Primary colon resection or Hartmann's procedure in malignant left-sided large bowel obstruction? The use of stents as a bridge to surgery

There is still significant debate regarding the best surgical treatment for malignant left-sided large bowel obstruction.Primary resection and anastomosis offers the advantages of a definite procedure without need for further surgery.Its main disadvantages are related to the increased technical challenge and to the potential higher risk of anastomotic leakage that occurs in the emergency setting.Primary resection with end colostomy(Hartmann's procedure) is considered the safer option.Tan et al compared in a systematic review and meta-analysis the use of self-expanding metallic stents(SEMS) as a bridge to surgery vs emergency surgery in the management of acute malignant left-sided large bowel obstruction.The authors concluded that the technical and clinical success rates for stenting were lower than expected.SEMS was associated with a high incidence of clinical and silent perforation.Stenting instead of loop colostomy can be recommended only if the appropriate expertise is available in the hospital.The goal of stenting,a decrease of the stoma rate,may be advocated only if the complication rates of stenting are lower than those of stoma creation in the emergency situation.Until now,this was not demonstrated in a prospective randomized trial.

Comparison of decompression tubes with metallic stents for the management of right-sided malignant colonic obstruction

BACKGROUND Emergency surgical resection is a standard treatment for right-sided malignant colonic obstruction; however, the procedure is associated with high rates of mortality and morbidity. Although a bridge to surgery can be created to obviate the need for emergency surgery, its effects on long-term outcomes and the most practical management strategies for right-sided malignant colonic obstruction remain unclear.AIM To determine the appropriate management approach for right-sided malignant colonic obstruction.METHODS Forty patients with right-sided malignant colonic obstruction who underwent curative resection from January 2007 to April 2017 were included in the study.We compared the perioperative and long-term outcomes of patients who received bridges to surgery established using decompression tubes and those created using self-expandable metallic stents(SEMS). The primary outcome was the overall survival duration(OS) and the secondary endpoints were the diseasefree survival(DFS) duration and the preoperative and postoperative morbidity rates. Analysis was performed on an intention-to-treat basis.RESULTS There were 21 patients in the decompression tube group and 19 in the SEMS group. There were no significant differences in the perioperative morbidity rates of the two groups. The OS rate was significantly higher in the decompression tube group than in the SEMS group(5-year OS rate; decompression tube 79.5%,SEMS 32%, P = 0.043). Multivariate analysis revealed that the bridge to surgery using a decompression tube was significantly associated with the OS(hazard ratio, 17.41; P = 0.004). The 3-year DFS rate was significantly higher in thedecompression tube group than in the SEMS group(68.9% vs 45.9%; log-rank test,P = 0.032). A propensity score–adjusted analysis also demonstrated that the prognosis was significantly better in the decompression tube group than in the SEMS group.CONCLUSION The bridge to surgery using trans-nasal and trans-anal decompression tubes for right-sided malignant colonic obstruction is safe and may improve long-term outcomes.

How to decide on stent insertion or surgery in colorectal obstruction?

Colorectal cancer is one of the most common cancers in western society and malignant obstruction of the colon accounts for 8%-29% of all large bowel obstructions. Conventional treatment of these patients with malignant obstruction requiring urgent surgery is associated with a greater physiological insult on already nutritionally replete patients. Of late the utility of colonic stents has offered an option in the management of these patients in both the palliative and bridge to surgery setting. This has been the subject of many reviews which highlight its efficacy, particulary in reducing ostomy rates, allowing quicker return to oral diet, minimising extended post-operative recovery as well as some quality of life benefits. The uncertainity in managing patients with malignant colonic obstructions has lead to a more cautious use of stenting technology as community equipoise exists. Decision making analysis has demonstrated that surgeons' favored the use of stents in the palliative setting preferentially when compared to the curative setting where surgery was preferred. We aim to review the literature regarding the use of stent or surgery in colorectal obstruction, and then provide a discourse with regards to the approach in synthesising the data and applying it when deciding the appropriate application of stent or surgery in colorectal obstruction.

