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Volvulus du sigmoïde
... If colonic torsion is not promptly reversed, this creates a vicious circle leading to colonic necrosis and ischemia-reperfusion injury. The two main mechanisms of torsion in sigmoid volvulus are believed to be either axial meso-colic volvulus (75% of the time) or organo-axial volvulus (25% of the time) [19]. ...
Sigmoid volvulus is a common surgical emergency, especially in elderly patients. Patients can present with a wide range of clinical states: from asymptomatic, to frank peritonitis secondary to colonic perforation. These patients generally need urgent treatment, be it endoscopic decompression of the colon or an upfront colectomy. The World Society of Emergency Surgery united a worldwide group of international experts to review the current evidence and propose a consensus guidelines on the management of sigmoid volvulus.
... The choice of treatment depends on the gestational age and the condition of the sigmoid colon. In the absence of signs of ischemia, endoscopic detorsion should be attempted, although it should always be kept in mind that endoscopic detorsion, which is successful in around 90% of cases outside of pregnancy, [13] is limited by the volume of the uterus, especially during the third trimester as in our case. [2] Some authors use a gastroscope that seems more flexible and better tolerated without sedation. ...
Sigmoid volvulus in pregnancy is a rare but potentially serious condition. It is related to a high risk of maternal and fetal morbidity and mortality. This is mainly due to delayed diagnosis and treatment. We report the case of a 38-year-old multiparous patient, pregnant at 32 weeks of gestation, who presented to the emergency room with intestinal obstruction evolving for 2 days. At the emergency room, radiological exploration revealed a sigmoid volvulus. Endoscopic decompression was unsuccessful. A midline laparotomy was performed urgently revealing a necrotic sigmoid colon. A sigmoidal resection with a colostomy (Hartmann's procedure) was performed. In utero, fetal death occurred intraoperatively. The patient was transferred to the intensive care unit. Induction of labor was performed on the 2nd postoperative day with vaginal delivery of a stillborn. Recovery was good with the restoration of intestinal continuity 4 months later. Through this case and a review of recent literature, we discuss the diagnostic and therapeutic difficulties of this rare entity and highlight the seriousness of delay in the management of this surgical emergency.
... Sigmoid volvulus (SV), common cause of intestinal obstruction, is the torsion of the sigmoid colon around its mesenteric axis leading to an acute colonic obstruction by strangulation [1,2]. ...
Sigmoid volvulus is the torsion of sigmoid colon around its mesenteric axis. It is a common cause of colonic obstruction in our regions. It requires a prompt and emergency management due to the high risk of occurrence of strangulation. As for internal hernia, it is a protrusion of a hallow viscus through an intraperitoneal defect.
Sigmoid volvulus remains a relatively rare cause of acute abdomen, with a 60% mortality rate in complicated cases with higher prevalence among elder males with a history of limited sufficiency. It often debuts as an occlusive clinical picture with few and unspecific biochemical alterations, except in advanced cases with objective signs of colonic ischemia and abdominal sepsis. As to imaging diagnosis, the simple abdominal X-rays show the characteristic and best known “coffee bean” sign, nevertheless the computed tomography scan is still considered the gold standard having a high specificity and sensitivity. Early diagnosis in stable patients allows a large range of surgical, endoscopic, or interventional options, either transitory or definitive. Complicated cases with abdominal sepsis or hemodynamic compromise often requires surgical management with a higher rate of complications.
Résumé
Le volvulus du côlon représente la troisième cause d’occlusion colique dans le monde, avec 2 localisations principales : le sigmoïde et le cæcum. Dans les pays occidentaux, le volvulus du sigmoïde touche préférentiellement l’homme âgé et le volvulus du cæcum, la femme plus jeune. Certains facteurs de risque sont communs aux différentes localisations, notamment la constipation chronique, le régime riche en fibres, l’utilisation fréquente de laxatifs, les antécédents de laparotomie et les prédispositions anatomiques. Le tableau clinique est aspécifique, avec le plus souvent une association douleur abdominale, météorisme et occlusion. L’examen complémentaire de référence est actuellement le scanner abdominopelvien, qui permet de faire le diagnostic et de rechercher d’éventuelles complications. La prise en charge dépend de la localisation du volvulus, du terrain, du malade et de la vitalité du côlon, mais reste une urgence médico-chirurgicale dans tous les cas. La chirurgie en urgence est la règle en cas de critères de gravité clinico-radiologiques, mais est associée à une morbi-mortalité élevée. En cas de volvulus du sigmoïde et en l’absence de critères de gravité, la stratégie idéale est une détorsion endoscopique suivie, dans les 2 à 5 jours, d’un traitement chirurgical consistant en une résection-anastomose sigmoïdienne. Les traitements endoscopiques exclusifs doivent être réservés aux patients ayant un risque opératoire excessif. Dans la localisation cæcale, l’endoscopie n’a pas de place et la chirurgie doit être systématique.
