Endoscopic Decompression of Sigmoid Volvulus: Review of 748 Patients

Abstract

Background:

Sigmoid volvulus (SV) is the twisting of the sigmoid colon around itself. Endoscopy both helps diagnosis and provides treatment in the absence of peritonitis or perforation in SV. Nevertheless, there are some controversies or limitations on this subject. The aim of this study is to evaluate the current role of the endoscopic decompression in the treatment of SV.

Materials and Methods:

The clinical records of 1040 patients with SV treated over a 55-year period from June 1966 to July 2021 were reviewed retrospectively until June 1986 and prospectively thereafter. For each case, preoperational parameters, treatment options, and prognosis were noted.

Results:

Endoscopic decompression was tried in 748 patients (71.9%). The procedure was successful in 585 cases (83.2%), whereas unsuccessful in 118 (16.8%) of 703 patients (94.0%) with viable bowel. The mortality rate was 0.5% (4 patients), the morbidity rate was 1.9% (14 patients), the early recurrence rate was 5.5% (32 patients), whereas the mean hospitalization period was 34.6 hours (range: 24–96 hours).

Conclusions:

Despite some controversies or limitations in some subjects including the strategy in ischemic or gangrenous cases, the factors affecting the success, kind of the used instruments, technical details of the application, role of the flatus tubes, and the specific topics such as SV in childhood or pregnancy, endoscopic decompression is the first-line therapy in selected patients with SV.

Introduction

Sigmoid volvulus (SV) is the twisting of the sigmoid colon around itself, causing a colonic obstruction.¹ Endoscopic decompression is the first treatment option with acceptable success, mortality, morbidity, and recurrence rates in selected patients with SV.^2,3 Endoscopy not only provides emergency nonoperative treatment and allows for elective surgery in SV, but also helps in diagnosis.⁴ Nevertheless, the rules of the usage of endoscopy in SV are relatively complex and there are some limitations or contraindications on this subject.⁵

Although SV is a rare disease worldwide, it is relatively common in some African, Asian, South American, Eastern and Northern European, and the Middle Eastern countries,⁶ including Turkey.^7,8 Over a 55-year period from June 1966 to July 2021, we have a 1040-case experience with SV including 748 endoscopic decompression practices, which is the largest single-center SV series over the world.⁹ With the occasion of this experience, I want to discuss both the current role of the endoscopic decompression in the treatment of SV and some important clues and pitfalls on this subject.

Materials and Methods

The clinical records of 1040 patients with SV were reviewed retrospectively until June 1986 (612 patients) and prospectively thereafter (428 patients). For each case, including 748 patients, in whom endoscopic decompression was tried, age, gender, previous volvulus attacks, pregnancy, comorbidity, symptom duration, symptoms, signs, diagnostic modalities, treatment options, mortality, morbidity, early recurrence rates (in the same hospitalization period), and length of stay were noted.

After diagnosis and resuscitation, nonoperative decompression was tried in patients without peritoneal irritation findings or gangrenous stool, whereas those with diagnostic problems, gangrenous stool, and muscular rigidity and/or rebound tenderness were treated with emergency surgery. During the endoscopic procedures, except for a limited patient population, no premedication was used, and when needed, propofol (2.5 mg/kg, intravenous) was preferred.

As instruments, rigid sigmoidoscopes (30-cm length, 2-cm diameter), were used from 1966 to 2003, whereas flexible sigmoidoscopes or colonoscopes (70- to 170-cm length, 1.2- to 1.5-cm diameter) were preferred from 1988 to date. In instrumentation, the torsion point was determined by demonstrating twisting of the lumen at a 20- to 30-cm distance from anal verge (Fig. 1a, b). In patients with brown-black mucosa and gangrenous effluent, which indicates mucosal gangrene (Fig. 1b), the procedure was terminated and emergency surgery was planned. In patients with viable bowel, the instrument was pushed proximally toward the opposite side of the twisting direction with gentle manipulation, controlled force, and minimal air insufflation. In most patients with evacuation of gas and stool, a rectal tube (30-cm length, 1- to 1.5-cm diameter) or rarely a sigmoid tube (50- to 70-cm length, 1- to 1.2-cm diameter) was placed under endoscopic guidance, and they were removed 6 to 24 hours later.

