Recurrent Sigmoid Volvulus after Sigmoidectomy: 3 Clinical Cases

Introduction: Recurrent sigmoid volvulus is a medical and surgical emergency. It is the recurrence of a twisting of the sigmoid loop around its mesenteric axis initiating an occlusion by strangulation. The risk factors of colonic volvulus are: a dolichosigmoid, a chronic constipation, a tumor, …In Western countries, recurrences of sigmoid volvulus after surgery are rare and due to a non resection of a dolicho-megacolon. Most African studies do not report any recurrence of sigmoid volvulus after sigmoidectomy. This work aims to describe three original cases of recurrence of sigmoid volvulus after sigmoidectomy recorded at the University Hospital of Brazzaville and to analyze their causes and surgical management. Clinical Observation: We studied the cases of three male patients, whose average age was 73 years, each of them having a history of chronic constipation and sigmoidectomy for sigmoid volvulus with an average delay of recurrence of 5.3 years. They all underwent emergency laparotomy for acute intestinal obstruction on scarred abdomen. The surgery permitted to unfold a recurrent volvulus of the sigmoid associated with circumferential scar fibrosis on the volvulated sigmoid loop. A second colectomy was performed. The histological results of the surgical specimens were normal for two patients and revealed signs of tissue necrosis for the third patient. The postoperative outcome was without incident for two patients. The third patient died after developing a septic shock. Conclusion: Recurrent sigmoid volvulus after sigmoidectomy is rare. The etiological factors for our three patients were incomplete sigmoidectomy during the first operation and chronic constipation.

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 sigrnoid 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 sigrnoid, 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 sigrnoidopexy 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 the remaining 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.

Metastatic low-grade endometrial stromal sarcoma of the sigmoid colon three years after hysterectomy

A 49-year-old woman, who had undergone hysterectomy for low-grade endometrial stromal sarcoma (ESS) 3 years ago, presented with a 2-wk history of lower abdominal pain. Barium enema and sigmoidoscopy disclosed a polypoid submucosal tumor. Histopathologic features of biopsy specimens from the lesion were similar to those of the resected uterine ESS. Under the diagnosis of metastatic ESS of the sigmoid colon, sigmoidectomy was performed. Microscopic examination demonstrated dense proliferation of spindle cells with little nuclear atypia, which were sometimes arranged in whorled pattern around abundant arterioles. Mitotic count is below 1 in 10 highpower fields. Immunohi-stochemically, the neoplastic cells were strongly positive for vimentin, estrogen receptor and progesterone receptor but negative for α-smooth muscle actin, S-100 protein and CD34. Thus, a final diagnosis of low-grade ESS metastasis to the sigmoid colon was made.Her postoperative course was uneventful and hormonal therapy with progestational agents is entertained.

Diverticulitis in the young patient-Is it different?

AIM： To prospectively study the incidence and the natural history of acute diverticulitis in young patients. METHODS： A total of 207 patients hospitalized at our hospital between January 2000 to February 2005 with the diagnosis of acute diverticulitis were included. Their demographic characteristics, medical history, physical, radiographic and endoscopic findings as well as therapy were recorded. Patients were followed every 6 mo for the first year and later annually. RESULTS： The mean patients＇ age was 61 （range 27-92） years. Twenty- five patients （12%） were younger than 45 years. Acute diverticulitis was significantly more prevalent among male in the young age group as compared to the older age group （19/25, 76% vs 61/182, 33%, respectively, P = 0.0001）. Complications occurred more often in the young age group; 32% vs 13%, （P = 0.002）. During follow-up, 6 patients （28%） remained asymptomatic in the young age group as compared to 87 patients （55%） in the older age group （P = 0.024）. As a result, sigmoidectomies were performed twice as often in the young age group （38% vs 13%, P = 0.002）. CONCLUSION： Diverticulitis in young patients has a male predominance, a more aggressive course with a higher rate of complications and a higher recurrence rate. An earlier surgical approach might be considered in young patients with acute diverticulitis.

