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History and
physical exam
Stricture on imaging
Left sided
Malignant with
curative intent, age
<70, ASA<3
Benign stricture
Right sided
Malignant with
palliative intent
Malignant with
curative intent, age
≥70, ASA≥3
One stage:
• Subtotal colectomy with anastomosis
• Segmental colectomy with anastomosis
Two stage:
• Subtotal colectomy, end ileostomy
• Subtotal colectomy, anastomosis, proximal diversion
• Segmental resection, end colostomy
• Segmental resection, anastomosis, proximal diversion
One stage surgery:
• Right colectomy
• Extended right colectomy
Two stage surgery:
• Right colectomy, ileostomy
Consider definitive
or bridge to
surgery SEMS
COLON
251
FIGURE 51-2
SEMS, self-expanding metallic stents.
Management of a large bo
wel obstruction resulting from a malignant or benign stricture.
In a patient suspected of having a malignant bowel obstruction,
preoperative staging should be performed to assist in tumor localization and establishing goals of treatment (curative vs. palliative). is
process includes a CT scan of the chest, abdomen, and pelvis, serum
carcinoembryonic antigen determination, a complete blood cell count,
and a comprehensive metabolic prole. A CT scan is particularly useful
as a clinical tool to evaluate not only the location of the tumor but also
lymphadenopathy, adjacent organ invasion, metastatic disease, and
carcinomatosis. Obstruction usually precludes a complete preoperative
colonoscopy, and thus this procedure can be performed on the table
aer an intraoperative gut lavage. A clearing colonoscopy obtained
within 3 months aer surgery or restoration of intestinal continuity is a
poor option because a signicant nding may indicate a second major
surgery. Final staging should be recorded according to the American
Joint Committee on Cancer system and should include completeness
of resection (i.e., R0 for no residual disease, R1 for microscopic residual
disease, and R2 for grossly residual disease).
Surgical management of a malignant large bowel obstruction is
inuenced by the patient’s age, comorbidities, clinical acuity, nutritional status, tumor location, stage of disease, degree of bowel dilation, and fecal load. A right-sided colonic resection and anastomosis
in a physiologically normal patient carries a low risk of leakage and
bowel dysfunction. Le-sided obstructions are more variable in presentation, and a broader range of surgical options is needed. A lesided or rectal anastomosis has a higher rate of leakage than does a
right-sided anastomosis, a risk that is further elevated in the presence of proximal bowel dilation and a heavy fecal load (Fig. 51-2). An
oncologic surgical resection should be attempted whenever possible,
including an en bloc resection of involved organs, such as the ureters,
ovaries, small bowel, or stomach.
Right-Sided Obstruction
R
esection and primary anastomosis is usually safe and can be deni-
tive treatment for right and transverse colon obstructions in the
ASA, American
Society of Anesthesiologists;
medically well patient with minimal proximal bowel dilation or
edema. Patients with signicant comorbidities or with increased risk
factors for an anastomotic leak such as mild to moderate hemodynamic instability, localized perforation, or proximal bowel dilation
may be managed with resection, primary anastomosis, and a protecting loop ileostomy. Primary resection with an ileostomy may be necessary in patients with free perforation, shock, signicant proximal
bowel dilation, or other high-risk intraoperative ndings.
Left-Sided Obstruction
anagement of partial le-sided bowel obstructions starts with
M
resuscitation, bowel rest, nasogastric decompression as clinically
indicated, and medical and nutritional optimization. If this approach
is successful, elective bowel preparation and surgery can follow.
Complete le-sided obstruction of the colon, particularly from rectosigmoid tumors, is traditionally managed with primary resection
with an end colostomy (the Hartmann procedure) because of concerns that proximal bowel dilation, a high fecal load, and medical
comorbidities place the patient at high risk for an anastomotic leak.
Resection with a colostomy is particularly appropriate in the setting
of peritonitis, shock, and patient frailty. is approach does imply,
however, that the patient will need to undergo a second signicant
operation at a later date to reverse the colostomy, or, as happens in
nearly a third of such cases, he or she will need to live with the permanent colostomy.
On-table colonic lavage (intraoperative mechanical bowel
cleansing) is a complementary technique that removes most of the
fecal load, thereby facilitating a primary le-sided anastomosis. A
loop ileostomy protecting a colorectal or coloanal anastomosis further decreases the risk of a major postoperative septic event. ese
techniques have the theoretical advantage of avoiding a permanent
colostomy or signicant morbidity of Hartmann reversal surgery.
On-table colonic lavage is performed aer completing the appropriate le-sided resection. A 3-L urologic bag of warm saline solution
252
Large BoweL oBstruction
FIGURE 51-3
Set up f
or on-table colonic lavage.
BO
X 51-2:
Anastomotic Leak and P
reoperative and Perioperative Patient Factors
P
•Age>70y
•A
•H
•S
•P
• Chronicimmunosuppressionorsteroiduse
•P
•M
ocal Bowel Factors Identied Intraoperatively
L
•P
•M
•P
•T
•L
•Di
• Abnormalairleaktest
symptoms. Surgical options to relieve obstructive symptoms in the
setting of carcinomatosis include (1) primary resection and anastomosis, (2) enterocolic bypass, (3) proximal loop ostomy without
resection, and (4) venting tube gastrostomy. To avoid a potential
closed loop obstruction, a proximal Hartmann procedure (without a
distal mucous stula) should not be considered.
