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Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)00993-3
10.1016/j.ijscr.2024.110212
110212
Case Report
Metachronous volvulus of the descending colon after resection of the sigmoid volvulus; a case report
Kebede Molla Asnake mollaasnake75@gmail.com
a⁎
Mohammed Sisay Mengistu b
Numaro Yilkal Teshome c
Mesfine Yohanes Yoseph yohanesyoseph@mtu.edu.et
b
Worku Adugnaw Bogale b
Birhanu Anteneh Messele antenehmessele@mtu.edu.et
a
a Department of Medicine, School of Medicine, College of Medicine and Health Sciences, Mizan - Tepi University, Mizan-Teferi 260, Ethiopia
b Department of Surgery, School of Medicine, College of Medicine and Health Sciences, Mizan - -Tepi University, Mizan-Teferi, Ethiopia
c Department of Surgery, Gebre Tsadik Shawo General Hospital, Bonga, Ethiopia
⁎ Corresponding author. mollaasnake75@gmail.com
25 8 2024
10 2024
25 8 2024
123 1102126 7 2024
18 8 2024
22 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction and importance

Volvulus of the large bowel is a pathological condition characterized by the twisting of the colon around itself, resulting in obstruction and potentially severe complications such as bowel ischemia and necrosis. The objective of this case report is to highlight the importance of considering volvulus as a differential diagnosis in patients with a history of colonic surgeries, particularly when presenting with symptoms indicative of bowel obstruction.

Case presentation

The case was a 55 years old male patient who underwent Hartman procedure three years back for an indication of gangrenous sigmoid volvulus. Three months later the colostomy was reversed and descending colo-rectal end-to-end anastomosis was performed. He currently presented to the emergency department with a one day history of abdominal distension which was progressive and associated with colicky persistent abdominal pain. Exploratory laparotomy was done which showed the descending colon was massively dilated and twisted 360 degree in the counterclockwise direction. The patient was discharged from the ward after one week stay.

Clinical discussion

Despite of the fact that volvulus is the third most common cause of bowel obstruction, consecutive bowel obstruction secondary to volvulus at a separate time and site is an extremely rare phenomenon.

Conclusion

A metachronous colonic volvulus is an extremely rare clinical entity. In a patient who presents with bowel obstruction with a history of prior sigmoid colectomy. it is important to consider metachronous volvulus as differential diagnosis specially in patients with significant risk factors or residing in a geographic area known with high rates of volvulus.

Hightlights

• Only a few cases of Metachronous volvulus have been reported as of mid-2024.

• It is a challenging diagnosis to make with clinical evaluation and conventional imaging.

• Should always be considered in the applicable patient to avoid unnecessary delay and complications.
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pmc1 Introduction

Volvulus of the large bowel is a pathological condition characterized by the twisting of the colon around itself, resulting in obstruction and potentially severe complications such as bowel ischemia and necrosis. If left undiagnosed and untreated, it can lead to bowel perforation, which is a life-threatening emergency. Patients with colonic volvulus typically present with symptoms such as abdominal pain and cramps, abdominal bloating, constipation, nausea and vomiting, and the inability to pass gas [1].

In the spectrum of bowel obstructions, colonic volvulus ranks as the third leading cause, with tumor obstruction and complicated sigmoid diverticulitis being the preceding factors globally. The prevalence of sigmoid volvulus as a cause of large bowel obstruction varies greatly geographically, from 1 to 7 % in the United States [4] to nearly 80 % in the Andes [[5], [6], [7]]. It accounts for 50–80 % of large bowel obstruction in the volvulus belt area such as Middle East, South America, Africa and Russia [[8], [9], [10], [11], [12]]. The highest incidence from Africa is reported from Ethiopia where it accounted for 56 % of patients with intestinal obstruction [13].

Sigmoid volvulus (SV) stands out as the most prevalent type, accounting for 60–80 % of cases [2,3]. This prevalence is largely attributed to the anatomical characteristics of the sigmoid colon, where one-third of all colon obstructions occur. Other less common sites of volvulus include the cecum (43 %), transverse colon (3 %), and splenic flexure (2 %) [4,5].

Interestingly, the occurrence of metachronous sigmoid and descending colon volvulus is an exceedingly rare phenomenon. Based on our literature search, there are only two reported case of descending colon volvulus with a previous history of sigmoidectomy [14]. A rare case of descending colonic volvulus presenting as large bowel obstruction 19 years after sigmoidectomy and descending colorectal anastomosis [15]. This rarity underscores the unique nature of the case described in the article, which involves a patient with a history of sigmoidectomy due to sigmoid volvulus presenting with volvulus of the descending colon [17]. The work has been reported in line with the SCARE criteria [18].

