SIGMOID VOLVULUS (STUDY OF 20 CASES)

SURGERY | CASE SERIES
SIGMOID VOLVULUS (STUDY OF 20 CASES)
Ketan Vagholkar∗,1 and Shantanu Chandrashekhar∗
∗Department of Surgery, D.Y.Patil University school of Medicine, Navi Mumbai-400706. MS. India.
ABSTRACT Background: Sigmoid Volvulus is the third most common cause of colonic obstruction and accounts for
2-4% of intestinal obstructions. A variety of abdominal and functional factors contribute to the development of sigmoid
volvulus. The progression of pathology is extremely rapid. Hence, understanding these factors enables early diagnosis
and prompt surgical intervention. Aims: 20 cases of surgically treated sigmoid volvulus were studied retrospectively
to identify and evaluate various factors causing morbidity and mortality in these patients. Results: The condition was
commonly seen in males, especially those who were institutionalized and were using laxatives for over 5 years. The
mean age was 65.2 years. Co-morbidities were a common accompaniment. 13 patients had diabetes, 12 patients had
hypertension, 2 patients had ischemic heart disease and 9 patients had the neurological disease (Parkinson’s disease).
6 patients had single co-morbidity, 13 patients had 2 co-morbidities and 1 patient had 3 co-morbidities. A plain X-ray
of the abdomen was diagnostic in all cases. The mean time interval from the onset of symptoms to hospital admission
was 8.1 hours, the time interval from hospital admission to confirmation of diagnosis was 2.1 hours. The mean time
interval from diagnosis to surgical intervention was 3.2 hours. The surgical options exercised were resection anastomosis
with a proximal diversion in 13 patients, Hartmann’s procedure in 6 patients, and primary resection anastomosis in
1 patient. Post-operative complications included ileus in 16 patients, stomal dysfunction in 4 patients, and surgical
infections in 10 patients. The mean duration of stay in hospital ranged from 7-13 days. Only 1 patient who had 2
co-morbidities developed complications and succumbed. Conclusion: Prompt diagnosis, optimization of haemodynamic
status including co-morbidities is essential before contemplating surgical intervention. Resection anastomosis with a
proximal diverting stoma is best suited for patients who have not developed a colonic perforation whereas Hartmann’s
procedure is indicated in patients presented with perforative peritonitis.
KEYWORDS Sigmoid volvulus diagnosis treatment
Introduction:
Sigmoid volvulus (SV) is a condition in which the sigmoid colon
wraps around itself and its mesocolon, causing a closed-loop
obstruction. SV is the most common type of volvulus of the
colon, followed by less common parts such as the caecum and
transverse colon. Sigmoid Volvulus continues to be one of the
Copyright © 2021 by the Bulgarian Association of Young Surgeons
DOI:10.5455/IJMRCR.Sigmoid-Volvulus-2020
First Received: October 21, 2020
Accepted: November 14, 2020
Associate Editor: Ivan Inkov (BG);
1
Department of Surgery, D.Y.Patil University school of Medicine, Navi Mumbai-400706.
MS. India, kvagholkar@yahoo.com, ORCID:0000-0002-3824-0531
most common causes of large bowel obstruction, especially on
the Indian subcontinent. It commonly affects individuals in
the age group of 60-70 years. It has a variable etiology. Both
anatomic and physiological factors play a significant role in the
development of sigmoid volvulus. A retrospective study of 20
cases treated over a period of 5 years was done to identify and
evaluate the clinical presentation, diagnostic tests, and treatment
strategies.
Materials and methods:
Objectives:
To study clinical presentation with respect to time frames,
diagnostic tests, and effective surgical options, including com-
plications and outcomes in treated cases of sigmoid volvulus.