Factors
mericanSocietyofAnesthesiologistsscore
emodynamic
ignicant
re-existingchronic
resenceofmetastatic
alnutrition
roximalbowel
arginal
roximalfecal
ensiononortechnicallynonoptimalanastomosis
ocalized
lo
stal
cationofanastomosis
Associated with Increased Risk of
erioperative Complications
ears
in
stability
ac
uteorchronic
lation,bowel
di
scularsupply,ischemia
va
ad
lo
inf
ectionorsepsis
co
di
arrheaorfecal
sease
di
morbidities
in
ragility,oredema
wallf
>3
continence
s connected to sterile cystoscopy tubing and a Foley catheter. e
i
Foley catheter is inserted into a controlled enterotomy in the terminal ileum, or an appendectomy is performed with a catheter placed
into the appendiceal stump. Sterile anesthesia tubing is tied into the
distal open end of the colon and passed o the eld into a bucket. A
saline solution lavage is performed until the colon is clear of solid
stool (Fig. 51-3). Bowel anastomosis with an air leak test, with or
without a protecting stoma, is then created.
Le-sided bowel obstruction may lead to signicant proximal distention, with barotrauma and ischemic injury to the right colon. is
condition may be severe enough to mandate a subtotal or total colectomy, with a primary anastomosis or an ostomy as appropriate. A
small proportion of patients will present with a locally advanced and
unresectable rectosigmoid tumor. is unfortunate situation may
best be managed with proximal loop diversion alone, which palliates
the acute obstruction and avoids the morbidity of a nontherapeutic
major resection. Factors determining the procedure of choice will
depend on the location of the obstruction, the stage of the tumor, the
age, condition, and comorbidities of the patient, the degree of viability or severity of dilation of the proximal bowel, and the surgeon’s
experience (Box 51-2).
Direct tumor invasion into adjacent organs or peritumoral adhesions should be resected en bloc with the primary tumor whenever
possible. Malignant cells can be present in up to 40% of peritumoral
adhesions, and with no reliable intraoperative method to distinguish
between benign and malignant adhesions, adjacent adhesions should
be excised en bloc. e most common organs involved by direct
tumor spread are the small bowel, abdominal wall/retroperitoneum,
urinary bladder, and gynecologic organs. Multivisceral resections
carry with them a higher risk of perioperative complications, but
operative mortality is similar to standard resection, and cure remains
a realistic possibility.
Carcinomatosis is oen underestimated by preoperative imaging
and may not be discovered until surgery. In such cases, cytoreductive tumor debulking does not improve patient survival and is not
indicated. Instead, the goals are palliation of current or likely future
Self-Expanding Metallic Stents
M
orbidity, mortality, and ostomy rates aer emergency colon surgery
are substantially higher than aer elective surgery. ese discouraging statistics suggest that a combined endoscopic and uoroscopic
placement of self-expanding metallic stents (SEMS) is a worthwhile
option to avoid emergency surgery in le-sided colon obstruction. e
theoretic advantage of SEMS is rapid decompression of the obstructed
colon, turning an emergency situation into an elective procedure.
SEMS can be utilized in two roles: as a bridge to surgery in potentially
curative cancer or as a denitive procedure for palliation of incurable
or unresectable cancer. As a bridge to surgery, SEMS facilitates relief
of the acute obstruction, permitting decompression of the dilated and
oen ischemic proximal bowel. e urgent condition is averted, allowing time to optimize the patient’s condition, comorbidities, and nutritional status, followed by elective single-stage denitive surgery.
SEMS has generally been reserved for patients with le-sided
malignant obstructions and should be performed by experienced
teams. e site of the obstruction must be endoscopically accessible,
traversable using endoscopic and/or uoroscopic means, with minimal bowel angulation, and room for a 2-cm proximal and distal stent
ange overlap. SEMS is generally not indicated in other parts of the
large intestine or for asymptomatic strictures. Right-sided obstruction can usually be managed with a right colectomy with relatively
low morbidity and ostomy rates. Use of SEMS is discouraged for rectal cancers because of signicant patient discomfort and a high stent
migration rate. Use for benign or extrinsic strictures carries an unacceptably high rate of perforation.