Volvulus of the Sigmoid Colon—Management in the Surgery “A” Department of the Teaching Hospital of Point G

Introduction: The volvulus of the sigmoid colon is the twist of the sigmoid handle on its mesocolic axis, achieving a low occlusion by strangulation. Methodology: The study was conducted in the surgery “A” department of the Teaching Hospital of Point G in Bamako. The study is retrospective and descriptive, over 5 years, ranging from January 2014 to December 2018. We conducted a comprehensive recruitment of all patients operated on for sigmoid volvulus during the study period. The only criterion for inclusion was patients operated on for volvulus of the sigmoid colon in the surgery “A” department of the Point G Hospital and the non-inclusion criteria were all patients operated on for other sigmoid pathologies without volvulation and patients operated on for other types of occlusions. Result: We conducted an exhaustive recruitment of 55 patients operated on for sigmoid volvulus during the study period. Sigmoid volvulus accounted for 13.75% of intestinal obstructions. The average age of patients was 48.013 ± 18.042 years with extremes of 24 years and 82 years. The age group 40 - 49 was the most represented at 21.8%. The sex ratio (M/F) was 8 in favour of male sex. The duration of the disease was less than 1-day in 50.94% of patients. There were two cases of ileo-sigmoid nodes. Immediate anastomosis resection was performed in 27 patients or 49.2% of cases. The time to restore continuity when specified was between 60 - 90 days and the median incision was the most common route of recovery at 80.8% of cases. The average length of hospitalization was 9 days with extremes of 2 days and 42 days. The morbidity rate was 7.3%. In our study we had 3 deaths or 5.5% of the cases. Conclusion: The volvulus of the sigmoid colon is the twist of the sigmoid handle on its mesocolic axis, achieving a low occlusion by strangulation. The volvulus of sigmoid is a serious surgical emergency that requires early diagnosis and management. In Mali, there is no validated consensus for the choice between immediate anastomosis resection if possible and multi-stage surgery. The purpose of this study is to evaluate the different surgical approaches carried out in the surgery “A” department of the Point G Hospital.

Staged Surgery for Giant Fecaloma Complicating Idiopathic Megacolon

Fecalomas that need surgical management are uncommon. We report a rare case of giant fecaloma in a 22 years old female, with a history of constipation since childhood and an abdominal mass. Abdomen CT scan revealed a giant fecaloma filling sigmoid lumen without signs of ischemia or either complications. Laparotomy and fecaloma extraction trough colotomy was undertaken after failure of conservative measures and endoscopic removal attempt. Hirschsprung disease having been ruled out, sigmoidectomy was performed for idiopathic megacolon. Post operative course was uneventful with good functional outcomes.

Surgical outcomes and their relation to the number of prior episodes of diverticulitis

Purpose:We aimed to investigate the relationship between the number of prior episodes of diverticulitis and outcomes of sigmoid colectomy.Methods:After institutional review board approval,a retrospective review was undertaken based on records of patients who underwent sigmoid resection with anastomosis for diverticulitis between 4 May 2007 and 29 February 2012.Patients were divided into two groups:0–3 attacks(group 1)and4 attacks(group 2).Statistical analyses were performed to determine whether the groups differed on demographic,intra-operative and postoperative variables.Results:We identified 247 patients who underwent sigmoid colectomy for diverticulitis(45 open,202 laparoscopic).The two groups did not differ significantly in age,gender,American Society of Anesthesiologists score,past surgical history,body mass index,length of stay,use of a stoma or number of prior hospitalizations for diverticulitis.Group 1 had a higher rate of abscesses(30.6 vs 6.8%,P<0.001)and fistulas(19.4 vs 0.9%,P<0.001);a longer operative time(190.1 vs 166.3 min,P=0.0024);and higher rates of postoperative complications(45.8 vs 23.3%,P<0.001)and conversion(17.1 vs 4.4%,P=0.0091).The most common surgical complications in groups 1 and 2 were wound infection(35 vs 10)and ileus(20 vs 8).Based on multivariate regression analysis,4 attacks were independently correlated with a lower complication rate(odds ratio=0.512,95%confidence interval=0.266–0.987,P=0.046).Conclusions:Patients who had4 previous attacks of diverticulitis had fewer postoperative complications.