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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)01012-5
10.1016/j.ijscr.2024.110231
110231
Case Series
Double ileo-sigmoid volvulus: Report of three (03) cases of ileo-sigmoid node
Sakiye Kodjo Abossisso a
Labou Kossi Albert a
Essobiyou Tamassi Bertrand tamassi2343@outlook.com
a⁎
Alassani Fousseni b
Akakpo Koffi Léonard a
Tchangai Boyodi b
a General Surgery Department, Sylvanus Olympio Teaching Hospital, Lome, Togo
b Visceral Surgery Department, Sylvanus Olympio Teaching Hospital, Lome, TOGO
⁎ Corresponding author. tamassi2343@outlook.com
03 9 2024
10 2024
03 9 2024
123 1102315 7 2024
23 8 2024
31 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

The ileo-sigmoid node is a rare condition that causes mixed intestinal obstruction. It is difficult to diagnose preoperatively and requires medical and surgical management. We report on managing 03 cases of the ileo-sigmoid node.

Case presentation

02 male patients (25 and 37 years old) and one female patient (43 years old) were seen in emergency for occlusive syndromes. The abdominal X-rays in our patients showed air-fluid levels of the small intestine type in two cases and of the mixed type in one case. The diagnosis of intestinal obstruction by strangulation was accepted in all three patients. Hypovolaemic shock was found in the female patient. All three patients had received preoperative resuscitation. Laparotomy revealed type II ileo-sigmoid nodes in 02 cases and type I in one. We noted ileal and sigmoid necrosis in 02 cases and ileal necrosis in 01 case. All three patients underwent ileal and sigmoid resection followed by colorectal anastomosis and terminal ileostomy. Post-operative management was straightforward in all the 03 cases.

Clinical discussion

The ileo-sigmoid node is a serious pathological situation, with the risk of rapid evolution of the intestines involved. It is a medical and surgical emergency requiring rapid and appropriate treatment.

Conclusion

The ileo-sigmoid node is a serious condition with a complex preoperative diagnosis. It is a medical and surgical emergency requiring rapid and appropriate management.

Highlights

• An ileo-sigmoid knot is a rare form of acute intestinal obstruction.

• It is a major medical and surgical emergency. Double strangulation rapidly leads to necrosis of the intestines concerned.

• Pre-operative diagnosis is difficult in rural areas, particularly because of CT scans.

• The morbidity and mortality associated with this pathological situation are severe.

• Exclusively surgical treatment must not be delayed.

Keywords

Node
Volvulus
Sigmoid
Ileum
Occlusion
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pmc1 Introduction

The ileo-sigmoid node is a loop formed by the ileum and the sigmoid colon, one wrapping around the other [1,2]. This is a rare entity, responsible for the development of strangulation occlusion [[1], [2], [3]]. The literature reports cases mainly in Africa and Asia [4]. The ileo-sigmoid node is a genuine medical and surgical emergency because of its rapid progression to intestinal necrosis. Its preoperative diagnosis is difficult and complex due to its clinical atypicality. Similarly, there is no consensus on its surgical management. The main objective is the rapid and adequate restoration of digestive transit. We report on the management of 03 cases of ileo-sigmoid nodes complicated by intestinal necrosis in a secondary hospital in Togo. The work has been reported in line with the PROCESS criteria [5].

2 Cases presentation

2.1 Case 1

A 25-year-old patient with an unknown pathological background was admitted to emergency with abrupt onset of abdominal pain, vomiting and complete cessation of bowel movements and gas for 3 days. The clinical examination revealed an occlusive syndrome with a stable haemodynamic state, prompting an abdominal X-ray which revealed multiple hydro-aeric levels, wider than high and central. The abdominal scan was not carried out because it was not available in the local area and the treatment was an emergency. The radio-clinical arguments led to the diagnosis of intestinal obstruction due to strangulation of the small bowel, and the patient was referred for surgery. The emergency pre-operative check-up consisted of a blood count and renal assessment (uraemia and creatinaemia). A hyperleukocytosis with neutrophilia of 11,200/mm3 was found. After preoperative resuscitation with intravenous crystalloid infusion, analgesics and antispasmodics, a median laparotomy in the operating room revealed a double volvulus of the small bowel (Fig. 1) and sigmoid complicated by ileal and sigmoid necrosis (Fig. 2); the sigmoid was found in the right iliac fossa. Untwisting identified the sigmoid as the active segment wrapping around the ileum and thus forming a type II ileo-sigmoid node. We performed an ileal and sigmoid resection, a colorectal end-to-end anastomosis and an end ileostomy. The patient received post-operative treatment combining analgesics, bi-antibiotic therapy and resumption of feeding on day 1 post-op. The postoperative course was straightforward.Fig. 1 Intraoperative view of a double volvulus of the ileum and sigmoid, creating an ileo-sigmoid node (yellow arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 1