This case highlights the importance of considering volvulus as a differential diagnosis in patients with a history of colonic surgeries, particularly when presenting with symptoms indicative of bowel obstruction. Early recognition and intervention are crucial in preventing severe complications and improving patient outcomes.

2 Case presentation

On 3/2/2024, fifty-five years old male patient presented to the emergency department with a one-day history of abdominal distension which was progressive and associated with colicky persistent abdominal pain which ranges 6–7 in pain scale. Although he was able to pass feces and flatus, he had two episodes of vomiting.

Three years ago, the patient underwent Hartman procedure for indication of gangrenous sigmoid volvulus after he gave informed consent. The whole sigmoid was removed as the intraoperative finding revealed totally gangrenous sigmoid segment. Additionally, end colostomy was done and the patient advised about colostomy care. Three months later, the colostomy was reversed by mobilizing the distal part of the descending colon and mobilizing the rectum for tension free descending colorectal end-to-end anastomosis. Following the procedure, he has had recurrent constipation for which he tried traditional medications; however, his condition didn't improve. He stated that he has no personal and family history of diabetes, hypertension or cancer and no known allergy.

On examination, he was anxious because he was in pain. His blood pressure was 100/65 mmHg, pulse rate was 101 per minute and the respiratory rate was 24 per minute. The respiratory, cardiovascular and nervous system examination revealed normal finding with pink conjunctiva and moist buccal mucosa. However, the abdominal examination showed, generalized distension with visible previous midline surgical scar, high pitched bowel sounds with hyper tympanic abdomen and mild left upper quadrant tenderness with no guarding or rebound tenderness. There was no palpable mass or hernia. The digital rectal examination (DRE) revealed loose stool on examining finger with no palpable mass or tenderness.

The CBC (complete blood count) investigation revealed a white blood cell count of 12,000 cells/mm3, hemoglobin level of 12.9 g/dl and platelet count of 266,000 cells/mm3 and an erect plain abdominal X-ray showed dilated loops of large bowel with multiple air fluid levels and gasless pelvis [Fig. 1]. However, the renal function test and serum electrolytes were with in normal range.Fig. 1 Erect plain abdominal X-ray showing dilated loops of large bowel with multiple air fluid levels and gasless pelvis.

Fig. 1

In view of above the provisional diagnosis of adhesive bowel obstruction was considered; consequently, he was resuscitated with 2 bags of normal saline, commenced on Iv antibiotics (ceftriaxone and metronidazole) and a nasogastric tube inserted through his nose for immediate decompression of the abdomen. Additionally, rectal tube deflation had been provided; however, the patient's condition didn't improve. Therefore, the patient was further evaluated and large bowel obstruction failed for rectal tube deflation was considered.

Although the x-ray finding suggested large bowel obstruction secondary to volvulus, recurrent or other site volvulus was a remote possibility. Consequently, emergency surgery had been considered and the patient was taken to operation room after taking written informed consent. While doing exploratory laparotomy, the team visualized the descending colon was massively dilated and twisted 360 degree in the counterclockwise direction. There was around 500 ml hemorrhagic exudate. The twisted descending colon carefully delivered and Hartmann's resection of the descending colon was done [Fig. 2]. The healthy upper rectum anchored as a stump. The postoperative course was uneventful and patient was discharged home 5 days after surgeryOn the 12th postoperative day, the patient was examined at the surgical referral clinic. He had no new complaints, no signs of surgical site infection, and a functional colostomy with formed stool through the stoma. He received advice on nutritional management and stoma care, with a follow-up scheduled in three months for definitive reversal surgery. During the second surgery, the Hartmann's colostomy was reversed, and a transverse colorectal anastomosis was performed. The patient stayed in the hospital for seven days post-surgery and was discharged with a follow-up appointment.Fig. 2 resected specimen of the descending colon.

Fig. 2

On the 14th postoperative day, he was re-examined at the referral clinic, where he was tolerating oral feeding well, with no abdominal pain or distension. Further outpatient follow-ups at 6 weeks and 6 months post-surgery revealed that the patient remained stable and had resumed normal activities.

