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40 Mesenteric Resection in Crohn’s Disease 403
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Part VIII
Surgery for Individual Conditions
Surgical Management of Intestinal Volvulus
Ashley J. Williamson and John C. Alverdy
Definition and Clinical Features
Volvulus refers to the torsion or twisting of a viscera and mainly involves organs of
the intestinal track. Organs may twist along two directions: organo-axial (longitudinally along the mese nteric axis) or mesentero-axial (perpendicular to the
mesenteric axis). Organo-axial volvulus is the most common type in the adult
population. Volvulus involves either the sigmoid colon or cecum in >95% of the
cases that occur in the adult population. Rare cases of small intestinal volvulus may
also occur. Gastric volvulus, a complication of large hiatal hernias generally seen in
the elderly, is beyond the scope of the current discussion. Symptoms of cecal and
sigmoid volvulus are consistent with large intestinal obstruction and include
abdominal pain, constipation or obstipation, nausea, and occasionally emesis.
Abdominal distension commonly is present. Physical examination often demonstrates marked abdominal distension, varying degrees of tenderness, and an empty
rectal vault on digital rectal exam. The greatest concern in patients with intestinal
volvulus is compromise of the blood supply to the organ. Compromised blood flow
to the segment of affected bowel is related to the relative twisting and obstruction of
the blood vessels within the mesentery. Diminished blood flow in affected blood
vessels may lead to bowel ischemia, visceral perforation and death. In the United
States, intestinal volvulus is more common in elderly patients, particularly those
with medical co-morbidities, chronic constipation, and neurophysiological impairment. Risk factors for intestinal volvulus are shown in Table 41.1.
Imaging is the most appropriate method for diagnosing intestinal volvulus.
Figures 41.1, 41.2 and 41.3 demonstrate imaging for cecal volvulus (Fig. 41.1) and
sigmoid volvulus (Figs. 41.2 and 41.3).
41
A. J. Williamson J. C. Alverdy (&)
Department of Surgery, University of Chicago, 5841 S. Maryland, Chicago, IL 60637, USA
e-mail: jalverdy@surgery.bsd.uchicago.edu
© Springer Nature Switzerland AG 2021
E. D. Ehrenpreis et al. (eds.), The Mesenteric Organ in Health and Disease,
https://doi.org/10.1007/978-3-030-71963-0_41
407
408 A. J. Williamson and J. C. Alverdy
Table 41.1 Risk factors for
colonic volvulus
Chronic constipation
Elderly patient
Frequent use of laxatives
Previous laparotomy
Anatomic predisopositions
Fig. 41.1 Supine view of the abdomen in a patient with acute abdominal pain. There is a saccular
dilated structure in the right mid abdomen (circle) corresponding to a dilated cecum. The cecum
should normally be located in the right lower quadrant (asterisk). There is a partial small bowel
obstruction. Dilated loops of small bowel are seen best in the left lower quadrant (arrow),
secondary to the volvulus. With permission from Dr. Abraham Dachman, Dr. Scott Sorensen and
Dr. Justin Ramirez
Description of Surgery
Initial intervention for intestinal volvulus is largely dictated by the location of the
volvulus. In sigmoid volvulus, rigid or flexible endoscopy should be employed first
in order to evaluate the extent of ischemia of the mucosa. In the absence of mucosal
ischemia or colonic perforation, endoscopic detorsion is the initial treatment of
choice for sigmoid volvulus and is successful in more than 90% of cases. First,
rectal insufflation is performed and may result in detorsion. If the volvulus remains,
the endoscope is advanced to the area where the spiraled appearing mucosa reaches
a narrowed portion or apex. Gentle pressure is applied to this area, producing the
desired effect of release of trapped air and detorsion. A soft tube is then passed
41 Surgical Management of Intestinal Volvulus 409
Fig. 41.2 Sigmoid volvulus demonstrated on plain abdominal film. Pathognomonic coffee bean
sign outlined by white circle
beyond the site of torsion and left in position. Imaging is used to demonstrate locate
the position of the tip of the tube and to confirm the efficacy of the procedure.
