Sigmoid volvulus is a frequent reason for emergency surgical admission. Despite Literature evidence and guidelines, the usual emergency treatment is bowel decompression and derotation, but at the price of a high rate of recurrence that in our series is about 75%, which is consistent with the available Literature [4–7, 11, 12]. Mortality has been shown to be up to 20% during recurrence and so endoscopic devolution must be considered only a temporary measure [7, 13] leading to a definitive treatment where possible.
Unfortunately, guidance on indications and timing of surgery are not very clear, and the decision remains with the emergency surgeon and the patient whose ability to understand, retain and use the information given may be impaired due to their chronic and acute illness.
Patients with normal CRP are more likely to undergo surgery. This finding can be related to a strict selection of patients, trying to avoid surgery in those patients with sepsis and therefore with high risk of mortality, as demonstrated by Heo et al. [14]. In fact, while for other conditions sepsis would prompt an emergency operation for source control, in already frail and looked-after patients, sepsis can be a terminal event and surgery can be considered futile.
Patients are more likely to undergo surgery within their first three admissions. This may relate to the patient’s fitness for surgery and/or to their complicated presentation. The ASCRS guidelines advised that after a single episode of volvulus elective surgery should be planned to prevent further recurrence [8], but not all patients are considered fit for surgery at their first admission. Despite the presence of objective criteria, fitness for surgery is often a matter of subjective evaluation that can be biased by personal ideas and impressions. As a matter of fact, in our series the choice of surgery was not influenced by the ASA score (Table 1), thus demonstrating that at the moment the surgical choice is still based on not-better-specified “clinical criteria”. On the contrary, we feel that surgery must be considered the first choice in patients whose fitness has been evaluated by strict evidence-based criteria, also considering the overall low surgical risk and the low risk of recurrence after surgical resection [7].
Quénéhervé et al. found that patients in their ‘no surgery group’ were older and frailer and agree that surgeons are more reluctant to carry our colonic surgery on this cohort of patients, therefore, quite expectedly, general conditions of the patients – and their frailty – may represent a factor to be considered when deciding the treatment strategy [3].
The timing of planned surgery remains controversial. Some suggest that definitive surgery should be carried out within 2–5 days of the initial volvulus [15, 16]. Furthermore Johansson et al. found that recurrence was more frequent after the second episode, leading us to believe that elective surgery should only be advised following the second recurrence and not the first [5]. Our series demonstrates that there is no significant difference of long-term survival according to timing of surgery (Fig. 2), therefore early surgery may be suggested against a late operation mostly to improve quality of life and reduce the risk of further admissions.
Long term survival in this cohort of patients strictly depends on the treatment they receive. Overall mean survival was about 5 years, but long-term survival can only be possible in patients who undergo a surgical resection, while only less than 20% of non-surgical patients are still alive 5 years after their presentation. Ifversen et al. found that patients who were treated surgically after the first occurrence had a far better survival. [4]. Interestingly, in our cohort, survival was not affected by timing of surgery and patients operated after the first two admissions had similar survival than those operated earlier. However, the actuarial curve is not completely overlapping (Fig. 2), allowing us to hypothesize that with a larger sample and a longer follow-up it could be possible to highlight an advantage for the patients who had an earlier operation.
Our study shows survival was better in patients with low social score. It is worth specifying that our “social score” is only indirectly related to medical conditions and general frailty, being on the contrary a classification of the social circumstances of the patient. While it is obvious that generally speaking more frail patients may likely need a more complex social support, we wonder if this is enough to justify a shorter survival in patients with high social score, independently of clinical frailty. In fact, in our analysis, frailty has not been found to be an independently prognostic variable. It looks like some frail patients who live independently may have better outcomes with respect to those with the same frailty who need strong social support. This is an interesting issue that should be analysed with a different study design on a larger population.
In our study survival was also better in women. This may be, at least partially, related to the fact that women were more likely to be offered a surgical operation, therefore they might have been in better general conditions. However, this recalls once again the issue of ‘clinical perception’. It is possible that women were perceived to be in better general conditions, without using objective criteria but only the surgical “first impression”. Another factor must be anyway taken into account, the natural longer survival and the greater resilience of female patients with respect to men [17].
This paper offers a significant insight on a selected cohort and allows to draw interesting conclusions that somewhat challenge the current conservative attitude towards patients treated for sigmoid volvulus, supporting clinical evidence and guidelines. However, beyond its intrinsic value, it can be regarded as a pilot study that can prompt further research. In fact, main limitations of our paper are the small sample size, and the retrospective nature, along with the relatively short follow-up. Although both our cohorts of surgical and non-surgical patients matched for every basic clinical aspect, the surgical decision was not always based on strict clinical criteria but mostly on the choice of the surgeon in charge. A proper randomised controlled trial would be able to clarify some still unsolved issues, such as indications, contraindications and timing of surgery.