain, distension and absolute constipation with vomiting.
There was no significant medical or surgical history. She
took no regular medications, and was a non-smoker and
non-drinker. Bedside observations were normal. A physical
examination revealed a distended tympanic abdomen with
tenderness across the lower abdomen but no signs of peri-
tonism. A urine dipstick test was unremarkable and blood
tests showed a raised white blood cell count (14.4 ×109
cells/L) and C-reactive protein (35mg/L). Urea and elec-
trolytes, hemoglobin and liver function tests were all
normal.
Radiographs of the abdomen (Figure 1) and chest
(Figure 2) showed gross dilatation of the right side of the
colon with Chilaiditi’s sign. A computed tomography (CT)
scan of the abdomen showed massive dilatation of the
caecum, which measured greater than 14 cm in diameter
(Figures 3, 4, and 5). The distal colon was collapsed with a
transition point in the mid abdomen suggestive of a volvu-
lus or band.
A nasogastric tube was inserted, intravenous fluid resus-
citation commenced and our patient underwent an emer-
gency exploratory laparotomy. Intra-operatively, the bowel
was found to be significantly dilated from the caecum to
the distal transverse colon and the distal small bowel was
mildly dilated, giving the impression of decompression
through an incompetent ileocaecal valve. There was a
* Correspondence: : marksage@doctors.org.uk
Department of Surgery, Ashford and St Peter’s Hospitals NHS Trust, Guildford
Road, Chertsey, Surrey KT16 0PZ, UK
JOURNAL OF MEDICAL
CASE REPORTS
© 2012 Sage et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Sage et al. Journal of Medical Case Reports 2012, 6:151
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volvulus of the transverse colon in the right upper quad-
rant. The transverse mesocolon appeared to take origin
from the right upper quadrant as opposed to the usual
location as an extension of the peritoneum from the pos-
terior abdominal wall centrally. There was no evidence of
colonic ischemia or serosal injury.
The large bowel was decompressed with a 14 gauge nee-
dle allowing the tightly held bowel to be manipulated
more easily. The large bowel was fully unraveled and the
volvulus corrected then decompressed distally into the
descending colon. The greater omentum on the transverse
colon was then fixed at both the hepatic and splenic flex-
ures by creating pouches in the lateral anterior abdominal
walls, and fixing the omentum within this with polydioxa-
none sutures (PDS). The central portion of the omentum
was purposefully caught in the mass closure of the wound
to ensure additional central fixation.
Post-operatively our patient made a good recovery. By
day five she was tolerating a full diet and was discharged
six days post-operatively. Despite a superficial wound in-
fection at two weeks, she made a full recovery with no
complications noted at her three month and six month
follow-up.
Discussion
Volvulus of the transverse colon is a rare surgical emer-
gency and as of 2008 there were only 100 published
cases worldwide. Transverse volvulus accounts for only
2% to 4% of cases of colonic volvulus, but carries a 33%
mortality rate [2,3]. It occurs most often in the second
and third decades of life with a second peak in the
seventh decade and is more common in women [2]. Up
to 50% of patients report experiencing similar symptoms
in the past [4]. A volvulus is caused by the twisting of
the colon on its vascular pedicle causing venous obstruc-
tion, followed by arterial compromise and, potentially,
ischemia [5,6].
Etiology can be acquired or congenital in nature [5-7].
The former commonly is due to adhesions, inflamma-
tory strictures, carcinoma or malposition of the colon
following previous surgery [5-8].
Congenital abnormalities include midgut malrotation,
resulting in abnormal fixation [2,4,8], congenital megaco-
lon [8], elongation and redundancy of the transverse colon
Figure 1 Radiograph of the abdomen showing gross dilatation
of the right side of the colon.
Figure 2 Radiograph of the chest showing gross dilatation of
the right side of the colon with Chilaiditi’s sign.
Figure 3 Computed tomography scan of the abdomen showing
massive dilatation of the caecum, which measured greater than
14 cm in diameter.
Figure 4 Computed tomography scan of the abdomen showing
massive dilatation of the caecum, which measured greater than
14 cm in diameter.
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and narrowing, absence or malfixation of the mesenteries
and their attachments [9], this being the etiology observed
in our patient’s case.
Transverse colon volvulus has been described in the
literature as subacute-progressive or fulminating [10].
Fulminating volvulus is a more aggressive form, rapidly
progressing due to closed loop obstruction resulting in
vascular compromise [4]. The subacute form, presents
with more subtle signs of obstruction [5,6].
Radiologically, it is classic to find a ‘bent inner tube’
sign on plain abdominal films [5] or a ‘bird’s beak’de-
formity on contrast enema [7].
With regards to management, in contrast to sigmoid
volvulus, which can often be decompressed during sig-
moidoscopy, transverse colon volvulus must be surgically
corrected [11]. When necrosis has occurred, resection of
the non-viable tissue may take the form of resection with
primary anastamosis or resection with colostomy or ileos-
tomy and mucous fistula [5]. However, many authors ad-
vocate segmental transverse colectomy or an extended
right colectomy as the treatment of choice, even in the
event of the bowel being viable, as it carries virtually no
risk of recurrence when compared to colopexy which has
a reported risk of 30% to 75% of recurrence. Indeed it has
also been documented that it is not uncommon that such
patients have presented previously with self-limiting epi-
sodes of subacute obstruction. This is thought to be due
to the intermittent volvulus of the transverse colon [4].
The argument in favour of colopexy over resection for
viable bowel resides in eliminating the risks associated
with the latter option. These include risks of anastomotic
leak, paralytic ileus, stenosis and the need for a stoma; all
of which carry considerable morbidity as well as mortality
[12]. Thus it would appear that colopexy appears the safer
short-term option for the patient with viable bowel intra-
operatively, whilst resection could potentially be prefer-
able in the longterm. The wide recurrence rate reported is
dated, however, and no colopexy technique used is entirely
identical. This makes it difficult at present to fully justify a
resection in such a group of patients [13]. The clear limi-
tation with our patient’s case is that whilst we have seen
our patient’s recovery six months from surgery, the long-
term success of the technique described here is unknown.
Conclusions
While rare, transverse colon volvulus must form part of
the clinician’s differential diagnosis when encountering a
patient with suspected bowel obstruction, especially in
younger patients with no previous surgical history. Ex-
ploratory laparotomy allows full identification of the
pathology and access for corrective and restorative man-
agement. The technique of fixing the greater omentum
in anterior abdominal wall pouches to correct anatomy
has been demonstrated here as a successful method of
treatment in the shortterm that may be considered.
Consent
Written informed consent was obtained from the patient
for publication of this case report and accompanying
images. A copy of the written consent is available for re-
view by the Editor-in-Chief of this journal.
Competing interests
The authors declare that they have no competing interests.
Authors’contributions
MS was involved in the initial diagnosis and management of our patient
upon presentation to hospital, and in reviewing the literature and writing
the initial manuscript. JY and KS were in theatre at the laparotomy and were
major contributors to the manuscript and edited its contents. KG was the
senior clinician involved in overseeing the care of our patient and approved
the final version of the manuscript. All authors read and approved the final
manuscript.
Received: 7 August 2011 Accepted: 13 June 2012
Published: 13 June 2012
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doi:10.1186/1752-1947-6-151
Cite this article as: Sage et al.:Colopexy as a treatment option for the
management of acute transverse colon volvulus: a case report. Journal
of Medical Case Reports 2012 6:151.
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