Fig. 2 Intraoperative view after detorsion of the node, showing ileal necrosis (white arrow), sigmoid necrosis (yellow arrow) and a narrow mesosigmoid (dissecting forceps). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 2

2.2 Case 2

This patient was received 3 weeks after the first patient. This 37-year-old patient, who had undergone appendectomy 4 years previously, was admitted to emergency with a 5-day history of fluid and gas arrest. Clinical examination revealed an occlusive syndrome with stable haemodynamics. An abdominal X-ray revealed mixed air-fluid levels, wider than high and higher than wide. Due to the patient's surgical background, a flange occlusion was considered and a laparotomy was indicated. Pre-operative preparation involved an intravenous crystalloid infusion and the use of analgesics and antispasmodics. The preoperative check-up was normal. The median laparotomy performed, revealed a double volvulus of the small bowel and sigmoid with ileal and sigmoid necrosis. Detorsion revealed a type II ileo-sigmoid node (Fig. 3). We performed an ileal and sigmoid resection followed by a colorectal end-to-end anastomosis and an end ileostomy. He was given analgesics and antibiotics post-operatively. Feeding was resumed on day 1 post-operatively. The postoperative course was straightforward.Fig. 3 Intraoperative view of the ileo-sigmoid node with intestinal necrosis (yellow arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 3

2.3 Case 3

This patient was admitted approximately 5 months after the second patient. A 43-year-old patient with an unknown pathological background was admitted to emergency with an abrupt onset of abdominal pain that had been evolving for 4 days, followed by vomiting and then cessation of matter and gas. Clinical examination revealed hypovolaemic shock associated with an occlusive syndrome. She was reanimated pre-operatively with crystalloids, colloids, analgesics and antispasmodics. An abdominal X-ray taken after the patient's haemodynamic status had stabilised revealed multiple central air-fluid levels that were wider than higher. A diagnosis of small bowel obstruction was made and a surgical indication was given. A hyperleukocytosis with neutrophilia of 13,000/mm3 was found A median laparotomy revealed a double volvulus of the small bowel and sigmoid with ileal necrosis. The small bowel was identified as an active segment after detorsion. We therefore adopted the diagnosis of a type I ileo-sigmoid node (Fig. 4). We performed not only an ileal resection but also a sigmoid resection because of the strolling nature of the sigmoid colon. An end-to-end colorectal anastomosis and an end ileostomy were performed. After the operation, she received analgesics, antibiotics and an infusion of crystalloid. She resumed oral feeding at 4 days post-op. The postoperative course was straightforward.Fig. 4 Intraoperative view of the ileo-sigmoid node (yellow arrow) and ileal necrosis. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 4

3 Discussion

The ileo-sigmoid node is a rare entity causing mixed intestinal obstruction by strangulation of the ileum and sigmoid colon [[1], [2], [3]]. The first description, by Parker et al., dates back to 1845 [1,2,6]. The rarity of this condition makes it impossible to establish its true incidence [4,6]. Indeed, only isolated cases of ileo-sigmoid nodes have been described in the literature. The ileo-sigmoid node is mainly found in Africa and Asia [4,6,8]. However, it is a serious condition with rapid progression to intestinal necrosis [1,2,4]. In our study, all three patients presented with intestinal necrosis.

