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Volvulus of the cecum
Volvulus M’ITH
of the Cecum
A REVIEW OF THE RECENT LITERATURE OCCURRING AS A POSTOPERATIVE H. SHEFFIELD
JECK,
From rbe Surgical Service, Vetemns Administration Medical Teaching Group, Kennedy Hospital, Memphis, Tennessee.
OF
A CASE
Oxford, Obio
one of mortalitS- rate, most reports cite mortafity statistics gathered from well known articles, none of tvhich includes any significant number of cases treated within the past ten years. It must he remembered, of course, that no one surgeon or clinic has had a Iarge enough experience with vofvuIus of the cecum to have statistics of significance. VoIvufus of the cecum is not a leading cause of intestinal obstruction. Percentage incidence has been given as \-arying from as low as .083 (I?] to as high as 1.3 [IO]. However, acute twisting of the cecum is an emergency and one which may carry a high mortality if not treated promptly, especially with the advent of gangrene of the colon. In 1905 Corner and Sargent [I] presented a 52.5 per cent mortaIit>- rate for collected patients operated upon and IOO per cent mortality for those patients treated without operation. More recently, in 1947, Young et al. [h] commented on the “appalling mortafof cecaI vofvuIus. In 1949 ity ” in treatment Donhauser and Atwefl (IO], in a review of loo cases, found an over-all mortality rate of 42 per cent. In those in whom gangrene of the cecum had occurred, the death rate rose precipitousI> to 72 per cent. Of the six new cases included in this study of Donhauser and Atwefl, three patients had advanced gangrene of the cecum at the time of exploration and failed to recover. The foregoing statistics, which are wide11 quoted, certainly fail to show a significant lowering of the mortality rate. Sixty-two cases of vofvuIus of the cecum, all proved at operation, have been coIIected from leading journals for a period extending over the Iast ten years jkzo]. In this series there were but eight deaths, for a mortality rate of onlv 12.9 per cent. Of these eight deaths, five patients [6,y,10] were found to have advanced gangrene of the cecum, two others [r?\ M’ere
of v-olvulus of the cecum are not rare in the surgical literature. In the Iast ten years approximately a dozen articles on this subject have appeared in the leading surgical journals. Tflere is a comprehensive hibfiographl on cecal vofvufus prior to that time, extending back to the year 1841 u-hen Rokitansky described the first case. Despite this, however, vof~~~fus of the cecum remains a refativefy rare condition and many a busy surgeon has never encountered this lesion in his surgical lifetime. in 1952 Dean [I I] estimated that somewhere in the neighborhood of 313 cases of cecal vofvulus had been reported. In 1956 Powell and Bowers [r9] stated that more than 400 cases have been described. Undoubtedly there have been other cases which have not found their way into print. Probably the only valid reason for reporting another case of vofvulus of the cecum is to focus further attention on this problem and thus promote an increased awareness of a condition, which prior to the last decade, has been so rareI?- diagnosed before operation. It is not the purpose of this presentation to attempt a thorough review of this subject or to theorize further on the etiology of cccaf vofvufus. The reader is referred to the man)- reviews in the medical literature [q-,~,~o,r,-1. However, a rather thorough perusal of the literature of the past ten years appears to indicate from the discussion accompanying the reported cases that little progress has been made in diagnosis and results of treatment. As to the former point, most writers have stated that the diffIcufty in diagnosis should not exist, and wouId not, save for a lack of awareness of possible torsion of the cecum. As to the latter question, which is
R
M.D.,
AND REPORT COMPLICATION
EPORTS
4’1
AmericanJournal01Surgery,Volume
06, Scpremher.
rnch
Jeck ring post-operativeIy must be exceedingIy rare because a carefu1 review of the literature recentIy by Pratt and FaIIis and to a Iess extent by myseIf has faiIed to reveaI a singIe case report.” NeIson then proceeded to report a case of ceca1 voIvuIus with onset four days foIIowing uterine suspension and right saIpingo-oophorectomy. Jordan and Beahrs [r6] have reported six cases of voIvuIus of the cecum occurring in the immediate postoperative period. The foIIowing report iIIustrates another such case. CASE
REPORT
A fifty-eight year old white man (0. L. W., No. 84041) was admitted to Kennedy Hospital on
FIG. I. Roentgenogram showing tremendously dilated cecum in the right Iower quadrant of the abdomen, accompanied with marked dilatation of the small boweI.
