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A novel interventional approach to sigmoid volvulus
European Journal of Radiology Extra 67 (2008) e83–e86
A novel interventional approach to sigmoid volvulus Alexandros N. Karavas a,c,1 , David L. Lee b,2 , Jeffrey B. Mendel b,2 , Alan W. Hackford a,∗ a Department of Surgery, St. Elizabeth’s Medical Center and Tufts University School of Medicine, Boston, MA, USA Department of Radiology, St. Elizabeth’s Medical Center and Tufts University School of Medicine,736 Cambridge Street, CMP 4R, Boston, MA 02135, USA c Department of Thoracic Surgery, Vanderbilt University Medical Center, 2971 The Vanderbilt Clinic, 1301 Medical Center Drive, Nashville, TN 37232 5734, USA b
Received 10 March 2008; accepted 6 May 2008
Abstract We report a case of a 96-year-old gentleman who presented with recurrent sigmoid volvulus and was deemed inoperable by either operative or endoscopic means due to his prohibitively high cardiac risk. The volvulus was managed with a computed tomography (CT)-guided sigmoidopexy using two gastrostomy tubes to affix the sigmoid colon to the abdominal wall by means of T-fasteners. The procedure was tolerated well by the patient. © 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Interventional radiology; Computed tomography; Sigmoid volvulus; Elderly
1. Introduction Sigmoid volvulus is a common cause of bowel obstruction and is the third most common cause of large bowel obstruction in the western world [1]. It usually affects institutionalized and elderly patients, who frequently have other comorbidities. Acute volvulus can be initially managed non-operatively in the majority of patients [2,3]. On the other hand, chronic volvulus represents a condition where episodes of acute sigmoid volvulus occur and are managed conservatively in a repeated fashion. A recurrence rate of up to 90% for non-operative management has been reported [1,4–6]. The high recurrence rate, along with the morbidity and mortality following emergent surgical intervention, have lead to the current recommendation of elective repair after successful non-operative management, as the patient’s condition allows.
∗ Corresponding author at: Division of Colorectal Surgery, St. Elizabeth’s Medical Center, 736 Cambridge Street, Boston, MA 02135, USA. Tel.: +1 617 789 2442; fax: +1 617 789 4207. E-mail addresses: [email protected] (A.N. Karavas), [email protected] (D.L. Lee), [email protected] (J.B. Mendel), [email protected] (A.W. Hackford). 1 Tel.: +1 615 818 5725; fax: +1 866 861 2830. 2 Tel.: +1 617 789 2740; fax: +1 617 779 6343.
1571-4675/$ – see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2008.05.002
This report presents a patient with recurrent sigmoid volvulus, who had been deemed a prohibitive risk for surgical or endoscopic intervention and underwent computed tomographyguided sigmoidopexy. This is the first, to our knowledge, interventional sigmoidopexy without the use of endoscopic guidance. 2. Patient A 96-year-old gentleman presented to the emergency department with a 2-day history of increasing abdominal distention and pain. A large bowel obstruction secondary to sigmoid volvulus was diagnosed based on an abdominal radiograph as well as computed tomography of the abdomen and pelvis (Fig. 1). Endoscopic decompression was performed in the emergency department and a silicone tube was left in the sigmoid colon to assist with further decompression. The patient had significant comorbidities including a remote right colectomy, known severe aortic stenosis with a moderately depressed left ventricular ejection fraction, and a history of a cerebrovascular accident. The surgical risk was substantial. A definite surgical intervention was deferred. The patient required two additional admissions within a period of less than 6 weeks for recurrence necessitating endoscopic decompression. Upon cardiologic evaluation, he was felt to be of prohibitive risk
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A.N. Karavas et al. / European Journal of Radiology Extra 67 (2008) e83–e86
Fig. 1. Computed tomography at initial presentation. The classic coffeebean sign (left) and the whirl sign (right).
