First described by Rokitansky in 1836, as the axial rotation of a segment of the intestine [1, 2, 5, 6–11], volvulus is the third cause of intestinal obstruction in the world [8, 9, 10]. Specifically, sigmoid volvulus represents 40 to 80% of the cases of intestinal torsion, with a higher prevalence in young men [12]. The incidence of sigmoid volvulus is superior in countries located in the “volvulus belt”, that include South America, Africa, Asia, the Middle East, and Eastern Europe [2, 13].
There is an association between chronic constipation, high fiber diet, frequent use of laxatives, diseases with hypermobility, history of laparotomies (due to adhesive between intestinal segments), and anatomical dispositions such as dolicosigmoid [2, 3, 5, 14].
Early diagnosis is essential to avoid ischemia or necrosis generated by the torsion of the dilated loop and to anticipate possible subsequent complications, for that reason it is important to define the patient's condition from admission to the emergency department [8–10, 15]. The presence of clinical or radiological signs of severity such as colon necrosis or perforation with or without shock, should be taken into account to take patients immediately to surgical management [2].
Previously, abdominal X-Ray was considered the gold standard diagnostic imaging in the presence of the “coffee bean” sign. However, CT has a higher diagnostic value (100% sensitivity and > 90% specificity), because it can identify the pathology as well as possible complications to select the most feasible approach [2, 6, 7, 16, 17].
In patients without severity criteria, colonoscopic devolvulation is usually the initial approach because of its diagnostic and therapeutic characteristics [1, 2, 18]. Some studies show an acceptable rate of effective devolvulation (76%) with early recurrence between 6 and 45%. For that reason, this procedure is not used as a definitive treatment, like Mulas et al. showed in their study, where 44.8% of the patients used as primary treatment colonoscopic devolvulation and had a relapse in the first 3 months after the procedure [2, 5, 7, 18, 19].
The incidence of colonic necrosis varies according to the series2. Severe comorbidities (chronic obstructive pulmonary disease, hypertension, ischemic heart disease, heart failure, diabetes, chronic renal failure, hemiplegia, parkinsonism), the presence of shock, prolonged duration of symptoms, and combined ileal and colonic volvulus were significantly associated with the risk of colonic necrosis. The age of the patient and/or a history of sigmoid volvulus and colonic necrosis will be crucial for the recovery and survival of the patient [2, 20].
The factors associated with greater recurrence and morbidity after endoscopic devolvulation are previous laparotomy, pregnancies, diabetes mellitus, hypertension, a neuropsychiatric history with impaired autonomy, extreme ages and prostration [2, 19, 21].
The definitive surgical approach and the time in which it must be performed remain controversial, due to the lack of more randomized studies and non-significant samples [5, 14]. Nevertheless, there are multiple management options depending on the clinical status of the patient, finding laparoscopic detorsion, meso-sigmoidopexy, exteriorization with late sigmoidectomy, sigmoidectomy with Hartmann or Mikulicz procedure, sigmoidectomy with primary anastomosis, among others [1, 5–9, 15]. Meso-sigmoidoplasty or meso-sigmoidopexy is associated with a high recurrence rate between 16% and 70% [18].
The lowest rates of recurrence are seen in patients who underwent sigmoidectomy [3, 18] at the same time, in this study, sigmoidectomy was performed according to the colonoscopic findings. The success of primary anastomosis is influenced by the patient’s stability and degree of necrosis, having effect on morbidity and mortality, showing a significant decrease in the recurrence rate. However, it is recommended only to execute in stable patients without colonoscopic necrosis due to the fact that these approaches relegate the creation of stoma by Hartmann’s procedure to unstable patients [5, 7, 15, 23].
Some series of cases show management in the first 48–72 hours after colonoscopic devolvulation [7]. Mulas et al. had a mean time of 4.5 days from diagnosis to performing of the procedure, [5] being similar to the average time shown in this study. Masami et al. evidenced three patients that underwent successfully colonoscopic devolvulation delayed by 1 week, 1 month and 3 months until laparoscopic sigmoidectomy, also showing no recurrence in 12 to 24 months of following up, demonstrating not only the viability of laparoscopic procedures in two cases per single port, but also no recurrence after resection [18].
Lopez et al. successfully intervened 13 patients, by colonoscopic devolvulation and subsequent laparoscopic sigmoidectomy, all presenting symptoms of intestinal obstruction secondary to sigmoid volvulus, having a mortality of 7% (1 patient), with a recurrence rate similar to the reported in studies where sigmoidectomy was not performed [7].. However, in our study, there were no recurrence or mortality after two years of follow-up.
Mulas et al. in their study included 75 patients, 34 of them were taken to non-surgical management, presenting a higher mortality of 26.4% and an early recurrence rate. On the other hand, a shorter recurrence time is evidenced with an average of 3.5 months in patients with medical management compared to 94.5 months in the group that received surgical management [5]. No recurrence or mortality was evidenced in our study.
In the case presented by Tomezzoli et al., a patient presenting sigmoid volvulus secondary to Hirschsprung's disease, had multiple volvulations despite endoscopic management. For this reason, laparoscopic management in this case was imperative to avoid recurrences. [22]
The main limitation of this study is its retrospective observational characteristics without randomization and with no control group. Therefore, it is subject to selection bias. In addition, as the frequency of complications is low, the N size and the follow-up of our study may be too small and too short to find the incidence of complications for this technique.