IntroductionThe management of sigmoid volvulus has remained a controversial issue to many surgeons. Rapid resection with colostomy fashioning has been done over time for gangrenous sigmoid volvulus. However, resection andprimary anastomosis has also been described with less complications and a shorter hospital stay.MethodsWe conducted a prospective study to determine the outcome of resection and primary anastomosis of sigmoid volvulus in Kisii Level 5 HospitalResultsThe causes of mechanical obstruction: sigmoid volvulus 30%, hernia 17.8%, adhesions 16.7%, faecal impaction 16.7%. Seventy five (75%) of the sigmoid volvulus was gangrenous and 85.2% of all the sigmoid  volvulus was managed by resection and primary anastomosis. Complications seen after resection and primary anastomosis were anastomotic leak at 4.5%, resection and colostomy fashioning wound dehiscence (33.3%) and mortality (33.3%). The average hospital stay was12.9 days after primary resection and anastomosis.ConclusionResection and primary anastomosis in gangrenous sigmoid volvulus can be practised with few complications and a short hospital stay. Surgeons in resource limited facilities can practice resection and primary anastomosis in the management of gangrenous sigmoid volvulus with good outcomes

Odhiambo, K

Riogi, B

English

AJOL - African Journals Online

The ANNALS of AFRICAN SURGERY. January 2013 Volume 10 Issue 136The ANNALS of AFRICAN SURGERY | www.sskenya.orgThe ANNALS of AFRICAN SURGERY. January 2013 Volume 10 Issue 1 37Safe Resection and Primary Anastomosis of Gangrenous Sigmoid VolvulusRiogi B. MBChB,  Odhiambo K. MBChB, MMed, Kisii Level 5 Hospital, Kisii, Kenya. Correspondence to: Dr Bahaty Riogi, P.O Box 13449-00100 Nairobi, Kenya, Email: bahaty86@gmail.com AbstractIntroductionThe management of sigmoid volvulus has remained a controversial issue to many surgeons. Rapid resection with colostomy fashioning has been done over time for gangrenous sigmoid volvulus. However, resection and primary anastomosis has also been described with less complications and a shorter hospital stay.MethodsWe conducted a prospective study to determine the outcome of resection and primary anastomosis of sigmoid volvulus in Kisii Level 5 HospitalResultsThe causes of mechanical obstruction: sigmoid volvulus 30%, hernia 17.8%, adhesions 16.7%, faecal impaction 16.7%. Seventy five (75%) of the sigmoid volvulus was gangrenous and 85.2% of all the sigmoid volvulus was managed by resection and primary anastomosis. Complications seen after resection and primary anastomosis were anastomotic leak at 4.5%, resection and colostomy fashioning wound dehiscence (33.3%) and mortality (33.3%). The average hospital stay was 12.9 days after primary resection and anastomosis.ConclusionResection and primary anastomosis in gangrenous sigmoid volvulus can be practised with few complications and a short hospital stay.Surgeons in resource limited facilities can practice resection and primary anastomosis in the management of gangrenous sigmoid volvulus with good outcomes. IntroductionSigmoid volvulus has been described over time and its management continues to evolve (1). Resection and colostomy has been used in gangrenous sigmoid colon with resection and primary anastomosis being done on viable gut (2). However, resection and primary anastomosis has also been described in gangrenous gut with few complications (3).  This study focuses on the management of sigmoid volvulus in a resource limited facility in Kenya by resection and primary anastomosis and its outcomes in terms of hospital stay and complications.Material and MethodsThis prospective study included all patients admitted to the surgical ward with clinical and radiological features of intestinal obstruction in the twelve month period between 1st July 2009 and 30th June 2010. Patients who succumbed before surgical review and confirmation of the diagnosis were excluded.  