Colonic volvulus is the third leading cause of colonic obstruction worldwide, occurring at two principal locations: the sigmoid colon and cecum. In Western countries, sigmoid volvulus preferentially affects elderly men whereas cecal volvulus affects younger women. Some risk factors, such as chronic constipation, high-fiber diet, frequent use of laxatives, personal past history of laparotomy and anatomic predispositions, are common to both locations. Clinical symptomatology is non-specific, including a combination of abdominal pain, gaseous distention, and bowel obstruction. Abdominopelvic computerized tomography is currently the gold standard examination, allowing positive diagnosis as well as detection of complications. Specific management depends on the location, patient comorbidities and colonic wall viability, but treatment is an emergency in every case. If clinical or radiological signs of gravity are present, emergency surgery is mandatory, but is associated with high morbidity and mortality rates. For sigmoid volvulus without criteria of gravity, the ideal strategy is an endoscopic detorsion procedure followed, within 2 to 5 days, by surgery that includes a sigmoid colectomy with primary anastomosis. Exclusively endoscopic therapy must be reserved for patients who are at excessive risk for surgical intervention. In cecal volvulus, endoscopy has no role and surgery is the rule.
The Hartmann procedure is used in the case of left-sided colonic disease, especially in the setting of emergency where intraoperative conditions contraindicate completion of an anastomosis. This procedure has been initially described for the management of colorectal cancer and is based on a sigmoïdectomy without restoration of intestinal continuity, including a left-sided iliac terminal stoma and closure of the rectal stump. Both procedure and underlying risk factors explain high rates of mortality and morbidity, around 15 and 50% respectively, and a low overall rate of subsequent restoration of internal continuity, less than 50%. The purpose of this review was to evaluate the value of the Hartmann procedure and its equivalents in colonic surgery, according to its indications: colorectal cancer, peritonitis from diverticular disease, anastomotic complications, ischemic colitis, left-sided colonic volvulus and abdominal trauma.
Résumé
L’intervention de Hartmann est indiquée dans certaines affections du côlon gauche, mais plus particulièrement dans le cadre de l’urgence où les conditions peropératoires contre-indiquent la confection d’une anastomose. Cette intervention a été initialement décrite pour la prise en charge du cancer colorectal. Elle est basée sur une sigmoïdectomie sans rétablissement de continuité digestive, avec confection d’une colostomie iliaque gauche terminale et fermeture du moignon rectal. Cette procédure et le terrain sous-jacent expliquent la fréquence des complications avec des taux de mortalité et morbidité respectivement proches de 15 % et 50 %, et un faible taux de rétablissement de continuité secondaire, globalement inférieur à 50 %. L’objectif de cette mise au point était de préciser la place de l’intervention de Hartmann et ses équivalents dans la pratique actuelle de la chirurgie colique, en fonction de ses différentes indications : cancer colorectal, péritonite d’origine diverticulaire, complications anastomotiques, colite ischémique, volvulus colique gauche ou traumatismes abdominaux.
In western countries intestinal obstruction caused by sigmoid volvulus is rare and its mortality remains significant in patients with late diagnosis. The aim of this work is to assess what is the correct surgical timing and how the prognosis changes for the different clinical types.
We realized a retrospective clinical study including all the patients treated for sigmoid volvulus in the Department of General Surgery, St Maria Hospital, Terni, from January 1996 till January 2009. We selected 23 patients and divided them in 2 groups on the basis of the clinical onset: patients with clear clinical signs of obstruction and patients with subocclusive symptoms. We focused on 30-day postoperative mortality in relation to the surgical timing and procedure performed for each group.
