Transcript Volvulus - WordPress.com

VOLVULUS
DR.M.RAVICHANDRA,M.S
ASST.PROF OF SURGERY
RIMS,SRIKAKULAM
DEFINITION
 A VOLVULUS IS TWISTING OR AXIAL
ROTATION OF A PORTION OF BOWEL
ABOUT IT’S MESENTRY
VOLVULUS
 OBSTRUCTION CAUSED BY
TWISTING OF THE INTESTINES
MORE THAN 180 DEGREES
ABOUT THE AXIS OF THE
MESENTERY
 1-5% OF LARGE BOWEL
OBSTRUCTIONS




SIGMOID ~ 65%
CECUM ~25%
TRANSVERSE COLON ~4%
SPLENIC FLEXURE
TYPES
 PRIMARY&SECONDARY
 PRIMARY
 CONGENITAL MALROTATION OF GUT
 ABNORMAL MESENTERIC ATTACHMENTS
 CONGENITAL BANDS
 SECONDARY
 ACQUIRED ADHESION
 (OR) STOMA
SIGMOID VOLVULUS
 WORLDWIDE - UP TO 50% OF
OBSTRUCTION
 INDIA, AFRICA, E. EUROPE
 MORE COMMONLY SEEN IN ELDERLY
PATIENTS IN WESTERN SOCIETIES
 RISK FACTORS
 CHRONIC CONSTIPATION
 PSYCHIATRIC PROBLEMS
 NON-WESTERN SOCIETIES
 HIGH RESIDUE DIET
PREDISPOSING FACTORS
 BAND OF ADHESIONS(PERIDIVERTICULITIS)
 OVER LOADED PELVIC COLON
 LONG PELVIC MESOCOLON
 NARROW PELVIC MESOCOLON
THE ACUTE ABDOMEN IN RHYME.ZACHARY
COPE,1881-1974
 SOMETIMES A BOWEL-COIL GETS OUT OF
PLACE
 BY TWISTING ROUND A NARROW BASE
 WITH GRADUAL STRANGULATING OF THE
BLOOD SUPPLY
 AND DANGER THAT THE AFFECTED COIL WILL
DIE
 THIS IS AVOLVULUS WHICH YOU SHOULD
LEARN
 IS FROM THE LATIN-VOLVERE-TO-TURN
*Image by 13304137@N06 via Flickr
*Image by 58123287@N00 via Flickr
PRESENTATION
 HX: ABDOMINAL PAIN,
DISTENSION,ABSTIPATI
ON,VOMITING OCCURS
LATE,HICCOUGH&RETC
HING NO FLATUS OR
BOWEL MOVEMENTS
 EXAM: TYMPANITIC
ABDOMEN,
DISTENSION, MILD
TENDERNESS,
PALPABLE MASS
SIGMOID VOLVULUS
 “BENT INNER TUBE”
APPEARANCE
 DILATED SIGMOID
LOOP WITH LIMBS
POINTING TOWARDS
THE RLQ
ZACHARY COPE
 THOUGH SOMETIMES IN A PERSON WHO IS FAT
THE DIAGNOSIS IS NOT CLEAR AS THAT
TIS THEN YOU GET HELP FROM PLAIN XRAY
WHICH GAS WITHIN THE GUT SHOWED WELL DISPLAY
SO THAT THE COIL YOU SEE IN THE RADIOGRAM
REACHING FROM PELVIS TO THE DIAPHRAGM
SIGMOID VOLVULUS
 “COFFEE BEAN”
APPEARANCE WITH
THE TWO TWISTED
LOOPS WITH A
CENTRAL DOUBLE
WALL COMPONENT
*Image by 66317200@N07 via Flickr
*Image by 35230739@N05 via Flickr
BARIUM ENEMA
 CONTRAINDICATE
D IN PATIENTS
WITH FREE AIR ON
AXR, CLINICAL
SIGNS OF
PERITONITIS, OR
SUSPICION FOR
NECROSED
BOWEL
 BIRD’S BEAK
 CAN
DECOMPRESS
MANAGEMENT OF CHOICE
 ENDOSCOPIC
DECOMPRESSION
 RIGID OR FLEXIBLE





PROCTOSIGMOIDOSCOPE