eIderIy and autopsy showed bronchopneumonia in both, and one patient died on the Iifty-first postoperative day of heart disease after having made a compIete gastrointestina1 recovery [ 121. AIthough 13 per cent is not a negIigibIe death rate, it is hardIy comparabIe to a mortaIity rate of 50 per cent, so often cited in the past. Increased diagnostic acumen and knowIedge of proper corrective surgica1 measures can hardIy cIaim aII the credit for improved resuIts in the treatment of voIvuIus of the cecum. Much of the credit must go to our improved methods of suction decompression, broadspectrum antibiotics and better knowIedge of the use of bIood, Auid and eIectroIyte repIacement therapy. Many authors have commented on the possibIe causa1 reIationship of previous abdomina1 operations, even remote ones, to the deveIopment of intestina1 voIvuIi. Dixon and Meyer [8] found that eIeven of tweIve patients with ceca1 voIvuIus had undergone previous operations; ten of these were intra-abdomina1 procedures. VoIvuIus of the cecum occurring as a postoperative comphcation has aIso received attention and study in the Iiterature. NeIson [3], writing in 1928, said, “. . . but voIvuIus occur412
ApriI 23, 1933, with a recurrent inguinal hernia of about four years’ duration. Left inguinal herniorrhaphy, performed in 1948, constituted the onIy surgica1 procedure this man had undergone. Past history reveaIed onIy that the patient had received treatment three years previousIy for “a positive blood test.” On physical examination positive fmdings were Iimited to the following: blood pressure 160/80, harsh diastoIic and soft systoIic heart murmurs and associated Corrigan puIse; there was an enIarged left externa1 inguina1 ring with a moderateIy large, easiIy reducibIe hernia1 sac descending into the s&otum. Laboratory work was unremarkable with the exception of positive seroIogic tests for syphilis. Left inguina1 herniorrhaphy was carried out under spina anesthesia on ApriI 29th. The course was uneventful unti1 the third postoperative day when marked distention of the Iower abdomen deveIoped, accompanied with discomfort but IittIe actua1 pain. The patient was treated with severa enemas and eliminated smaI1 amounts of gas. The distention became more marked, however, and a Iarge tympanitic mass the size and shape of a footbalI was very prominent, Iying diagonaIIy in the right lower abdomina1 quadrant. A coIon tube was inserted in the rectum but did not heIp reduce distention. Fiat x-ray flIms of the abdomen were taken and reveaIed a hugeIy diIated coIonic loop occupying the right Iower abdomen and peIvis. ConsiderabIe gas was visibIe in the remainder of the coIon and aIso in the smaI1 boweI. (Fig. I.) A diagnosis of voIvuIus of the sigmoid colon was thought to be most likely. However, sigmoidoscopy to a distance of 25 cm. faiIed to visuaIize a site of twisting in the coIon. The patient’s temperature was 99.4%. (ora1); the white blood ceII count was 12,000 per cu. mm., with 88 per cent segmented neutrophiIs and 12 per cent lymphocytes. There was stiI1 IittIe complaint of abdomina1 pain and no vomiting had occurred. A Levin tube had been pIaced in the stomach and Wangensteen suction instituted. About ten hours after onset expIoratory Iaparotomy was undertaken under genera1 endo-
VoIvuIus tracheal anesthesia. The peritoneum was opened through a lower midline incision. A tremendously dilated cecum, measuring 17 cm. in diameter, was encountered. There appeared to be a constriction in the region of the mid-ascending coIon; the transverse colon was moderatelv diIated but the descending colon was normal in s”ize. Due to the Iarge size of the cecum and the presence of many dilated loops of small intestine obscuring the field it was not possible to visualize readily the actual site of twisting in the colon. However, on the assumption that a \-olvulus was present, the cecum was gently rotated 180 degrees in a counterclockwise direction. Immediately there was a rush of gas into the transverse colon and the size of the cecum diminished. It was then easily apparent that the cecum and ascending colon had a long mesentery, were very mobile and were readily dispIaced from their usual anatomica position. Considerable atony of the cecum remained but the coIor was good and no splitting of the serosal covering had occurred. A Iarpe mushroom catheter was inserted as a cecostomy tube and brought out through a right lower quadrant stab wound. There was considerable evacuation of gas and liquid fecal material. The midline wound was closed in layers and reinforced with retention sutures. PostoperativeIy the patient had a very persistent ilcus despite continuous suction decompression, enemas, prostigminc and carefu1 attention to eIectrolyte balance. The ileus gradually subsided after bring intermittently troublesome for a period of ten days. Bowel movements per rectum were recstabhshed, the cecostomy tube was removed and the fistula healed promptly. SuperficiaI separation of the midline wound deveIoped; this was subjected to secondary closure and healed weII. The patient was discharged home in good condition on June I 5, 1953. In December, 1953, follow-up studies revealed the patient to be asymptomatic except for moderately resistant constipation. Barium enema showed diverticulosis of the colon and an enIarged, pendulous cecum.
