Management of Sigmoid Volvulus

Initial Assessment and Diagnosis

• Sigmoid volvulus typically presents with symptoms ranging from non-specific abdominal pain to acute abdomen, predominantly affecting elderly patients (mean age 56-77 years) 1
• Diagnosis should be confirmed through plain abdominal radiographs (first line) looking for the classical "coffee bean sign" and abdominal CT (gold standard) showing dilated colon with air/fluid level and the "whirl sign" representing twisted colon and mesentery 1, 2

Treatment Algorithm

• For patients with septic shock, bowel ischemia, or perforation, immediate surgical intervention is mandatory, with surgical options including resection with Hartmann's procedure or sigmoid resection with primary anastomosis 3, 1
• Mortality rate for emergency surgery is significant (12-20%) with surgical site infections being the most common complication (42.86%) 3
• For uncomplicated sigmoid volvulus, first-line treatment is endoscopic decompression with a success rate of 70-91% and complication rates of 2-4.7% in geriatric patients 4, 3, 1
• After successful decompression, definitive sigmoid resection should be performed during the same hospital admission to prevent recurrence, with elective sigmoid resection having significantly lower mortality (5.9%) compared to emergency surgery (40%) 4, 3, 5
• Without resection, recurrence rates are extremely high (45-71%) 5

Special Considerations

• Risk factors for mortality that require special attention include age over 60 years, presence of shock on admission, and history of previous volvulus episodes 4
• Laparoscopic approach may be suitable in select cases when performed by surgeons experienced with the technique, but benefits in emergency setting remain unclear compared to open approach 3, 1, 5
• Ischemia-reperfusion injury after derotation can aggravate intestinal dysfunction, requiring careful monitoring and supportive care 4

Vessel Ligation in Sigmoidectomy

Special Considerations

• For benign conditions like sigmoid volvulus, a full oncological anterior resection with high ligation is not typically needed, with the main consideration being ensuring adequate vascular supply to the remnant colon, as recommended by the World Journal of Emergency Surgery 6, 7
• In emergency sigmoidectomy for volvulus, the decision to perform isolated sigmoid colectomy versus high anterior resection should consider the vascular supply to the remnant colon, according to the World Journal of Emergency Surgery 6, 7, 8
• For sigmoid volvulus cases, resection of infarcted bowel should be performed without detorsion and with minimal manipulation to prevent release of endotoxin, potassium, and bacteria, as suggested by the World Journal of Emergency Surgery 8
• In these emergency cases, end colostomy creation (Hartmann procedure) is often appropriate for hemodynamically unstable patients or those with significant comorbidities, as recommended by the World Journal of Emergency Surgery 9, 10

Evidence‑Based Management of Acute Sigmoid Volvulus

Immediate Surgical Indications

• Patients presenting with septic shock, clinical evidence of bowel ischemia or perforation, or peritonitis should proceed directly to operative intervention rather than endoscopic decompression. World Journal of Emergency Surgery reports these signs as absolute indications for surgery. 11

Diagnostic Imaging

• Plain abdominal radiography is the first‑line imaging modality; the presence of the “coffee‑bean” sign suggests sigmoid volvulus. 11
• Contrast‑enhanced abdominal CT is the diagnostic gold standard, demonstrating a dilated colon with air‑fluid levels and the characteristic “whirl” sign of twisted mesentery. 11

Surgical Strategy for Hemodynamically Stable Patients

• In stable patients without peritonitis, sigmoid resection with primary anastomosis is an acceptable definitive operative option, offering the benefit of bowel continuity while avoiding a stoma. This recommendation is supported by the same emergency surgery source. 11

Management in Pregnancy

• Endoscopic detorsion is the preferred initial approach for pregnant patients, although its efficacy may be limited in the third trimester due to uterine size. 11
• A multidisciplinary care plan—involving surgery, obstetrics, and neonatology—is essential and should be tailored to gestational age and fetal prognosis. 11
• Definitive surgical resection can be safely performed from the second trimester onward without appreciable adverse fetal outcomes. 11
• Reported maternal mortality ranges from 6 % to 12 %, while fetal mortality ranges from 20 % to 26 % in this population. 11

Management of Sigmoid Volvulus Due to Redundant Sigmoid Colon

Initial Assessment and Indications for Emergency Surgery

• Patients presenting with clinical signs of bowel ischemia, perforation, or peritonitis should proceed directly to emergency surgery. [12][13]
• When infarcted bowel is identified, resection must be performed without prior detorsion and with minimal manipulation to limit endotoxin release. 12

Endoscopic Decompression (When Hemodynamically Stable)

• Urgent flexible colonoscopic decompression is recommended (instead of rigid sigmoidoscopy) because it achieves a 76 % success rate, with 2 % morbidity and 0.3 % mortality. 13
• Successful detorsion requires the endoscopist to visualize and traverse both transition points and to perform a mandatory mucosal inspection at the end of the procedure to confirm viability. [13][12]
• After a successful detorsion, a decompression tube should be left in place. [13][12]
• The procedure must be aborted immediately if advanced mucosal ischemia or impending perforation is observed; such patients require emergency colectomy. [13][12]