The tube is left in place after endoscopic decompression in order to facilitate
bowel movement and preparation as indicated. Urgent surgical resection of the
sigmoid colon should occur in patients with signs or symptoms of sigmoid ischemia
or unsuccessful detorsion of the sigmoid volvulus.
410 A. J. Williamson and J. C. Alverdy
Fig. 41.3 Cecal volvulus demonstrated on plain film with volvulus outlined by white circle
Cecal volvulus is most often managed operatively. Endoscopic techniques
produce a favorable result in only 12% of cases. Furthermore, the endoscopic
manipulation of cecal volvulus carries the risk for injury to bowel that is already
compromised.
Indications for Surgery
Cecal volvulus is an indication for urgent operative intervention. Signs and
symptoms of ischemia including peritonitis on physical exam and hemodynamic
instability are indications for surgery in patients with sigmoid volvulus. Laboratory
and radiographic findings suggestive of the requirement for surgery rather than
initial endoscopic decompression include leukocytosis, acute kidney injury, acidosis, free air, bowel wall edema, free fluid within the abdomen and pneumatosis of
the bowel wall.
41 Surgical Management of Intestinal Volvulus 411
Contraindications
Endoscopic reduction should not be attempted in patients with signs of ischemia as
indicated above. Operative contraindications include patients who are unfitto
undergo general anesthesia, at which time a detailed goals of care conversation with
the patient and family must take place. Patients who are not operative candidates
may become candidates for endoscopic decompression.
Preparation of Patient
Upon initial concern for intestinal volvulus, patients should be urgently evaluated by
a surgical team. Often, patients require rapid rehydration and adequate IV access
should be obtained. Use of a nasogastric tube to decompress proximal dilation is often
performed. Electrolyte abnormalities are corrected prior to intervention as release of
torsion may result in the release of stored metabolites into the bloodstream. If there is
concern for ischemic compromise of the bowel, antibiotic coverage should be chosen
to cover gut flora. Accurate measurement of urine production during resuscitation and
treatment is performed following insertion of an indwelling bladder catheter.
How the Procedures Are Performed
In cases of cecal volvulus and sigmoid volvulus with signs and symptoms of bowel
compromise, the patient should be taken to the operating room for urgent bowel
resection. For sigmoid volvulus, patients are most often placed in the supine
position; however, a lithotomy position may be considered for ease of endoscopic
evaluation. Perioperative antibiotic prophylaxis is indicated given the risk of
infection. Most commonly, the procedure is performed as an open exploratory
laparotomy as compared to laparoscopy given the severe dilation of the bowel and
need to completely evaluate cause of intestinal volvulus (the lead point). The role of
minimally invasive laparoscopy in the management is currently under evaluation.
A midline incision is made with careful exposure of bowel, taking note of any
murky fluid, blood, or air present in the abdomen upon entry. Areas of ischemia or
perforation should be identified for segmental resection and bowel anastomosis to
areas of well perfused tissue. In general, necrotic bowel should be resected with
minimal manipulation and without detorsing in an effort to minimize the release of
endotoxins from necrotic bowel after detorsion. The bowel shall be explored in its
entirety in an effort to the extent of affected bowel or new diagnoses.
Operation for cecal volvulus involves the performance of laparotomy, bowel
exposure and exploration, and identification of non-viable bowel. Segmental
resection for the cecum is performed with the understanding that removal of the
ileocecal valve may have some long-term outcomes on bowel function.
412 A. J. Williamson and J. C. Alverdy
The most critical step in both operations occurs with the decision of whether to
reconnect the bowel with a primary anastomosis with creation of a defunctionalized
anastomosis with diverting loop, or an end ostomy. The most common operation
described for sigmoid pathology is the Hartmann’ s procedure in which the sigmoid
colon is resected, a rectal stump is left in place, and an end colostomy is matured at
the skin to proximally divert the fecal stream. Diversion is favored in settings where
the bowel is edematous and friable, there is a size mismatch between proximal and
distal portions, or the patient is critically ill and requires a shorter operation.