Comment. AImost without exception, those who have written on ceca1 voIvuIus have commented on the chronic, recurrent nature of this disorder. As early as Igo5 Corner and Sargent [r] noted that patients with voIvuIus of the cecum are IikeIy to give a history of habitua1 constipation, occasiona attacks of pain on the right side, nausea, and often, rapid puIse and eIevation of temperature. Such an attack, it is stated, is reIieved by the passage of fIatus and Iiquid feces. The patient cited in this report is no exception. Further questioning of the patient after recovery from the operation reveaIed that he had suffered for many years \vith resistant constipation requiring frequent
of Cecum laxatives for relief. He had aIso noted occasiona “bloating,” sometimes relieved by bouts ol diarrhea and the passage of considerable gas. This case of voIvuIus of the cecum occurred abruptly on the third day folIowing a reIativel> simple repair of a recurrent inguinal hernia on the Ieft side. What was the possibIe predisposing factor here? Manipulation of the intestines and withdrawa of abdomina1 packs have been suggested as causes for the development of volvulus. A review of the operative note for the herniorrhaphy reveaIs no handling of the bowel and no insertion of abdominal packs. It is interesting to note that two of .Jordnn and Reahrs’ cases of cecal volvuIus occurring in the immediate postoperative period folIowed operations in which the peritonea1 cavity was not entered. In one case the primary surgical procedure was biIatera1 simpIe mastectomy, and in the second case voIvuIus follo\~ecl the final stage of a bilateral supra- ant1 infradiaphragmatic sympathectomy for hypertension. The inciting cause of volvuIus may be anything . . \vhlch drsturbs an already mobile cccum, one which has a Iong mesentery and is therefore not well secured in the right lower abdominal quadrant. AIso implicated in the literature have been: pregnancy, labor, violent peristalsis, intra-abdominal tumors, cysts, fecaliths, foreign bodies, congenita1 bands and strictures, inffammatory conditions of the colon and habitual constipation. SpeciaI emphasis has been pIaced on obstructing lesions of the left coIon as predisposing to cecal voIvulus [I;]. Young et al. [6] have bvritten, “Although the diagnosis of acute voIvuIus of the cecum is not usually made pre-operatively, it is believed that b?; carefui r-ray study and a thorough review of the history and physical tindings, it can be arrived at more frequentI!-.” Other authors have commented on the fact that exact preoperative diagnosis is rarely made [7,rr,r,~]. In the Iiterature on cecal volvulus of the past decade, thirty-two case reports were studied in which a preoperative diagnosis has been specificaIIy mentioned [h-19]. It is rewarding to note
that
in twenty-four
of these
a diag-
nosis of c‘voIvuIus” had been made prior to operation. Furthermore, in fifteen of these thirty-two reports, the site of the \-olvulus was correctly placed preoperativeI)in the cecum. This is apparently no longer a situation, then, in which the diagnosis is rareI\- made. Most authors are agreed that x-ray is ver\helpful in the diagnosis of torsion of the cecum.
