ORIGINAL PAPER ORIGINAL PAPER The ANNALS of AFRICAN SURGERY | www.annalsofafricansurgery.com Role of Rigid Endoscopic Detorsion in the Management of Sigmoid Volvulus Ngeno M, Ooko PB, Seno S, Oloo M, Topazian HM, White RE Tenwek Hospital Correspondence to: Dr. Mercy Ngeno, PO Box 39-20400, Bomet, Kenya. Email: [email protected] Abstract respectively. Eleven (13%, n=99) patients declined Introduction: Sigmoid Volvulus (SV) is a common surgery after successful endoscopic detorsion, cause of bowel obstruction in Africa, affecting a while 87 patients had semi-elective surgery, an relatively young and healthy population. There has average of 3.5 days post detorsion. Sixty patients been little research regarding the use of endoscopic had emergency surgery, with gangrenous bowel detorsion in the management of SV from East Africa. noted in 43 (72%) cases. Patients undergoing The aim of this study was to determine the outcome emergency surgery had a higher morbidity rate of patients with SV managed by endoscopic (27% vs. 5%, p=0.0002), and a higher mortality detorsion at a single institution over a 9 year period. rate (12% vs. 0, p=0.002) compared to those Methods: A retrospective review of all patients having semi-elective surgery due to the presence of admitted with SV at Tenwek Hospital in Bomet, gangrenous bowel. Conclusion: Rigid endoscopic Kenya from January 2006 to October 2014 was detorsion is appropriate in the initial management done. Data were collected on demographics, clinical of any stable patient with clinical and radiological features suggestive of sigmoid volvulus without outcome. Results: There were 159 cases with a mean features of peritonitis. presentation, operative findings, management, and age of 41.1 years (range 15-87). Rigid endoscopic Keywords: Sigmoid Volvulus, Endoscopic Detorsion, detorsion was attempted in 125 (79%) patients. Rigid Sigmoidoscopy, Outcomes. The success, early recurrence, and mortality rate for rigid endoscopic detorsion was 79%, 6%, and 0% Ann Afr Surg. 2015; 12(2): 85-8. Introduction There has been little literature from East Africa on Sigmoid volvulus (SV) is an abnormal twisting of the the use of endoscopic detorsion in the management sigmoid colon on its mesentery, leading to luminal of SV. The purpose of this study was to determine obstruction, and vascular occlusion (1). It occurs in the outcome of patients with SV managed by the face of a redundant sigmoid colon with a narrow endoscopic detortion at Tenwek Hospital in, Bomet, mesenteric attachment secondary to chronic Kenya. constipation, irregular bowel habits or a bulky, high Methods common cause of acute intestinal obstruction and A retrospective review of all patients admitted with thefiber leading diet (2,3). cause In of many large seriesbowel fromobstruction Africa, (2,4-6).SV is a a diagnosis of SV at Tenwek Hospital, in Bomet Non-operative detorsion has been advocated for in County, Kenya over a 9 year period (January 2006 the initial management of acute sigmoid volvulus in stable patients lacking features suggestive of with a diagnosis of SV based on clinical, radiological (plain,to October upright 2014). abdominal Cases X-rays),were defined endoscopic as patients and, at allows for mechanical detorsion, decompression ofbowel massively gangrene distended (7,8). Rigid proximalor flexible colonoscopybowel, and knotting or those without a clear diagnosis of SV at assessment of bowel viability (1,7,9-11). SV rigidtimes, sigmoidoscopy operative findings. or laparotomy Patients with were ileo-sigmoid excluded. commonly occurs 15-25 cm from the anal verge, Data were extracted on age, gender, presenting thus easily accessible by rigid sigmoidoscopic signs and symptoms, non-operative and operative examination and amenable to decompression (12). outcome. Data were assessed using Fisher’s exact over rigid sigmoidoscopy, the equipment and around testprocedures, and unpaired operative t test findings,as appropriate. complications P-values lessand theWhile clock flexible expertise endoscopy required has maysignificant be unavailable advantages in many resource-limited settings (8-12). All cases presenting with features of bowel than or equal to 0.05 were accepted as significant. 