Volvulus of the cecum

Volvulus of the LAZARUS ~IANOIL, From he Surgical Pboenis, Asia.

Department,

Memorial

M.D.,

Hospital,

Cecum

Phoenix,

Arizona

Incidence. VoIvuIus of the cecum is commonIy a disease of young aduIts, 50 per cent of Corner and Sargent’s’* patients being between the ages of twenty and forty years. Nevertheless the condition may occur at any age. The youngest case reported was in an infant ten months oId, and the oIdest in a man eighty-nine years of age. The case to be reported is that of a ninety year old white man. Jordan and Baehrs,lg whiIe reporting six cases of voIvuIus of the cecum as a postoperative compIication at Mayo CIinic between 1939 and 1952, reviewed abdominal operations for a tenyear period from 1939 to 1948. At the clinic 5 I ,000 abdomina1 operations were performed during that period, with onIy four of the six cases of voIvuIus of the cecum reported. At the Massachusetts Genera1 HospitaIzO over a period of fifty-seven years there were six cases (I. I 5 per cent) in 520 cases of acute intestina1 obstruction. In Touro Infirmary,21 New OrIeans, during a sixteen-year period the incidence was 1.4 per cent in cases of obstruction. In Boston City HospitaI, of 956 cases of intestina1 obstruction from 1934 to 1943 there was onIy one case (. I per cent). In spite of this low incidence it is important to review the subject because earIy diagnosis and treatment wiI1 Iower the high mortaIity. Symptomatology. Onset may be sIow and insidious with pain in the right Iower quadrant, tenderness and varying degrees of distention which may simuIate an attack of appendicitis. If onset is sudden with the patient suffering from vioIent abdominal pain, vomiting, constipation and abdomina1 distention, one may suspect signs of acute intestina1 obstruction. PascaIis** stated that he attended several persons with suspected appendicitis who were found at Iaparotomy to have a twisted right coIon. Preoperative diagnosis of voIvuIus of the right haIf of the colon has been made very infrequently in the past. The possibilities of roentgen examination as a means of making the diagnosis have been recognized. McGraw et. aI.” beIieve that from their experience it may be the most important single factor in

VOLVULUSof the cecum is a comparatively rare condition. However, it occurs now and then, as noted in the infrequent case reports in the Iiterature.l-g It warrants greater recognition, as the condition is associated with a very high mortality if treatment is deIayed too long. In cases of acute abdominal pain or intestina1 obstruction one shouId bear this condition in mind. The need for early diagnosis and immediate surgica1 treatment in the usual acute case is emphasized by ChaIfant’s’O figures of ninetysix patients operated upon, of whom 67 per cent died. Pratt and FaIIisll stated the mortaIity rate was about 50 per cent. In more recent reports by Dixon and Meyer,12 Seneque and Couade,13 and Gerwig,‘” advances in diagnostic and surgical technics have greatIy lowered the mortality rate of cecal volvuIus. Review of the literature would indicate that survival is most certain when boweI resection is avoided by earIy recognition and treatment of the condition before the bIood supply is seriously embarrassed. EtioZogAt. CecaI voIvuIus basically is the resuIt of a congenital defect or embryoIogic accident, as torsion of the right coIon depends on an abnorma1 degree of mobiIity of the cecum and ascending coIon. Any long mesentery which would allow the right colon to be displaced to the left side furnishes the potentia1 for a voIvuIus. In 125 norma adult cadavers studied consecutiveIy by WoIfer et. aI.15 it has been demonstrated that in I 1.2 per cent the cecum is mobile enough to aIIow the development of a voIvuIus. The inciting etioIogy may be mechanical or may be due to as yet incompletely understood physioIogic fauIts in the complex functioning of the right coIon. Instances of voIvuIus have occurred in pregnancy, labor and postpartum, and postoperatively. I6 Miller and CIaggett17 stated that other causes might be violent peristaIsis folIowing heavy purgation or overeating, abdomina1 tumors, mesenteric cysts, direct vioIence or habitua1 constipation. 264

VolvuIus

of Cecum

dctcrmining the condition. They savv three c’ascs of vnlvulus of the cccum during 1947 in \\.liiclr the diagnosis \v:rs 111:1tlc l)r”ol)~‘r:lti\.c‘l\’ with rocnlgcn studies. The symptomatoIogy may vary some~.hat depending on whether the voIvuIus is acute, subacute or a recurring type. In the acute type there is a compIete or nearly compIete obstruction of the lumen of the bowel due to its being twisted on itself, and there may be impairment of the blood supply to the invoIved Ioop. In the subacute type the twisting is not so great, the degree of obstruction is Iess and the symptoms are not so vioIent. The twist in the bowe1 may reIieve itseIf spontaneousIy 0nIy to recur at some later date. Treatment. The surgical procedure will vary somewhat depending upon the nature and condition of the bowel found at the time of surgery. In early cases in which the bowel is viabIe detorsion with or without cecostomy is advisable. Fixation of the bow-e1 wiI1 accompIish a permanent cure of the underlying hypermobiIity of the cecum in most cases if the condition of the patient or the decompressed bowels permits. Cecoplastic procedures wouId seem indicated in chronic or partial voIvuIus. Resection by exteriorization after the method of Mikulicz or iIeotransverse colon anastomosis is performed only when the bowel or its mesentery is no longer viable. The advisabiIity of performing a prophyIactic cecopexy when an ectopic cecum is encountered in the course of other surgery or on s-ray studies has been suggested. CASE