Jeck Simple flat and upright films of the abdomen have been found to be sufficient in most cases, aIthough many writers have stressed the positive vaIue of retrograde barium study of the coIon when the diagnosis is in doubt. McGraw et a1. [7] express the opinion that the criteria for diagnosis are present in the simpIe x-ray fiIm of the abdomen and they beIieve that the barium enema should be reserved for the obscure cases. The six x-ray diagnostic criteria outIined by McGraw are recommended to the reader. It has often been stated in the Iiterature that the fiat roentgenogram in cecal voIvuIus shows the cecum in an abnorma1 position. It has also been cIaimed that go per cent of these ectopic cecums Iie in the Ieft upper quadrant [6,r1]. AbnormaI position of the diIated cecum is undoubtedIy a common finding and a vaIuabIe diagnostic point. As to the great majority (go per cent) being found in the Ieft upper quadrant, a review of cases from the Iast decade does not substantiate this cIaim. Thirtyfive cases were found in which the ffat fiIm x-ray findings were described [6-rg]. In these a dilated cecum was noted in the left upper quadrant in onIy thirteen reports (37 per cent). It is noteworthy that a large, dilated Ioop of bowe1, identified before or after operation as the cecum, has been found in aI1 the abdomina1 quadrants. Once the diagnosis of voIvuIus of the cecum is reasonabIy certain in a patient with acute intestina1 obstruction, treatment must not be delayed. Treatment is surgical and is we11 standardized. In the non-gangrenous cases, derotation with cecostomy and/or cecopexy wiI1 suffice to reIieve obstruction and distention and fix the cecum in the right lower quadrant, thus preventing further twisting. In the doubtful or frankIy gangrenous cases, resection of the right coIon with primary ileo-transverse colon anastomosis, a MikuIicz type of resection or even exteriorization of the invoIved bowe1 are the procedures demanded, the choice depending on the findings and the condition of the patient. The former procedure is probabIy the most formidabIe but is the one of choice, if since it materialIy circumstances permit, shortens the hospita1 stay. SUMMARY
A case of voIvuIus of the cecum is presented in which simpIe detorsion and cecostomy re-
suIted in a favorabIe outcome. The probIem of cecal voIvuIus is discussed briefly and several important diagnostic criteria are emphasized. A short review of the recent Iiterature is presented and reveals that increasing experience with this condition has resuIted in improved diagnostic accuracy and a considerabIy lower mortality rate. REFERENCES I. CORNER, E. M. and SARGENT, P. W. G. VolvuIus
of the caecum. Ann. Surg., 41: 63-75, 1905. 2. PRATT, J. D. and FALLIS, L. S. VoIvuIus of cecum and ascending coton. J. A. M. A., 89: I 225, 1927. 3. NELSON, H. M. Postoperative voIvuIus of cecum. Am. J. Surg., 5: 398-400, 1928. 4. MCGOWAN, J. M. and DIXON, C. F. VoIvuIus of the cecum-report of case. Proc. Sta$ Meet., Mayo Clin., I I : 337-341, 1936. 5. WOLFER, J. A., BEATON, L. E. and ANSON, B. J. VoIvuIus of the cecum: anatomical factors in its etioIog;v and report of a case. Surp.. ti _. Gynec. I Obst.,y4: 882-894, 1942. 6. YOUNG, E.L., MORRISON, H. R. and WILSON, W. E. VoIvuIus of the cecum and ascending colon. New England J. Med., 237: 78-86, 1947. 7. MCGRAW, J. P,, KREMEN, A. J. and RICLER, L. G. The roentgen diagnosis of voIvuIus of the cecum. Surgery, 24: 793-804, 1948. 8. DIXON, C. F. and MEYER, A. C. VoIvuIus of the cecum. S. Clin. Nortb America, 28: 953363, 1948. g. MELCHIOR, E. VoIvuIus of the cecum-an appea1 for primary resection with report of 6 cases. Surgery, 25: 251-256, 1949. IO. DONHAUSER, J. L. and ATWELL, S. VoIvuIus of the cecum-a review of IOO cases in the Iiterature and a report of 6 new cases. Arch. Surg., 58: 129148, 1949. I I. DEAN, D. L. VoIvuIus of the decum: with report of 2 cases. Ann. SW&, 136: 319-325, 1952. 12. BYRNE, J. J., SWIFT, C. C. and FARRELL, G. E., JR. VoIvulus of the cecum. Arch. Surg., 64: 378-383, 1952. 13. RYAN, A. J. and BURBANK, J. VoIvuIus of the cecum. Am. J. Roentgenol., 68: 39g-402, 1952. 14. GLASS, B. A. and ABRAMSON, If. D. VoIvuIus of cecum due to Iithopedion. Am. J. Surg.. 86: 348352. 1953. 15. DESFORGES, G. and WILSON, H. VoIvuIus of the cecum. Am. J. Surg., 86: 116119, 1953. 16. JORDAN, G. L. and BEAHRS, 0. H. VoIvuIus of the cecum as a postoperative complication. Ann. Surg., 137: 245-249, 1953. 17. WILSON, H. E., DESFORGES, G., DUNPHY, H. G. and CAMPBELL, A. J. A. VoIvuIus of the cecumemphasis on possible predisposing lesions of the left coIon. Arch Surg., 68: 593-604. 1954. 18. YOUNG, M. 0. Coexistent voIvuIus of the spIenic Aexure and cecum. Surgery, 37: 983-990, 1955. 19. POWELJ_,J. H. and BOWERS, R. F. VoIvuIus of the cecum. Ann. Surg., 143: 126129, 1956. 20. NELSON, T. G. and BOWERS, W. F. VoIvuIus of the cecum and sigmoid coIon. Arch. G-g., 72: 469478. 1956.