Initial case series with SEMS demonstrated high clinical success
rates along with decreased morbidity, colostomy rates, and length
of stay compared with urgent resection for symptomatic le-sided
malignant strictures. ese results popularized SEMS as a bridge to
surgery in patients with obstructing le colon cancers who are candidates for curative operations. Unfortunately, several recent small,
randomized controlled studies with long-term oncologic followup have been less optimistic. ree studies were terminated early
COLON
253
History and
FIGURE 51-4
physical exam
Plain films
+/– water soluble
contrast enema,
CT scan
Volvulus
Management of a large bo
CO2 endoscopy
Sigmoid
Resuscitation
Cecal
wel obstruction resulting from volvulus.
because of a high rate of adverse events in the stent arm and one was
terminated early because of a high anastomotic leakage rate in the
primary surgery arm. Although short-term results favor SEMS, a
meta-analysis revealed that mean morbidity rates were similarly high
othgroups:
forb
ergency surgery. Even more concerning data were the long-term
em
10.7%forS
EMSas
ridgetosurgeryand
ab
12.4%for
oncologic outcomes, which showed a marked increase in local recurrence rates for patients managed with SEMS versus surgery (50% to
53% vs. 15% to 28%). Reecting the need to balance short-term morbidity and mortality with long-term oncologic outcomes, the latest
uropeanSocietyof
E
end primary surgery for the management of malignant le colon
m
strointestinal
Ga
En
doscopy
guide
linesrecom
obstruction, with use of SEMS reserved for patients deemed to be
at particularly high risk (i.e., American Society of Anesthesiologists
score ≥
3,age>70y
o
r for palliation of unresectable/incurable cancer.
ears,andthepresenceof
sig
nicant
morbidities)
co
Decompression
decompression
-
Elective
sigmoidectomy
No
Urgent right colectomy
CO2,
Carbon dioxide; C T, computed tomography.
Urgent
sigmoidectomy
COLONIC VOLVULUS
olonic volvulus is a twisting of a mobile loop of colon around a nar-
C
row mesentery. is phenomenon causes a complete, closed-loop,
large bowel obstruction and a physiologic continuum of changes
of increased luminal pressure, venous occlusion, arterial occlusion,
thrombosis, and necrosis, with eventual perforation. e most common sites are the sigmoid colon (60%) followed by the cecum (35%).
Colonic volvulus is more common in developing countries where
ber intake is much higher. Clinical presentation typically includes
acute onset of colicky abdominal pain, distention, nausea, vomiting,
and obstipation. Pain out of proportion to physical ndings increases
the concern for strangulated bowel. Unfortunately, the clinical assessment of ischemia is challenging and nonspecic.
SIGMOID V
Patients with sigmoid volvulus are more likely to be male, older, institutionalized, taking psychiatric medications, and/or constipated
(Fig. 51-4). Aer volume and electrolyte resuscitation, the diagnosis can
be suggested with an abdominal plain lm. Typically, a very distended
loop of colon is present within the right upper quadrant with the thinnest/sharpest contour pointed toward the le lower quadrant. Plain lms
alone may not distinguish between other causes of large bowel obstruction. A retrograde, water-soluble enema can show the classic “bird’s
beak” deformity at the site of the twist in the rectosigmoid (Fig. 51-5).
OLVULUS
FIGURE 51-5
beak” a
A r
ppearance in a patient with sigmoid volvulus.
etrograde water-soluble enema showing the “bird’s
Observation of free air on imaging or peritonitis mandate immediate
surgery. e stable patient should undergo decompression urgently with
exible sigmoidoscopy utilizing either water or carbon dioxide insuation, because air insuation may increase the risk of barotrauma. Rigid
proctoscopy is an acceptable alternative if the twist is within reach. Aer
endoscopically seeing the twist or point of obstruction, one should gently push. e colon should decompress as the scope tip passes the point
of obstruction and enters a cavernous loop of bowel. A large amount of
uid and air will evacuate. e mucosa should be inspected; necrosis
mandates emergency sigmoid resection. A rectal tube can then be placed
endoscopically to maintain colonic decompression, followed by medical
optimization and a plan for an elective sigmoid colectomy during the
same admission. e risk of recurrence with nonoperative management
ecentlybeenstatedtobe
hasr
dep
ends on the quality of the bowel, patient nutrition, patient stability,
67%.ede
cisiontoanastomosethe
co
lon
and medical comorbidities.
254
Large BoweL oBstruction
r use of a cecostomy tube have been described, they are rarely indi-
o
cated or performed.
Rare forms of colonic volvulus involve the transverse colon, the
splenic exure, and ileosigmoid knotting. For the rst two presentations, one should proceed directly to either a segmental colectomy
or an extended right colectomy if indicated on the basis of bowel
viability. e last very rare type, ileosigmoid knotting, is treated via
urgent surgery. ere, if the ileum can be detorsed from the sigmoid,
resection can be limited to the compromised bowel segment(s) only.
However, oen detorsion is not possible and en bloc resection is
mandated.
FIGURE 51-6
CEC
atients with cecal volvulus tend to be younger and female. e
P
A plain abdominal radiogra
AL VOLVULUS
ph of cecal volvulus.
abdominal plain lm may show a very distended, kidney-bean–
shaped loop of colon within the le upper quadrant, with the inner
curvature of the loop pointed toward the right lower quadrant
(Fig. 51-6). Should the patient be seen in the emergency department and sent directly for a CT scan, a cecal volvulus oen shows
dilated small bowel, a large dilated loop of colon, and whorling
of the ileocolic mesentery. Unlike patients with sigmoid volvulus,
endoscopic decompression is unlikely to be successful, and the
merican
A
roceeding with an urgent right colectomy. Although colopexy and/
p
S
ociety
for Ga
strointestinal
En
doscopy
ecommends
r
g g e
u
S
A
SGEStandardsofPracticeCommittee,Harrison
palaneni V, etal. e role of endoscopy in the management of patients
with known and suspected colonic obstruction and pseudo-obstruction.