INSERTED INTO RECTUM
GUSH OF AIR/FECES -->
SUCCESSFUL DECOMPRESSION
RECTAL TUBE
SUCCESSFUL IN 85-90% OF CASES
RECURRENCE RATE >60%
DECREASED RISK FOR BOWEL
NECROSIS IF TREATED EARLY
 COLON ISCHEMIA, PERFORATION
 ELECTIVE RESECTION
OPERATIVE MANAGEMENT FOR SIGMOID
VOLVULUS
 ELECTIVE RESECTION
 SAME ADMISSION
 EMERGENT LAPAROTOMY
 OPERATION DEPENDS ON
VIABILITY OF THE BOWEL
 RESECTION AND
ANASTOMOSIS
 HARTMANN RESECTION
 EXTERIORIZATION RESECTION
(PAUL MICKULISZ
PROCEDURE)
 DETORSION
 DETORSION WITH COLOPEXY
 PERCUTANEOUS COLOSTOMY
 PERCUTANEOUS
SIGMOIDPEXY
 DELAYED RESECTION WITH PRIMARY
ANASTOMOSIS
 MORTALITY RATE 8%
 OPERATIVE MORTALITY RELATED TO
VIABILITY OF BOWEL
 VIABLE 12% VS NONVIABLE 53% MORTALITY
AN ANECDOTE
 A FRAGILE LADY IN HER MID 80S
SUFFERED ONE EPISODE AFTER ANOTHER
BUT EACH TIME SHE WAS THOUGHT UNFIT
FOR AN ELECTIVE OPERATION ON A
BENIGN CONDITION. AFTER HER 12TH
VOLVULUS SHE HAD PROVED HER CASE
AND WAS SUBJECTED TO SIGMOIDECTOMY
FROM WHICH SHE RECOVERED
UNEVENTFULLY AND WAS DISCHARGED
AFTER 5 DAYS
CECAL VOLVULUS
 LESS COMMON THAN SIGMOID VOLVULUS
 PARIETAL PERITONEUM FAILS TO CONNECT
WITH THE CECUM AND RIGHT COLON
 PRESENT IN ABOUT 10% OF POPULATION
 INCREASED MOBILITY OF BOWEL, RESULTING
IN IT FOLDING ON ITS AXIS OR UPWARD
 TORSION OCCURS PROXIMAL TO CECUM
 RISK FACTORS:
 DISTAL OBSTRUCTION, PREGNANCY, ADHESIONS,
CONGENITAL BANDS, PROLONGED CONSTIPATION,
METEORISM (AIR IN INTESTINES) THAT OCCURS
WITH NON-PRESSURIZED AIR TRAVEL
 HX: ABDOMINAL PAIN,
COLICKY
 DISTENTION
 AXIAL TORSION TYPE
 TWIST 180-360 DEGREES
ON LONGITUDINAL AXIS
OF ASCENDING COLON
(DISTAL ILEUM AND
ASCENDING COLON)
 ASSOCIATED WITH
BOWEL COMPROMISE,
ISCHEMIA, AND
PERFORATION
 CECAL BASCULE
 CECUM FOLDS
ANTERIORLY ON
ASCENDING COLON
 MAY RESULT IN
INTERMITTENT
OBSTRUCTIVE
SYMPTOMS
X-RAYS
 “COMMA” SHAPED
 CONVEXITY TOWARD
RIGHT AND
DOWNWARD
 BE - RISK OF
PERFORATION WITH
GETTING
AIR/CONTRAST TO
RIGHT COLON
*Image by 77814749@N00 via Flickr
C.T OF CAECAL VOLVULUS
*Image by 77814749@N00 via Flickr
MANAGEMENT
 DECOMPRESSION
WITH COLONOSCOPE
 LESS SUCCESSFUL
THAN WITH SIGMOID
VOLVULUS
 EMERGENT
OPERATION IF SIGNS
OF VASCULAR
COMPROMISE
OPERATIVE MANAGEMENT FOR CECAL VOLVULUS
 DETORSION ±
APPENDECTOMY
 CECOPEXY/LAPAROSCOPIC
CECOPEXY
 SUTURE R COLON TO LATERAL