3 Discussion

Colonic volvulus is the axial twisting of the colon on its vascular pedicle [17]. Colonic volvulus occurs when a segment of large bowel becomes torsional, and it often leads to bowel obstruction and strangulation. Colonic volvulus is the third leading cause of large bowel obstruction [18].

Volvulus occurs in those portions of the colon possessing a mesentery, including the sigmoid, cecum, and transverse colon. Rarely, volvulus develops in the splenic flexure [19] because of congenital absence or surgical division of the normal fixation structures (the gastrocolic, phrenicocolic, and splenocolic ligaments). The descending colon is usually surrounded by peritoneum on three sides and is a retroperitoneal structure without a mesocolon. However, the primitive dorsal mesocolon may fail to fuse with the parietal peritoneum in the fourth through the fifth month of gestation, resulting in a persistent descending mesocolon [20]. This failure permits mobility of the descending colon, resulting in considerable variation in its position. Commonly, the descending colon swings to the midline or slightly to the left of the midline [21], leaving a space into which all or a part of the small bowel may migrate.

The typical patient of sigmoid volvulus age is between 40 and 60 years old which is strongly associated with chronic constipation [22]. Chronic constipation may produce a large, redundant colon that predisposes to volvulus, especially if the mesenteric base is narrow [23]. In developing countries, consumption of high fiber diet leads to overloading of the sigmoid colon, causing it to twist around the mesentery [24]. These factors were observed in our patient, who was suffering from sigmoid volvulus when he was 52 years old and had history of chronic constipation.

Other predisposing factors for developing large bowel volvulus are congenital anatomical variations such as increased colonic length and abnormal fixation, Chagas disease resulting in megacolon, distal obstruction such as carcinoma of the sigmoid, previous abdominal surgery and pregnancy. There is a male predominance and a geographical variation, with a higher incidence in African, Asian and Eastern countries [25].

The presence of a megacolon during primary intervention is a well-known risk factor for recurrence of volvulus [25]. In the literature, the incidence of recurrent volvulus after previous resection and primary anastomosis is 22 % to 36 % [26].

The diagnosis of colonic volvulus can generally be suspected on conventional abdominal radiography and can be confirmed with a barium enema. CT is much more specific than a barium study in delineating the presence, cause, level, and degree of bowel obstruction; signs of strangulation; and associated abnormalities outside the bowel wall, such as calcified lymph nodes in the mesentery [27]. Though typical CT imaging features may be absent in 1/4th of all patients [28]. In our patient, the markedly distended bowel loop depicted on radiography was suggestive of large bowel obstruction, but the exact level of obstruction was hard to identify with confidence due to unavailability of CT scan.

The management of colonic volvulus depends on the clinical status of the patient. Surgical treatment of colonic volvulus is dependent on its presentation and location in the large bowel. Several surgical options endoscopic detorsion and laparoscopic surgery might be considered in the management of a metachronous volvulus [29].

In the absence of clinical and radiological signs of necrosis or perforation, the initial management of volvulus involves colonoscopic derotation and decompression followed by semi-elective resection and anastomosis after optimizing the patient. This approach increases the chances of having a single stage definitive procedure. A detorsion without resection of the colon is associated with high recurrence rates. If endoscopic derotation and decompression fails, the patient should be taken for an operation [30].

A similar case is reported of descending colonic volvulus with a previous sigmoidectomy in Mercy Hospital, St Louis, MO, USA. This was managed with a two-stage procedure. Firstly, an endoscopic decompression (deflation) with flexible sigmoidoscopy was performed and then, two days' later, a laparoscopic anterior colon resection including resection of the previous colorectal anastomosis was done [26]. Another similar case is reported of descending colonic volvulus with a previous sigmoidectomy in Debre Markos University, East Gojjam, Ethiopia. It was managed with an infraumbilical laparatomy incision. The colonic volvulus was derotated and deflated with a rectal tube intraoperatively and extraperitonealization of the descending colon was done. A rare case of descending colonic volvulus presenting as large bowel obstruction 19 years after sigmoidectomy and descending colorectal anastomosis [15].

Several authors also report failed attempts at non-operative management [30,32,33]. as in our case, he had an initial attempt at non-operative decompression with rectal tube which was unsuccessful. The patient is then prepared for surgery and Hartmann's resection of the descending colon was done.

However, if there is evidence of necrosis or perforation clinically or radiologically, surgery is mandatory. Resection of involved segments is mandatory followed by ostomy or primary anastomosis depending on the bowel status and patient stability [31].