414
of the Cecum
A REVIEW OF THE RECENT LITERATURE OCCURRING AS A POSTOPERATIVE H. SHEFFIELD
JECK,
From rbe Surgical Service, Vetemns Administration Medical Teaching Group, Kennedy Hospital, Memphis, Tennessee.
OF
A CASE
Oxford, Obio
one of mortalitS- rate, most reports cite mortafity statistics gathered from well known articles, none of tvhich includes any significant number of cases treated within the past ten years. It must he remembered, of course, that no one surgeon or clinic has had a Iarge enough experience with vofvuIus of the cecum to have statistics of significance. VoIvufus of the cecum is not a leading cause of intestinal obstruction. Percentage incidence has been given as \-arying from as low as .083 (I?] to as high as 1.3 [IO]. However, acute twisting of the cecum is an emergency and one which may carry a high mortality if not treated promptly, especially with the advent of gangrene of the colon. In 1905 Corner and Sargent [I] presented a 52.5 per cent mortaIit>- rate for collected patients operated upon and IOO per cent mortality for those patients treated without operation. More recently, in 1947, Young et al. [h] commented on the “appalling mortafof cecaI vofvuIus. In 1949 ity ” in treatment Donhauser and Atwefl (IO], in a review of loo cases, found an over-all mortality rate of 42 per cent. In those in whom gangrene of the cecum had occurred, the death rate rose precipitousI> to 72 per cent. Of the six new cases included in this study of Donhauser and Atwefl, three patients had advanced gangrene of the cecum at the time of exploration and failed to recover. The foregoing statistics, which are wide11 quoted, certainly fail to show a significant lowering of the mortality rate. Sixty-two cases of vofvuIus of the cecum, all proved at operation, have been coIIected from leading journals for a period extending over the Iast ten years jkzo]. In this series there were but eight deaths, for a mortality rate of onlv 12.9 per cent. Of these eight deaths, five patients [6,y,10] were found to have advanced gangrene of the cecum, two others [r?\ M’ere
of v-olvulus of the cecum are not rare in the surgical literature. In the Iast ten years approximately a dozen articles on this subject have appeared in the leading surgical journals. Tflere is a comprehensive hibfiographl on cecal vofvufus prior to that time, extending back to the year 1841 u-hen Rokitansky described the first case. Despite this, however, vof~~~fus of the cecum remains a refativefy rare condition and many a busy surgeon has never encountered this lesion in his surgical lifetime. in 1952 Dean [I I] estimated that somewhere in the neighborhood of 313 cases of cecal vofvulus had been reported. In 1956 Powell and Bowers [r9] stated that more than 400 cases have been described. Undoubtedly there have been other cases which have not found their way into print. Probably the only valid reason for reporting another case of vofvulus of the cecum is to focus further attention on this problem and thus promote an increased awareness of a condition, which prior to the last decade, has been so rareI?- diagnosed before operation. It is not the purpose of this presentation to attempt a thorough review of this subject or to theorize further on the etiology of cccaf vofvufus. The reader is referred to the man)- reviews in the medical literature [q-,~,~o,r,-1. However, a rather thorough perusal of the literature of the past ten years appears to indicate from the discussion accompanying the reported cases that little progress has been made in diagnosis and results of treatment. As to the former point, most writers have stated that the diffIcufty in diagnosis should not exist, and wouId not, save for a lack of awareness of possible torsion of the cecum. As to the latter question, which is
R
M.D.,
AND REPORT COMPLICATION
EPORTS
4’1
AmericanJournal01Surgery,Volume
06, Scpremher.
rnch
Jeck ring post-operativeIy must be exceedingIy rare because a carefu1 review of the literature recentIy by Pratt and FaIIis and to a Iess extent by myseIf has faiIed to reveaI a singIe case report.” NeIson then proceeded to report a case of ceca1 voIvuIus with onset four days foIIowing uterine suspension and right saIpingo-oophorectomy. Jordan and Beahrs [r6] have reported six cases of voIvuIus of the cecum occurring in the immediate postoperative period. The foIIowing report iIIustrates another such case. CASE
REPORT
A fifty-eight year old white man (0. L. W., No. 84041) was admitted to Kennedy Hospital on
FIG. I. Roentgenogram showing tremendously dilated cecum in the right Iower quadrant of the abdomen, accompanied with marked dilatation of the small boweI.