Palliative treatment for incurable malignant colorectal obstructions: A meta-analysis

AIM:To perform a meta-analysis of palliative stent placement vs palliative surgical decompression for management of incurable malignant colorectal obstructions.METHODS:The databases of Medline,Web of Science,Embase,and the Cochrane Central Register of Controlled Trials were searched from their inception to July 2012 for studies(prospective,retrospective,randomized controlled trials,and case-control trials)designed as comparative analyses of patients with incurable malignant colorectal obstructions treated by selfexpanding metallic stents(SEMS)or palliative surgery.No language restrictions were imposed.The main outcome measures were hospital stay,intensive care unit admission,clinical success rate,30-d mortality,stoma formation,complications,and overall survival time.The data extraction was conducted by two investigators working independently and using a standardized form.The Mantel-Haenszel 2method was used to estimate the pooled risk ratios with 95%CI under a fixed-effects model;when statistical heterogeneity existed in the pooled data(as evaluated by Q test and I2statistics,where P<0.10 and I2<25%indicated heterogeneity),a random-effects model was used.RESULTS:Thirteen relevant articles,representing837 patients(SEMS group,n=404;surgery group,n=433),were selected for analysis.Compared to the surgery group,the SEMS group showed lower clinical success(99.8%vs 93.1%,P=0.0009)but shorter durations of hospital stay(18.84 d vs 9.55 d,P<0.00001)and time to initiation of chemotherapy(33.36 d vs15.53 d,P<0.00001),and lower rate of stoma formation(54.0%vs 12.7%,P<0.00001).Additionally,the SEMS group experienced a significantly lower rate of30-d mortality(4.2%vs 10.5%,P=0.01).Stent-related complications were not uncommon and included perforation(10.1%),migration(9.2%),and occlusion(18.3%).Surgery-related complications were slightly less common and included wound infection(5.0%)and anastomotic leak(4.7%).The rate of total complications was similar between these two groups(SEMS:34.0%vs surgery:38.1%,P=0.60),but the surgeryrelated complications occurred earlier than stent-related complications(rate of early complications:33.7%vs13.7%,P=0.03;rate of late complications:32.3%vs12.7%,P<0.0001).The overall survival time of SEMSand surgery-treated patients was not significantly different(7.64 mo vs 7.88 mo).CONCLUSION:SEMS is less effective than surgery for palliation of incurable malignant colorectal obstructions,but is associated with a shorter time to chemotherapy and lower 30-d mortality.

支架置入后择期手术与急诊手术治疗结直肠恶性梗阻临床价值的对比研究

目的：探讨内镜联合X线置放金属支架后择期手术与急诊外科手术相比,两者治疗可切除性结直肠恶性梗阻的临床价值及安全性。方法：回顾性分析2001年5月－2012年10月本院94例结直肠恶性梗阻患者的临床资料。其中30例经内镜联合X线临时置入金属支架,择期行手术治疗;64例行急诊手术治疗。比较支架组与急诊手术组的一期切除吻合率。手术时间。术后通气时间。住院时间。并发症发生率及住院期间病死率等指标并观察支架置入操作成功率。临床缓解率。并发症发生率及置入后接受剖腹手术和腹腔镜手术情况。结果：①支架组一期切除吻合率明显高于急诊手术组（96.67% vs 53.13%,P 〈 0.001）。支架组术后并发症明显低于急诊手术组（6.67% vs 25.00%,P 〈 0.05）。支架组住院期间病死率与急诊手术组相比,无统计学差异（P 〉 0.05）。支架组手术时间。术后通气时间分别为（156.13 ± 49.79）min,（3.60 ± 1.40）d,明显低于急诊手术组。支架组住院时间与急诊手术组相比,无统计学差异（P 〉 0.05）;②支架组中30例放置金属支架,操作成功率100%（30/30）,临床缓解率96.67%（29/30）,并发症发生率6.67%（2/30）,支架置入后平均（8.9 ± 1.0）d行择期手术。支架组接受腹腔镜手术的患者明显多于急诊手术组（P 〈 0.01）。支架组中剖腹手术的手术时间短于微创腹腔镜术（P 〈 0.05）,剖腹术后并发症明显低于微创腹腔镜术（P 〈 0.05）,但剖腹术患者的住院时间明显长于腹腔镜术的患者（P 〈 0.05）。结论：内镜联合X线置放金属支架可迅速、有效缓解结直肠恶性梗阻症状。经支架置入后择期手术与急诊手术相比安全性高,且增加一期切除吻合率,并减少并发症,可作为缓解结直肠恶性梗阻的一项有效治疗方法。剖腹手术仍是结直肠恶性梗阻支架置入后的主要手术方式。通过支架置入,可使部分患者获得微创手术机会。