REPORT

F. G., a ninety year oId white man, was seen at his home late in the afternoon on August 8, 1953, because of acute pain in the abdomen. The patient was totaIIy blind foIlowing surgery for glaucoma thirteen years previousIy. He had otherwise been in fairly good heaIth up to the morning of the day first seen. Pain in the right lower quadrant had started about 10:30 A.M., increasing in severity, and late in the afternoon he had nausea but no vomiting. The abdomen was getting extremeIy painfu1 and distended and rigid on the right side, so much so that the patient requested something to relieve the pain. The patient stated that his bowels were reguIar every day and were of norma coIor and consistency, that he had no gastrointestina1 symptoms and his appetite had always been good. 26s

He had had no loss of weight in recent years and had no gcnitourinary svinI)toms. Considering his age :~iitl I~lintliicss II{. inaililgcd to gist about without tlilliculty. Ilc secmccl to bc I’airly alert, coopcrati\,e and responded to questions readily. Examination disclosed a swelling on the right side of the abdomen. There was a marked point of tenderness over McBurney’s point and rigidity of the right side with elevntion of a circumscribed mass. His temperature was 98.6”~., heart rate 76 and blood pressure I IO, 70. There was a reducible left indirect inguinal hernia, 3 by 4 cm. The patient had been aware of this for the past thirty years but it had not troubled him. The patient was a very sIender, IittIe man about go pounds in weight. The diagnosis when the patient was first seen was an acute surgica1 condition of the abdomen although the specific underlymg cause was not too certain. Acute appendrcltis with peritonitis was primariIy considered aIthough it seemed a bit far-fetched to have such a condition occur in a man at that age. Torsion of the omentum, acute perforation of iIeoceca1 malignancy, although no suggestive history could be ascertained of irregularity of the gastrointestinal tract, voIvuIus of the cecum and mesenteric thrombosis were aIso considered as possible diagnoses. The patient was admitted to the hospital. Laboratory examination revealed the following: red blood cells, 3,850,ooo; white blood cells, 9,800; hemogrobin 77 per cent, 12 gm. Urinalysis showed a trace of albumin, 30 to 40 white blood cells, 30 to 40 red blood ceIIs and no casts. A urinalysis repeated on August IO, 1953, showed a trace of albumin. The entire fieId was covered with white blood cells; there were no red bIood cells. Immediate surgery was decided upon instead of deIaying for further observation and study with x-rays. It seemed that if any relief of the acute condition could be given, especially in such an old man, it would have to be investigated as soon as possible before changes in the abdomina1 organs would be irreversible. Under Iight pentothaI@ gas-oxygen-ether anesthesia the abdomen was opened through a right pararectus incision in the paraumbilicai region. The peritoneum was tense, and when opened free bloody fluid was present. The cecum was sought in the right gutter but was found to lie freely toward the midline, acutely distended to about 8 by IO cm. and twisted on

VoIvuJus of Cecum its long mesentery cIockwise one and a half times along with the ascending colon. This \vas lollowed clrstally ant1 found to be free from attachment to the lateral wail up to the hepatic flexure. The latter was the point of normal attachment. The transverse colon appeared to be norma in size. The stomach was moderateIy distended but no evidence of tumors was present. The twist in the cecum and ascending coIon was relieved by rotating the coIon counterclockwise. The fluids and gases were gently expressed from the cecum toward the transverse coIon, coIIapsing the distended cecum which appeared viable although thinned out and acuteIy congested. The appendix was looked for at the end of the taenia coIi and about the junction of the iIeoceca1 valve but there seemed to be no trace of it. There was no indication or sign of its atrophic former existence. It must have been congenitaIIy absent aIong with the improper deveIopment of the right mesocoIon embryoIogicaIIy. The iIeum was then inspected and found to be normal. There was no evidence of a Meckel’s divertic&m. No attempt was made to fix the cecum to the IateraI waII because of its friabIe and thinned-out condition. Resection and repair by anastomosis or exteriorization did not seem indicated. Examination of the Iiver showed it to be norma in size and consistency, but the gaIIbIadder was found markedIy distended and fuI1 of smaI1 stones. This was removed without any diffrcuIty, a Penrose drain was inserted to Morrison’s pouch through a stab wound and the wound was closed in Iayers. The patient stood the operation weI1. Wangensteen suction was instituted and the patient was fed through the veins for two days, at which time he was allowed to get out of bed. He continued to do well and had a norma voluntary bowe1 movement on the fourth day. The skin clips were removed on the fifth day and the wound appeared cIean and we11 heaIed. He was discharged from the hospita1 on August 15, 1953, just one week after his admission and surgery. He was brought to the offrce the foIlowing week and has since been getting aIong uneventfuIIy and eating very weII.