Gastrointest Endosc
A
tamanalp SS. Treatment of sigmoid volvulus: a single-center experience of
952 patients over 46.5 years. Tech Coloproctol
B
ruzzi M, Lefevre JH, Desaint B, etal. Management of acute sigmoid volvulus:
short- and long-term results. Colorect Dis
B
uechter KJ, Boustany C, Caillouette R, Cohn Jr I. Surgical management
oftheac
156(3 pt 1):163–168.
C
hang
of colon cancer. Dis Colon Rectum. 2012;55(8):831–843.
Finan PJ, Campbell S, Verma R, et al. e management of malignant
l
arge
2007;9(s
Gi
ngold
Surg. 2012;25(4):236–244.
Park SH, Lee JH, Lee SS, etal. CT colonography for detection and characteri-
sation of synchronous proximal colonic lesions in patients with stenosing
colorectal cancer. Gut
R
akinic J. Colonic volvulus. In: Beck DE, Roberts PL, Saclarides TJ, etal.,
eds. e ASCRS Textbook of Colon and Rectal Surgery. 2nd ed. New York:
Springer Science+Business Media; 2011. [chapter 23].
Sabbagh C, Browet F, Diouf M, etal. Is stenting as “a bridge to surgery” an
oncologically safe strategy for the management of acute, le-sided, ma-
lignant, colonic obstruction? A comparative study with a propensity score
analysis. Ann Surg
va
n Hoo JE, van Halsema EE
stents for obstructing colonic and extracolonic cancer: European Society
ofGa
dosc
e d
S t
utelyobstructed
GJ, K
aiser AM, Mills S, etal. Practice parameters for the management
b
owel
uppl
D, M
urrell Z. Management of colonic volvulus. Clin Colon Rectal
strointestinal
.2014;80(5):747–761.e1-75.
a d i n g
R
e
.2010;71(4):669–679.
co
o
bstruction:
4):1–17.
A
.2012;61(12):1716–1722.
.2013;258(1):107–115.
En
doscopy
Ar
lon.
CPGBI
,V
anbiervliet
(ESGE)c
ME, A
.2013;17(5):561–569.
.2015;17(10):922–928.
127c
eviewof
p
s
osition
tatement.
G, et
al. Self-expandable metal
guide
linical
nderson MA, Ap-
ases.Am J Surg. 1988;
C
line.Gastrointest En-
olorectal Dis.
C
V
ODUCTION
INTR
n this chapter, we review the presentation, diagnostic strategy, and
I
treatment algorithms for colonic volvulus.
Colonic volvulus is the torsion of a mobile loop of bowel with an
elongated mesentery and a narrow pedicle. e twisting of the bowel
around its mesenteric blood supply leads to acute luminal obstruction
and decreased blood ow to the bowel wall that can progress to ischemia,
infarction, and, eventually, perforation. Volvulus is rare in developed
countries, where it is the cause of 2.5% of all cases of large bowel intestinal obstruction (LBO). However, volvulus causes up to 80% of LBO cases
worldwide and remains the third leading cause of LBO behind cancer
and diverticulitis. Volvulus must be distinguished from all other causes
of colonic distention, including neoplasms, diverticulitis, inammatory
bowel disease, Ogilvie syndrome, Hirschsprung disease, and ileus.
Two main types of volvulus present in adults: sigmoid and cecal.
Historically, 60% of colonic volvulus cases were sigmoid, with cecal
volvulus accounting for 20% to 40%. However, the incidence of cecal
volvulus has been increasing in developed countries, while the incidence of sigmoid volvulus remains stable. A recent United States–
based study found cecal volvulus in approximately 60% of patients
and sigmoid volvulus in 40%. Less common is transverse colon volvulus, which occurs in 2% to 4% of cases. e types of volvulus dier
dramatically in their patient population and management.
Deborah S.
and ascending colon twist 180 to 360 degrees around each other along
the longitudinal axis of the ascending colon. is torsion is similar to
sigmoid volvulus, except it occurs in a clockwise direction. is form
has a high mortality, because the mesenteric torsion is associated with
vascular compromise, which can lead to ischemic gangrene and perforation. e cecal bascule subtype presents in one third of cecal volvulus cases. e cecum folds on itself anteromedially over the ascending
colon, creating a ball-valve type obstruction at the level of the ileocecal
valve. Because no torsion of the ileocolic mesentery is present, vascular
compromise is rare and occurs only when signicant distention prevents the cecum from unfolding into its normal position. Several risk
factors have been identied, including congenital bands, cathartics, a
high-ber diet, previous pelvic surgery, and pregnancy.