大肠癌致肠梗阻49例外科诊治探讨

目的 探讨大肠癌致肠梗阻的诊断和手术方法。方法 回顾分析 1990～ 2 0 0 0年间 4 9例大肠癌致肠梗阻病例的外科治疗资料。结果 4 6例结肠癌致肠梗阻病人一期右半结肠切除吻合 10例 ,一期左半结肠切除吻合 2 7例 ,一期左半结肠切除吻合 ,近端结肠造口 6例 ,左半结肠切除、近端结肠造口、关闭远端结肠 3例 ( Hartmann造口 )。3例直肠癌致肠梗阻病人 ,肿瘤无法切除 ,作乙状结肠造口 1例 ,横结肠造口 ,肠梗阻缓解后行 Mile’s手术 2例。全组无吻合口瘘和死亡病例。结论 为了提高 5年生存率和减少二期手术 ,结肠癌致肠梗阻应争取一期切除吻合。合理选择手术方法 ,做好术中结肠灌洗和围手术期治疗是手术成功的关键。文章还强调了大肠癌早期诊断的重要性。

非透视结肠自扩张金属支架置入过渡治疗急性梗阻性结直肠癌的临床分析

目的探讨非透视下结肠自扩张金属支架置入治疗急性梗阻性结直肠癌患者的安全性和有效性。方法回顾性分析2014年3月至2017年12月湖南省人民医院63例非透视结肠自扩张金属支架置入治疗急性梗阻性结直肠癌患者的临床资料。采用双人肠镜操作法,进镜至肿瘤部位后探寻狭窄孔并插入非血管腔道导丝,沿导丝将自扩张金属支架置入并通过狭窄段,释放支架于目的位置。结果 63例急性梗阻性结直肠癌患者中升结肠及结肠肝曲癌1例,横结肠癌2例,结肠脾曲癌6例,降结肠癌9例,乙状结肠癌29例,直乙交界及直肠癌16例。支架置入成功率100%,支架置入操作时间为5~35 min,平均(12.3±4.6)min。除1例严重感染合并水电解质酸碱平衡紊乱患者术后1 d死亡外,其余患者均术后第2 d进食流质饮食,2~4 d左右临床症状完全缓解,于术后2~3周手术治疗。结论非透视下结肠自扩张金属支架置入治疗急性梗阻性结直肠癌患者安全有效,是急性梗阻性结直肠癌由急诊手术向限期手术转变的有效过渡治疗手段。

Colorectal stenting for palliation and as a bridge to surgery:A 5-year follow-up study

AIM: To evaluate the long-term effectiveness of colonic stents in colorectal tumors causing large bowel obstruction.METHODS: We retrospectively analyzed data from 49 patients with colorectal cancer who had undergone colorectal stent placement between January 2008 and January 2013. Patients' symptoms,characteristics and clinicopathological data were obtained by reviewing medical records. The obstruction was diagnosed clinically and radiologically. Histopathological diagnosis was achieved endoscopically. Technical success rate(TSR)was defined as the ratio of patients with correctly placed SEMS upon stent deployment across the entire stricture length to total number of patients. Clinical success rate(CSR) was defined as the ratio of patients with technical success and successful maintenance of stent function before elective surgery(regardless of number of SEMS deployed) to total number of patients. The surgical success rate(SSR) of colorectal stent as a bridge to surgery was defined as the ratio of patients with successful surgical procedures. Unsuccessful surgical outcomes were defined as being due to insufficient colonic decompression. The technical,clinical,surgical success rates and complications after stenting were assessed.RESULTS: The median age of patients was 64(36 to 89). 44.9% of patients were male and 55.1% were female. Eighteen patients had the obstruction located in the rectum,15 patients in the rectosigmoid region,10 patients in the sigmoid region,and 6 patients had a tumor causing obstruction in the proximal colon. Each patient was categorized pathologically as stage 2(32.7%,16 patients) or stage 3(42.9%,21 patients) and 12 patients(24.4%) had metastatic disease. None of the patients received chemotherapy before stenting. Stenting was undertaken in 37 patients as a bridge to surgery,and in 12 patients stents were used for palliation. Median time to surgery after stenting was 30 ± 91.9 d. All surgery was completed in one single operation and thus no colostomy with stoma was needed. The median overall survival rate of patients with stage 2-3 colorectal cancer was 53.1 mo and stage 4 was 37.1 mo(P = 0.04). Metastatic colorectal patients who were treated palliatively with stents had backbone chemotherapy with oxaliplatin and/or irinotecan-based regimens plus antiangiogenic therapies,especially bevacizumab. Resolution of the obstruction and clinical improvement was achieved in all patients. The technical,clinical and surgical success rates were 95.9%,100% and 94.6%,respectively.CONCLUSION: The efficacy and safety of colonic stents was demonstrated both as a bridge to surgery and for palliative decompression. In addition,results emphasize the importance of the skills of the endoscopist in colonic stenting.