84 The ANNALS of AFRICAN SURGERY. July 2015 Volume 12 Issue 2 The ANNALS of AFRICAN SURGERY. July 2015 Volume 12 Issue 2 85 The ANNALS of AFRICAN SURGERY | www.annalsofafricansurgery.com correction of electrolyte imbalances where present, endoscopic detorsion was successful in all six cases. andobstruction administration had intravenous of IV antibiotics (IV) fluid as resuscitation, appropriate. Ofdetorsion the 99 duepatients to a slippedwho had flatus successful tube. Repeat endoscopic rigid Patients with suspected SV but without features detorsion, 87 (88%) had surgery, 11 (13%) declined of peritonitis (i.e. rebound tenderness, rigidity or surgery, and one, a 16 year-old female, had a rectal guarding) had endoscopic detortion attempted using biopsy to evaluate for hirschprung’s disease. The rigid sigmoidoscopy. If detortion was successful and mean duration between successful rigid endoscopic no features of bowel ischemia noted, a rectal tube detorsion and surgery was 3.5 days (range 1-7).At was inserted and secured using a 1.0 non-absorbable operation, a viable and redundant sigmoid colon suture. Non-operative detorsion were carried out by was noted in all 87 patients. Resection and primary surgical residents with close consultant supervision. anastomosis was performed in 85 patients, resection Bowel prep was initiated within 12-24 hours after and Hartman’s colostomy in one patient (due to successful detortion if the patient’s vital signs inability to achieve a tension free anastomosis remained stable, with no recurrence of symptoms or sigmoidopexy in one patient. Morbidities following foul smelling bloody stool. A repeat plain abdominal semi-electivein a patient surgerywith significant were noted malnutrition), in 5 (5%) patients and X-ray was not routinely ordered after successful including 4 cases of surgical site infection and one detorsion. Patients who had recurrence of symptoms case of anastomotic leak. No mortalities occurred among this group. peritonitis, underwent repeat rigid sigmoidoscopy. Emergency surgery was undertaken in patients due to a slipped flatus tube, but without features of Semi-elective, open sigmoid resection and primary who had unsuccessful endoscopic detorsion (15), anastomosis were performed within 2-4 days of features suggestive of bowel gangrene at endoscopy detorsion, unless the patient declined surgery. (ischemic mucosa in 2, bloody, and foul smelling Emergent explorative laparotomy was undertaken in stools in 9), peritonitis (28) at presentation, or strong patients with features of peritonitis on physical exam, consideration of other diagnosis apart from SV (6). strong consideration of other diagnosis apart from At laparotomy, 43 (72%) patients in this group had SV, after unsuccessful endoscopic detortion, or when gangrenous bowel (Table 2). The incidence of bowel features suggestive of bowel ischemia (dark mucosa gangrene in patients with peritonitis at 89% was and/or foul smelling bloody stool) were noted at much higher than those without peritonitis who detorsion. A primary anastomosis was performed had unsuccessful rigid endoscopic detorsion at 33% after resection of viable or gangrenous sigmoid colon (p=0.0003). Resection and primary anastomosis if the patient was stable, the resected bowel edges was performed in 39 cases with viable or gangrenous were well vascularized, there was no fecal peritonitis, bowel, and a colostomy fashioned after resection of and a tension free anastomosis could be achieved. On- gangrenous bowel in 21 cases . Morbidities, in this table lavage was not performed in any patient. group, were noted in 16 (27%) patients, with surgical site infection (11, 18%) being the most common Results complication . There were no case of anastomotic There were 159 cases during the study period leak. Seven (11.6%) patients died (four with a comprising of 143 (90%) males and 16 (10%) colostomy after resection of gangrenous bowel, two females. The mean age was 41.1 years (range 15-87) after primary resection and anastomosis (PRA) with the majority (70%) of patients aged 50 years and of gangrenous bowel and one after PRA of viable below (Table 1). bowel). Causes of death included severe sepsis (4), The mean duration of symptoms was 2.7 days (range pulmonary embolism (2), and severe pneumonia 6 hours-14 days). The most common signs and (1). The mortality rate in this group, based on bowel symptoms were abdominal distension (150, 94%), status, was 5.9% in patients with viable bowel and abdominal pain (143, 90%), abdominal tenderness 14% in patients with gangrenous bowel (P=0.7). (116, 73%), constipation (110, 69%), vomiting (102, The overall morbidity rate, mortality rate and mean 64%), empty rectal vault on digital exam (74, 47%), length of stay for all cases were 13%, 4% and 8.7 and peritonitis (28, 18%). days (range 2-26) respectively. Patients who had Rigid endoscopic detorsion was attempted in 125 emergency surgery had a higher morbidity rate (27% (79%) patients who had clinical and radiologic vs. 5%, p=0.0002), higher mortality rate (12% vs. 0, features consistent with SV without features of p=0.002) and a similar duration of stay (8.5 days vs. 9.3 peritonitis on physical exam, and was successful in days, p= 0.2) compared to patients undergoing semi- 99 (79%) patients (Figure 1). Early SV recurrence