FIG. 1.

(a) Endoscopic appearance of sigmoid volvulus. (b) Endoscopic appearance of gangrenous sigmoid volvulus. G, gangrenous mucosa; S, twisted obstructive lumen; V, viable mucosa. Color images are available online.

Elective surgical sigmoid resection was applied in selected patients, who approved elective surgery, whereas others were discharged after a few hours to 2 days observation period by evaluating a control examination and X-ray radiography. Patients with unsuccessful endoscopic decompression or early recurrence were also treated with emergency surgery.

This study was approved by institutional review board (B.30.2.ATA.0.01.00/220).

Results

Treatment options and results are shown in Figure 2. Endoscopic decompression was tried in 748 patients (71.9%) with a mean age of 60.6 years (range: 15–92 years), whereas male/female ratio was 4.8 (618 versus 130 patients). Of 656 patients, in whom data were obtained, 171 (26.1%) had a previous SV attack (1.4 attacks per person), 192 (29.3%) had comorbid disease, whereas 7 female patients (5.4%) were pregnant. The mean symptom period was 32.2 hours (range: 3 hours to 7 days). The mean clinical features were abdominal pain/tenderness (98.9%), distention (96.0%), obstipation/constipation (91.5%), empty rectum (68.9%), vomiting (63.7%), hypokinetic/akinetic bowel sound (40.2%), and hyperkinetic bowel sound (35.5%). The diagnostic accuracy of clinical examination together with X-ray radiography was 81.4% in 520 of evaluated 639 patients, whereas it was 97.3% (109/112) in computed tomography (CT), 95.0% (38/40) in magnetic resonance imaging (MRI), and 98.7% in diagnostic endoscopy (150/152).

FIG. 2.

Treatment options and results.

Endoscopic decompression procedures and results are given in Table 1. When 45 patients (6.0%) with gangrenous bowel were excluded, endoscopic decompression was successful in 585 cases (83.2%), whereas unsuccessful in 118 (16.8%) of 703 patients (94.0%) with viable bowel. The mortality rate was 0.5% (4 patients), the morbidity rate was 1.9% (14 patients), and the early recurrence rate was 5.5% (32 patients), whereas the mean hospitalization period was 34.6 hours (range: 24–96 hours). When compared, the success rate was higher (84.5% versus 81.8%), the mortality and morbidity rates were lower (0.3% versus 0.9% and 1.3% versus 2.6%, respectively), and the hospitalization period was shorter (31.6 versus 38.2 hours) in flexible endoscopy, whereas the early recurrence rate was lower (3.3% versus 7.4%) in rigid endoscopy.

Table 1.

Endoscopic Decompression Procedures and Results

Parameter	Rigid endoscopy, n (%)	Flexible endoscopy, n (%)	Total, n (%)
Total	351 (46.9)	397 (53.1)	748
Gangrenous bowel	16 (4.6)	29 (7.3)	45 (6.0)
Viable bowel	335 (95.4)	368 (92.7)	703 (94.0)
Successful	274 (81.8)	311 (84.5)	585 (83.2)
Unsuccessful	61 (18.2)	57 (15.5)	118 (16.8)
Mortality	3 (0.9)	1 (0.3)	4 (0.5)
Toxic shock	2	1	3
Perforation, peritonitis	1	0	1
Morbidity	9 (2.6)	5 (1.3)	14 (1.9)
Renal failure	8	4	12
Perforation, peritonitis	1	0	1
Myocard infarction	1	1	2
Early recurrence	9 (3.3)	23 (7.4)	32 (5.5)
Hospitalization period	38.2 hours	31.6 hours	34.6 hours