Ketan Vagholkar et al./ International Journal of Medical Reviews and Case Reports (2021) 5(1):134-139

Figure 1 Age distribution
Methodology: Case records of 20 patients with an established
diagnosis of sigmoid volvulus who had undergone surgical
intervention in the period from January 2015 to February 2020,
were studied retrospectively. A proforma was prepared and
the data of each patient was entered into it. Demographic data
included age, sex, and social background with respect to staying
alone or in an institution was documented.
The previous history of constipation requiring chronic use of
laxatives and the presence of comorbidities was noted. Comor-
bidities included diabetes, hypertension, ischemic heart disease
and chronic neurological diseases such as Parkinson’s disease.
The onset, duration and progress of presenting symptoms were
noted. The various relevant time intervals were studied. These
included time from onset of symptoms to hospital admission
(hours), from admission to confirmation of diagnosis (hours),
from establishing the diagnosis to surgical intervention (hours)
and the duration of stay in hospital (days). The diagnostic basis
was studied. This included clinical evaluation, abdominal X-ray,
and CT-scan of the abdomen. The choice of the surgical option
was noted. These included resection anastomosis with proximal
diversion, resection of the twisted segment with Hartmann’s
procedure, and primary resection without proximal diversion.
The complications studied were ileus, stomal dysfunction, and
surgical site infections. The duration of stay in hospital and
mortality was evaluated.
Results:
The mean age was 65.2± SD 5.8 years. (Figure 1) There were 16
males and 4 females. (Figure 2) The number of institutionalised
patients were 6. (Figure 3) 19 patients were using laxatives chron-
ically for over five years. (Figure 4) 13 patients had diabetes, 12
had hypertension, 2 had ischaemic heart disease, and 8 had the
neurological disease (Parkinson’s disease). Six patients had a
single comorbidity, 13 patients had two comorbidities, and one
had three comorbidities.
(Figure 5) The diagnosis was made based on clinical exami-
nation and abdominal x-ray confirmed by CT scan. The mean
time interval from onset of symptoms to hospital admission was
8.1± SD 2.9 hours.
(Figure 6) The mean time interval from hospital admission
to confirmation of diagnosis was 2.1± SD 0.22 hours. The mean
time interval from diagnosis to surgical intervention was 3.2±
SD 1.0 hours.
(Figure 7) The surgical options used were resection anasto-
moses with a proximal diversion in 13 patients, resection of
Figure 2 Gender distribution
Figure 3 Institutionalisation Status
Figure 4 Laxative usage

Figure 5 Co morbidities
Figure 6 Time from onset of symptoms to admission (hours)
Figure 7 Time from diagnosis to surgery (hours)
Figure 8 Surgical options (option1: resection anastomosis with
proximal colostomy, option2: Hartmann’s procedure, option3:
resection anastomosis without proximal stoma)
Figure 9 Complications (complication1: ileus, complication2:
stoma related complications, complication3: surgical site infec-
tions)
the affected segment with Hartmann’s procedure in 6 patients
and primary resection anastomosis in one patient. (Figure 8)
Post-operative complications included ileus in 16 patients, 4 had
stomal oedema, and 10 had surgical site infections. (Figure 9)
The mean duration of stay in hospital was 9.8± 1.5 days ranging
from 7 to 13 days. (Figure 10) Only one patient who had two
comorbidities and developed all complications succumbed.
Discussion
Volvulus of the sigmoid colon is usually seen in the elderly popu-
lation. The aetiology is multi-factorial. Various anatomic factors
are contributory to the development of sigmoid volvulus. These
include redundancy of the sigmoid colon, dolichomesentery
which means that the mesentery is wider than long and narrow-
ing of the sigmoid mesentery. These factors are usually acquired
[1]. However, in a select few cases, they may even be congenital.