for anesthesia. Definitive surgical or endoscopic interventions requiring, at a minimum, sedation were, therefore, not further considered. A percutaneous approach was elected. The procedure was performed under local anesthesia in the CT and interventional radiology suites after colonic preparation with cathartics. The goal was to provide sufficient fixation of the sigmoid colon to avoid recurrent volvulus. This was accomplished by fixing the loop of sigmoid colon at two sites, one site at the descending portion and one site at the ascending portion of this loop. Fixation was accomplished by percutaneously placing self-retaining gastrostomy tubes into the sigmoid with the aid of T-fasteners. The patient received Fleet Phospho–Soda as well as neomycin and erythromycin for bowel preparation. A rectal tube was introduced in the rectum and this was insufflated with air.
Using computed tomography, the sigmoid colon loop was identified and the absence of residual volvulus was confirmed. In order to minimize procedure time, two interventional radiologists (DL, JBM) performed the percutaneous sigmoidostomies simultaneously in the CT suite. CT-fluoroscopy (Brilliant 16, Phillips, The Netherlands) was used intermittently during the procedure. After local anesthesia with 1% lidocaine, one T-fastener (Cook, Bloomington, IN) was placed within the lumen of the ascending and descending sigmoid limbs respectively and retracted to the anterior abdominal wall. Two additional T-fasteners were placed in each limb to create three-point fixation at each site. The patient was then moved to the interventional radiology suite where, under fluoroscopic control, an 18-gauze needle was advanced into each of the ascending and descending sigmoid limbs within the triangle formed by the three T-fasteners. Sequential
Fig. 2. Placement of T-fasteners under CT guidance (left). Two 14-Fr loop locking type tubes within the ascending and descending loop of the sigmoid (right).
A.N. Karavas et al. / European Journal of Radiology Extra 67 (2008) e83–e86
e85
Fig. 3. Tube exchange on day 4 (left) with 14-Fr foley-type catheter. Balloons were eventually filled with 5–10 ml sterile water (arrow). Tube exchange on day 38 with Mickey-type catheters.
dilation of the tracts was performed over guidewires and 14French locking-loop gastrostomy tubes (Cook, Bloomington, IN) were placed into each limb through peel-away sheaths. Stool was aspirated from each of the colostomy tubes and subsequent contrast administration through the tubes confirmed their satisfactory positioning (Fig. 2). The patient’s hospital course was notable for postoperative bleeding per rectum. This was felt to be likely due to a T-fastener perforating a sigmoid vessel. The patient remained hemodynamically stable, but required transfusion of 2 units of packed red blood cells. The bleeding was ultimately self-limiting, but the decision was made to replace the tubes with balloon-type tubes that would offer a compression effect between wall of sigmoid and abdominal wall (Fig. 3). This was performed on the 4th day after his procedure. He was subsequently discharged home in stable condition. The patient underwent exchange of the sigmoidopexy tubes to Mic-Key low-profile feeding tubes on the 38th day after his procedure to facilitate his care (Fig. 3). He remained event-free until 6 months after the initial sigmoidopexy when he developed an episode of small bowel obstruction. This was followed by pneumonia that ultimately led to his death. Computed tomography at that time revealed intact Mic-Key tubes and no evidence of recurrence of the volvulus or procedure-related morbidity. 3. Discussion Sigmoid volvulus often affects patients who frequently are at very high operative risk. While endoscopic or even radiologic decompression with contrast enema constitute the mainstay of acute management, recurrent episodes usually require surgical intervention for definitive management [3].
