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Combined 06 clinical training--pathology benign_volvulus
 

Combined 06 clinical training--pathology benign_volvulus

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Combined 06 clinical training--pathology benign_volvulus Combined 06 clinical training--pathology benign_volvulus Presentation Transcript

  • The Next Era in GI Surgery BioDynamix TM Anastomosis The Colon Ring Clinical Training Team BENIGN PATHOLOGY Volvulus
  • Sigmoid and Cecal Volvulus – Introduction
    • Volvulus - rotation of the gut on its own mesenteric axis.
    • Produces partial or complete intestinal obstruction.
    • Blood supply is compromised, resulting in intestinal ischemia.
    • Venous congestion leading to infarction can occur.
    • Arterial supply is rarely compromised.
    • Long narrow-based mesentery predisposes to volvulus.
  • Sigmoid Volvulus
    • The sigmoid is the commonest site of colonic volvulus.
    • Accounts for 5% of large bowel obstruction.
    • Usually seen in elderly or those with psychiatric disorders.
    • Commonest cause of obstruction in Africa / Asia.
    • Incidence is 10 times higher than in Europe or USA.
  • Clinical Features
    • Large bowel obstruction –
      • Pain
      • Constipation
      • Vomiting
    • Disproportionate abdominal distension.
    • 50% patients have had a previous episode.
    • Severe pain and tenderness suggest ischemia.
  • Clinical Features
    • Plain abdominal x-ray may show a large ‘bean’ shaped loop of large bowel arising from pelvis.
  • Sigmoid Volvulus
    • Gangrenous loop—
  • Management
    • Conservative management can be attempted.
    • Resuscitation with intravenous fluids is essential.
    • Sigmoidoscopy and/or Barium enema can be both diagnostic and therapeutic.
    • Obstruction is usually at ~15 cm which, when passed, produces release of flatus and decompression.
    • Flatus tube can be inserted and left in place for 2-3 days.
    • 80% of patients will resolve with conservative management.
  • Management
    • If decompression occurs, no emergency treatment is required.
    • 50% will develop a further episode of volvulus within 2 years.
    • If decompression fails or features of peritonitis occur, the options are:
      • Sigmoid colectomy and primary anastomosis.
      • Hartmann’s procedure.
      • Sigmoidopexy best avoided.
  • Cecal Volvulus
    • Less common than sigmoid volvulus.
    • Less likely to result in complete obstruction.
    • Usually “flops” upward on its mesentery rather than undergoing a complete rotation (such as with the sigmoid).
    • Rarely requires resection.
    • May usually be treated with cecopexy (to right gutter).
    • Less likely to recur after cecopexy.