In the present study, the majority of patients were aged. In aged
patients, there is a combination of redundancy of the sigmoid
colon and dolichomesentery. Out of 20 patients studied, 16 were
males. (Figure 2) Various anatomical factors play an important
role in male preponderance. These include a smaller pelvic inlet
and dolichomesentery. The incidence of non-pregnant females
is extremely low. However, the condition has been reported
in pregnant females. This is due to the enlarged uterus, which

Figure 10 Duration of hospital stay (days)
pushes the redundant sigmoid colon out of the pelvis, thereby
causing volvulus [1]. Institutionalized patients are particularly
predisposed to the development of sigmoid volvulus [2]. These
individuals are less mobile, bed-ridden and invariably suffer
from chronic constipation, thereby leading to chronic laxative
use. In the present study, 19 out of 20 patients were using oral
laxatives for over a period of 5 years. (Figure 4) The cathar-
tic colon may be a result of chronic laxative abuse which could
predispose to two serious conditions of the colon in the aged pop-
ulation. These include colonic pseudo-obstruction and sigmoid
volvulus [2]. Therefore, a history of chronic laxative use with
sudden onset of massive distention of the abdomen should raise
the suspicion of these two conditions. In chronically constipated
individuals the sigmoid colon is chronically distended and be-
comes redundant, thereby predisposing to volvulus. In addition
to this, most of the patients suffer from chronic neuropsychiatric
disorders as well as metabolic diseases which increase the risk
of sigmoid volvulus. In the present study, 4 comorbidities were
commonly seen. (Figure 5) These included diabetes, hyperten-
sion, ischemic heart disease and chronic neurological disorders.
13 patients had diabetes. Long term diabetes leads to autonomic
neuropathy, thereby slowing down the gut motility and function.
Such patients are usually chronically constipated, leading to the
redundancy of the sigmoid colon. 12 patients in the present
study had hypertension. Various medications used for treating
hypertension, such as calcium channel blockers, are known to
decrease or slow down gut motility. This causes a chronically
loaded colon predisposing to sigmoid volvulus. 2 patients in
the study had ischemic heart disease. Ischemic heart disease in
the long term may cause a decrease in blood supply to the gut,
in turn, causing a slowing of gut function. Chronic neurologic
disorders such as Parkinson’s disease is commonly associated
with colonic dysmotility [3]. In the present study, 8 patients
were on treatment for Parkinson’s disease. Both the long term
effects on the autonomic nervous systems as well as the effect of
medications on gut motility can lead to the slowing of colonic
activity, predisposing to sigmoid volvulus.
The patient usually presents with sudden onset of abdom-
inal distension which rapidly progresses associated with the
inability to pass both faeces and flatus. Clinical presentation
depends upon the progression of the pathology. A complete
twist of the sigmoid colon leads to obstruction of both, the in-
flow and outflow of a colon. This is a typical example of a large
bowel closed-loop obstruction. Due to obstruction at both ends,
the twisted segment distends due to large volume of gas being
formed by the bacteria trapped in the twisted loop. The disten-
tion increases rapidly leading to impairment of the blood supply.
Bacterial translocation of the gut flora occurs in this ischemic
loop. The venous outflow is compromised first. This increases
congestion until the arterial supply is compromised. The colonic
mucosa is particularly susceptible to an ischemic insult. This
further leads to the impaired barrier function and enhances the
translocation of bacteria. The ischemia significantly affects the
muscular layer and serosa, leading to necrosis and perforation
[3, 4, 5]. Once perforation occurs, signs of perforative peritonitis
set in. tachycardia and hypotension are seen Abdominal signs
progress to guarding and rigidity. Sigmoid volvulus can become
a recurring situation in those patients treated conservatively.
The base of the mesentery eventually contracts due to fibrosis
leading to a chronically distended large bowel.
Quick presentation to the hospital is essential for early diag-
nosis and treatment. In the present study, the interval between
the onset of symptoms to admission was 8.1± SD2.9 hours. More
first, the presentation to the hospital, quicker is the diagnosis
followed by treatment. In patients who present early, the inci-
dence of perforation with faecal peritonitis is significantly less,
thereby improving surgical outcomes. The typical symptoms are
acute pain in the abdomen, accompanied by rapidly increasing
abdominal distention in an elderly patient [5, 6]. As time elapses,
there may be vomiting, pallor and severe prostration. A physi-
cal examination will reveal tachycardia, pallor and hypotension.