Defunctionalize anastomoses involve the creation of an anastomosis, with proximal
loop colostomy diversion to eliminate passage of fecal material through the anastomosis while it heals. The decision on which surgical approach is best should be
individualized for each patient and their clinical condition.
Specific operations for cecal volvulus involve either an ileocolonic anastomosis
or ileostomy. Surgical decision making is the same as described above, with the
understanding that ileostomies present a higher risk for dehydration and increased
maintenance with liquid stool being present when compared to colostomy.
Typical Abnormal Findings
Typical findings including a massively dilated large bowel with potential small
bowel dilatation. The bowel is often friable from edema, and rates of ischemia vary
with location. Cecal volvulus is at greatest risk for ischemia at the time of diagnosis,
with a reported rate of nonvia ble or gangrenous cecum occurring in up to 44% of
patients in medical literature reviews.
Alternatives to Surgery
If a sigmoid volvulus is able to be successfully reduced, it is recommended that the
patient been seen for follow up for an elective sigmoidectomy. These surgeries
involve removal of sigmoid redundancy in its entirety to reduce risk of recurrent
sigmoid volvulus. If the patients have megacolon (that may be primarily present or
may occur secondary to chronic constipation), a sub-total colectomy is considered.
Operative detorsion, or detorsion with fixation of the sigmoid to the abdominal
peritoneum (abdominal pexy) represents an alternative to other forms of operative
intervention. These procedures are viewed less favorably given their increased
recurrence rates of volvulus as compared to operative resections. Endoscopic fixation or pexy onto the abdominal wall in patients unfit to undergo general anesthesia or a major operation have been described but the long- term outcome of this
procedure is not well known at this time.
41 Surgical Management of Intestinal Volvulus 413
When viable bowel is present in patients with cecal volvulus, operative detorsion, detorsion with cecopexy, and cecostomy are potential alternatives to cecal
resection. Studies have evaluated cecopexy or detorsion alone in patients with cecal
volvulus and have been shown the development of fewer wound infections, mortality rates of 10–13%, and recurrent volvulus in 12–13% of cases. Cec ostomy
decreases recurrent cecal volvulus to approximately 14% of patients but overall
morbidity with this procedure is over 50%.
Outcomes
Largest trials report success rates of 60–95% of endoscopic detorsion for sigmoid
volvulus. Recurrent sigmoid volvulus during admission is reported in approximately 4% of patients, while long term recurrence noted in 43–75% of patients.
Operative resection remains the gold standard for cecal volvulus. Abdominal and
wound complications approach 28% in reviews of the procedure, whereas recurrent
volvulus after cecal resection is an exceptionally rare event.
Complications
Hartmann’s procedure and colonic resection with primary anastomosis remain the
two most common surgical approaches for these patients, with Hartmann’s procedures traditionally occurring in patients who are more seriously ill. Due to their
performance in clinically compromised patients, Hartmann’s procedures are not
surprisingly found to have more postoperative complications and mortality when
compared to primary anastomosis operations (8% vs. 5%). Anastomotic leak is
reported in approximately 7% of cases of patients undergoing primary anastomosis.
Of note, creation of a colostomy creates an increased socio-economic burden on
patients. This includes the need for ongoing post-operative care and the purchase of
ostomy supplies. While dehydration is uncommon in patients with a colostomy
compared to those having an ileostomy, economic factors should be considered
procedure selection.
The presence of ischemia during cecal volvulus is an independent risk factor for
mortality when surgical resection is required. A cecal volvulus with evidence of
ischemia has reported rates of mortality between 31 and 44% given that patients are
often frail, elderly and present in emergent conditions.
Summary
While the Hartmann’ s procedure has been traditionally viewed as a procedure with
high associated complications, more recent data suggest that it safe and effective in
complex situations such as sigmoid volvulus. Rapid diagnosis and treatment is