不同部位肠梗阻影像学检查的诊断意义

目的探讨腹部平片检查、泛影葡胺口服法造影、64层螺旋cT检查对不同部位肠梗阻的诊断意义。方法回顾性分析142例肠梗阻患者资料，均行腹部平片、泛影葡胺造影和cT检查，比较其诊断效果。结果三者对小肠梗阻诊断率为62．5％、85％、77．5％，部位诊断率为0％、90％、78．75％，原因诊断率为0％、71％、65％。三者对大肠梗阻诊断率为53．23％、73．17％、92％，部位诊断率为38．17％、60．98％、98％，CT检查对梗阻原因诊断率为91％。结论64层螺旋cT检查对肠梗阻部位、原因诊断有极大意义，尤适用于大肠梗阻。泛影葡胺造影在小肠梗阻的诊断和治疗中均有较好的临床应用价值，是CT检查的有益补充。

支架或导管缓解恶性大肠梗阻的临床疗效对比研究

目的:研究支架或导管缓解恶性大肠梗阻的临床疗效。方法:分析72例恶性大肠梗阻患者的临床资料。随机将入选者分成S组(自膨式金属支架置入内镜架桥治疗,SEMS)和T组(经肛肠梗阻导置入内镜架桥治疗管,TDT),每组36例,比较两组患者的临床疗效。结果:T组与S组大肠梗阻缓解率分别为97.2%、94.4%。T组恢复口服营养补充(oral nutritional supplements,ONS)时间明显低于S组,卡氏功能状态量表(Karnofsky performance status,KPS)评分明显高于S组(P<0.01)。结论:SEMS与TDT在恶性大肠梗阻患者中均具有良好的临床疗效,其中TDT患者恢复ONS更快,功能状况恢复情况更优秀。

大肠癌致肠梗阻的外科治疗(附40例报告)

目的 :探讨大肠癌致急性肠梗阻的处理方法。方法 :分析我院 1 990— 2 0 0 0年间 4 0例大肠癌致肠梗阻的外科治疗临床资料。结果 :4 0例病人 ,结肠癌 2 8例 ,直肠癌 1 2例 ,中晚期病例占 92 .5 % ,I期行右半结肠切除 1 0例 ;I期左半结肠切除 8例 ,I期行左半结肠或直肠上段癌切除 ,近端结肠造口 ,远端肠管闭合备 II期吻合 1 9例 ;肿瘤无法切除行乙状结肠造口 3例 (直肠癌 )。围手术期死亡率 5 .0 % (2 / 40 )。结论 :提高对大肠癌肠梗阻的认识 ,降低误诊率 ,合理选择术式 ,做好围手术期的处理 ,是减少并发症。

大肠癌致肠梗阻急诊手术治疗

目的 :探讨大肠癌致肠梗阻急诊处理方法。方法 :分析 1996年 1月～ 2 0 0 0年 12月间大肠癌致肠梗阻急诊手术的临床资料。结果 : 期右半结肠切除吻合术 18例 , 期左半结肠切除吻合术 2 2例 , 期左半结肠切除或肿瘤姑息切除 Hartm ann手术 12例 ,各种肠造瘘 8例。发生吻合口漏 1例 ,行 2次手术造瘘。无死亡病例。结论 :早期手术 ,合理的手术方式 ,正确的围手术期治疗可收到良好的疗效。

Colonic gallstones:a case report

BACKGROUND:Colonic gallstone is an uncommon entity with high morbidity and mortality due to various reasons. It remains a diagnostic challenge because of delayed and non-specific presentations,especially in the elderly population,often with multiple co-morbidities. METHOD:We present a case of 81-year-old woman who had a large bowel obstruction due to colonic gallstone. RESULTS:Immediately after a cholecysto-colonic fistula was found by laporotomy,she underwent a single stage enterolithotomy,cholecystectomy and fistula closure. CONCLUSIONS:A single stage enterolithotomy,cholecys- tectomy and fistula closure is ideal for this condition. Various other surgical options in the literature are discussed.

