Controversies in Sigmoid Volvulus ...

[opr8n]

I recently had a 70 y/o patient, presented with sigmoid volvulus, very distended and painful, but no peritoneal signs, labs all ok, no obvious evidence of dead gut ...

1. Whats the point of decompressive colonoscopy really? If you are in house and have access to an OR even if in the middle of the night, why not just take the person to the OR? You could say that decompressing them allow you to prep them (which I dont do anyways on normal colons) and you can possibly do a primary anastomosis (which I never do in this situation with bowel dilated to 13cm, size mismatch)

2. If you do decompressive colonoscopy, do you leave a rectal tube for decompression? (my personal opinion is I have never seen a decompressing rectal tube besides the garden hose watering my lawn)

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[ESU_MD]

I think most would just operate. The decompression in a non peritoneal patient is a waste. Can be useful in someone who is not an operative candidate though. .. Like advanced dementia, etc..

 

[45408]

I think most would just operate. The decompression in a non peritoneal patient is a waste. Can be useful in someone who is not an operative candidate though. .. Like advanced dementia, etc..

Exactly what I was going to say. We've had a few patients who have been decompressed several times this way, but they're so close to the brink that putting them under general anesthesia might be the last thing that ever happens to them.

 

[dpmd]

Don't know the answer, but by decompressing them could you sit on things for long enough to resolve the mismatch?

 

[SLUser11]

I recently had a 70 y/o patient, presented with sigmoid volvulus, very distended and painful, but no peritoneal signs, labs all ok, no obvious evidence of dead gut ...

1. Whats the point of decompressive colonoscopy really? If you are in house and have access to an OR even if in the middle of the night, why not just take the person to the OR? You could say that decompressing them allow you to prep them (which I dont do anyways on normal colons) and you can possibly do a primary anastomosis (which I never do in this situation with bowel dilated to 13cm, size mismatch)

2. If you do decompressive colonoscopy, do you leave a rectal tube for decompression? (my personal opinion is I have never seen a decompressing rectal tube besides the garden hose watering my lawn)

I'm typing on my phone so ill be briefer than usual. I think detorsion is very helpful, and I routinely detorse the volvulized colon, with a rigid proctoscope if possible, otherwise a flex sig. I leave a 36 french chest tube in there, and sew it to the buttcheek with a heavy silk or ethibond. If I am successful with the proctoscope, which I usually am, then I place the chest tube right through the scope, which is by far the easiest and safest way to do it.

Volvulus doesn't usually happen at a convenient time of day, and detorsion allows you to do the case electively instead of at 2am with the OR skeleton crew. You can also learn more about the patient's comorbidities prior to cutting, which may affect what you do and how you do it.

While a bowel prep may not be necessary, it is much easier to operate on a decompressed colon. It allows for an easier case and a smaller incision. It allows for a laparoscopic case as well. Decompressing a massively dilated colon while on the table is messy and more prone to mistakes.

If the bowel is decompressed, you can usually do a safe anastomosis. I would only do a colostomy if the patient was sick or had significant incontinence.

At the end of the day, elective surgeries have better outcomes than emergent ones for a multitude of reasons. You have a better crew, a physiologically optimized patient, more time to think and plan out your approach, etc.

 

[Buzz Me]

Agree with the above post. I've never used a chest tube before for colonic decompression - have always used a large-caliber red rubber catheter (up to 28-French), placed gently with or without a rigid procto.

 

[SLUser11]

I think most would just operate. The decompression in a non peritoneal patient is a waste. Can be useful in someone who is not an operative candidate though. .. Like advanced dementia, etc..

I have an opposite opinion. I would never decompress a patient with peritoneal signs....that's the patient I would take straight to the OR.

For patients who cannot tolerate surgery, I've heard peripherally of surgeons placing PEG tubes through the sigmoid to pexy it to the abdominal wall (usually at two separate points). I've never done this, but I find it intriguing.....

 

[dpmd]

I have an opposite opinion. I would never decompress a patient with peritoneal signs....that's the patient I would take straight to the OR.

For patients who cannot tolerate surgery, I've heard peripherally of surgeons placing PEG tubes through the sigmoid to pexy it to the abdominal wall (usually at two separate points). I've never done this, but I find it intriguing.....