Signs and Symptoms
C
ecal volvulus presents with symptoms of a distal small bowel
obstruction—colicky abdominal pain, nausea, vomiting, and obstipation. Eighty-ve percent of aected patients have acute obstruction
at presentation. A constricting band is found across the ascending
colon intraoperatively.
Diagnostic Imaging
Keller
CEC
AL VOLVULUS
Backgr
C
ascending colon and a xed point for the mobile segment to twist
around. e main predisposing condition is failed fusion of the
ascending colon to the retroperitoneum, a congenital anomaly
found in 10% to 22% of individuals. is condition creates a mobile,
intraperitoneal ascending colon that can twist around its own mesentery. Other risk factors are adhesions from previous surgery and
an abdominal mass that serves as a fulcrum for rotation. No geographic distribution has been identied, but incidence is increased
in developed countries with higher rates of previous abdominal surgery. Compared with sigmoid volvulus, cecal volvulus occurs more
frequently in a younger (mean age 53 years), female population.
Pathoph
T
colic) and mesentericoaxial (cecal bascule). Axial torsion presents
in two thirds of cecal volvulus cases. In this subtype, the distal ileum
ound and Demographics
ecal volvulus presents when there is both an abnormally mobile
ysiology
wo classic volvulus patterns exist—axial torsion (true cecal or ceco-
On a
n abdominal radiograph, the small bowel is distended, whereas
the distal colon is decompressed. e classic radiograph nding is a
round loop of air-distended bowel with haustral markings directed
toward the le upper quadrant (Fig. 52-1). In axial torsion, the medially placed ileocecal valve indents the dilated cecum, giving the
characteristic “coee bean” shape. With cecal bascule, the redundant
cecum ips up medially into the upper abdomen, causing a dilated
cecum and small bowel. Plain radiographs are insucient to conrm
cecal volvulus in 33% to 85% of cases. Barium enema demonstrates a
“bird’s beak” or column cuto sign in the right colon and is diagnostic in 88% of cases. However, performance of this study may unnecessarily delay surgery, so it should not be used routinely. A computed
tomography (CT) scan is the test of choice. Pathognomonic CT signs
include dilated small bowel and cecum centered on the whirled mesentery (“the whirl sign”) and an ileocecal twist. CT delineates the
cause and level of high-grade obstruction and provides evidence of
closed-loop obstruction or ischemia, facilitating timely management.
However, almost 50% of cases are not diagnosed until laparotomy.
reatment
T
rompt diagnosis and surgery can prevent the complications of
P
cecal volvulus, which include closed-loop bowel obstruction and
255
256
ColoniC VolVulus
countries, and in persons of advanced age, explaining the anatomic
basis, higher male occurrence, and higher rates of failed colonoscopic
reduction among older patients.
FIGURE 52-1
scular compromise, gangrene, perforation, and death. e overall
va
complication rate (17%) and mortality rate (<1%) are relatively low.
e choice of surgery depends on the patient’s clinical condition. In
severely debilitated patients, cecostomy is a reasonable option but
is associated with a wound infection rate of 40% to 50% and recurrence rates up to 5%. Endoscopic decompression has been used
but is less eective than for sigmoid volvulus, and the success rate
is only 15% to 20%. Cecopexy—that is, xation of the right colon
and cecum—is associated with recurrent volvulus in 20% to 30% of
patients. Percutaneous decompressive cecostomy performed under
CT guidance has also been described an alternative to colonoscopy
and surgical cecostomy for treatment of massive cecal distention in
poor surgical candidates. Because all nonoperative techniques have
high recurrence and complication rates, a right hemicolectomy
with primary ileocolic anastomosis is the procedure of choice in a
t patient.
SIGMOID V
Backgr
S
long, redundant sigmoid colon and a narrow mesentery. A geographic
distribution has been identied, with the “volvulus belt” extending
across Latin America, the Middle East, sub-Saharan Africa, Scandinavia, Russia, Pakistan, and India. Sigmoid volvulus is more common in men, in persons with neurologic disease, paraplegia, diabetes
mellitus, Chagas disease, and megacolon, and in residents of nursing homes. Chronic fecal overloading, which elongates and dilates
the sigmoid colon, is a predisposing factor. In nonendemic areas, the
fecal overloading is due to chronic constipation, whereas in endemic
areas, it stems from the bulky stool of a ber-rich diet. Anatomic
studies have also found longer sigmoid colon lengths in males, as
well as in subjects in sub-Saharan Africa compared with Western
ound and Demographics
igmoid volvulus is an acquired condition found in patients with a
Radiogra
phic findings of cecal volvulus.
OLVULUS
Pathoph
In persons with sigmoid volvulus, the redundant sigmoid colon
rotates around its mesentery, causing distension and obstruction.
