Volvulus of the Sigmoid Colon without Necrosis: Therapeutic Aspects in Hospital Fousseyni Daou Hospital in Kayes, Mali ()
1. Introduction
Sigmoid volvulus is the torsion of the sigmoid loop on its mesocolic axis, resulting in a low colonic occlusion by strangulation [1].
Its incidence in the world is estimated at 2 persons per 100,000 inhabitants, volvulus represents 50% of intestinal obstructions in developing countries and 5% in the West [2].
In the United States of America it is the third most common cause of colonic obstruction after colonic cancer and diverticulosis [3]. This pathology is frequently observed in young adults in African and Indian series, in the West it occurs rather in the elderly [4] [5].
The main risk factor is anatomical due to the existence of a dolichosigmoid, other risk factors are cited such as pregnancy, pelvic tumor, surgery of the small pelvis, chronic constipation and a diet rich in fiber [6] [7].
Sigmoid volvulus is a medical-surgical emergency, the diagnosis is clinical and paraclinical especially on the unprepared abdomen radiograph (ASP).
The overall mortality can reach an average of 32.1% in case of necrosis [8] [9].
The choice of operative technique has always been a subject of controversy between practitioners: the ideal colectomy, untwisting and colostomy according to Hartman.
In Mali, according to a study carried out at the CHU Gabriel TOURE in 2011, the volvulus of the sigmoid without necrosis represented 19.04% of all intestinal obstructions, in our series it was 11.6%.
We carried out this work in order to evaluate our surgical methods in an emergency context, and the influence of comorbidities factors on the choice of surgical techniques.
2. Patients and Methods
This was a retrospective cross-sectional study conducted from January 2014 to December 2021 in the general surgery department at the Fousseyni Daou Hospital in Kayes.
Were included in this study all patients operated for sigmoid vovulus without necrosis, were not included patients operated for sigmoid volvulus with necrosis and other forms of volvulus.
Criteria of judgment: the diagnosis of occlusion by volvulus of the sigmoid without necrosis was evoked in front of the occlusive syndrome made of abdominal pain, vomiting, a stop of the contents and gases, an abdominal distension sometimes asymmetrical; confirmed by the presence of hydro-aeric levels higher than wide in double jamb on the radiography of the abdomen without preparation and the absence of necrosis confirmed per operatively (Figure 1).
The data were collected from the operative report register and the medical records, and collated on a survey form.
The data were processed using Epi info version 6 software; a survey authorization was requested and obtained from the administration of the hospital in Kayes.
This research was carried out according to the principles of the Helsinki statement (http://www.wma.net/fr/30publications/10policies/b3/).
3. Results
We collected the records of 31 patients operated for volvulus of the sigmoid colon without necrosis. There were 29 men and 2 women, i.e. a sex ratio of 14.5. The average age was 55 years with extremes (29 - 77 years). 45.2% (14/31) of the patients were from rural areas, 61.3% (19:31) were engaged in agro-pastoral activities. The average consultation time was 2.4 days. Comorbidities were present in 11 cases (35.5%) (see Table 1). Median laparotomy was the approach in all patients. The operative techniques were sigmoidectomy with immediate colorectal anastomosis in 19 cases (61.3%), untwisting with colopexy in 11 cases (35.5%), colostomy according to Hartman in 1 case (3.2%) (Cf Table 2).
In sigmoidectomy with immediately colorectal anastomosis (Cf Figure 1): the mean age was 46.16 years (Cf Table 2) with extremes of 29 - 60 years. The comorbidity factor was present in 1 case (5.2%) (see Table 3). The average duration of the operation was 3 hours and 09 minutes. The postoperative course (see Table 4) was simple in 12 cases (63.1%), morbidity was 6 cases (31.5%), four suppurations (4/6), two anastomotic fistulas (2/6); mortality was 1 case (5%), it was related to the complication of an anastomotic fistula; the average length of hospitalization was 9.6 days with extremes of 7 - 38 days.
In untwisting with colopexy: the average age was 65.91 years with extremes of 61 - 78 years (see Table 2) the comorbidity factor was present in 9 cases (9/11) (see Table 3), the average duration of the operation was 1 hour and 19 minutes, the postoperative course was simple in 9 cases (9/11) (see Table 4); the morbidity was 1 case of revolvulus (1/11); the mortality was 1 case (1/11) following a hypoglycemic coma in a diabetic patient; the average length of hospitalization was 7.2 days with extremes of 6 - 13 days.