大承气汤联合自膨式金属支架在左半结直肠恶性梗阻治疗中的应用

目的:探讨大承气汤联合自膨式金属支架(SEMS)在左半结直肠恶性梗阻(MLBO)治疗中的作用及安全性。方法:选取2018年1月—2020年6月天津市人民医院收治的因MLBO行SEMS治疗的患者78例。随机化分为大承气汤组38例,聚乙二醇组40例。两组患者均进行限期手术治疗,在后续治疗时,大承气汤组口服大承气汤(1袋,125 mL/次,2次/d),聚乙二醇组口服聚乙二醇(舒泰清,A剂+B剂各2袋/次,饮用水冲调至125 mL/次,2次/d),比较2组术前准备时间、腹腔镜率、手术时间、并发症发生率、造口率、排气时间、术后住院时间、淋巴结清扫数目及术后病理水肿程度等差异。结果:大承气汤组的术前准备时间为6(5,7)d,低于聚二乙醇组的8(6,9)d,差异有统计学意义(P<0.001)。大承气汤组限期手术的腹腔镜率为65.8%,高于聚乙二醇组的40.0%,差异有统计学意义(P=0.023)。大承气汤组在造口率(21.1%vs 50.0%)及并发症发生率(15.8%vs 40.0%)方面亦优于聚乙二醇组(均P<0.05)。两组的淋巴清扫数目无明显差异(P=0.2),但大承气汤组的病理组织水肿程度比聚乙二醇组轻,差异有统计学意义(P=0.043)。结论:大承气汤可有效提高MLBO放置SEMS后限期手术的肠道准备效率及质量,提高腹腔镜成功率,并明显降低限期手术并发症发生率及造口率。

支架或导管缓解恶性大肠梗阻的回顾性队列研究

目的比较SEMS和TDT置入在恢复恶性大肠梗阻中的应用价值。方法收集单中心2012~2016年接受SEMS(n=26)和TDT(n=22)置入的48例恶性大肠梗阻患者资料,比较两组技术成功率、临床症状缓解情况、并发症、达开放EN时长、功能状态评估及后续治疗选择等指标。结果两组技术成功率均为100%,无穿孔发生。SEMS组和TDT组梗阻症状缓解比例分别为96.2%(25/26)和95.5%(21/22),导管移位分别为7.7%(2/26)和18.2%(4/22)(P=0.26,达开放EN时长为2 IQR(0~2)天和3 IQR(2~5)天(P=0.001),KPS功能状态评分为75 IQR(50~80)分和35 IQR(30~50)分(P=0.001)。接受外科手术、单用化疗和不接受手术或化疗而行口服营养补充的患者比例在SEMS组为30.8%(8/26)、7.7%(2/26)和61.5%(16/26),在TDT组为31.8%(7/22)、0和59.1%(13/22);其中二期手术的患者比例在SEMS和TDT组分别为25.0%(2/8)和57.1%(4/7),吻合口瘘仅见于TDT组(1/7)。结论 SEMS和TDT法均能有效缓解恶性大肠梗阻症状,技术成功率及安全性好。SEMS开放EN更快、术后功能状态更优。

急性结肠梗阻的诊断与治疗

目的:探讨急性结肠梗阻的诊断、围手术期处理及手术方式的选择。方法:回顾分析我院1991年1月～1997年11月间手术治疗的急性结肠梗阻57例。结果:癌性结肠梗阻占71.9％(41/57),而术前确诊率仅31.7％(13/41)。术前选用预防性抗生素静滴,术中行肠减压及结肠灌洗,行Ⅰ期切除手术44例,占77.2％(44/57),同时Ⅰ期吻合36例,占81.8％(36/44),其中左半结肠病变者占55.6％(20/36),无死亡及吻合口漏发生。结论:对急性结肠梗阻应加强术前诊断和认识,完善术前术中处理是降低Ⅰ期肠切除和吻合术后并发症和死亡率的关键.