eIderIy and autopsy showed bronchopneumonia in both, and one patient died on the Iifty-first postoperative day of heart disease after having made a compIete gastrointestina1 recovery [ 121. AIthough 13 per cent is not a negIigibIe death rate, it is hardIy comparabIe to a mortaIity rate of 50 per cent, so often cited in the past. Increased diagnostic acumen and knowIedge of proper corrective surgica1 measures can hardIy cIaim aII the credit for improved resuIts in the treatment of voIvuIus of the cecum. Much of the credit must go to our improved methods of suction decompression, broadspectrum antibiotics and better knowIedge of the use of bIood, Auid and eIectroIyte repIacement therapy. Many authors have commented on the possibIe causa1 reIationship of previous abdomina1 operations, even remote ones, to the deveIopment of intestina1 voIvuIi. Dixon and Meyer [8] found that eIeven of tweIve patients with ceca1 voIvuIus had undergone previous operations; ten of these were intra-abdomina1 procedures. VoIvuIus of the cecum occurring as a postoperative comphcation has aIso received attention and study in the Iiterature. NeIson [3], writing in 1928, said, “. . . but voIvuIus occur412
ApriI 23, 1933, with a recurrent inguinal hernia of about four years’ duration. Left inguinal herniorrhaphy, performed in 1948, constituted the onIy surgica1 procedure this man had undergone. Past history reveaIed onIy that the patient had received treatment three years previousIy for “a positive blood test.” On physical examination positive fmdings were Iimited to the following: blood pressure 160/80, harsh diastoIic and soft systoIic heart murmurs and associated Corrigan puIse; there was an enIarged left externa1 inguina1 ring with a moderateIy large, easiIy reducibIe hernia1 sac descending into the s&otum. Laboratory work was unremarkable with the exception of positive seroIogic tests for syphilis. Left inguina1 herniorrhaphy was carried out under spina anesthesia on ApriI 29th. The course was uneventful unti1 the third postoperative day when marked distention of the Iower abdomen deveIoped, accompanied with discomfort but IittIe actua1 pain. The patient was treated with severa enemas and eliminated smaI1 amounts of gas. The distention became more marked, however, and a Iarge tympanitic mass the size and shape of a footbalI was very prominent, Iying diagonaIIy in the right lower abdomina1 quadrant. A coIon tube was inserted in the rectum but did not heIp reduce distention. Fiat x-ray flIms of the abdomen were taken and reveaIed a hugeIy diIated coIonic loop occupying the right Iower abdomen and peIvis. ConsiderabIe gas was visibIe in the remainder of the coIon and aIso in the smaI1 boweI. (Fig. I.) A diagnosis of voIvuIus of the sigmoid colon was thought to be most likely. However, sigmoidoscopy to a distance of 25 cm. faiIed to visuaIize a site of twisting in the coIon. The patient’s temperature was 99.4%. (ora1); the white blood ceII count was 12,000 per cu. mm., with 88 per cent segmented neutrophiIs and 12 per cent lymphocytes. There was stiI1 IittIe complaint of abdomina1 pain and no vomiting had occurred. A Levin tube had been pIaced in the stomach and Wangensteen suction instituted. About ten hours after onset expIoratory Iaparotomy was undertaken under genera1 endo-
VoIvuIus tracheal anesthesia. The peritoneum was opened through a lower midline incision. A tremendously dilated cecum, measuring 17 cm. in diameter, was encountered. There appeared to be a constriction in the region of the mid-ascending coIon; the transverse colon was moderatelv diIated but the descending colon was normal in s”ize. Due to the Iarge size of the cecum and the presence of many dilated loops of small intestine obscuring the field it was not possible to visualize readily the actual site of twisting in the colon. However, on the assumption that a \-olvulus was present, the cecum was gently rotated 180 degrees in a counterclockwise direction. Immediately there was a rush of gas into the transverse colon and the size of the cecum diminished. It was then easily apparent that the cecum and ascending colon had a long mesentery, were very mobile and were readily dispIaced from their usual anatomica position. Considerable atony of the cecum remained but the coIor was good and no splitting of the serosal covering had occurred. A Iarpe mushroom catheter was inserted as a cecostomy tube and brought out through a right lower quadrant stab wound. There was considerable evacuation of gas and liquid fecal material. The midline wound was closed in layers and reinforced with retention sutures. PostoperativeIy the patient had a very persistent ilcus despite continuous suction decompression, enemas, prostigminc and carefu1 attention to eIectrolyte balance. The ileus gradually subsided after bring intermittently troublesome for a period of ten days. Bowel movements per rectum were recstabhshed, the cecostomy tube was removed and the fistula healed promptly. SuperficiaI separation of the midline wound deveIoped; this was subjected to secondary closure and healed weII. The patient was discharged home in good condition on June I 5, 1953. In December, 1953, follow-up studies revealed the patient to be asymptomatic except for moderately resistant constipation. Barium enema showed diverticulosis of the colon and an enIarged, pendulous cecum.