The patients were managed using intravenous fluids, ‘nil per oral’ and a nasogastric tube for gastric decompression. The patients were scheduled for emergency laparotomy within six hours of admission and those with intra-operative diagnosis of sigmoid volvulus were followed up post-operatively. The surgeries were performed by a surgeon or a medical officer in surgical department under supervision.Kisii level 5 Hospital is a government facility in Kisii County in the rural parts western Kenya. It serves as a referral facility and an apex of emergency surgical care for South Nyanza and parts of Rift Valley Province.Resection and colostomy fashioning was done on very sick patients and colon with heavy faecal loading. Resection and primary anastomosis was performed on patients who were stable. Anastomosis was done in two layers using absorbable sutures.A case of intestinal obstruction was considered as failure to pass stool with associated abdominal pain, distention and vomiting. A plain radiograph was taken to confirm the diagnosis. Burst abdomen was defined as omentum or viscera seen through the wound. Anastomotic leak was defined as the presence of faecal fistula or anastomotic breakdown at laparotomy following peritonitis. Wound infection was defined as pus draining spontaneously or requiring drainage. Duration of hospital stay was determined by the length of hospital stay from the day of admission till the day the patient was discharged from the surgical department. Mortality was defined as death occurring within the hospital during the admission.Data was entered into Microsoft excel and analysed and results presented in charts, graphs and tables for discussion.ORIGINAL ARTICLE ses of mechanical obstruction were sigmoid volvulus and col stomy fashioning was perfo med on very ick patie ts and colon withheavy faecal loading. Resection and pri aryanastomosis was perform d on patients who werestable. Anastomo is was do e in two layers The ANNALS of AFRICAN SURGERY | www.sskenya.orgThe ANNALS of AFRICAN SURGERY. January 2013 Volume 10 Issue 1 37The ANNALS of AFRICAN SURGERY. January 2013 Volume 10 Issue 138ResultsNinety patients (90) were diagnosed to have intestinal obstruction and were eligible for the study.The causes of intestinal obstruction are shown in the table below (Table 1)Table 1 – causes of intestinal obstructionCAUSE NUMBER PERCENTAGE %Sigmoid volvulus 27 30Hernia 16 17.8Adhesions 15 16.7Faecal impaction 15 16.7Intussusception 6 6.7Ileal volvulus 5 5.7Helminths 4 4.4Colonic mass 2 2.2The sex distribution for intestinal obstruction was females 18 (20%) and 72 (80%) males whereas for sigmoid volvulus 26 males (96.3%) and 1 female (3.7%)The age, monthly distributions and surgical procedures are shown in the table below;Table 2- age, monthly distribution and surgical outcome of sigmoid volvulusCHARACTERISTICAge(yr),Month,Surgical procedureFREQUENCY<10 yrs 110-20 021-30 931-40 241-50 551-60 3>60 5January 0February 0March 1April 2May 3June 2July 4August 7September 4October 3November 0December 0Resection and primary anastomosis23Resection and colostomy 3De-rotation and sigmoidopexy120 cases (74.1%) of sigmoid volvulus were reported as gangrenous and 7 cases (25.9%) were viable intra-operatively.11 cases of sigmoid volvulus were compound in nature and 16 were simple.There was 1 anastomotic leak following resection and primary anastomosis, 1 burst abdomen and 1 mortality following resection and colostomy fashioning.The average hospital stay was 12.9days following resection and primary anastomosis and 14.5 days after resection and colostomy fashioning.DiscussionSigmoid volvulus is the commonest cause of mechanical intestinal obstruction in Kisii Level 5 Hospital at 30%. This is similar to Eritrea where sigmoid volvulus accounted for 37.6% of all acute intestinal obstruction and 20-54% in high incidence areas (4, 5). Sigmoid volvulus has a male predominance as seen in studies in Africa and the developed countries (6, 7). The low incidence in women is thought to be due to the capacious pelvis and the lax abdominal wall that allows spontaneous untwisting of the sigmoid colon (8). Majority of patients were admitted between July and September with a peak in August which is the harvest season in Kisii region. Its postulated that sigmoid volvulus is common during post harvest season, post war season and after Ramadan fasting as people relish large meals and this leads to bulky stool and thus twisting of the sigmoid colon (9,10).  