In the obstruction group mortality rate was 44% and it concerned only the patients who had clinical signs and symptoms of peritonitis and that were treated with a sigmoid resection (57%). Conversely none of the patients treated with intestinal derotation and colopexy died. In the subocclusive group mortality was 35% and it increased up to 50% in those patients with a late diagnosis who underwent a sigmoid resection.
The mortality of patients affected by sigmoid volvulus is related to the disease stage, prompt surgical timing, functional status of the patient and his collaboration with the clinicians in the pre-operative decision making process. Mortality is higher in both obstructed patients with generalized peritonitis and patients affected by subocclusion with late diagnosis and surgical treatment; in both scenarios a Hartmann's procedure is the proper operation to be considered.
The variable incidence of sigmoid volvulus, which depends on the presence of an elongated sigmoid colon, suggests the possibility of variations in the length of the sigmoid colon. This study was undertaken among the three major population groups to prove this hypothesis.
Radiological films of patients of the three population groups (African, Indian and White) undergoing barium enema were reviewed. The stature was measured by the distance from T12 to L4. The collective length of the rectum and sigmoid colon as well as the entire colon was measured on the barium enema film using an opisometer. Measurement was from the upper border of the symphysis pubis to the upper border of the left iliac crest. The level of the apex of the sigmoid colon loop and its redundancy were also assessed.
There were 109 patients (61 females) undergoing barium enema (39 Africans, 49 Indians, and 21 Whites). For the entire group the T12-L4 distance was 16.6 +/- 2.2 cm and the entire colon length was 133 cm (range 88-262 cm) and was significantly longer among African patients (P = 0.003). The combined length of the rectum and sigmoid colon was 48.8 +/- 15.7 cm (Africans 60.9 +/- 14.4 cm, Indians 41.3 +/- 12.2 cm and Whites 44 +/- 11.6 cm). The sigmoid colon was significantly more redundant in Africans (90%), compared to Indians (25%) and Whites (24%) (P = 0.003 for Indians and P = 0.048 for whites). The apex of the sigmoid colon reached L1-L3 in 54% among Africans, 6% among Indians and in 10% among Whites (10%).
African patients had the longest combined length of the rectum and sigmoid colon translating into a long sigmoid colon. They also had the highest number of redundant sigmoid colon. This may explain the high incidence of sigmoid volvulus in African patients.
The current status of sigmoid volvulus (SV) was reviewed to assess trends in management and to assess the literature.
The literature on SV was retrieved using PubMed, Embase, Scopus, Pakmedinet, African Journals online (AJOL), Indmed and Google scholar. These databases were searched for text words including 'sigmoid', 'colon' and 'volvulus'. Relevant nonindexed surgical journals published from endemic countries were also manually searched. We focused on original articles published within the last 10 years; but classical references prior to this period were also included. Seminal papers published in non-English languages were also included.
Sigmoid volvulus is a leading cause of acute colonic obstruction in South America, Africa, Eastern Europe and Asia. It is rare in developed countries such as USA, UK, Japan and Australia. Characteristic geographic variations in the incidence, clinical features, prognosis and comorbidity of SV justify recognition of endemic and sporadic subtypes. Controversy on aetiologic agents can be minimized by classifying them into 'predisposing' and 'precipitating' factors. Modern imaging systems, although more effective than plain radiographs, are yet to gain popularity. Emergency endoscopic reduction is the treatment of choice in uncomplicated patients. But it is only a temporizing procedure, and it should be followed in most cases by elective definitive surgery. Resection of the redundant sigmoid colon is the gold standard operation. The role of newer nonresective alternatives is yet to be ascertained. Although emergency resection with primary anastomosis (ERPA) has been controversial in the past, it is now increasingly accepted as a safe option with superior results. Management in elderly debilitated patients is extremely difficult. Paediatric SV significantly differs from that in adults. SV is frequently associated with neuropsychiatric diseases, diabetes mellitus and Chagas disease. The overall mortality in recent studies is < 5%.
There are almost no randomised controlled studies. According to the grading system of Oxford Center for Evidence Based Medicine (CEVM), available published evidence is at level 4. The recommendations resulting form this review are of 'C' grade.