Per abdominal examination will reveal a distended abdomen
which is tympanic on percussion. In the initial phases, there
may be tenderness. However, once the colon perforates, there
will be signs of peritonitis such as rebound tenderness, guard-
ing and rigidity. The clinical features are typical, and therefore,
no delay should be caused in arriving at a tentative diagnosis.
However, rectosigmoid malignancy leading to proximal disten-
tion should be kept in mind while clinically evaluating such
patients. After admission to hospital, aggressive resuscitation is
essential, which also includes the optimization of comorbidities.
This will render the patient relatively fit to undergo emergency
surgery, which in most of the cases, is lifesaving. A trial of flatus
tube reduction or detorsion can be attempted provided there
are no abdominal signs suggestive of peritonitis. If facilities for
endoscopy are available, then a flexible sigmoidoscopy can help
in reducing the torsion. This intermediate intervention can help
in better preparation for a definitive surgical procedure during
the same admission [6, 7, 8]. Sigmoidoscopic reduction involves
the gentle insertion of the scope with the mild rotation of the
endoscope tip to the side opposite to the torsion. Concomitantly
gentle air insufflation is done. [9, 10] Flexible sigmoidoscopy can
be performed for attempting a reduction in uncomplicated cases
wherein there are no signs of peritonitis. The success rate ranges
from 48-95% in early presentations. [10, 11]This can reduce both
the complication rates as well as mortality in sigmoid volvulus.
However, in the present study, a trial of flatus tube reduction
was successful in a single patient who had recurrent episodes of
volvulus. This allows good preparation and a definitive proce-
dure can subsequently be done in the index admission without
a proximal stoma [13].
In the present study, the average duration from hospital ad-
mission to confirmation of diagnosis was 2 hours. This time
included initial resuscitation, establishing the diagnosis and op-
timization of comorbidities. Plain X-ray abdomen is diagnostic
in sigmoid volvulus [13]. The findings are best described as
coffee bean sign or kidney bean sign. CT scan is confirmatory.

Absence of rectal gas, inverted U shaped distended sigmoid
colon, coffee bean sign and disproportionate enlargement of the
sigmoid colon are the most common findings. In addition, CT
helps to rule out any underlying malignancy of the large bowel
[14]. Therefore it enables to distinguish sigmoid volvulus from
other causes of large bowel obstruction. In the present study,
all patients underwent a plain X-ray abdomen and a CT scan
prior to undergoing surgical intervention. Once the diagnosis
is established, exploratory laparotomy needs to be done at the
earliest. Various surgical options can be exercised depending
upon the intraoperative findings. Presence or absence of these
includes resection anastomosis of the twisted loop with a proxi-
mal diverting colostomy. Hartmann’s procedure is performed in
case of perforated or extremely thinned out colon and resection
anastomosis without proximal diversion in patients in whom
the dilatation is not significant [14,15]. In the present study, 13
patients underwent resection anastomosis with proximal diver-
sion, 6 patients underwent Hartmann’s procedure, whereas only
1 patient underwent primary resection anastomosis without
proximal diversion. (Figure 8)
The twisted loop of the sigmoid colon is massively dilated
with the extremely thinned out wall. This poses a great technical
challenge in achieving a proximal and distal segment which
are congruent with their diameters. As a result, a significant
portion of the colon requires resection. Despite all precautionary
measures, the diameter of the proximal and distal segment may
not match exactly. Therefore even if resection anastomosis is
performed, there is a high likelihood of leakage from the anas-
tomotic site [16, 17, 18]. The shocked state of the patient by
virtue of hypovolemia and sepsis increases the risk of leakage.
