The management of acute sigmoid volvulus

A.Z. SULE, D. IYA, P.O. OBEKPA, B. OGBONNA, J.T. MOMOH and B.T. UGWU
Department of Surgery, Jos University Teaching Hospital, Jos, Plateau State, Nigeria

In a descriptive prospective study, twenty-seven patients with sigmoid volvulus and three with ileosigmoid knotting had primary resection of the redundant sigmoid colon with immediate anastomosis after intraoperative antegrade colonic irrigation. There was no clinical anastomotic leak nor mortality in any of our patients. Superficial wound infection occurred in four patients (13.3%). Intraoperative colonic irrigation time ranged between 25 to 50 minutes with a volume of saline/Hartmann’s required to achieve a clean colon ranging between 1.5 to 5.0 litres. The duration of hospital stay ranged between 7 and 14 days. The result of this study suggests that resection of acute sigmoid volvulus and primary anastomosis after antegrade intraoperative colonic lavage is safe provided the patient is reasonably fit.

Keywords: acute sigmoid volvulus, primary resection, anastomosis, intraoperative colonic lavage

The incidence and demographic features of sigmoid volvulus, when the sigmoid colon twists on its mesentery, varies around the world. In the developed world, sigmoid volvulus is responsible for 5% of large bowel obstructions and occurs in elderly and frail patients with intercurrent medical illnesses.¹ Therefore, the initial treatment, in the absence of clinical features of large bowel gangrene or peritonitis, consists of detorsion by sigmoidoscopy and transrectal intubation as described by Bruudsgaard.² Failure to achieve detorsion, clinical evidence or suspicion of perforation or gangrene requires emergency laparotomy. At laparotomy, various operative procedures have been adopted in the emergency management of sigmoid volvulus. However, permanent cure can only be ensured by resection of the sigmoid colon and reanastomosis.

In the developing world, where sigmoid volvulus constitutes 50% of large bowel obstructions, mortality following emergency surgery for acute sigmoid volvulus is low. This is mainly due to the fact that the patients are relatively young and healthy and, therefore, better able to recover from the disorder and its surgical treatment.¹ Hence, a single staged method of treatment that ensures a permanent cure, avoids a colostomy, reduces number of procedures and associated morbidity and mortality, and shortens duration of hospital stay, is desirable. Clinical and experimental evidence supports the view that a clean bowel is an important factor in surgery of the left colon and rectum; those parts of the bowel which normally have solid faeces and a high bacterial count.^3,4,5

We embarked, therefore, upon an evaluation of a definitive one-stage resection of the redundant colon and primary anastomosis after on-table antegrade colonic lavage as described by Dudley et al.⁶ In this article we report our experience with this method.

Thirty consecutive patients with acute sigmoid volvulus were treated over a 4 year period (1993 - 1997 inclusive) in a Teaching Hospital in Jos, Plateau State, Nigeria. The diagnosis of sigmoid volvulus was made from the history of a large bowel obstruction (constipation, abdominal distension and abdominal pain), which was often recurrent , and the plain abdominal radiographs in 16 patients. In the latter, the cardinal features were the inverted ‘coffee bean’ or ‘omega’ sign of the distended, twisted, sigmoid colon.

Laparotomy was performed on all patients after active fluid resuscitation, correction of any electrolyte and acid base disturbances, and establishment of satisfactory urine output (catheter monitoring). Gentamycin 80mg, ampicillin 500mg and metronidazole 500mg were administered intravenously at the time of induction of anaesthesia. Two more doses were given every 8 h in those patients with viable bowel and for 5 days in those with infarcted bowel.

At laparotomy, viability of the bowel was assessed through a lower mid line incision. Gaseous distention of the large bowel was relieved either by needle or Foley catheter aspiration. Primary resection was carried out and on-table colonic irrigation, as described by Dudley et al⁶, was used to clear the colon of faecal matter. Colonic ends were trimmed until there was free bleeding. Immediate two layer inverting anastomosis was carried out with an inner continuous layer of 3/0 chromic catgut and an outer interrupted seromuscular layer of 3/0 silk. None of the anastomoses were protected by a proximal stoma. A corrugated drain was inserted down to the colonic anastomosis in all cases through a separate stab incision. The vertical low mid line incisions were closed by mass closure using monofilament nylon.