Abstract Sigmoid volvulus is a surgical emergency the initial treatment of which is endoscopic decompression. For those deemed unfit for subsequent elective operative intervention, percutaneous sigmoidopexy using traditional colonoscopic techniques has been described as an acceptable alternative. We report a medically unfit 85 year old patient with recurrent sigmoid volvulus who underwent endoscopic colonic fixation using a Scope Guide magnetic imaging system. This allowed accurate manipulation and fixation of the redundant sigmoid loop under direct vision. Use of magnetic image guidance in percutaneous endoscopic sigmoidopexy has not been reported before and we believe it improves the accuracy and safety of this technique.
A technique of mesocoloplasty for the prevention of recurrence of sigmoid volvulus is described. The manoeuvre is simple, and does not open the gut. It can be performed confidently by junior doctors undergoing surgical training and appears to be an eminently safe technique as a routine procedure in any emergency service.
One hundred and thirty-four patients with acute sigmoid volvulus are analysed. When the diagnosis is made preoperatively, decompression per rectum is effective in 85 per cent of cases, and should be the initial treatment of choice unless gangrene of the bowel is suspected. In this situation emergency laparotomy should be performed and where gangrenous bowel is confirmed a Hartmann resection appears to be associated with a low mortality and least complications. When the sigmoid loop is found to be viable, it should still be resected. The merits and pitfalls of various procedures in this situation are discussed.
This study was a retrospective review of a series of patients with sigmoid volvulus to identify risk factors for recurrence and recommend appropriate treatment.
Thirty-five patients with sigmoid volvulus were treated over 8 years.
Six patients had emergency surgery for peritonitis. Twenty-eight of the other 29 patients had successful endoscopic decompression; 15 of these patients had elective surgery during the same admission. Twelve of the 14 patients who refused operation after endoscopic decompression developed recurrent volvulus, a median of 2.8 months later. Eight subsequently agreed to surgery and underwent elective operation following repeat decompression. Of 29 patients who had surgery, 27 had sigmoid colectomy (two were initial Hartmann procedures) and two had subtotal colectomy. Six patients who had sigmoid colectomy developed recurrent volvulus. Concomitant megacolon and megarectum at the time of initial surgery were significant predictors of recurrence.
Subtotal colectomy, carried out as the primary procedure if there is concomitant megacolon or megarectum, might reduce the risk of recurrent sigmoid volvulus.
Emergency resection and primary anastomosis of unprepared left-colon is a controversial subject. Although this approach has been reported in several series, there is paucity of data on the relative safety of it in viable vs. gangrenous colon especially when the gut is unprepared.
Case records of 57 consecutive patients with acute sigmoid volvulus were reviewed; there were 27 with gangrenous colon (group G) and 30 with viable colon (group V). All of them had undergone emergency resection and primary anastomosis without on-table lavage or caecostomy.
Group G had a lower mean haemoglobin value (8.4 vs. 9.7 g/dl) and higher incidence of circulatory shock on admission (26% vs. 7%) and required more blood transfusion (85% vs. 53%) than group V. Mean hospital stay (16 vs. 12 days), overall anastomotic leak (15% vs. 27%) and mortality (3.5% vs. 3%) did not differ significantly between the groups. However, the rate of wound infection in Group G was four times greater than that of group V.
One-stage restorative resection without on-table lavage or caecostomy appears to be a promising alternative in the emergency management of acute sigmoid volvulus. Comparison of primary anastomosis in gangrenous vs. viable colon did not reveal any significant difference in hospital stay, rate of anastomotic leak or mortality. However, the risk of wound infection was more in patients with gangrenous sigmoid volvulus.
The laparoscopic approach for the treatment of sigmoid volvulus has been a rare surgical indication. This phase 2 study investigated the feasibility and surgical outcomes of elective laparoscopic surgery for sigmoid volvulus.