31例大肠癌致肠梗阻的外科治疗分析

目的:探讨大肠癌致肠梗阻的外科手术治疗方法。方法:回顾分析本院1999年1月～2001年12月期间31例大肠癌致肠梗阻病人的外科手术治疗资料。结果:31例大肠癌致肠梗阻病人,手术行Miles4例,Dixon2例,右半结肠Ⅰ期切除吻合7例,左半结肠Ⅰ期切除吻合9例,左半结肠Ⅰ期行肿瘤切除、Hartmann肠造口术4例,剖腹探查活检加结肠造口术3例,仅剖腹探查活检2例。术后产生并发症12例(占38.7%),死亡2例(占6.45%)。结论:重视对大肠癌致肠梗阻的认识,选择合理术式,加强围手术期处理,是保证手术的安全性,减少并发症的发生,提高疗效的重要措施。

成人急性大肠梗阻手术治疗预测因子的多因素分析

目的 :探讨成人急性大肠梗阻手术治疗的预测因子,建立手术治疗的预测模型。方法 :回顾性分析2008年1月—2012年1月住院治疗的306例大肠梗阻的患者资料。结果:患者高热(体温>38.5℃)、非手术治疗时间、腹痛进行性加重、腹部压痛包块、腹膜炎体征、腹部手术史、白细胞计数、乳酸脱氢酶、尿素氮水平、CT检查见肠壁不规则增厚、结肠截断征、结肠内稀便、结肠内粪块等13个危险因素与大肠梗阻手术治疗密切相关。对有意义的13个变量行多因素Logistic回归分析,共有8个因素进入Logistic回归方程,按其作用的强度依次为:高热、肠壁不规则增厚、腹部压痛包块、腹膜炎体征、结肠内稀便、乳酸脱氢酶、白细胞计数和结肠内粪块。Logistic回归预测模型预测结肠梗阻是否手术治疗的准确度为88.56%(271/306),敏感度为94.58%(227/240),特异度为66.67%(44/66)。结论:8个因素Logistic回归模型可较好的预测成人急性大肠梗阻是否需要手术治疗。

68例大肠癌并发肠梗阻的外科治疗

目的 :探讨大肠癌并发肠梗阻的外科治疗方法 .方法 :回顾性分析 1990至 2 0 0 1年收治手术的 6 8例大肠癌致肠梗阻病例资料 .结果 :6 8例患者中一期行右半结肠切除 14例 ;一期行左半结肠切除 30例 ;一期行左半结肠或直肠上段癌切除 ,近端结肠造瘘 ,封闭远端结肠或直肠二期吻合 17例 ;直肠癌晚期无法切除根治行乙状结肠造瘘 7例 .术后并发症发生 13 2 3% (9/6 8) ,围手术期死亡 4 4 1% (3/6 8) .结论 :提高对本病的认识 ,根据病情合理选择外科治疗方法 。

Clinical considerations and therapeutic strategy for sigmoid volvulus in the elderly:A study of 33 cases

AIM: To evaluate different types of treatment for sigmoid volvulus and clarify the role of endoscopic intervention versus surgery. METHODS: A retrospective review of the clinical presentation and imaging characteristics of 33 sigmoid volvulus patients was presented, as well as their diagnosis and treatment, in combination with a literature review. RESULTS: In 26 patients endoscopic detorsion was achieved after the first attempt and one patient died because of uncontrollable sepsis despite prompt operative treatment. Seven patients had unsuccessful endoscopic derotation and were operated on. On two patients with gangrenous sigmoid, Hartmann's procedure was performed. In five patients with viable colon, a sigmoid resection and primary anastomosis was carried out. Three patients had a lavage "on table" prior to anastomosis, while in the remaining 2 patients a diverting stoma was performed according to the procedure of the first author. Ten patients were operated on during their first hospital stay (3 to 8 d after the deflation). All patients had viable colon; 7 patients had a sigmoid resection and primary anastomosis, 2 patients had sigmoidopexy and one patient underwent a near-total colectomy. Two patients (sigmoidectomy-sigmoidopexy) had recurrences of volvulus 43 and 28 mo after the initial surgery. Among 15 patients who were discharged from the hospital after non-operative deflation, 3 patients were lost to follow-up. Of theremaining 12 patients, 5 had a recurrence of volvulus at a time in between 23 d and 14 mo. All the five patients had been operated on and in four a gangrenous sigmoid was found. Three patients died during the 30 d postoperative course. The remaining seven patients were admitted to our department for elective surgery. In these patients, 2 subtotal colectomies, 3 sigmoid resections and 2 sigmoidopexies were carried out. One patient with subtotal colectomy died. Taken together of the results, it is evident that after 17 elective operations we had only one death (5.9%), whereas after 15 emergency operations 6 patients died, which means a mortality rate of 40%. CONCLUSION: Although sigmoid volvulus causing intestinal obstruction is frequently successfully encountered by endoscopic decompression, however, the principal therapy of this condition is surgery. Only occasionally in patients with advanced age, lack of bowel symptoms and multiple co-morbidities might surgical repair not be considered.