Intervention
sigmoid colon, volvulus, intestinal obstruction
ENDO, RECURRENCE, SIGMOID VOLVULUS, INTESTINAL OBSTRUCTION, VOLVULUS, SEPARATION
In this study, the investigators tried to relieve intestinal obstruction due to sigmoid volvulus then preventing recurrence of volvulus only in high risk surgical elderly patients with high risk of anesthesia. Initially, a rectal deflating tube was tried in all patients with a high success rate in relieving obstruction but recurrence was the rule and a conflicting issue especially in this category of patients. Thus, in this study, the investigators focused only on this category of the patients who were not responding to the rectal deflating tube. Patients who were managed by rectal deflating tube were excluded from the start of the trial. Therefore, randomization of the patients was only done after rectal deflating tube trial failure. Patients in endoscopic group were subjected for endoscopic untwist of volvulus first then endoscopic fixation of sigmoid colon, while patients in surgical group were subjected for simple loop proximal colostomy first then sigmoid fixation or excision.For Endoscopic Group: no colostomy was performed, but it was just a transmural fixation. After admission of patients to the emergency department and confirmation of the diagnosis, the included patients in this group were subjected for rapid resuscitation in ICU (intensive care unit) or inpatient bed according to patient’s general condition. The resuscitated patients rapidly underwent colonoscopy under sedation in operative room (OR) to untwist the volvulus by passing the colonoscopy (CF260 series; Olympus, Tokyo, Japan) to the site of volvulus. The untwist was performed under radiological guidance of C-arm by gas suction and insufflation till untwisting was achieved. Then the rectal tube was inserted under colonoscopic guidance and visualization to avoid recurrence of volvulus and also for bedside washing and irrigation of the colon by ringer or saline solution (500cc /8h for 1 or 2 days) to evacuate the colon from fecal matter and for mechanical preparation of the colon, during this period all patients were kept nothing per mouth.After that (on postoperative day 2 or 3 “POD 2 or 3”), patients were transferred again to operative theater (OR) for sigmoid colon fixation by endoscopy (as shown in Fig. The technique was performed by two doctors (one for endoscopic procedure and the other one for sigmoid fixation procedure).The patients were sedated after intravenous preoperative ceftriaxone and metronidazole injection.Then colonoscopy was performed in lithotomy position to locate the site of sigmoid colon fixation using radiological colonography by injection of radio-opaque dye via the endoscopy.Then the tip of an artery forceps was externally positioned at anterior abdominal wall in the left lower quadrant to meet tip of colonoscopy or by trans-illumination against skin of anterior abdominal wall with indentation by index finger of surgeon’s hand. These points of fixation were arranged in circular manner, two parallel lines or even along the course of sigmoid with 1cm distance between each other. The pattern of points of fixation depended on the contour of patient’s abdomen, course and accessibility of sigmoid colon, and surgeon’s preference. In this study, the investigators used a two-shot anchor device (Olympus, Tokyo, Japan) that is used specifically for gastric fixation, to fix the sigmoid colon at anterior abdominal wall or Endo Close Device (Trocar Site Closure Device). The two-shot anchor device has two threads with T-shaped metal bar, each device is used for fixation at one point, each device has two buttons with a double, click top button, first thread with metal bar is released by pressing the first marked button with one press on top button for complete separation of the thread from the device, then the second thread is released by pressing the second marked button with another press on top button for complete separation from the device, then the two threads are pulled up against anterior abdominal wall then are tied together.At this point, the skin was incised by scalpel about (2–3 mm puncture) then widening the puncture by artery forceps at level of subcutaneous tissue. A 2-shot anchor device (Olympus, Tokyo, Japan) was inserted to anchor and tether the sigmoid colon to anterior abdominal wall. We used a 20-gauge needle for further confirmation of site of fixation.We performed a suction test to exclude the presence of any intervening organs between the sigmoid colon and anterior abdominal wall.After that, the 2-shot anchor device was passed through the puncture to be entered inside the sigmoid colon and the thread with a metal T-bar was detached and pulled towards the anterior abdominal wall.We repeated the previous steps at multiple points through multiple incisions (4–5 points of fixation).Fixation of sigmoid colon [On the following day before patient’s discharge, CT-colonography (virtual colonoscopy) was performed to confirm sigmoid fixation and avoid missing any leak.Patients in surgical group underwent simple loop sigmoid colostomy proximal to site of obstruction in all patients in this group under general anesthesia by lower small exploratory midline incision, then deflating the sigmoid colon after untwisting, then simple loop sigmoid colostomy was done, then later after 6 weeks, all patients were subjected for surgical sigmoid fixation ( in 5 patients) or sigmoidectomy (in 4 patients due to large size colon and long mesentery of sigmoid colon or recurrence) after good colonic preparation either by open or laparoscopic approach according to patient general condition. For sigmoid fixation, closure of colostomy was done first by primary closure, and then extra-mural fixation of sigmoid colon was done to anterior abdominal wall by multiple interrupted simple sutures. However, sigmoidectomy was performed in cases of large size sigmoid colon with long mesentery and recurrent cases; resection anastomosis was done including site of colostomy by circular staplers.