HTA: high blood pressure. BPCO: chronic obstructive pulmonary disease.
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Table 3. Surgical techniques, age and comorbidity factors.
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Table 4. Operative follow-up according to surgical technical.
In Hartman’s colostomy: the age was 63 years (Cf Table 2), the comorbidity factor was a non obstructive sigmoid tumor (Cf Table 3), the duration of the operation was 2 hours 36 minutes, the hospital stay was 17 days, the morbi-mortality was null (Cf Table 4).
From a general point of view, the postoperative course was simple in 22 cases (71%), the overall morbidity was 7 cases (22.6%) and the mortality 2 cases (6.4%).
4. Discussion
Our study was carried out at the second referral hospital of Kayes, it focused on sigmoid volvulus without necrosis which is a medical-surgical emergency whose management is a subject of controversy among practitioners.
It took place over a period of 7 years (2014-2021), thirty-one patients (29 men, 8 women). The mean age was 55 years with extremes (29 - 77 years), this result is comparable to those reported by other African authors [10] [11] [12]. This age is lower than in European and Asian series [5] [13] in which advanced age is a comorbidity factor and the mortality rate is higher if associated with other chronic diseases [14]. The male sex was the most predominant in our study 93.5%; this male predominance has been found by other authors [13] [15] [16], only in an Australian study the female sex was predominant [17] the women would be relatively protected thanks to the anatomy of their pelvis [13].
Three surgical techniques were used in our study:
Sigmoidectomy with immediately colorectal anastomosis was performed in 61.3% of cases and the mean age was 46.16 years with extremes of 29 - 60 years, our criterion of choice for this technique was the absence of major comorbidity factors. The choice of this technique was previously a subject of controversy among practitioners for several reasons: the colonic preparation, the various studies have removed any equivocation on this subject, Raventhiran et al. [18] in his study he confirmed that colonic anastomosis can be done per operatively without colonic preparation, the colonic preparation prolongs the operative time by 30 - 60 minutes [19].
The surgeon’s experience in performing this technique is important because of the difference in length between the colonic and rectal portions.
Sigmoidectomy with immediate colorectal anastomosis has been performed by several authors with rates varying between 38.23% and 100% [4] [16] [20] [21] The morbidity related to this technique in our series was 6 cases (6/19), 4 parietal suppurations (4/6), 2 anastomotic fistulas (2/6) Kuzut et al. [22] found 7% of anastomotic fistula, and 14% of parietal suppuration. The mortality associated with sigmoidectomy with colorectal anastomosis was 5%. Kuzut et al. [22] found 11%.
Untwisting of the sigmoid colon with colopexy: during our study we performed this surgical technique in 35% (11/31) and the average age of the patients was 65.91 years, the presence of comorbidity factor was 82% (9/11) which was our criterion of choice for this technique.
The patients were operated on by laparotomy, unlike in the West where it is done by laparoscopy, and the success rate is 70% to 90% [8] [23]. The rate of 35% found in our study is close to those found in the literature, 33.61% [9] [24]. The advantage of this technique is the reduction in the duration of the operation, which is the shortest compared to other techniques. In our series the average duration was 1 hour 19 minutes, Diarra et al. found 50 minutes [25]. The disadvantages of this technique are: persistence of abdominal meteorism, intermittent constipated, refusal of a second operation and recurrence. In our study the recurrence rate was 9% (1/11), Grossman et al. [3] in the United States found 23%, Khanna et al. [2] found 38.4% recurrence.
Hartman colostomy: we performed this technique in 3.2% (1/31), the patient’s age was 63 years, the comorbidity factor that motivated the use of this technique was the presence of a non-obstructive tumor on the sigmoid. The use of this technique in the literature varies from 0% to 3% [9] [21] [24]. We did not perform a colostomy according to Bouilly Volkman, contrary to Touré et al. in Senegal [4] who performed it in 61.76% of cases. At the end of our study the overall morbidity was 22.6%. In the literature it is 7% - 17% [16] [24] [26]. The overall mortality was 6.4%. This rate varies according to the authors between 3% and 20% [4] [16] [24].
Limitations of this study were unworkable records; the sample size was insufficient to use some statistical data.
5. Conclusion
The volvulus of the sigmoid without necrosis is a medical-surgical emergency, the choice of the operative technique can be influenced by the factors of comorbidity and the morbimortality depends on it.