Comment. AImost without exception, those who have written on ceca1 voIvuIus have commented on the chronic, recurrent nature of this disorder. As early as Igo5 Corner and Sargent [r] noted that patients with voIvuIus of the cecum are IikeIy to give a history of habitua1 constipation, occasiona attacks of pain on the right side, nausea, and often, rapid puIse and eIevation of temperature. Such an attack, it is stated, is reIieved by the passage of fIatus and Iiquid feces. The patient cited in this report is no exception. Further questioning of the patient after recovery from the operation reveaIed that he had suffered for many years \vith resistant constipation requiring frequent
of Cecum laxatives for relief. He had aIso noted occasiona “bloating,” sometimes relieved by bouts ol diarrhea and the passage of considerable gas. This case of voIvuIus of the cecum occurred abruptly on the third day folIowing a reIativel> simple repair of a recurrent inguinal hernia on the Ieft side. What was the possibIe predisposing factor here? Manipulation of the intestines and withdrawa of abdomina1 packs have been suggested as causes for the development of volvulus. A review of the operative note for the herniorrhaphy reveaIs no handling of the bowel and no insertion of abdominal packs. It is interesting to note that two of .Jordnn and Reahrs’ cases of cecal volvuIus occurring in the immediate postoperative period folIowed operations in which the peritonea1 cavity was not entered. In one case the primary surgical procedure was biIatera1 simpIe mastectomy, and in the second case voIvuIus follo\~ecl the final stage of a bilateral supra- ant1 infradiaphragmatic sympathectomy for hypertension. The inciting cause of volvuIus may be anything . . \vhlch drsturbs an already mobile cccum, one which has a Iong mesentery and is therefore not well secured in the right lower abdominal quadrant. AIso implicated in the literature have been: pregnancy, labor, violent peristalsis, intra-abdominal tumors, cysts, fecaliths, foreign bodies, congenita1 bands and strictures, inffammatory conditions of the colon and habitual constipation. SpeciaI emphasis has been pIaced on obstructing lesions of the left coIon as predisposing to cecal voIvulus [I;]. Young et al. [6] have bvritten, “Although the diagnosis of acute voIvuIus of the cecum is not usually made pre-operatively, it is believed that b?; carefui r-ray study and a thorough review of the history and physical tindings, it can be arrived at more frequentI!-.” Other authors have commented on the fact that exact preoperative diagnosis is rarely made [7,rr,r,~]. In the Iiterature on cecal volvulus of the past decade, thirty-two case reports were studied in which a preoperative diagnosis has been specificaIIy mentioned [h-19]. It is rewarding to note
that
in twenty-four
of these
a diag-
nosis of c‘voIvuIus” had been made prior to operation. Furthermore, in fifteen of these thirty-two reports, the site of the \-olvulus was correctly placed preoperativeI)in the cecum. This is apparently no longer a situation, then, in which the diagnosis is rareI\- made. Most authors are agreed that x-ray is ver\helpful in the diagnosis of torsion of the cecum.