The most commonly performed procedure involves sigmoid resection, which will eliminate the redundant and floppy colon [2]. Some authors have suggested subtotal colectomy for definitive prevention of recurrence [6–9]. Non-resective surgical procedures include mesosigmoidoplasty (remodeling of the sigmoid mesocolon) or colopexy (fixation of the colon to the abdominal wall with bands, e.g. with Gore-Tex strips) [10,11] have also been reported. Recently, non-surgical procedures have been suggested as means of managing recurrent sigmoid volvulus in patients with high operative risk and usually low life expectancy [12]. Using the techniques utilized for placement of percutaneous endoscopic gastrostomy (PEG) tubes, these procedures have included endoscopic assessment to identify the sigmoid loop and assist with inflation and approximation of the loop to the abdominal wall [13]. Endoscopic techniques require at least conscious sedation to facilitate comfort during the procedure. In this report, the procedure was performed under local anesthesia only. Insufflation was performed via a rectal tube to ensure contact between the sigmoid loop and the abdominal wall. Computed tomography was then used to confirm bowel position and placement of the T-fasteners. This procedure was performed under local anesthesia and was tolerated well by the patient and obviated the need of endoscopy or conscious sedation, which might have jeopardized the clinical condition of this patient with severe aortic stenosis. With this approach, as with endoscopic methods, bleeding and intraperitoneal leakage of colonic contents could be expected to be the major significant complications. In this case, the procedure was, in fact, complicated by selflimited colonic bleeding, felt to be due to perforation of a vessel by either a T-fastener or a colopexy tube. A balloon-type catheter might prevent this problem by providing pressure to tampon-
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A.N. Karavas et al. / European Journal of Radiology Extra 67 (2008) e83–e86
ade the bleeding vessel against the abdominal wall. However, a Foley-type balloon catheter lacks rigidity and requires creating an end hole to allow placement over a guidewire and, also has the potential for obstruction. The loop-locking tube initially used here, on the other hand, is easily placed through a peelaway sheath over a guidewire and is low profile. The Mic-Key low profile tube, that was ultimately placed, is best for long-term management but requires a mature tract for secure positioning. 4. Conclusion In conclusion, surgical management of recurrent sigmoid volvulus still constitutes the best means of prevention of recurrence. However, old age and multiple morbidities may pose a very high surgical risk in certain patients. Computed tomography-assisted placement of sigmoidopexy tubes may provide a low risk interventional alternative to the non-operative patient. References [1] Grossmann EM, Longo WE, Stratton MD, Virgo KS, Johnson FE. Sigmoid volvulus in Department of Veterans Affairs Medical Centers. Dis Colon Rectum 2000;43:414–8.
[2] Pfeifer J. Volvulus des Dickdarms. J Gastrointest Hepatol Erkr 2003;1:6–13. [3] Madiba TE, Thomson SR. The management of sigmoid volvulus. J R Coll Surg Edinb 2000;45:74–80. [4] Shepherd JJ. The epidemiology and clinical presentation of sigmoid volvulus. Br J Surg 1969;56:353–9. [5] Bak MP, Boley SJ. Sigmoid volvulus in elderly patients. Am J Surg 1986;151:71–5. [6] Chung YF, Eu KW, Nyam DC, Leong AF, Ho YH, Seow-Choen F. Minimizing recurrence after sigmoid volvulus. Br J Surg 1999;86:231–3. [7] Friedman JD, Odland MD, Bubrick MP. Experience with colonic volvulus. Dis Colon Rectum 1989;32:409–16. [8] Ryan P. Sigmoid volvulus with and without megacolon. Dis Colon Rectum 1982;25:673–9. [9] Harbrecht PJ, Fry DE. Recurrence of volvulus after sigmoidectomy. Dis Colon Rectum 1979;22:420–4. [10] Bach O, Rudloff U, Post S. Modification of mesosigmoidoplasty for nongangrenous sigmoid volvulus. World J Surg 2003;27:1329–32. [11] Salim AS. Percutaneous deflation and colopexy for volvulus of the sigmoid colon: a new approach. J R Coll Surg Edinb 1990;35:356–9. [12] Pinedo G, Kirberg A. Percutaneous endoscopic sigmoidopexy in sigmoid volvulus with T-fasteners: report of two cases. Dis Colon Rectum 2001;44:1867–9 [discussion 1869–70]. [13] Daniels IR, Lamparelli MJ, Chave H, Simson JN. Recurrent sigmoid volvulus treated by percutaneous endoscopic colostomy. Br J Surg 2000;87: 1419.