The ileo-sigmoid node is most common in young males in their 3rd and 4th decades [1,3,4,7]. Men have a high mesocolon, a narrow pelvis and more muscular muscles [3,7]. This configuration does not favour spontaneous devolvulation [3]. Although the aetiopathogenesis is poorly understood, several factors have been incriminated in the occurrence of this entity [[2], [3], [4]]. Anatomically, a very active ileum with a long mesentery associated with a short root is a predictive factor [1,3]. This facilitates rotation of the ileum around the foot of the sigmoid colon. A dietary factor is also incriminated. In patients who eat only one meal a day, rapid repletion of the jejunum predisposes it to torsion around the empty ileum, thus sweeping away the sigmoid loop [1,3].

Depending on the mechanism of formation, we distinguish 04 types of ileo-sigmoid nodes according to Alver et al. [1,3,4]. This classification takes into account the active digestive segment responsible for the torsion. In type I, the ileum is the active segment wrapping around the passive sigmoid [[1], [2], [3]]. Type II results from the sigmoid torsion which attracts the passive small intestine [[1], [2], [3]]. In the exceptional type III, it is the ileo-caecal junction that wraps around the sigmoid loop, while in type IV, it is not possible to determine the active segment [[1], [2], [3]]. Types I and II have subtypes A and B depending on whether the rotation is clockwise or anticlockwise [1].

The typical clinical picture of the ileo-sigmoid node combines early vomiting in favour of upper intestinal obstruction and early cessation of transit, sometimes with frank meteorism in favour of lower intestinal obstruction [1,3,7]. However, preoperative diagnosis of the ileo-sigmoid node is difficult [3,4,6,8]. It is established in only about 20 % of cases, the radio-clinical picture being most often atypical [1,3,9]. Abdominal CT scans can make a significant diagnostic contribution by demonstrating 02 types of air-fluid levels (in the small intestine and the large intestine) associated with a whirlpool sign, pathognomonic of a volvulus [3,7,10]. In our series, none of our patients underwent an abdominal CT scan due to its unavailability in the local area and the urgent nature of the management of their intestinal obstruction.

The ileo-sigmoid node is a medical and surgical emergency which must be managed without delay [1,2,7]. Surgical treatment, although not codified, should aim to remove the strangulation and re-establish an effective and adequate digestive transit [2,4,9,10]. The problem is to re-establish digestive continuity during the same operation or at a later date [1]. We opted for ileostomies to avoid the risk of anastomotic fistulas, which would make repeat surgery difficult. The ileo-sigmoid node is a serious pathological situation with a severe prognosis [1,3,6]. Morbidity is approximately 25 %, while mortality is around 12 % [3]. The prognostic factors for this condition are the time taken for admission and management, the patient's general condition and the existence of intestinal necrosis [1,3].

4 Conclusion

The ileo-sigmoid node is a rare condition with rapid aggravation. It is responsible for double intestinal obstruction by strangulation, with a risk of rapid progression to intestinal necrosis. Its aetiopathogenesis is poorly understood and its preoperative diagnosis is difficult because of the radio-clinical atypicality. The ileo-sigmoid node is associated with a significant morbidity and mortality rate, requiring rapid and appropriate management to preserve vital prognosis.

Consent for publication

Written informed consent was obtained from the patients to publish 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.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Ethical approval

Ethical approval for this study was provided by the ethics committees of the Dapaong Regional Hospital Center, Dapaong, Togo on 27 June 2022 (N° 00063-06-22).

Funding

The authors declare they have received no funding for the preparation of this document.

Author contribution

LKA and ETB carried out the study design and data acquisition; AF and AKL carried out the literature review; SAK, ETB and LKA wrote the manuscript; All authors participated in the revision of the manuscript.

All other authors contributed to the data collection. All authors read and approved the final manuscript.

Guarantor

Tamassi Bertrand ESSOBIYOU, M.D., General Surgery Department, Sylvanus Olympio University Hospital Center, TOGO.

Research registration number

N/A.

Conflict of interest statement

The authors have no financial, consultative, institutional, or other relationships that might lead to bias or conflict of interest.

Data availability

Data sharing does not apply to this article, as no datasets were generated or analyzed during the current study.

Acknowledgements

None.
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