When distended, the antimesenteric border lengthens more than the
mesenteric border, and the sigmoid twists to accommodate. Further
distension occurs in the closed loop from hyperperistaltic emptying
of the proximal colon and bacterial fermentation. Luminal obstruction occurs when the torsion reaches 180 degrees, and vascular
compromise occurs at 360 degrees. e distal obstruction can cause
progressive cecal dilatation, and eventual perforation can occur in
patients with a competent ileocecal valve.
ysiology
Signs and Symptoms
cute obstruction is the presentation in 60% to 70% of cases,
A
whereas other patients report chronic episodes of abdominal pain,
distention, obstipation, and constipation, consistent with repeated
subclinical episodes of volvulus. Nausea and vomiting develop
with progressive obstruction. Patients are commonly elderly and
debilitated, and thus only a limited history may be available. Massive abdominal distention is common, and examination reveals
tympany over the dilated, thin-walled colon loop. Respiratory
and cardiovascular compromise may be present from the massive
abdominal distention. Worrisome signs include progression to
constant pain, indicating development of a closed-loop obstruction, and rebound tenderness, signifying peritonitis from ischemic or perforated bowel. At this stage, signs of systemic toxicity
may be present.
Diagnostic Imaging
adiographic diagnosis can be made through abdominal radio-
R
graphs, a contrast enema, or a CT scan. e classic plain lm nding
is a dilated, U-shaped colon loop projected toward the right upper
quadrant—the “bent inner tube” sign (Fig. 52-2). In the middle of
this loop is a vertically oriented white stripe that represents the two
apposing walls of the obstructed loop of sigmoid colon. Abdominal
radiographs are insucient for denitive diagnosis in 49% of sigmoid
cases. On a water-soluble contrast enema, sigmoid volvulus is seen as
a smooth, tapered point of obstruction at the rectosigmoid junction—
the “bird’s beak.” CT scan ndings include an inverted U-shaped distended sigmoid colon with a mesenteric twist (the “whirl sign”), the
absence of rectal gas, the coee bean sign, disproportionate sigmoid
enlargement, convergent, crossing transition points (the “X-marksthe-spot” sign), and invagination of the mesenteric fat that gives the
impression of a split in a single twisted loop of bowel (the “split-wall”
sign).
Endoscopy is used for diagnosis of ischemia and necrosis and
therapeutic decompression. e site of the twist is seen as a mucosal
spiral and luminal stenosis with dilated sigmoid colon distally and
ischemic mucosa.
reatment
T
n 1947, Bruusgaard reported successful treatment with procto-
I
scopic decompression and placement of a rectal tube, paving the
way for today’s therapeutic algorithms in the management of sigm
oid volvulus. Emergency endoscopic reduction remains the treat
m
ent of choice in acute sigmoid volvulus without diuse peritonitis
-
Single line
formed by
lateral wall
COLON
Descending
colon
Double line
formed by
medial walls
257
Rectum
A
B
Sigmoid volvulus
C
FIGURE 52-2
. 52-3). Reduction should be attempted rst with a rigid procto-
(Fig
Radiogra
scope. If this maneuver is unsuccessful, then reduction with a exible endoscope should be attempted. e endoscope is advanced
through the spiral narrowing, into the dilated bowel. is maneuver
straightens the twisted colon, dramatically releasing air and stool.
Viability of the mucosa can be assessed. Placement of a rectal tube
beyond the point of obstruction can allow further decompression,
phic findings of sigmoid volvulus.
temporarily prevent recurrent volvulus, and facilitate electrolyte correction, hydration, and bowel preparation for elective surgery. Endoscopic decompression has success rates of 70% to 90% in emergency
situations.
Although it is successful for emergency decompression, nonoperative management is associated with a high recurrence rate. At least
70% of patients experience a recurrence within 2 years, and 60% have a
258
ColoniC VolVulus
Volvulus suspected
PeritonitisStable, no peritonitis
Imaging:
Abdominal X-Ray
CT-scan
Water-soluble contrast enema
Endoscopic reduction:
Rigid proctoscopy
Flexible endoscopy
Successful
Yes No
Placement of a rectal tube
beyond the point of obstruction
Semi-elective sigmoid
resection within 48–72 hours
Emergency surgery
Unsuccessful OR
Mucosa not viable, signs of ischemia
Mucosa viable, no
perforation, no
ischemia
Sigmoid resection with
anastomosis
Sigmoid resection with
colostomy
FIGURE 52-3
ngrenous colon at recurrence (versus only 6% at initial presentation).
ga
orithm for diagnosis and treatment of volvulus.
Alg
us colonoscopic decompression is a bridge to elective sigmoid resection, not a denitive treatment. Surgical resection should be performed
within 48 to 72 hours, during the same hospital stay, aer mechanical
bowel preparation. e main surgical options include sigmoid colon
resection with primary anastomosis, sigmoid colon resection with end
ostomy, detorsion and sigmoidopexy, and detorsion alone. Authors of
a recent report found that among cases managed surgically, sigmoid
colon resection was performed in 89% of cases, whereas detorsion with
or without xation procedures remained uncommon. For patients
who refuse elective surgical resection or have unacceptably high surgical morbidity, alternative management strategies, such as percutaneous
endoscopic colostomy, have been successfully performed in a small
series. Resection of the redundant sigmoid colon with primary anastomosis remains the treatment of choice.