Sigmoid volvulus in Kisii Level 5 Hospital is found in the young age group of 21-30 with an average of 25.7 years. This is not common in other studies which show an average of 52 years in high endemic areas 7  and  67 years  in the United States by Wuepper et al (11).  Majority of the sigmoid volvulus cases were gangrenous at 75%, this is not consistent with reports from Eritrea (11%) and Tanzania (57%)(4,12). The high rates of gangrenous gut could be due to patients presenting late after being managed in peripheral health facilities such as sub-district hospitals before being referred for surgical intervention. The complication following resection and primary anastomosis is low at 4.3% for anastomotic leak, while resection and colostomy fashioning had mortality at 33% and burst abdomen at 33%.  Table 1..Table 2- age, monthly distribution and surgical outcome of sigmoid volvulusCHARACTERISTICAge(yr),Month,FREQUENCY<10 yrs 110-20 02 -30 931-40 241-50 551-60 3>60 5January 0Febr 0March 1April 2May 3June 2July 4August 7September 4Octob r 3November 0December 0Surgical p ocedureResection and primary anastomosis23Resection and colostomy 3De-rotation and sigmoidopexy1 as one anastomotic leak fo lo ing  pri ary anastomosis, one burst abdo en one mortality following resection and e e ic areas (7) and 67 years in the United States (11).The ANNALS of AFRICAN SURGERY. January 2013 Volume 10 Issue 138The ANNALS of AFRICAN SURGERY | www.sskenya.orgThe ANNALS of AFRICAN SURGERY. January 2013 Volume 10 Issue 1 39However the figures are not comparable due to the few patients who underwent resection and colostomy fashioning. The high rates of complications after resection and colostomy fashioning are not fully due to the procedure but may be attributed to by the poor condition of the patients pre-operatively. The average hospital stay after resection and primary anastomosis is 12.9 days and 14.5 days after resection and colostomy. The duration is longer in the latter as the second stage of colostomy refashioning has not been accounted for. Emergency resection and primary anastomosis in gangrenous sigmoid volvulus has been performed with safety without on table lavage, however, mortality of 15-25% have been reported in some centres (13, 14, 15, 16, 17). In this study, a lower mortality following resection and primary anastomosis of gangrenous sigmoid volvulus is reported.ConclusionSigmoid volvulus is the commonest cause of mechanical intestinal obstruction in Kisii Level 5 Hospital. It occurs in the younger age group with the majority having gangrenous loop. Resection and primary anastomosis in gangrenous sigmoid volvulus can be practised with few complications and a short hospital stay. Surgeons in resource limited facilities can practice resection and primary anastomosis in the management of gangrenous sigmoid volvulus with good outcomes.References1. Ballantyne GH, Brandner MD, Beart RW, Ilstrup DM.vovulus of the colon. Incidence and mortality. Ann Surg 1985;202:83-92.2. Taha SE, Suleman SI. Volvulus of the sigmoid colon in Gezira Br J Surg. Br J Surg 1980; 67: 433-5.3. Madiba TE, Thomson SR. Rreview article, management of sigmoid volvulus J.R Coll. Surg.Edinb. 2000; 45: 74-80.  