Residing in the “Volvulus Belt” of Africa, in addition to the other predisposing factors described, this case completely fits within the risk profile. The presence of a megacolon during primary intervention is a well-known risk factor for recurrence of volvulus and dividing the attachments of the remaining colon theoretically further increases this risk. Therefore, it is recommended to consider a subtotal colectomy in the presence of a megacolon, instead of partial resection of the involved bowel segment [33].

Limitation of this study is inability to determine cause-effect relationship and lack of ability to generalize although it detected this extremely rare clinical condition and offers high educational value [34].

4 Conclusion

A metachronous colonic volvulus is an extremely rare clinical entity. Preoperative diagnosis is challenging. Overall, metachronous colonic volvulus must be considered in the differential diagnosis of bowel obstruction, particularly in patients with significant risk factors or residing in a geographic area known with high rates of volvulus. Early diagnosis and prompt management with endoscopic decompression is recommended if there are no symptoms and signs of peritonitis. If deflation is unsuccessful or if there are symptoms and signs of peritonitis from the outset, emergency surgery is indicated. The surgical options include extraperitonealization, diversion colostomy or resection and primary end-to-end anastomosis, depending on patient co-morbidity, hemodynamic condition, nutritional status and the operator. If deflation is unsuccessful or if there are symptoms and signs of peritonitis from the outset, emergency surgery is indicated. The surgical options include extraperitonealization, diversion colostomy or resection and primary end-to-end anastomosis, depending on patient co-morbidity, hemodynamic condition, nutritional status and the operator.

Abbreviations

CBC Complete Blood Count

CT Computed Tomography

DRE Digital Rectal Examination

IV Intravenous

LBO Large Bowel Obstruction

SV Sigmoid Volvululs

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Ethical Clearance was obtained from the Research and Ethics Review Committee of College of Medicine and Health Sciences, Mizan-Tepi University. Here is the Reference no: HSE/00429/2012.

Date: 20/12/2023.

Funding

No funding.

Author contribution

Molla Asnake Kebede, MD, Involved in the conception and design of the study, drafting and revising of the article and final approval of the version to be submitted and also involved in direct management of the patient.

Sisay Mengistu Mohamed, MD, Involved in the conception and design of the study, drafting and revising of the article and final approval of the version to be submitted and also involved in direct management of the patient.

Yilkal Teshome Numaro, MD, Involved in the design of the study, drafting and revising of the article and final approval of the version to be submitted.

Yohanes Yoseph Mesfine, MD, Involved in the design of the study, drafting and revising of the article and final approval of the version to be submitted.

ABW, Involved in the design of the study, drafting and revising of the article and final approval of the version to be submitted.

AMB Involved in the design of the study, drafting and revising of the article and final approval of the version to be submitted.

All authors agreed to be accountable for all aspects of the manuscript.

Guarantor

Molla Asnake Kebede.

Research registration number

Not applicable.

Conflict of interest statement

Declared no conflict of interest.

Molla Asnake Kebede is an Assistant Professor, Department of Medicine, School of Medicine, College of Medicine and Health Sciences at Mizan – Tepi University, Ethiopia. MA is a Medical Doctor and specialty certificate in Drug resistant tuberculosis management.

Sisay Mengistu Mohammed is Assistant Professors of General Surgery, Department of Surgery, School of Medicine, College of Medicine and Health Sciences at Mizan – Tepi University, Ethiopia. SM is Medical Doctors and has Specialty Certificate in General Surgery.

Yilkal Teshome Numaro is a General Surgeon, Department of Surgery, Gebre Tsadik Shawo General Hospital, Bonga, Ethiopia. YT is Medical Doctors and has Specialty Certificate in General Surgery.

Yohanes Yoseph Mesfine is a General Practitioner in the Department of Surgery, School of Medicine, College of Medicine and Health Sciences at Mizan – Tepi University, Ethiopia. YM is a Medical Doctor.

Adugnaw Bogale Worku is Assistant Professors of Orthopedics and Trauma surgery, Department of Surgery, School of Medicine, College of Medicine and Health Sciences at Mizan – Tepi University, Ethiopia. SM is Medical Doctors and has Specialty Certificate in Orthopedics and Trauma surgery and Public health.

Anteneh Messele Birhanu is an Assistant Professor, Department of Medicine, School of Medicine, College of Medicine and Health Sciences at Mizan – Tepi University, Ethiopia. MA is a Medical Doctor and specialty certificate in public health.

Acknowledgements

We would like to thank the department of surgery staff members and study participant.
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