PARACOLIC GUTTER OR USE
LATERAL PERITONEAL FLAP
 CECOSTOMY
 RESECTION
 RIGHT COLECTOMY WITH
PRIMARY ANASTOMOSIS
RESULTS
 DETORSION ± APPENDECTOMY
 HIGH RATE OF RECURRENCE (NOT COMMONLY
DONE ANYMORE)
 CECOPEXY
 DO NOT NEED TO HAVE PREPPED BOWEL
 RECURRENCE 25%
 CECOSTOMY ± CECOPEXY
 COMBINED PROCEDURE MORE EFFECTIVE IN
PREVENTING RECURRENCE
 RESECTION
 PRIMARY ANASTOMOSIS UNLESS PERITONEAL
CONTAMINATION IS PRESENT
TRANSVERSE COLON VOLVULUS
 LESS COMMON AREA FOR VOLVULUS(4%)
 ASSOCIATED WITH MOBILE RIGHT COLON,
DISTAL OBSTRUCTION, CHRONIC
CONSTIPATION, CONGENITAL MALROTATION
OF THE MIDGUT
 USUALLY NOT DIAGNOSED PREOPERATIVELY
 NO CHARACTERISTIC RADIOLOGICAL
FINDINGS EXCEPT COLONIC DILATATION
 RESECTION OF TRANSVERSE COLON
 HIGH RATE OF RECURRENCE IF TREATED WITH
DETORSION ALONE
VOLVULUS NEONATARUM
 PREDISPOSED BY ARRESTED ROTATION OF
GUT WITH A RESULTANT NARROW
MESENTERY OF SMALL BOWEL & CAECUM
 SYMPTOMS – VOMITINGS,ABDOMINAL
DISTENTION, & DEHYDRATION
 AXR REVEALS SIGNS OF DUODENAL
OBSTRUCTION
 LAPAROTOMY REVEALS DISTENDED
STOMACH & COILS OF INTESTINE
 TORSION IS IN CLOCKWISE DIRECTION
 OPERATION REDUCTION BY UNTWISTING &
DIVISION OF ANY SECONDARY OBSTRUCTIVE
LESIONS LIKE TRANSDUODENAL BAND OF
LADD
VOLVULUS OF SMALL INTESTINE
 OCCURS IN LOWER ILEUM
 PRIMARY & SECONDARY
 PRIMARY
 SPONTANEOUS
 IN AFRICANS
 FOLLOWING CONSUMPTION OF LARGE
VOLUME OF VEGETABLE MATTER
 SECONDARY
 WEST
 ADHESIONS PASSING TO PARIETIES/FEMALE
PELVIC ORGANS
 TREATMENT - REDUCTION OF TWIST &
TREAT UNDER LYING CAUSE
VOLVULUS OF STOMACH
 ROTATION OF STOMACH AROUND THE
AXIS AND 2 FIXED POINTS THE CARDIA &
THE PYLORUS
 2 TYPES
 HORIZONTAL(ORGANO AXIAL) M.C
 VERTICAL(MESENTERIO AXIAL)
 USUALLY ASSOCIATED WITH A
DIAPHRAMATIC DFEFECT AROUND
ESOPHAGUS AND THERE IS
PARAESOPHAGEAL HERNIATION
VOLVULUS OF STOMACH CONTD…
 TRANSVERSE COLON MOVES UPWARDS TO




LIE UNDER THE LEFT HEMIDIAPHRAGM
DURING THIS PROCESS IT TAKES STOMACH
ALONG WITH IT
STOMACH& COLON BOTH ENTER THE
CHEST THROUGH THE EVENTRATION OF
DIAPHRAGM
CHRONIC- DIFFICULTY IN EATING
ACUTE MAY PRESENT WITH ISCHAEMIA
VOLVULUS OF STOMACH CONTD…
 TREATMENT
 BOTH OPEN&LAP
 REDUCTION OF SAC & CONTENTS
 CLOSURE OF DEFECT IN DIAPHRAGM WITH
MESH
 SEPARATE STOMACH FROM TRANS. COLON
 PERFORM ANTERIOR GASTROPEXY
*Image by 65358032@N06 via Flickr