Therefore it is a safe practice to perform proximal diversion by
way of a colostomy in order to ensure good anastomotic heal-
ing. This stoma can be closed after 12 weeks with a prior distal
cologram. In certain presentations, the colon may be on the
verge of perforation or may have even perforated leading to
frank faecal peritonitis. In such a situation, it is safe to avoid any
sort of anastomosis. [19, 20]The affected segment needs to be
resected with the creation of a proximal stoma and closure of the
distal remnant. This option is specifically helpful in extremely
old and septic patients. The stoma may serve as a permanent
colostomy in most of the patients, especially in those who are
institutionalized as these patients may not withstand a second
surgery. A primary resection anastomosis without any proxi-
mal stoma is applicable to those patients in whom there is no
distention. This is seen explicitly in patients who have a history
of recurrent episodes of volvulus which may be self-correcting
or may be reduced by emergency room intervention with either
a flatus tube or flexible sigmoidoscopy. [21] In such patients,
the calibre of the sigmoid colon is within normal limits, and the
surgeon can easily perform a sigmoid resection with a primary
anastomosis [22, 23, 24].
Due to the variability in a presentation concerning the time
of presentation and associated factors such as hypotension, sep-
ticaemia and comorbidities, a multitude of complications can de-
velop which include ileus, a complication of the stoma and surgi-
cal site infections [24]. Complications related to the stoma giving
rise to persistent ileus is extremely common. In the present study,
16 out of 20 patients developed ileus and 4 developed stoma
complications. 10 out of the 20 patients developed surgical site
infections. (Figure 9) Correction of fluid and electrolyte balance
and at times nasogastric decompression are helpful. Surgical
site infections are a common accompaniment seen in patients
undergoing surgery for sigmoid volvulus. In the present study,
10 patients developed surgical site infections. In the present
study, various factors could have led to surgical site infections.
These include initial volume depletion, electrolyte disturbances,
peritonitis, prolonged duration of surgery on an emergency ba-
sis and comorbidities. Meticulous wound care techniques at the
time of operation can prevent these complications. The duration
of stay in patients undergoing surgery for sigmoid volvulus is
variable, as seen in the present study. In 10 patients, the stay
varied between 7-9 days, in 6 patients the stay varied between
10-11 days and in 4 patients the stay varied between 12-14 days.
The mean duration of stay in the present study was 9.85 days.
(Figure 10) The longer duration of stay in hospital is due to slow
recovery of gut function as well as the recovery of other systems
such as the cardiopulmonary and renal system. [25] Chest in-
fection is a common sequel in these patients [26]. Majority of
these patients have poor respiratory reserves, thereby predispos-
ing to lung-collapse and infection in the post-operative period.
Rigorous chest physiotherapy is pivotal in preventing chest com-
plications. In the present study, one patient succumbed. The
patient developed severe chest infection leading to septicaemia.
Conclusion
Sigmoid volvulus is a disease commonly seen in institutional-
ized aged patients with chronic consumption of laxatives. Early
diagnosis, optimization of hemodynamic status, including co-
morbidities, is essential before contemplating surgical interven-
tion. A trial of sigmoidoscopic reduction, if successful, may
help in better preparation for definitive surgical intervention.
Resection anastomosis with a proximal diverting stoma is best
suited for patients who do not have any perforation, whereas a
Hartmann’s procedure is indicated in patients presenting with
perforations.
Acknowledgements:
I would like to thank Dean of D.Y.Patil University School of
Medicine, Navi Mumbai, India for allowing to publish this case
series.
Funding
This study received no fund.
Conflict of interest
There are no conflicts of interest to declare by any of the authors
of this study
Patient informed consent
The authors certify that they have obtained all appropriate pa-
tient consent forms. In the form the patient(s) has/have given
his/her/their consent for his/her/their images and other clini-
cal information to be reported in the journal. The patients un-
derstand that their names and initials will not be published and
due efforts will be made to conceal their identity, but anonymity
cannot be guaranteed.
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