19 Colonic Volvulus Michael D. Hellinger and Randolph M. Steinhagen Introduction/Historical Perspective Throughout most of the 19th century, management was nonoperative. Operative intervention was reserved for life- Volvulus of the bowel refers to a twisting or torsion of the threatening situations. High mortality rates for intestinal intestine about its mesentery. The term volvulus, which may operations in the face of obstruction were the reasons cited in involve any segment of the intestinal tract from stomach to rec- avoiding surgery. With advances in anesthesia and antisepsis, tum, is a Latin word for twisted used by the Romans to signify surgical procedures were developed. In 1883, Atherton per- this condition.1 Volvulus of the colon usually occurs in the formed the first successful operative detorsion of a sigmoid sigmoid or cecum, but may involve any segment of colon. In volvulus in the United States. The next year, Treves recom- addition, synchronous volvulus of the sigmoid and cecum,2 or mended colectomy for volvulus complicated by gangrene. By sigmoid and ileum may occur.3 In the United States, volvulus 1889, in fact, all of the surgical options for volvulus, includ- represents a rare cause of intestinal obstruction, encompassing ing detorsion, -pexy, and resection with or without stoma, had less than 5% of large bowel obstructions. However, worldwide been described.1,7 it is a much more common form of large bowel obstruction, Early in the 20th century, with improvements in early diag- representing more than 50% of the cases in some countries.4–6 nosis and rapid therapy, mortality rates began to decrease and The first record of colonic volvulus is found in the Ebers surgical therapy became the mainstay. Mortality rates Papyrus from ancient Egypt. This record stated that either decreased from 30%–60% to under 20%. Mortality for gan- volvulus would spontaneously reduce or the segment of bowel grenous bowel remained high (30%–40%), reflecting a delay would “rot in his belly.” The writings further document that if in diagnosis and treatment. Moynihan’s statement in 1905 this condition did not resolve, the patient should be prepared that a mortality of greater than 10% is the mortality of delay for remedies to induce detorsion. As early as 1500 BC, there- had been confirmed in many series.1,7 Until the mid-20th cen- fore, it was recognized that detorsion was crucial for resolution tury, immediate surgical intervention was the standard of care. of this condition. Even in ancient times, a high fiber diet was In 1947, Bruusgaard, from Norway, challenged the routine believed to be contributory to the development of volvulus. At surgical approach, and reported a success rate of 86% for non- that time, treatment was directed at symptoms and relief of the operative reduction of sigmoid volvulus with proctoscopic obstruction. External manipulation combined with purgatives decompression and placement of a rectal tube.9 This paved the was the treatment of the times. Hippocrates advocated use of a way for today’s therapeutic algorithms in the management of 10-digit long suppository and air blown into the anus with a colonic and specifically sigmoid volvulus.1,7 Finally, with wide- metal worker’s bellows. This is perhaps the earliest predeces- spread use of flexible endoscopy, many authors have reported sor to today’s sigmoidoscopic decompression.1,7 successful detorsion and decompression of all forms of colonic During subsequent years, reports concerning colonic volvulus using the colonoscope or flexible sigmoidoscope.10–15 volvulus were infrequent. It was not until the 19th century, Because of high recurrence rates, these endoscopic methods are when investigators began attempting to determine causes of currently recommended as definitive treatment only for very disease, that this entity was discussed further. Perhaps the fact high-risk individuals who are too ill to undergo surgery, and as that volvulus was not recognized as a cause of colonic a temporizing measure until eventual surgery under more con- obstruction was accounted for by the rarity of the diagnosis trolled conditions for all other patients.1,7,9,14–16 before the 1800s. In 1872, Crise reported 12 cases, and in The differential diagnosis of colonic volvulus encompasses 1884 Treves reported 34 cases of colonic volvulus. In 1894, any cause of colonic distention. This includes all of the Obalinski recognized regional variations in frequency of mechanical as well as the nonobstructive causes. Mechanical volvulus.1,7,8 causes include colonic and extracolonic neoplasms, as well as 286 19. Colonic Volvulus 287 benign entities such as diverticulitis and inflammatory bowel disease. Nonobstructive causes include colonic pseudo- obstruction (Ogilvie’s syndrome), and various intraabdominal processes that may result in an intestinal paralysis. In addi- tion, Hirschsprung’s disease must also be considered.5,6,17 Cecal Volvulus Incidence and Epidemiology Worldwide, cecal volvulus accounts for 40%–60% of all colonic volvuli. Originally