Mortality rates for sigmoid volvulus are approximately 10% and
are signicantly higher than in cases of cecal volvulus. Bowel gangrene, peritonitis, coagulopathy, stoma creation, and chronic kidney
disease are strong predictors of mortality. Emergency surgery carries
a substantial risk of mortality and should be reserved for patients
ith bowel gangrene, perforation, peritonitis, unsuccessful nonsur-
w
gical detorsion, and early recurrence. Techniques for nonoperative
management should be used to convert an emergency procedure in
a poorly prepared patient to a semi-elective procedure in a medically
optimized patient.
Although use of laparoscopic techniques has been increasing,
their use is still reported in fewer than 4% of cases. e use of laparoscopy was not found to aect mortality.
TRANSVERSE COLON VOLVULUS
Backgr
T
tion. It occurs in only 2% to 4% of volvulus cases but has the highest
mortality rate of any volvulus— estimated at 33%. e onset is most
oen in the second and third decades of life, and it is more common
in women.
ound and Demographics
ransverse colon volvulus is a very rare cause of large bowel obstruc-
COLON
259
Pathophysiology
ransverse colon volvulus occurs because of mechanical, physi-
T
ologic, and congenital causes that promote nonfixation, elongation, and chronic redundancy of the transverse colon. Among
the causes are distal colonic obstruction, adhesions, previous surgery, excess mobility of the right colon, inflammatory
strictures, carcinoma, chronic constipation, Hirschsprung disease, malrotation, and anatomic defects in the normal liver and
colon attachments.
Transverse colon volvulus is categorized as either acute fulminating or subacute progressive types. Fulminating volvulus is an aggressive form, rapidly progressing to vascular compromise as a result of
a closed loop obstruction. e subacute form presents with more
subtle signs of obstruction.
Diagnostic Imaging
ransverse colon volvulus demonstrates the pathognomic bird’s beak
T
deformity on Gastrogran enema or loops of dilated large bowel with
two air uid levels on abdominal radiographs.
Signs and Symptoms
e acute fulminating type is associated with acute epigastric pain,
nausea and vomiting, rebound tenderness, leukocytosis, absent
bowel sounds, and limited abdominal distension. Immediate surgical intervention is necessary to resect compromised bowel before
gangrene and perforation occurs. e subacute progressive type has
massive abdominal distension but minimal abdominal pain, symptoms of obstruction, rebound tenderness, and elevations in leukocyte
count. Timely treatment is necessary in the subacute type to avoid
progression.
Up to 50% of patients with transverse colonic volvulus report
experiencing previous episodes of self-limited obstruction, likely as
a result of intermittent subacute volvulus.
Treatment
nlike sigmoid volvulus, nonoperative treatment of transverse colon
U
volvulus is inadequate and risks progression of necrosis and death. A
segmental transverse colectomy or an extended right colectomy is the
treatment of choice, even if bowel is viable, because it carries virtually
no risk of recurrence. Colopexy, where the redundant U-shaped loop
of the transverse colon is sutured to the adjacent limbs of ascending and descending colon, also has been described. It eliminates the
risks associated with resection, but there is a high risk of recurrence,
reportedly between 30% to 75%.
g g e
S
u
Ala
tise OI, Ojo O, Nwoha P, etal. e role of the anatomy of the sigmoid
colon in developing sigmoid volvulus: a cross-sectional study. Surg Radiol
Anat. 2013;35:249.
Atamanalp SS. Treatment of sigmoid volvulus: a single-center experience of
952 patients over 46.5 years. Tech Coloproctol. 2013;17(5):561–569.
Delabrousse E, Sarlieve P, Sailley N, etal. Cecal volvulus: CT ndings and cor-
relation with pathophysiology. Emerg Radiol. 2007;14:411.
Haaga JR, Bick RJ, Zollinger RMJ. CT-guided percutaneous catheter cecos-
to my. Gastrointest Radiol. 11987;2:166.
Habre J, Sautot-Vial N, Marcotte C, Benchimol D. Caecal volvulus. Am J Surg.
2008;196:e48.
Halabi WJ, Jafari MD, Kang CY, et al. Colonic Volvulus in the United
States: Trends, Outcomes, and Predictors of Mortality. Ann Surg.
2014;259(2):293–301.
Lou Z, Yu ED, Zhang W, etal. Appropriate treatment of acute sigmoid volvu-
lus in the emergency setting. World J Gastroenterol. 2013;19:4979.
Madiba TE, omson SR. e management of cecal volvulus. Dis Colon Rec-
tum. 2002;45:264.
Margolin DA, Whitlow CB. e pathogenesis and etiology of colonic volvu-
lus. Semin Colon Rectal Surg. 1999;10:129.
Martin MJ, Steele SR. Twists and turns: a practical approach to volvulus and
intussusception. Scand J Surg. 2010;99:93.
Rahbour G, Ayantunde A, Ullah MR, etal. Transverse colon volvulus in a 15
year old boy and the review of the literature. World J Emerg Surg. 2010;5:19.