Definitive Surgical Resection (Index Admission)

• Sigmoid colectomy must be performed during the same hospital admission after successful endoscopic decompression to prevent recurrence. 14
• Without resection, the recurrence rate is 45–71 %, and each recurrent episode carries risk of ischemia, perforation, and death. 14
• The entire length of the redundant sigmoid colon should be removed to minimize the chance of repeat volvulus. 14
• In the non‑emergency setting, a primary anastomosis without a stoma is typically feasible. 14

Procedures to Avoid (Non‑resectional Options)

• Detorsion alone, sigmoidopexy, and mesosigmoidoplasty have recurrence rates of 16–36 % and are considered inferior to definitive sigmoid colectomy. 14

Post‑Decompression Discharge Considerations

• Discharging a patient after successful endoscopic decompression without definitive surgery results in a 61 % recurrence rate (median 31 days); 25 % of those recurrences require emergent colectomy. [13][12]

High‑Risk Patients and Alternative Strategies

• Endoscopic fixation techniques (e.g., percutaneous endoscopic colopexy) may be reserved for patients with prohibitive surgical risk, but they carry a 10 % major complication rate. 14

Outcomes of Conservative Management

• Mortality associated with conservative treatment alone ranges from 9 % to 36 %. 14
• In a series where only colonoscopic decompression was employed, mortality reached 36.4 %. 14

Guideline for Diagnosis and Management of Sigmoid Volvulus

Diagnostic Imaging

• Plain abdominal radiographs are the first‑line imaging modality, and the presence of a “coffee‑bean” sign projecting toward the upper abdomen suggests sigmoid volvulus. 15
• When plain films are inconclusive or when ischemia or perforation is suspected, contrast‑enhanced CT should be performed; it provides an 89 % diagnostic yield and demonstrates the characteristic “whirl” sign of twisted mesentery. 15
• Blood gas analysis and lactate measurement are essential, but bowel ischemia can occur even without hyperlactatemia, especially in older patients with neuropsychiatric impairment. 15
• A water‑soluble contrast enema may confirm the diagnosis by showing a “bird’s‑beak” sign, but it is strictly contraindicated if perforation is suspected. 15

Indications for Immediate Emergency Surgery (No Endoscopy)

• Presence of septic shock mandates urgent sigmoid resection without prior endoscopic attempt. 16
• Clinical evidence of bowel ischemia or perforation, peritonitis on examination, or free intraperitoneal air on imaging all require immediate operative intervention. [15][16]

Surgical Options in the Emergency Setting

• Hartmann’s procedure (sigmoid resection with end colostomy) is recommended for hemodynamically unstable patients or when fecal contamination is present. 16
• Emergency surgery for sigmoid volvulus carries a mortality range of 12–40 % and a surgical‑site infection rate of approximately 43 %. 16

Endoscopic Decompression for Uncomplicated Cases

• In patients without signs of ischemia, perforation, or peritonitis, urgent flexible colonoscopy is the first‑line treatment, achieving successful detorsion in 60–95 % of cases. 15
• Successful detorsion requires the endoscopist to visualize and traverse both transition points of the volvulus. 15
• A mandatory mucosal inspection at the conclusion of the procedure is needed to assess sigmoid viability; detorsion should be aborted if advanced mucosal ischemia or imminent perforation is observed. 15
• After successful detorsion, a decompression tube should be left in situ to maintain luminal patency. 15

Definitive Management After Endoscopic Success

• Sigmoid resection must be performed during the same hospital admission following successful endoscopic decompression to prevent recurrence. 16
• Recurrent volvulus after non‑definitive treatment carries a high risk of ischemia, perforation, and death. 15
• Elective sigmoid resection can be performed via a laparoscopic approach in selected centers, although the benefit in emergency settings remains uncertain. 16

High‑Risk Patients Unsuitable for Conventional Surgery

• Percutaneous endoscopic colopexy (endoscopic fixation) may be considered for patients with prohibitive surgical risk, acknowledging a major complication rate of about 10 %. 16

Critical Mortality Risk Factors

• Age greater than 60 years, shock on admission, and a prior history of sigmoid volvulus are associated with increased mortality and should prompt aggressive management. 16

Post‑Decompression Care

• Immediate fluid resuscitation is required to mitigate ischemia‑reperfusion injury. 16
• Broad‑spectrum antibiotics should be administered to control bacterial translocation across an ischemic intestinal wall. 16
• Patients must be monitored closely for intestinal ulceration and perforation secondary to reperfusion injury. 16

Management in Pregnancy

• Maternal mortality from sigmoid volvulus in pregnancy ranges from 6–12 %, and fetal mortality ranges from 20–26 %. 17
• Initial endoscopic detorsion is preferred, but its effectiveness may be limited in the third trimester due to uterine size. 17
• Definitive sigmoid resection can be safely performed from the second trimester onward without significant adverse fetal outcomes. 17