Clinical guideline for management of sigmoid volvulus

One discussion this week included revolvulus after colonic decompression.

Reference: Vogel JD, et al. Clinical practice guidelines for colon volvulus and acute colonic pseudo-obstruction. Diseases of the Colon and Rectum. 2016 Jul;59(7):589-600. doi: 10.1097/DCR.0000000000000602

Summary: Volvulus occurs in the sigmoid colon or cecum in >95% of cases, with the remainder involving either the transverse colon or the splenic flexure of the colon. Sigmoid volvulus affects patients who are older, with more comorbid medical and neuropsychological conditions, compared with those with cecal volvulus.

Clinical Guideline: “Rigid or flexible endoscopy should be performed to assess sigmoid colon viability and to allow initial detorsion and decompression of the colon. Grade of Recommendation: Strong recommendation, based on low- or very low-quality evidence, 1C” (p.591).

In the absence of colonic ischemia or perforation, the initial treatment of sigmoid volvulus is endoscopic detorsion, which is effective in 60% to 95% of patients. After successful detorsion of the sigmoid colon, a decompression tube should, in general, be left in place for a period of 1 to 3 days to maintain the reduction, allow for continued colonic decompression, and facilitate mechanical bowel preparation, as needed.

In patients with sigmoid volvulus who undergo successful endoscopic detorsion without subsequent intervention, index admission and long-term recurrent volvulus have been observed in 3-5% and 43-75% of patients. With this high risk of recurrent volvulus and the attendant risks associated with each episode, operative intervention should be strongly considered in appropriate patients during the index admission or soon thereafter.

In cases in which advanced mucosal ischemia, peroration, or impending perforation of the colon is discovered during endoscopy, the procedure should be aborted in favor of emergent operative intervention.

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