A novel interventional approach to sigmoid volvulus Alexandros N. Karavas a,c,1 , David L. Lee b,2 , Jeffrey B. Mendel b,2 , Alan W. Hackford a,∗ a Department of Surgery, St. Elizabeth’s Medical Center and Tufts University School of Medicine, Boston, MA, USA Department of Radiology, St. Elizabeth’s Medical Center and Tufts University School of Medicine,736 Cambridge Street, CMP 4R, Boston, MA 02135, USA c Department of Thoracic Surgery, Vanderbilt University Medical Center, 2971 The Vanderbilt Clinic, 1301 Medical Center Drive, Nashville, TN 37232 5734, USA b
Received 10 March 2008; accepted 6 May 2008
Abstract We report a case of a 96-year-old gentleman who presented with recurrent sigmoid volvulus and was deemed inoperable by either operative or endoscopic means due to his prohibitively high cardiac risk. The volvulus was managed with a computed tomography (CT)-guided sigmoidopexy using two gastrostomy tubes to affix the sigmoid colon to the abdominal wall by means of T-fasteners. The procedure was tolerated well by the patient. © 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Interventional radiology; Computed tomography; Sigmoid volvulus; Elderly
1. Introduction Sigmoid volvulus is a common cause of bowel obstruction and is the third most common cause of large bowel obstruction in the western world [1]. It usually affects institutionalized and elderly patients, who frequently have other comorbidities. Acute volvulus can be initially managed non-operatively in the majority of patients [2,3]. On the other hand, chronic volvulus represents a condition where episodes of acute sigmoid volvulus occur and are managed conservatively in a repeated fashion. A recurrence rate of up to 90% for non-operative management has been reported [1,4–6]. The high recurrence rate, along with the morbidity and mortality following emergent surgical intervention, have lead to the current recommendation of elective repair after successful non-operative management, as the patient’s condition allows.
∗ Corresponding author at: Division of Colorectal Surgery, St. Elizabeth’s Medical Center, 736 Cambridge Street, Boston, MA 02135, USA. Tel.: +1 617 789 2442; fax: +1 617 789 4207. E-mail addresses: [email protected] (A.N. Karavas), [email protected] (D.L. Lee), [email protected] (J.B. Mendel), [email protected] (A.W. Hackford). 1 Tel.: +1 615 818 5725; fax: +1 866 861 2830. 2 Tel.: +1 617 789 2740; fax: +1 617 779 6343.
1571-4675/$ – see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2008.05.002
This report presents a patient with recurrent sigmoid volvulus, who had been deemed a prohibitive risk for surgical or endoscopic intervention and underwent computed tomographyguided sigmoidopexy. This is the first, to our knowledge, interventional sigmoidopexy without the use of endoscopic guidance. 2. Patient A 96-year-old gentleman presented to the emergency department with a 2-day history of increasing abdominal distention and pain. A large bowel obstruction secondary to sigmoid volvulus was diagnosed based on an abdominal radiograph as well as computed tomography of the abdomen and pelvis (Fig. 1). Endoscopic decompression was performed in the emergency department and a silicone tube was left in the sigmoid colon to assist with further decompression. The patient had significant comorbidities including a remote right colectomy, known severe aortic stenosis with a moderately depressed left ventricular ejection fraction, and a history of a cerebrovascular accident. The surgical risk was substantial. A definite surgical intervention was deferred. The patient required two additional admissions within a period of less than 6 weeks for recurrence necessitating endoscopic decompression. Upon cardiologic evaluation, he was felt to be of prohibitive risk
e84
A.N. Karavas et al. / European Journal of Radiology Extra 67 (2008) e83–e86
Fig. 1. Computed tomography at initial presentation. The classic coffeebean sign (left) and the whirl sign (right).