4. Habteab M, Management of sigmoid volvulus in Eritrea, 2002   www.unige.ch.5. Lal SK, Morgenstern R, Vinjirayer EP, Matin A. Sigmoid volvulus an update. Gastrointest Endosc Clin N Am 2006 16: 175–87.6. Sule  AZ. One stage procedure in the management of acute sigmoid volvulus. J.R Coll. Surg Edinb 44 june 1994,164-6.7. Raveenthiran V. Volvulus of the sigmoid colon. Ass. Colproct. G. Br and Ireland. march 2010.   8. Bruusgaard C. Volvulus of the sigmoid colon and its treatment. Surg. 1947; 22: 466–78. 9. Saidi F. The high incidence of intestinal volvulus in Iran. Gut 1969; 10: 838–41.10. De U. Sigmoid volvulus in rural Bengal. Trop Doct 2002; 32: 80–2.11. Wuepper KD, Otteman MG, Stahlgren LH. An appraisal of the operative and nonoperative treatment of sigmoid volvulus. Surg Gynecol Obstet. 1966 Jan;122(1):84–88.12. Keller A and Aeberhard P. Emergency resection and primary anastomosis for sigmoid volvulus in an African population. J Colorectal Dis. 1990;5:(4)209-212.13. Iqbal T, Zarin M, Iqbal A, Tahir F, Iqbal J, Wazir M.A. Results of primary closure in the management of gangrenous and viable sigmoid volvulus. Pak J Surg 2007; 23: 118–21.14. Raveenthiran V. Restorative resection of unprepared left colon in gangrenous versus viable sigmoid volvulus. Int J Colorectal Dis 2004; 19: 258–63.15. Nizamuddin S, Qureshi S, Ghazanfar S. Six-year experience of sigmoid volvulus. Pak J Surg 2008; 24: 5–8.16. Coban S, Yilmaz M, Terzi A, Yildiz F, Ozgor D, Ara C, Yologlu S, Kirimlioglu V. Resection and primary anastomosis with or without modified blow-hole colostomy for sigmoid volvulus. World J Gastroenterol 2008; 14: 5590–4.17. Dulger M, Cunturk NZ, Utkan NZ, Gonullu NN. Management of sigmoid volvulus. Hep Gastroenterol 2000; 47: 1280-3.     , ). In this study, a lower mortality following resection and primaryanastomosis f gangrenous sigmoid volvulus ireported.. ll  G , Brandner MD, Beart RW, et al . Vo-vulus of the colon. Incidence and mortality. Ann Surg 1985;202:83-92..  . l l s of the sigmoid colon i  i   J .  J  ; : .. i  TE, Thomson SR. review article, man-agement of sigmo d v lvulus J.R Coll. Surg Edinb. 2000; 45: 74-80..  ,  f sig oid volvulus in ritrea,  w .unige.ch.. l SK, Morgenstern R, Vinjirayer EP, et al. Sigmoid volvulus an update Gastrointest Endosc Clin N Am 2006 16: 175–87.. l  AZ. One stage procedure in the man gement of acute sigmoid volvulus. J.R Coll. Surg Edinb 44 june 1994,164-6.7. Raveenthiran V. Volvulus of the sig oid colon. Ass. Colproct. G. Br and Ireland. march 2010.8. Bruusgaard C. Volvulus of the sigmoid colon and its treatment. Surg. 1947; 22: 466–78.9. Saidi F. The high incidence of intestinal volvulus in Iran. Gut 1969; 10: 838–41.10. De U. Sigmoid volvulus in rural Bengal. Trop Doct 2002; 32: 80–2.11. Wuepper KD, Otteman MG, Stahlgren LH. An ap-praisal of the operative and nonoperative treat-ment of sigmoid volvulus. Surg Gynecol Obstet. 1966; 122(1):84–88.12. Keller A and Aeberhard P. Emergency resection and primary anastomosis for s gmoid volvulus in an Af-rican population. J Colorectal Dis. 1990;5:(4)209-212.13. Iqbal T, Zarin M, Iqbal A, et al. Results of pri ary closure in the management of gangrenous and vi-able sigmoid volvulus. Pak J Surg 2007; 23: 118–21.14. Raveenthiran V. Restorative resection of unpre-pared left colon in gangrenous versus viable sig-moid volvulus. Int J Colorectal Dis 2004; 19: 258–63.15. Nizamuddin S, Qureshi S, Ghazanfar S. Six-year ex-perience of sigmoid volvulus. Pak J Surg 2008; 24: 5–8.16. Coban S, Yilmaz M, Terzi A, Yildiz F, Ozgor D, Ara C, Yologlu S, Kirimlioglu V. Resection and primary anastomosis with or without modified blowhole colostomy for sigmoid volvulus. World J Gastroenterol 2008; 14: 5590–4.17. Dulger M, Cunturk NZ, Utkan NZ,  et al. Management of igmoid volvulus. Hep Gastroenterol 2000; 47: 1280-3.

Safe Resection and Primary Anastomosis of Gangrenous Sigmoid Volvulus

https://www.ajol.info/index.php/aas/article/download/91361/80857

Safe Resection and Primary Anastomosis of Gangrenous Sigmoid Volvulus

Abstract

Similar works

Full text

Available Versions

AJOL - African Journals Online