Discussion

Current guidelines on coloproctology recommend the endoscopic treatment as the first-line therapy in the absence of peritonitis and perforation, whereas surgical treatment is suggested in patients with the above-mentioned adverse events in addition to unsuccessful decompression and recurrence in SV.^1,2 Similarly, a great number of authors support this idea with strong recommendation based on variable clinical pieces of evidence.^{5–7,10–15} Although most of the above-mentioned clinical manifestations requiring emergency surgery are well defined, in my opinion and experience, the relationship between the endoscopy and bowel ischemia or gangrene is still an escaper and insuperable problem in the decision-making process due to the difficulties in the early and accurate diagnosis of ischemia and gangrene. Bowel gangrene is seen in 6.1%–30.2% of all SV patients, whereas it is seen in 10.7%–93.4% of surgically treated cases, and increases the mortality rate from 0%–40% to 3.7%–80%.^4,16,17 It is clear that endoscopy is the unique way to demonstrate mucosal viability. Nevertheless, to prevent a risk of bowel perforation or absorption of toxic material, endoscopy is avoided when the bowel gangrene is suspected or determined in the preoperational period. Similarly, when endoscopy demonstrates bowel gangrene, the procedure is terminated and emergency surgery is planned. However, to diagnose the bowel gangrene accurately is not easy before endoscopic examination. Although some clinical and laboratory findings including gangrenous stool, fever, muscular rigidity, rebound tenderness, hypotension, shock, somnolence, leukocytosis, and metabolic acidosis suspect bowel gangrene, unfortunately, except for gangrenous stool, which is determined in anamnesis or rectal examination, the others are not pathognomonic.^16,17 In addition, to distinguish borderline ischemic mucosa from gangrenous bowel, the first that may be diagnosed with black mucosa including yellow-reddish spots in the endoscopy,¹⁸ and may be treated with repeater endoscopies under careful clinical observation, is quite difficult.¹⁶

The success rate of the endoscopic decompression in SV varies from 55% to 94%,^{2,4–7,10,12–15} which is compatible with our 83.2% success rate. Despite lacking randomized controlled data,⁹ history of open abdominal surgery, use of laxatives, excessive abdominal distention,¹² and high-grade rotation of mesenteric axis (>90°, particularly >135° from the horizontal line in X-ray)¹⁹ are thought as indicators of the unsuccessful endoscopic decompression as well as the requirement of surgical treatment. As seen, all above-mentioned parameters are relative, which do not prevent an attempt to the endoscopic decompression. According to me, more practical parameters, which relatively indicates the failure of endoscopic decompression, are late admission (≥72 hours), which causes excessive gas generation in closed loop, and the presence of over-rotation (≥360°), which may be diagnosed by CT or MRI, and makes the procedure more difficult.

Endoscopic decompression may be performed by rigid or flexible sigmoidoscopy, or colonoscopy with similar success rates,^5,7,10 as was demonstrated in our series. Rigid endoscopes are still preferred in some areas including undeveloped or ever-developing countries, particularly due to their availability, accessibility, and inexpensiveness.²⁰ However, most authors favor flexible endoscopes over rigid instruments because of their superior diagnostic performance and lower complication rate,^6,7,10,12 as was confirmed in our series with 84.5% versus 81.8% of success and 1.3% versus 2.6% of complication rates. From my point of view, additionally, flexible endoscopes have two important advantages: first, they are better tolerated by the patients arising from small diameters and flexible bodies, which hurt less, and second, they have a better usage by the practitioners due to long bodies, which keep practitioners' distance from the patient, and movable tips, which provide an easier maneuver.

The technique of endoscopic decompression is well defined in the literature. After the determination of torsion line at a 20- to 30-cm distance from anal verge, the endoscope is pushed forward by gentle manipulation and minimal air insufflation. After the instrument passes through the torsion site, air suction straightens the distended colon, and torsion is often resolved,^2,3,5,10 as was applied in our cases. However, to the best of my belief, additionally, two important technical maneuvers affect the success of the procedure: first, the force used to push the instrument, which must be well controlled to obtain an untwisting in addition to avoiding a perforation, and second, the rotation of the tip toward the opposite side of the twisting, which makes the untwisting easier.