for anesthesia. Definitive surgical or endoscopic interventions requiring, at a minimum, sedation were, therefore, not further considered. A percutaneous approach was elected. The procedure was performed under local anesthesia in the CT and interventional radiology suites after colonic preparation with cathartics. The goal was to provide sufficient fixation of the sigmoid colon to avoid recurrent volvulus. This was accomplished by fixing the loop of sigmoid colon at two sites, one site at the descending portion and one site at the ascending portion of this loop. Fixation was accomplished by percutaneously placing self-retaining gastrostomy tubes into the sigmoid with the aid of T-fasteners. The patient received Fleet Phospho–Soda as well as neomycin and erythromycin for bowel preparation. A rectal tube was introduced in the rectum and this was insufflated with air.
Using computed tomography, the sigmoid colon loop was identified and the absence of residual volvulus was confirmed. In order to minimize procedure time, two interventional radiologists (DL, JBM) performed the percutaneous sigmoidostomies simultaneously in the CT suite. CT-fluoroscopy (Brilliant 16, Phillips, The Netherlands) was used intermittently during the procedure. After local anesthesia with 1% lidocaine, one T-fastener (Cook, Bloomington, IN) was placed within the lumen of the ascending and descending sigmoid limbs respectively and retracted to the anterior abdominal wall. Two additional T-fasteners were placed in each limb to create three-point fixation at each site. The patient was then moved to the interventional radiology suite where, under fluoroscopic control, an 18-gauze needle was advanced into each of the ascending and descending sigmoid limbs within the triangle formed by the three T-fasteners. Sequential
Fig. 2. Placement of T-fasteners under CT guidance (left). Two 14-Fr loop locking type tubes within the ascending and descending loop of the sigmoid (right).
A.N. Karavas et al. / European Journal of Radiology Extra 67 (2008) e83–e86
e85
Fig. 3. Tube exchange on day 4 (left) with 14-Fr foley-type catheter. Balloons were eventually filled with 5–10 ml sterile water (arrow). Tube exchange on day 38 with Mickey-type catheters.
dilation of the tracts was performed over guidewires and 14French locking-loop gastrostomy tubes (Cook, Bloomington, IN) were placed into each limb through peel-away sheaths. Stool was aspirated from each of the colostomy tubes and subsequent contrast administration through the tubes confirmed their satisfactory positioning (Fig. 2). The patient’s hospital course was notable for postoperative bleeding per rectum. This was felt to be likely due to a T-fastener perforating a sigmoid vessel. The patient remained hemodynamically stable, but required transfusion of 2 units of packed red blood cells. The bleeding was ultimately self-limiting, but the decision was made to replace the tubes with balloon-type tubes that would offer a compression effect between wall of sigmoid and abdominal wall (Fig. 3). This was performed on the 4th day after his procedure. He was subsequently discharged home in stable condition. The patient underwent exchange of the sigmoidopexy tubes to Mic-Key low-profile feeding tubes on the 38th day after his procedure to facilitate his care (Fig. 3). He remained event-free until 6 months after the initial sigmoidopexy when he developed an episode of small bowel obstruction. This was followed by pneumonia that ultimately led to his death. Computed tomography at that time revealed intact Mic-Key tubes and no evidence of recurrence of the volvulus or procedure-related morbidity. 3. Discussion Sigmoid volvulus often affects patients who frequently are at very high operative risk. While endoscopic or even radiologic decompression with contrast enema constitute the mainstay of acute management, recurrent episodes usually require surgical intervention for definitive management [3].