The clinical course and postoperative complications were carefully documented. Wound infection was defined as the presence of pus, either discharging spontaneously or requiring drainage. Samples of wound discharge were obtained for bacteriological culture. Anastomotic leak was defined as the presence of a faecal fistula or anastomotic breakdown seen either at sigmoidoscopy, laparotomy following peritonitis or at postmortem. Hospital stay was defined as the total time spent in the hospital for the presenting complaint and, if necessary, for a subsequent procedure; mortality was considered as death occurring in hospital.

The 30 patients comprised 23 men and 7 women with an age range of 22-70 years. The age distribution is shown in Table 1. Only three of the 30 patients (with ileosigmoid knotting) had gangrenous bowel.

Age (years)	Number
20 - 30	4
31 - 40	8
41 - 50	6
51 - 60	5
61 - 70	7
71 - 80	-
Total	30

The outcome of the 30 patients treated by resection and immediate anastomosis after antegrade irrigation of the colon is shown in Table 2. Superficial wound infection occurred in four patients. Two were in patients who had a single resection and the remaining two were in the three patients that had undergone more than one resection. All the infected wounds eventually healed with conservative measures. There was no clinical anastomotic leak. There was also no mortality in any of our patients. The duration of hospital stay ranged between 7 and 14 days.

Procedure	Number of patients	Wound infection
Resection and primary anastomosis	27	2
Double resection with primary ileoileal and colorectal anastomosis	3	2
Total	30	4

The volume of fluid (normal saline/Hartman solution) required to achieve a colon free of faeces and debris ranged between 1.5 and 5.0 litres. The time taken to achieve such a colon ranged between 25 to 50 minutes.

Various surgical procedures have been employed in the management of sigmoid volvulus. Cure is only guaranteed by resection and anastomosis of the sigmoid colon. Simple procedures have been found to be not always successful and are not advocated when bowel gangrene or compound volvulus is present.⁷ Sigmoidoscopic detortion and laparotomy with detortion and colopexy are associated with significant morbidity and mortality rates. High morbidity rates are also reported following resection and colostomy compared with primary resection and anastomosis.⁷

There was no mortality following sigmoid colectomy and primary anastomosis in our series. Similar procedures in the elderly Caucasian population often yielded significant mortality^7,8,9 thus supporting the view that elderly, frail patients with intercurrent medical illnesses, withstand the procedure poorly. Clinical anastomotic leak was not a complication in this study, demonstrating that anastomosis of well vascularised bowel ends with well placed sutures in a clean colon is important. The three patients with compound gangrenous volvulus required resection of both gangrenous loops and primary ileoileal and colorectal anastomosis. They all survived, with superficial wound infections in two of the patients as the only complication. These three patients presented early and were relatively fit. The oldest was 50 years.

The increased operating time required is important. Contemporary anaesthetic techniques, however, are such that the additional time does not expose most of the young patients to any markedly increased risk. In our patients, whose circulatory state was stable, the extra time was well spent, since it avoided the need for a further operation.

The duration of hospital stay ranged between 7 to 14 days. This is shorter than the times published for staged procedures. There seems to have been a considerable saving in hospital bed usage as well as the total cost of hospital expenses.

In view of the scarcity and cost of colostomy appliances, the attitude of our society towards patients with a colostomy, and the lack of appropriate toilet facilities in our environment, a one-stage procedure for obstructed sigmoid colon is an attractive and preferred option.

Primary anastomosis of the large bowel following sigmoid volvulus should be carried out more frequently, provided that the patient is reasonably fit and time is taken to clear the bowel. This is very important in our own environment, where patients are poor, hospital care often unaffordable and hospital beds are few.

We would like to thank the Consultant Surgeons at Jos University Teaching Hospital (JUTH) for their kind assistance, advice and encouragement. Our grateful thanks are also due to Mr Sylvanus Chime who typed the script.

Correspondence: Dr A Z Sule, Department of Surgery, Jos University Teaching Hospital, Jos, Plateau State, Nigeria

�1999 The Royal College of Surgeons of Edinburgh, J.R.Coll.Surg.Edinb.,44; 3: 164-6

One-stage procedure in the management of acute sigmoid volvulus