After a successful endoscopic decompression, flatus tube placement is another controversial subject in SV. Despite inadequate randomized controlled data,⁹ a rectal or sigmoid tube is traditionally placed in the rectosigmoid region and left in place for a 1- to 3-day period to facilitate further colonic decompression as well as to prevent volvulus recurrence,^2,7,12,14,15 as was performed in most of our cases. In my clinical experience, almost all of the patients complain about tube, which is a relatively painful procedure in application, conservation, and removal. In addition, it is frequently displaced during the first degasification or defecation, and repetitive applications are generally neglected by both the patients and the practitioners. It should not be forgotten that one of the basic rules of tube application is to perform it under an endoscopic or fluoroscopic guidance, which is frequently difficult or impossible in repetitive applications, which leads to complications including bowel perforation.²¹ For these reasons, I recently quit the tube application in most cases. According to preliminary results of my new practice on a few cases, although the tube application may decrease early recurrence rate, after removal of the tube by practitioners or the patients, or spontaneous discharge, this rate increases and comes to similar levels.

After a successful endoscopic decompression, SV recurrence is seen in 3%–75% of the patients,^19,22,23 as was seen in 5.5% of our patients in the same hospitalization period in addition to the presence of a volvulus attack history in 25.9% of our cases. Although the extension of the sigmoid colon to subphrenic space and liver overlap (extension finding) in CT image are presented as a predisposing factor for recurrent SV,²⁴ advanced age, male gender, volvulus history, and childhood SV are more practical indicators for recurrent SV.^2,7,10,25 Although after successful endoscopic decompression of SV, elective surgical sigmoid resection is suggested in select well-conditioned and nonelderly patients to prevent recurrence,^2,3,6,7,10 unfortunately, patient selection criteria are not objectively identified.⁹ According to my current classification system, patients younger than average life expectancy (70–75 years old) and those with American Society of Anesthesiologists (ASA) score 1–3 are potential candidates for elective surgery.⁴

The mortality rate of the endoscopic decompression varies from 0% to 19%, whereas the morbidity rate is between 0% and 26.4%,^5,7,10,12,13 which are compatible with our 0.5% of mortality and 1.9% of morbidity rates. The most common complications are bowel perforation and systemic problems, whereas the most common death causes are peritonitis and toxic shock.^{5,7,10,12,13,21}

Regarding the specific topics, childhood and pregnancy are the main discussion subjects in the endoscopic decompression of SV. Although SV in childhood is generally thought as a nightmare and is traditionally treated surgically,^7,10,26 as was practiced in all of our 12 children cases in default of pediatric endoscopes, some encouraging results are recently reported.^25,27 Similarly, although an enlarged uterus is thought as an impediment to the endoscopic decompression in pregnant cases with SV,^10,28 some prospering results related to the successful endoscopic decompression are published in recent years,^29,30 as was applied with an 83.3% success rate in 6 of our 10 pregnant patients.

Conclusion

In SV, endoscopy is the unique way to demonstrate the mucosal viability, but it is avoided when the bowel gangrene is suspected or determined. Late admission and over-rotation are the main indicators of the failure in endoscopic decompression of SV. Flexible endoscopes are better tolerated by the patients and they have a better usage by the practitioners. A minimal force used to push the endoscope and the gentle rotation of the tip of the instrument toward the opposite side of twisting make the decompression easier. Although a flatus tube application may decrease the early recurrence rate, after the removal or discharge, the recurrence rate of SV comes to similar levels. Advanced age, male gender, volvulus history, and childhood volvulus are the main indicators for SV recurrence. Patients younger than average life expectancy (70–75 years old) and those with ASA score 1–3 are potential candidates for elective surgery in SV.

Footnotes

Disclosure Statement

No competing financial interests exist.

Funding Information

The author received no financial support.

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