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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)01076-9
10.1016/j.ijscr.2024.110295
110295
Letter to the Editor
Letter to the Editor RE: “Gangrenous transverse colon volvulus in a male patient who underwent Hartmann's procedure. A rare case report”
Callender Karla callenderkarla@gmail.com

Department of Surgery, Queen Elizabeth Hospital, Martindale's Road, Bridgetown, St. Michael, Barbados
14 9 2024
10 2024
14 9 2024
123 1102957 9 2024
12 9 2024
© 2024 The Author
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/).
Highlights

• Sigmoid volvulus is the most common type of colonic volvulus and early recognition and intervention is essential.

• Endoscopic detorsion is the initial step once bowel ischemia and perforation are absent clinically or radiologically.

• Sigmoid colectomy is definitive management to reduce recurrence.

• Metachronous transverse colon volvulus is a rare occurrence that can follow surgical operations for sigmoid volvulus.

Keywords

Sigmoid volvulus
Evidence-based guidelines
Endoscopic detorsion
Sigmoid colectomy
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pmcDear Editor,

In the case report “Gangrenous transverse colon volvulus in a male patient who underwent Hartmann's procedure. A rare case report” by Kebede et al., the authors report a case of a male patient presenting with metachronous transverse colonic volvulus [1]. He underwent a Hartmann's procedure and subsequent reversal for gangrenous sigmoid volvulus six years ago. The patient presented in extremis, had transverse colon resection with spectacle colostomy but succumbed to his illness post-operatively [1]. Transverse colonic volvulus is rare, accounting for 1–4 % of cases [2]. The main aim of the article is to highlight the importance of early clinical recognition and operative management [1]. After reading this case report, I thought it only necessary to write a letter on the management of the more common sigmoid volvulus.

The sigmoid colon is involved in 60–75 % of cases of volvulus [2]. The Latin word volvere, ‘to roll or twist’, gives rise to the term. The colon twists around its mesentery resulting in a closed loop obstruction. When increasing intraluminal pressure compromises the blood supply, necrosis ensues leading to gangrene and subsequent perforation [2]. This is why management of volvulus is so crucial because a delay can increase morbidity and mortality. What are the various management strategies and when is each indicated?

As per the evidence-based World Society of Emergency Surgery (WSES) consensus guidelines, it is recommended that complete clinical evaluation and laboratory investigations be done to look for bowel ischemia [2]. This includes arterial blood gas and lactate level. Any features suggestive of bowel ischemia or perforation indicates emergency surgery. Once bowel ischemia and perforation are not identified clinically or radiologically, the first step is endoscopic detorsion with flexible preferred to rigid sigmoidoscopy due to higher diagnostic accuracy and lower perforation rate. To say that endoscopic detorsion is successful, the endoscopist must go past two transition points and after detorsion must visualise the mucosa to assess viability. A flatus tube is usually left in situ to facilitate continued decompression. Once nonviable mucosa is identified after endoscopic detorsion, emergent sigmoid colectomy is warranted. Recurrence after successful detorsion is common (43–75 % of cases) and even when the mucosa is viable, prophylactic sigmoid colectomy is still recommended either in the same admission or soon after discharge. All in all, sigmoid colectomy is indicated in four scenarios:1. Clinical or radiological evidence of bowel ischemia or perforation (emergent)

2. Unsuccessful endoscopic detorsion (urgent)

3. Non-viable mucosa after successful endoscopic detorsion (emergent)

4. Viable mucosa after successful endoscopic detorsion (elective) [2].

Emergent surgical options include Hartmann's procedure and sigmoid resection with diverted or nondiverted colorectal anastomosis [2]. Decision on technique should be based upon individual patient characteristics. There is insufficient data supporting one over the other. There is a role for emergent laparoscopic sigmoidectomy in sigmoid volvulus as well. Two things are important intraoperatively:1. Resect ischemic or infarcted bowel without untwisting as this triggers release of toxins and increases risk of perforation.

2. If concomitant megacolon is encountered, isolated sigmoid colectomy is not enough and a subtotal colectomy is warranted.

Another surgical technique is percutaneous endoscopic colostomy (PEC). Though it is inferior to sigmoid colectomy for decreasing recurrence, it is recommended for patients unfit for major abdominal surgery, for example, the elderly. The sigmoid colon is fixed to the anterior abdominal wall via a PEC tube to reduce chances of bowel retwisting [2].

In the article “To Resect or Not to Resect: A Nationwide Comparison of Management of Sigmoid Volvulus,” Rafaqat et al. conducted a retrospective cohort database study to compare recurrence risk between patients who underwent endoscopic detorsion alone versus detorsion with prophylactic sigmoid colectomy [3]. The primary outcome was readmission for colonic volvulus and they concluded that detorsion with prophylactic sigmoid colectomy had a lower readmission rate compared with endoscopic detorsion alone. On the flip side, there was an associated higher complication rate, longer hospital stays and costs. The authors owed the recurrence of colonic volvulus after prophylactic colectomy to elongation and dilatation of the remnant colon or inadequate sigmoid resection during the operation [3]. Recall the 50-year-old male patient in the case report who underwent rectosigmoid resection but presented six years after with large bowel obstruction due to volvulus of the transverse colon [1]. Metachronous transverse colonic volvulus is a rare entity with limited literature on it, but a high index of suspicion must be maintained.

Below, is a simplified illustration of the evidence-based consensus guidelines reported by WSES. (See Diagram 1) It is worth noting that these guidelines are recommendations based on available evidence and should not dictate a surgeon's judgement [2]. Factors like institution resources, patient characteristics, skill and expertise may alter a surgeon's plan of action [2].Diagram 1 Simplified illustration of the WSES guidelines on management of sigmoid volvulus.

Diagram 1

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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References

1 Kebede Molla Asnake Gossaye Bizuayehu Tassew Tekle Alemayehu Beharu Gebre Tariku Gero Mesfine Yohanes Yoseph Abebe Tesfahun Mengistu Gangrenous transverse colon volvulus in a male patient who underwent Hartman procedure. A rare case report Int. J. Surg. Case Rep. 123 2024 110205 ISSN 2210-2612 10.1016/j.ijscr.2024.110205 https://www.sciencedirect.com/science/article/pii/S2210261224009866 39181034
2 Tian B.W.C.A. Vigutto G. Tan E. WSES consensus guidelines on sigmoid volvulus management World J. Emerg. Surg. 18 2023 34 10.1186/s13017-023-00502-x 37189134
3 Rafaqat Wardah Lagazzi Emanuele McChesney Shannon Smith Michael C. UrRahman Mujeeb Lee Hanjoo DeWane Michael P. Khan Aimal To resect or not to resect: a nationwide comparison of management of sigmoid volvulus J. Surg. Res. 297 2024 101 108 ISSN 0022-4804, 10.1016/j.jss.2023.12.054 https://www.sciencedirect.com/science/article/pii/S002248042400043X 38484451