uncertainty of a definite diagnosis did not deter early exploration as time secmcd of the csscncc. To Jmvc waitccl and studied the patient’s condition for a more specific diagnosis with or without supportive treatment would have been disastrous in view of the lindings encountered. Second, congenita1 absence of the appendix was an interesting observation which will be reported at a Iater date. Third, the decision to remove a coexisting diseased gaIIbIadder proved a satisfactory one in this case. It wiI1 certainIy remove the possibiIity of acute gaIIbIadder disease in this man of advanced age shouId he Iive for many more years. FinaIIy, his surprisingly quick recovery emphasized better than many words can describe the advisabiIity of immediate expIoration in a patient, regardless of age, with an acute surgica1 condition of the abdomen with findings of voIvuIus of the cecum. SUMMARY I. Reported herein is a case of voIvuIus of the cecum in a ninety year oId man treated by simpIe detorsion without Fixation, with good results. 2. VoIvuIus of the cecum shouId be considered in acute conditions of the abdomen, especiaIIy with pain in the right Iower side, IocaIized distention with or without nausea and vomiting. 3. EarIy expIoration in suspected cases of voIvuIus of the cecum is imperative if the mortaIity in this condition is to be Iowered. Roentgen studies may be very heIpfu1 in diagnosis if such studies can be made while the patient is prepared for surgery. 4. The precipitating cause of voIvuIus in this patient’s congenitally redundant mesentery, with absence of fixation to the Iateral abdominal waI1, is unknown. REFERENCES

R. H. VoIvuIus of the cecum. Brit. M. J., I : 83-86, 1947. SMITH, R. S. VoIvuIus of the cecum. Northwest Med., 51: 678-681, 1952. WELBORN, M. R. VolvuIus of the cecum. J. Indiana M. A., 44: 2630. 1951. YOUNG, E. L., MORRISON, H. R. and WILSON, W., JR. VoIvuIus of the cecum and ascending colon. New Engfand J. Med., 237: 78-86, 1947. 5. CRANE, A. P. DoubIe voIvuIus. Arch. Path., 49: CARDINER,

COMMENT

This case has been of special interest for severa reasons. First, an acute condition of the abdomen was encountered in a frai1 ninety year old man who had previousIy been weI1. The

356-359,

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6. BRADY, J. H. VoIvuIus of the cecum with left sided coIon. California ti West. Med., 64: 77-79, 1946. 266

voI\~uIus of Cecun1 7. GIBSON,Ii. 1I. and hluscRove, J. E. VolvuIus of the cccum. I’IYJ~. S/n[r AIce/., ,%,~(I,\YI C/in., 23: 260 264, IC)4X. X. GOWH~Y, N. A. Volvulus of the C’<~III~I\vith rcversed rotation of midgut. Bril. hf. J., yI 1, ,045. y. STILLMAN, I. Ii. Two cases of volvulus of the cacum. Bril. A4. J., 2: 253, 1948. IO. CHALFANT. S. A. Torsion of the cecum with review of the lkeraturc and report of a case. Am. J. Obst. 6’~Gpx, 2: 597-600, 1921. I I. PRATT, J. P. and FALUS, L. S. Volvulus of the cecum and ascending colon: report of 3 cases. J. A. M. A., 89: 1225-1230, 1927. 12. Drxo~, C. F. and l\lEYER, A. C. VoIvulus of the ;T4y. S. Clin. North Americu, 28: 953-963,

I j: 424, r940. 18. COKRER. l% 21. and SARGENT. i'. Ii'. G. vo~vu~us of the cecum. Ann. Surg., 41: 63, 1yo5. 10. JORDAN, G. 1.. nncl HAEIIKS, 0. II. Volvulus of the cccum as a postoperative complication. Ann. SUrC’., 137: 24$-Z@,, 1053. 20. S\VEE:T. K. 11. Vo~dus of the cecum; acute and chronic with report of 8 cases. New England J. Med., 213: 287-293, 1935. 21. BKOWM. D. C. and ~ICHAKDY. G. Acute and chronic crcal volvulus. Am. J. Digest. Dis., 9: 177-180, 1042. 22. PASCALIS, G.-i%-esse m&d., 37: I 578-1579, 1929. 27. MCGRAW. J. B.., KKEMEN. A J. and RIEGER. L. G. Roentgen diagnosis of’ VOIVUIUS of the &cum. Surgery, 24: 793-804. 1948.

13. SENEQUE, J. and COUADE, M. Quelques considkrations sur les voIvuIus aigus du catcum. J. de cbir., 64: 409-419, 1948. 14. GERWIC., W. Il., JR. VoIvulus of the colon. Arch. Surg., 60: 721-742, ‘95”. 15. WOLFER, J. A., BEATON, L. E. and ANSON, B. J. VolvuIus of the cecum, anatomical factors in its

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