Jeck Simple flat and upright films of the abdomen have been found to be sufficient in most cases, aIthough many writers have stressed the positive vaIue of retrograde barium study of the coIon when the diagnosis is in doubt. McGraw et a1. [7] express the opinion that the criteria for diagnosis are present in the simpIe x-ray fiIm of the abdomen and they beIieve that the barium enema should be reserved for the obscure cases. The six x-ray diagnostic criteria outIined by McGraw are recommended to the reader. It has often been stated in the Iiterature that the fiat roentgenogram in cecal voIvuIus shows the cecum in an abnorma1 position. It has also been cIaimed that go per cent of these ectopic cecums Iie in the Ieft upper quadrant [6,r1]. AbnormaI position of the diIated cecum is undoubtedIy a common finding and a vaIuabIe diagnostic point. As to the great majority (go per cent) being found in the Ieft upper quadrant, a review of cases from the Iast decade does not substantiate this cIaim. Thirtyfive cases were found in which the ffat fiIm x-ray findings were described [6-rg]. In these a dilated cecum was noted in the left upper quadrant in onIy thirteen reports (37 per cent). It is noteworthy that a large, dilated Ioop of bowe1, identified before or after operation as the cecum, has been found in aI1 the abdomina1 quadrants. Once the diagnosis of voIvuIus of the cecum is reasonabIy certain in a patient with acute intestina1 obstruction, treatment must not be delayed. Treatment is surgical and is we11 standardized. In the non-gangrenous cases, derotation with cecostomy and/or cecopexy wiI1 suffice to reIieve obstruction and distention and fix the cecum in the right lower quadrant, thus preventing further twisting. In the doubtful or frankIy gangrenous cases, resection of the right coIon with primary ileo-transverse colon anastomosis, a MikuIicz type of resection or even exteriorization of the invoIved bowe1 are the procedures demanded, the choice depending on the findings and the condition of the patient. The former procedure is probabIy the most formidabIe but is the one of choice, if since it materialIy circumstances permit, shortens the hospita1 stay. SUMMARY
A case of voIvuIus of the cecum is presented in which simpIe detorsion and cecostomy re-
suIted in a favorabIe outcome. The probIem of cecal voIvuIus is discussed briefly and several important diagnostic criteria are emphasized. A short review of the recent Iiterature is presented and reveals that increasing experience with this condition has resuIted in improved diagnostic accuracy and a considerabIy lower mortality rate. REFERENCES I. CORNER, E. M. and SARGENT, P. W. G. VolvuIus
of the caecum. Ann. Surg., 41: 63-75, 1905. 2. PRATT, J. D. and FALLIS, L. S. VoIvuIus of cecum and ascending coton. J. A. M. A., 89: I 225, 1927. 3. NELSON, H. M. Postoperative voIvuIus of cecum. Am. J. Surg., 5: 398-400, 1928. 4. MCGOWAN, J. M. and DIXON, C. F. VoIvuIus of the cecum-report of case. Proc. Sta$ Meet., Mayo Clin., I I : 337-341, 1936. 5. WOLFER, J. A., BEATON, L. E. and ANSON, B. J. VoIvuIus of the cecum: anatomical factors in its etioIog;v and report of a case. Surp.. ti _. Gynec. I Obst.,y4: 882-894, 1942. 6. YOUNG, E.L., MORRISON, H. R. and WILSON, W. E. VoIvuIus of the cecum and ascending colon. New England J. Med., 237: 78-86, 1947. 7. MCGRAW, J. P,, KREMEN, A. J. and RICLER, L. G. The roentgen diagnosis of voIvuIus of the cecum. Surgery, 24: 793-804, 1948. 8. DIXON, C. F. and MEYER, A. C. VoIvuIus of the cecum. S. Clin. Nortb America, 28: 953363, 1948. g. MELCHIOR, E. VoIvuIus of the cecum-an appea1 for primary resection with report of 6 cases. Surgery, 25: 251-256, 1949. IO. DONHAUSER, J. L. and ATWELL, S. VoIvuIus of the cecum-a review of IOO cases in the Iiterature and a report of 6 new cases. Arch. Surg., 58: 129148, 1949. I I. DEAN, D. L. VoIvuIus of the decum: with report of 2 cases. Ann. SW&, 136: 319-325, 1952. 12. BYRNE, J. J., SWIFT, C. C. and FARRELL, G. E., JR. VoIvulus of the cecum. Arch. Surg., 64: 378-383, 1952. 13. RYAN, A. J. and BURBANK, J. VoIvuIus of the cecum. Am. J. Roentgenol., 68: 39g-402, 1952. 14. GLASS, B. A. and ABRAMSON, If. D. VoIvuIus of cecum due to Iithopedion. Am. J. Surg.. 86: 348352. 1953. 15. DESFORGES, G. and WILSON, H. VoIvuIus of the cecum. Am. J. Surg., 86: 116119, 1953. 16. JORDAN, G. L. and BEAHRS, 0. H. VoIvuIus of the cecum as a postoperative complication. Ann. Surg., 137: 245-249, 1953. 17. WILSON, H. E., DESFORGES, G., DUNPHY, H. G. and CAMPBELL, A. J. A. VoIvuIus of the cecumemphasis on possible predisposing lesions of the left coIon. Arch Surg., 68: 593-604. 1954. 18. YOUNG, M. 0. Coexistent voIvuIus of the spIenic Aexure and cecum. Surgery, 37: 983-990, 1955. 19. POWELJ_,J. H. and BOWERS, R. F. VoIvuIus of the cecum. Ann. Surg., 143: 126129, 1956. 20. NELSON, T. G. and BOWERS, W. F. VoIvuIus of the cecum and sigmoid coIon. Arch. G-g., 72: 469478. 1956.
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