Patients with sigmoid volvulus were first offered colonoscopic decompression for their acute colonic obstruction. If the colonic decompression was successful, complete bowel preparation was performed, followed by elective laparoscopically assisted sigmoidectomy. The details of the laparoscopic procedures are shown in the video. Briefly, the redundant sigmoid colon is totally mobilized by a laparoscopic medial-to-lateral dissection sequence, after which it is exteriorized, transected, and reconstructed by end-to-end anastomosis. In the authors' experience, the medial-to-lateral approach is highly efficient for the laparoscopic mobilization of the redundant sigmoid colon. We believe that the longer the lateral abdominal wall attachment of the sigmoid colon is preserved, the better the exposure and the easier the dissection. If the risk of anastomotic leakage is considered high in a specific case, protective ileostomy is selectively preformed. Before entering the current study, the patients were well informed about the advantages and disadvantages of laparoscopic surgery. The enrollment of patients was selective according to the appropriate eligibility criteria. This study was approved by the Institutional Review Board of the National Taiwan University Hospital. The patients' clinicopathologic data and surgical outcomes were prospectively evaluated.
Between August 2001 and April, 2005, a total of 14 patients (10 men and 4 women) with sigmoid volvulus were treated with the described procedure. The age distribution of the patients was 68.4 +/- 12.2 years. The attack of sigmoid volvulus was the first episode for eight patients, the second episode for 4 patients, and the third episode (or more) for two patients. The body mass index (BMI) of the patients was 26.8 +/- 4.4 kg/m(2). The physical status (classification of American Society of Anesthesiology [ASA]) was 1 for five patients, 2 for eight patients, and 3 for 1 patient. During the laparoscopy, all the patients presented with the pathognomonic findings of sigmoid volvulus including redundant sigmoid colon, narrow sigmoid mesenteric pedicle, and mesosigmoiditis with mesenteric fibrosis and scarring, as shown in the video. The length of the resected colon was 32 +/- 6 cm. The operation time was 194.6 +/- 32.4 min, and the blood loss was 44.0 +/- 12.4 ml. The abdominal wound consisted of four 5 to 12 mm working ports and a 5 cm major wound for exteriorization of the sigmoid colon. Some surgeons have shown that a sigmoid volvulus can be resected through a 5-cm left lower quadrant incision with very little mobilization of the colon because of its redundancy. In this context, the laparoscopic approach competed with the minilaparotomy method in terms of adequate sigmoid resection, lysis of mesosigmoid adhesion, and tension-free colorectal anastomosis. Protective ileostomy was performed for the only patient with a physical status of ASA 3. There was no mortality in this case series. However, pneumonia developed postoperatively in one patient, acute myocardial infarction in one patient, and wound infection in two patients. Excluding the two patients who experienced postoperative pneumonia and acute myocardial infarction, the duration of the postoperative ileus was 48 +/- 12 h, the postoperative hospitalization was 7 +/- 1 days, and the degree of postoperative pain was 3.5 +/- 0.5 according to the visual analog scale. The return to partial activity required 18 +/- 2.5 days, and the return to full activity required 28.4 +/- 5.6 days. As compared with the overall costs for a conventional sigmoid colectomy, which are completely covered by the National Bureau of Health Insurance of Taiwan, the expenses for the patients undergoing laparoscopic procedures were significantly higher by approximately 24,000.0 NT dollars +/- 2,635.0 (1 U.S. dollar = 32 NT dollars). These higher expenses must be borne by the patients themselves.
Considering that patients with sigmoid volvulus often are elderly and chronically ill, laparoscopic elective surgery after a successful colonoscopic decompression may be a good choice for a selected group of patients in terms of minimized surgical complications and quick convalescence.
Percutaneous endoscopic colostomy (PEC) is an alternative to surgery in selected patients with recurrent sigmoid volvulus, recurrent pseudo-obstruction or severe slow-transit constipation. A percutaneous tube acts as an irrigation or decompressant channel, or as a mode of sigmoidopexy. This prospective study evaluated the safety and efficacy of this procedure at a single tertiary referral centre.
Nineteen patients with recurrent sigmoid volvulus, ten with idiopathic slow-transit constipation and four with pseudo-obstruction underwent PEC. The tube was left in place indefinitely in those with recurrent sigmoid volvulus or constipation, whereas in patients with pseudo-obstruction it was left in place for a variable period of time, depending on symptoms.
Thirty-five procedures were performed in 33 patients. Three patients developed peritonitis, of whom one died, and ten patients had minor complications. Symptoms resolved in 26 patients.
This large prospective study has confirmed the value of PEC in the treatment of recurrent sigmoid volvulus and pseudo-obstruction in high-risk surgical patients.