described in 1837 by Rokitansky, it remains, however, an uncommon cause of intestinal obstruction. The worldwide incidence is estimated at 2.8–7.1 per million people per year. Most reported cases occur in younger individuals with a predilection for females.18–20 In a review of the published literature between 1959 and 1989, Rabinovici et al.19 found a mean age of 53 years and a female to male ratio of 1.4:1. Pathogenesis/Etiology True cecal volvulus is actually an axial torsion of the cecum, terminal ileum, and ascending colon about its mesentery (Figure 19-1A). A variant, cecal bascule (Figure 19-1B), occurs when the cecum folds anteriorly over the ascending colon with- out an axial twist. This represents approximately 10% of cases of cecal volvulus. Review of patient characteristics indicates that there is a high rate of prior abdominal operations in patients who subsequently develop cecal volvulus, and previ- ous surgery has been considered to be a potential causative fac- tor. A clear prerequisite is a mobile cecum and ascending colon. A congenital component involves lack of fixation of the right colon, which then assumes an intraabdominal position.4,18–20 In fact, a cadaver study revealed an 11% incidence of freely mobile right colons, and a 26% incidence of cecal mobility suf- ficient to allow folding. The authors concluded that 37% had cecums mobile enough to allow for volvulus.4 However, because cecal volvulus is so rare, factors other than cecal mobility must be involved. Prior abdominal sur- gery with colonic mobilization, recent surgical manipulation, adhesion formation, congenital bands, distal colonic obstruc- tion, pregnancy, pelvic masses, extremes of exertion, and hyperperistalsis have all been implicated.4,18–20 During abdominal surgery, excessive mobilization or manipulation of the cecum and ascending colon or placement/withdrawal of packs may precipitate postoperative volvulus.4 Previous FIGURE 19-1. A Schematic illustration of a cecal volvulus. reports of cecal volvulus reveal that 30%–70% of patients had B Schematic illustration of a cecal bascule. undergone prior surgery.19,20 In the long term, an adhesive band may act as a fulcrum for a previously mobilized ileum and right colon to rotate axially. Displacement of the cecum Clinical Presentation by an enlarged uterus or pelvic mass may also promote volvu- lus. In fact, several series report that 10% of patients with Symptoms and signs of cecal volvulus are that of small bowel cecal volvulus are pregnant at the time of presentation.4,20 obstruction. The majority of patients present with abdominal 288 M.D. Hellinger and R.M. Steinhagen pain, distention, constipation, nausea, and vomiting. Abdominal distention is less marked than with more distal forms of colonic volvulus. The presentation may be that of an acute obstruction or one of an intermittent or recurrent pattern. In the intermittent pattern, because duration of symptoms is brief, diagnosis may be quite difficult. Acute volvulus results in a closed loop cecal obstruction and distal small bowel obstruction. This may progress to a more fulminant presenta- tion when ischemia and gangrene develop. At that point, the patient will present with peritoneal signs and systemic mani- festations of an acute abdominal process. Before onset of gan- grene, fever and leukocytosis are unreliable factors.17–19,21 Diagnosis The diagnosis is most often made on the basis of the combi- nation of clinical presentation and plain abdominal films or barium enema. Plain films may identify the classic coffee bean deformity directed toward the left upper quadrant (Figure 19- 2A). If not, barium enema may reveal a “bird’s beak” or col- umn cut-off sign in the right colon (Figure 19-2B).4,17–19 In the review by Rabinovici et al., 53% of cases were diagnosed pre- operatively with clinical evaluation combined with radiologic investigation. The diagnosis was suspected in 46% of plain films, and barium enema was diagnostic in 88% of cases when obtained. However, 47% were not diagnosed until laparo- tomy.18 Although barium enema is of clear value when the diagnosis is in question, in obvious cases, performance of this study may needlessly delay surgical therapy. It therefore should not be routinely used.4 Treatment/Outcome Laparotomy remains the primary treatment modality for cecal volvulus. Many patients are not diagnosed until exploration, and nonoperative modalities have generally been unsuccessful. However, both radiographic and endoscopic reduction have been reported. Whereas radiographic attempts at reduction are generally believed to carry a high risk of perforation, other modalities have been used as temporizing measures.4,5,16,18 Percutaneous decompression via computed tomographic scan guidance has been reported to be effective in decompressing a massively dilated colon in otherwise inoperable candidates.22,23 Although significantly less efficacious than in the treatment of distal volvulus, colonoscopic reduction of cecal volvulus (Figure 19-3) has been reported with some success.