Sounds cool, but seems like you could achieve the same effect with a suture passer or something-then they wouldn't have a tube hanging out. Maybe sutures would cut through the bowel though?

 

[Apollyon]

I'm typing on my phone so ill be briefer than usual.

That's why you're the bomb. The topic is squarely in your provenance, and you put up a concise, informational post - your being "brief" is more comprehensive than the average SDN contribution.

(Edit: and I am not a paid endorser.)

 

[ESU_MD]

I have an opposite opinion. I would never decompress a patient with peritoneal signs....that's the patient I would take straight to the OR.

For patients who cannot tolerate surgery, I've heard peripherally of surgeons placing PEG tubes through the sigmoid to pexy it to the abdominal wall (usually at two separate points). I've never done this, but I find it intriguing.....

PEG tube through the sigmoid!!! Hardcore, God bless Texas

 

[SLUser11]

Sounds cool, but seems like you could achieve the same effect with a suture passer or something-then they wouldn't have a tube hanging out. Maybe sutures would cut through the bowel though?

I think you may be on to something. There's no reason why the suture should cut through the bowel if done correctly. The only thing I can think of is that it will take multiple passes of a sharp instrument, which may increase the chances of tagging something you don't want...like small bowel, iliac vein, etc.

The PEG tubes could be cut down to a short length, and they only have to be in long enough for scarring to occur (I would arbitrarily think 6 weeks). There would be a chance of a persistent colocutaneous fistula, but this would most likely close on its own.

PEG tube through the sigmoid!!! Hardcore, God bless Texas

I heard about that from a Florida surgeon. In Texas, we just operate regardless of patient condition.


In my mind, the PEG tube approach is nifty, but I always think about how well my plan would fail. If the demented 95 year old patient pulled out the PEG, the resulting intra-peritoneal bowel movement would likely be lethal. Also, there's a reason why we don't do simple sigmoidopexies to fix this problem operatively...the recurrence rate is high.

I think the best approach in these patients is to detorse, temporize with a rectosigmoid tube, and optimize the patient's physiologic status....then bite the bullet and put the sigmoid in the bucket. Since there's minimal or non-existent mobilization needed, a smash-and-grab sigmoidectomy through a small infraumbilical incision seems like the safest approach.

 

[tussy]

I'm typing on my phone so ill be briefer than usual. I think detorsion is very helpful, and I routinely detorse the volvulized colon, with a rigid proctoscope if possible, otherwise a flex sig. I leave a 36 french chest tube in there, and sew it to the buttcheek with a heavy silk or ethibond. If I am successful with the proctoscope, which I usually am, then I place the chest tube right through the scope, which is by far the easiest and safest way to do it.

Volvulus doesn't usually happen at a convenient time of day, and detorsion allows you to do the case electively instead of at 2am with the OR skeleton crew. You can also learn more about the patient's comorbidities prior to cutting, which may affect what you do and how you do it.

While a bowel prep may not be necessary, it is much easier to operate on a decompressed colon. It allows for an easier case and a smaller incision. It allows for a laparoscopic case as well. Decompressing a massively dilated colon while on the table is messy and more prone to mistakes.

If the bowel is decompressed, you can usually do a safe anastomosis. I would only do a colostomy if the patient was sick or had significant incontinence.

At the end of the day, elective surgeries have better outcomes than emergent ones for a multitude of reasons. You have a better crew, a physiologically optimized patient, more time to think and plan out your approach, etc.

totally agree, couldn't have said it better! I also use a 36F chest tube, but I don't suture it, just tape it really well.

 

[opr8n]

I leave a 36 french chest tube in there, and sew it to the buttcheek with a heavy silk or ethibond. If I am successful with the proctoscope, which I usually am, then I place the chest tube right through the scope, which is by far the easiest and safest way to do it.
QUOTE]

Interesting, never seen or done this but it sounds very reasonable.

 

[europeman]

Peritonitis mandates OR


No peritonitis mandates attempt at decompression so u can convert to elective case with more options and better outcomes.


For cecal volvulus though I just take them to OR for ileocolic rxn with or without peritonitis of the cecum is big (I dunno... Depends on patient but I'll come in middle of night if its 12cm for sure for example).