Discussion
fatty anterior abdominal wall, necrosis, fever, fecal fistula, sigmoid volvulus, anastomotic leak and small intestinal, wound infection, intestinal injury, skin necrosis, intestinal ischemia, co-morbidity, volvulus, pelvic abscess, fistula, pain, peritonitis, failure of endoscopic fixation
RECURRENCE, INTESTINAL OBSTRUCTION, WOUND INFECTION, NECROSIS, ADHESIONS, PELVIC ABSCESS, PERITONITIS, ASPIRATION PNEUMONIA, SUBCUTANEOUS EMPHYSEMA, CHEST INFECTION, INTESTINAL ISCHEMIA, ADVERSE EVENT, ANASTOMOTIC LEAK, COMPLICATIONS, SIGMOID VOLVULUS, OTHER COMPLICATION, SKIN NECROSIS, VOLVULUS, SEPTIC SHOCK
As the incidence rate of acute sigmoid volvulus is high in elderly patients and is usually associated with serious and fatal complications if remains untreated, and also as the elderly patients usually have much co-morbidity, the least invasive maneuver to treat volvulus should be advised [In addition to its diagnostic and therapeutic advantages, the endoscopic approach is characterized with shorter operative time, shorter length of hospital stay, faster management, and no need for general anesthesia. For these advantages, the endoscopy has the upper hand in managing volvulus, especially in elderly patients with much co-morbidity [In this study, we included patients with body mass index below 35 as the higher body mass index is usually associated with failure of endoscopic fixation because of thick and fatty anterior abdominal wall that makes it difficult for two-shot anchor device to reach sigmoid colon lumen, so the thinner the patient, the higher success rate.In endoscopic group, after endoscopic untwisting of volvulus, patients were subjected to fixation within 1 or 2 days after colonic preparation while in surgical group, patients had been firstly subjected to colostomy then after at least 6 weeks, they underwent the definitive surgery; hence, the quality of life was better in the endoscopic group.In this study, there was no need for general anesthesia in the endoscopic group, so the endoscopic approach seems suitable for patients with American Society of Anesthesiologists III and IV classes and elderly patients with many comorbidities, as well.Also, endoscopic fixation is feasible in those patients with a past history of recurrent volvulus and/or past history of previous abdominal operation as in this study, unlike the traditional surgery for sigmoid volvulus as when it is performed in patients with a past history of abdominal surgery, it may be associated with a high incidence of lethal complications such as intestinal injury because of the existing adhesions.In this study, the complications included chest infection, skin necrosis, peritonitis, pelvic abscess, small intestinal injury, and wound infection. In the endoscopic group, only 2 patients developed fever because of chest infection. Other complications did not occur in the endoscopic group as the site of fixation was only 2mm in length, so the incidence rate of wound infection was extremely rare. In this study, various complications such as intestinal injury, fecal fistula, pelvic abscess, and peritonitis were not seen in endoscopic group because all procedure’s steps were performed under radiological guidance. However, in the surgical group, there were 3 patients with chest infection, 3 patients with peritonitis (due to fecal fistula, anastomotic leak, and small intestinal injury), 3 patients with pelvic abscess (due to anastomotic leak and small intestinal injury), 1 patient with small intestinal injury (this occurred in patient with history of previous abdominal surgery due to extensive adhesions), 3 patients with wound infection (due to fecal fistula), and 3 patients with skin necrosis at colostomy site (due to fecal fistula). Mortality has occurred in one patient in surgical group due to fecal fistula, peritonitis, and septic shock. In surgical group patients, the complications occurred 6 weeks later after sigmoid fixation or excision.In comparison to the present study, Imakita et al. included 8 patients with American Society of Anesthesiologists classes > 3 and excluded patients with intestinal ischemia and necrosis. Imakita et al. performed colonoscopy assisted percutaneous sigmoidopexy in 8 patients, with median age of 72.5 years. Their results showed that median procedure time was 72.5 min; median time for fixation was 16 min; the only perioperative adverse event elicited was subcutaneous emphysema in one patient; no patients developed peritonitis, small intestinal injury, peritoneal collection, wound infection, nor intestinal obstruction. In the previously mentioned study, no recurrence occurred during the 1-year follow up period, while 3 patients died due to aspiration pneumonia after 4 months (not related to the procedure). So our study is in consistence with Imakita et al. that there was no recurrence after endoscopic fixation of sigmoid colon with no other complications related to the procedure [We used WHOQOL-BREF questionnaire that has 26 items to assess the quality of life. This questionnaire has four domains included which are physical health domain (7 items), psychological health domain (6 items), social relationship domain (3 items), and environmental health domain (8 items); it also has quality of life and general health item. Each separate item is scored from 1 to 5 on a response scale. The scale is then stipulated as a five point ordinal scale. The score is then changed linearly to a 0–100 scale. The physical health domain includes items on mobility, daily activities, functional capacity, energy, pain, and sleep. The psychological domain includes items on self-image, negative thoughts, positive attitude, self-esteem, mentality, learning ability, memory concentration, religion, and mental status. The social relationship domain includes items on personal relationship, social support, and sex life. The environmental health includes items on financial resources, safety, health and social services, living physical environment, opportunities to acquire new skills and knowledge, recreation, general environment (noise, air pollution, etc.), and transportation. The score below 50 means poor quality of life, score between 50 and 75 means good quality of life, and score more than 75 means excellent or high quality of life. The quality of life was assessed 9 months after sigmoid fixation in endoscopic group or sigmoid fixation or excision in surgical group.This study has some limitations, the small sample size that may not give powerful statistical conclusions. The small sample size was due to low incidence rate of sigmoid volvulus. Inclusion of only elderly patients with American Society of Anesthesiologists III and IV classes, and exclusion of patients < 60 years old and patients who responded to deflating rectal tube are other limitations of this study (those responders to deflating rectal tube were excluded and managed later by sigmoid fixation either by surgery or endoscopy; or sigmoid excision; or follow up according to the patient’s general condition or patient’s choice, as this study was mainly directed towards high risk surgical elderly patients who did not respond to rectal deflating tube to avoid morbidities and mortality associated with untwisting the sigmoid colon. More large studies should be performed to include different categories of the patients in order to prove the efficacy and safety of endoscopic sigmoid fixation). Many other trials should be done in the future for all patients with sigmoid volvulus as endoscopic sigmoid fixation may be safe and effective in all patients. The strength of the present study is being a randomized controlled trial that compared endoscopic intervention on one hand with the surgical intervention on the other hand. Also, it proved the efficacy and safety of the endoscopic fixation of sigmoid colon in elderly high risk surgical patients. Moreover, it shortened the wait period before sigmoid fixation or excision (median waiting time was 6 weeks