The most commonly performed procedure involves sigmoid resection, which will eliminate the redundant and floppy colon [2]. Some authors have suggested subtotal colectomy for definitive prevention of recurrence [6–9]. Non-resective surgical procedures include mesosigmoidoplasty (remodeling of the sigmoid mesocolon) or colopexy (fixation of the colon to the abdominal wall with bands, e.g. with Gore-Tex strips) [10,11] have also been reported. Recently, non-surgical procedures have been suggested as means of managing recurrent sigmoid volvulus in patients with high operative risk and usually low life expectancy [12]. Using the techniques utilized for placement of percutaneous endoscopic gastrostomy (PEG) tubes, these procedures have included endoscopic assessment to identify the sigmoid loop and assist with inflation and approximation of the loop to the abdominal wall [13]. Endoscopic techniques require at least conscious sedation to facilitate comfort during the procedure. In this report, the procedure was performed under local anesthesia only. Insufflation was performed via a rectal tube to ensure contact between the sigmoid loop and the abdominal wall. Computed tomography was then used to confirm bowel position and placement of the T-fasteners. This procedure was performed under local anesthesia and was tolerated well by the patient and obviated the need of endoscopy or conscious sedation, which might have jeopardized the clinical condition of this patient with severe aortic stenosis. With this approach, as with endoscopic methods, bleeding and intraperitoneal leakage of colonic contents could be expected to be the major significant complications. In this case, the procedure was, in fact, complicated by selflimited colonic bleeding, felt to be due to perforation of a vessel by either a T-fastener or a colopexy tube. A balloon-type catheter might prevent this problem by providing pressure to tampon-
e86
A.N. Karavas et al. / European Journal of Radiology Extra 67 (2008) e83–e86
ade the bleeding vessel against the abdominal wall. However, a Foley-type balloon catheter lacks rigidity and requires creating an end hole to allow placement over a guidewire and, also has the potential for obstruction. The loop-locking tube initially used here, on the other hand, is easily placed through a peelaway sheath over a guidewire and is low profile. The Mic-Key low profile tube, that was ultimately placed, is best for long-term management but requires a mature tract for secure positioning. 4. Conclusion In conclusion, surgical management of recurrent sigmoid volvulus still constitutes the best means of prevention of recurrence. However, old age and multiple morbidities may pose a very high surgical risk in certain patients. Computed tomography-assisted placement of sigmoidopexy tubes may provide a low risk interventional alternative to the non-operative patient. References [1] Grossmann EM, Longo WE, Stratton MD, Virgo KS, Johnson FE. Sigmoid volvulus in Department of Veterans Affairs Medical Centers. Dis Colon Rectum 2000;43:414–8.
[2] Pfeifer J. Volvulus des Dickdarms. J Gastrointest Hepatol Erkr 2003;1:6–13. [3] Madiba TE, Thomson SR. The management of sigmoid volvulus. J R Coll Surg Edinb 2000;45:74–80. [4] Shepherd JJ. The epidemiology and clinical presentation of sigmoid volvulus. Br J Surg 1969;56:353–9. [5] Bak MP, Boley SJ. Sigmoid volvulus in elderly patients. Am J Surg 1986;151:71–5. [6] Chung YF, Eu KW, Nyam DC, Leong AF, Ho YH, Seow-Choen F. Minimizing recurrence after sigmoid volvulus. Br J Surg 1999;86:231–3. [7] Friedman JD, Odland MD, Bubrick MP. Experience with colonic volvulus. Dis Colon Rectum 1989;32:409–16. [8] Ryan P. Sigmoid volvulus with and without megacolon. Dis Colon Rectum 1982;25:673–9. [9] Harbrecht PJ, Fry DE. Recurrence of volvulus after sigmoidectomy. Dis Colon Rectum 1979;22:420–4. [10] Bach O, Rudloff U, Post S. Modification of mesosigmoidoplasty for nongangrenous sigmoid volvulus. World J Surg 2003;27:1329–32. [11] Salim AS. Percutaneous deflation and colopexy for volvulus of the sigmoid colon: a new approach. J R Coll Surg Edinb 1990;35:356–9. [12] Pinedo G, Kirberg A. Percutaneous endoscopic sigmoidopexy in sigmoid volvulus with T-fasteners: report of two cases. Dis Colon Rectum 2001;44:1867–9 [discussion 1869–70]. [13] Daniels IR, Lamparelli MJ, Chave H, Simson JN. Recurrent sigmoid volvulus treated by percutaneous endoscopic colostomy. Br J Surg 2000;87: 1419.