Vandendries C, Julles MC, Boulay-Coletta I, etal. Diagnosis of colonic vol-
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S t
e d
R
a d i n g
e
S
C
P-
(O S)
Theodor
ODUCTION
INTR
A
cute colonic pseudo-obstruction, also known as Ogilvie syndrome,
is a nonmechanical, functional obstruction of the large intestine. It
has become a well-known clinical entity, but in many regards it is
poorly understand and dicult to manage. In 1948 a British surgeon,
Sir Heneage Ogilvie, rst described acute colonic pseudo-obstruction in two patients who had colonic dilatation without an obvious
mechanical cause. Both patients had extensive invasion and destruction of the celiac plexus associated with retroperitoneal malignancy.
Ogilvie hypothesized that this neural involvement produced a functional obstruction. Today, acute colonic pseudo-obstruction is a
dierential diagnosis for hospitalized patients who have abdominal
distention. Diagnosis without undue delay is crucial because of the
need to exclude a mechanical obstruction and the risk of colonic
perforation. Conservative measures oen lead to resolution. When
medical therapy fails or is contraindicated, endoscopy can be eective in achieving decompression, and surgery is the last resort. New
advanced techniques in endoscopy, such as the use of decompression
tubes and percutaneous endoscopic cecostomy, have decreased the
need for resection.
e J. Saclarides and Elizabeth Berger
EPIDEMIOLOGY
e incidence of Ogilvie syndrome is unknown, but most studies
indicate that elderly patients are at greatest risk. In a review by Vanek
etal of 400 cases, a list of associated conditions was compiled, which
included obstetric, gynecologic, or pelvic surgery (19%); trauma/
orthopedic procedures (18%); infection (10%); cardiac events (10%);
and neurologic events (9%). Other conditions connected with acute
pseudo-obstruction of the colon included electrolyte imbalances,
certain medications, organ transplant, connective tissue disorders,
and debilitated states (Box 53-1).
ETIOLOGY
S
everal hypotheses have been proposed regarding the cause of
pseudo-obstruction, but it is unlikely that any single theory can
explain all cases. It is a functional disturbance in colonic motility in
that there is no mechanical obstruction.
e enteric nervous system is the primary determinant of motility function in both the small and large intestines, whereas the
central nervous system modulates motility patterns established by
the enteric system. Enteric nerves contain a variety of neurotransmitters responsible for smooth muscle contraction or relaxation;
acetylcholine, neurokinin A, and substance P are stimulatory neurotransmitters, and vasoactive intestinal polypeptide and nitric
oxide are inhibitory. e extrinsic inuences of the sympathetic
260
n
erves from the thoracic and lumbar segments of the spinal cord
tend to decrease motility, whereas parasympathetic nerves from the
brainstem via the vagus nerve, as well as sacral spinal segments,
increase motility.
To explain an acute colonic pseudo-obstruction, Ogilvie theorized that there was an imbalance in the activity of the autonomic
nervous system, with parasympathetic overactivity leading to dilatation of the colon. However, current evidence favors a relatively
increased sympathetic tone and/or a decreased parasympathetic tone
leading to a functionally obstructed distal colon and a relaxed proximal colon (adynamic colon). e evidence that favors this theory is
the association of acute pseudo-obstruction with diseases that cause
disturbances in the autonomic input to the gut and the remarkable
response to pharmacologic therapy.
In other instances, the anticholinergic activity of certain drugs
decreases parasympathetic activity, thereby creating an atonic segment of bowel. Other theories point to factors that produce excess
sympathetic activity, such as myocardial infarction, surgery, or
trauma, as the precipitating cause.
SIGNS AND
ilvie syndrome may present similarly to a mechanical obstruction,
Og
with marked abdominal distention the most consistent physical nding associated with abdominal pain or discomfort. Nausea, vomiting, and constipation also can be associated with the syndrome but
are not always present. In fact, 40% of patients have diarrhea. e
abdominal pain may be colicky, but frequently it is constant pain
related to the intestinal distention. Signs of systemic toxicity usually do not appear unless catastrophic complications occur, such as
perforation. Although abdominal tenderness is found in only 50%
of patients, its presence in the right lower quadrant suggests cecal
ischemia and impending perforation. e main diagnostic clue is the
clinical presentation. e patient is typically male (with a 2:1 male to
female ratio), oen elderly, and usually has been hospitalized with a
serious systemic illness, an unrelated surgical problem (e.g., coronary
bypass or orthopedic surgery), or traumatic injuries (e.g., a pelvic
fracture or burns).
According to the law of Laplace, for a given pressure, the tension in
the wall of a hollow organ increases in direct proportion to the radius
of the organ. e equation can be simplied as T = P × R. Because the
cecum is the widest segment of the colon, increases in intraluminal
pressure cause the greatest increases in wall tension there. e cecum
is therefore at highest risk for ischemia and for longitudinal splitting
of the serosa and tenia, with herniation of the mucosa. e diameter
of the cecum at which perforation occurs remains debatable. Vanek
found that a cecal diameter of 12 cm or less is rarely associated with
perforation. A cecal diameter of 14 cm has a 23% incidence of perforation. erefore, a range in cecal diameter of 9 to 12 cm has been
SYMPTOMS