Combined 06 clinical training--pathology benign_volvulus

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  • Combined 06 clinical training--pathology benign_volvulus

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

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