Treatment of Sigmoid Volvulus with Colonic Ischemia, Perforation, Peritonitis, or Septic Shock on Admission
Clinical Scenario
In 5–25% of patients presenting with sigmoid volvulus, admission findings include colonic ischemia, bowel perforation, peritonitis, or septic shock. This subset cannot be managed conservatively or with endoscopic decompression — it demands immediate operative intervention.
Upfront urgent surgery is required.
When sigmoid volvulus is complicated by ischemia, perforation, peritonitis, or septic shock, an urgent upfront operation is the mandated course of action.
Surgical Approach — Overview
Management is centred on urgent colectomy with resection of infarcted bowel, carried out with specific intraoperative technique designed to limit systemic contamination. The decision between single-stage and staged reconstruction hinges on the patient's overall condition and intraoperative findings — the complete decision algorithm and operative criteria are detailed in the full protocol.
References
DOI: 10.1186/s13017-023-00502-x
- In 5–25% of patients with sigmoid volvulus, they will present with colonic ischemia, perforation, peritonitis or septic shock on admission.
- These patients require upfront urgent colectomy.
- If the patient presents with septic shock or bowel ischemia or perforation, an urgent upfront surgery is warranted.
- Intraoperatively, resection of infarcted bowel should be performed without detorsion and with minimal manipulation to prevent release of endotoxin, potassium and bacteria into the general circulation and to avoid perforation of the colon.
- Performing a single-step resection and anastomosis or a Hartmann's procedure should be based on the patient's overall clinical condition and intraoperative findings, e.g., presence of abdominal fecal contamination.
- Despite the evidence, end colostomy creation is often the most appropriate choice for hemodynamically unstable patients or when there are significant concomitant factors, such as increased ASA or Acute Physiology and Chronic Health Evaluation II score, coagulopathy, acidosis or hypothermia, all of which add prohibitive risk to the integrity of a colorectal anastomosis.
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