Department of surgery, College of Medicine, Kirkuk University
Introduction: volvulus is a twisting or axial rotation of a portion of bowel about its mesentery. Large Bowel Volvulus (LBV) accounts for (5%) of all organic large bowel obstructions and are most common between 50 and 60 years of ages .The reported incidence of the various forms of LBV, (59%) for sigmoid volvulus (SV), (39%) for caecal volvulus (CV) and (2%) for transverse colon volvulus. The diagnosis of acute LBV can be challenging because its clinical presentation has low specificity compared with other non-traumatic abdominal pain. Emergency surgery is the appropriate treatment for those who present with diffuse peritonitis, intestinal perforation or ischemic necrosis.
Aim of the study: To review the comparison and benefits of emergency operative procedures in the treatment of patients with acute large bowel volvulus in the emergency setting.
Place and Duration: Department of General Surgery at Azadi-teaching hospital in Kirkuk city from December 2008 to December 2013.
Patients and Methods: Total 48 patients; 31 male (64.6%) and 17 female (35.4%) (95.8%) patients were over 55 years of age. were included in the study of which 41 (85.4%) diagnosed preoperatively with acute sigmoid volvulus on emergency laparotomy. The remaining 7 patients (14.6%) with caecal volvulus. The choice of surgical procedure depended on the; large bowel viability, time of presentation following onset of obstructive features, extent of proximal colonic dilatation, co morbid diseases and surgeon’s preference. For acute sigmoid volvulus; 11 patient (27.2%) patients underwent sigmoid resection with primary anastomosis (RPA), 18 patient (43.9%) underwent Hartmann’s procedure and 12 patients (29.3%) operated by sigmoid resection with Paul-Mikulicz. For caecal volvulus; Right hemicolectomy performed for three patients (42.9%), caecopexy in two (28.6%) and caecostomy in other two patients (28.6%). Results: Abdominal distension and constipation occurs in all patients (100%), while (95.8%) presented with abdominal pain and peritonitis in (79.2%) (41.5%) has a previous history of bowel decompression either by endoscopic instruments or deflation by rectal tube with a recurrence rate of (76.0%). Chronic medical illnesses are found in most of the patients. LBV is presented in two forms sigmoid (85.4%) of cases, the rest (14.6%) with caecal volvulus. (33.4%) of cases presented with gangrenous colon while bowel perforation (fecal peritonitis) in (4.2%). The operative procedures ;- one stage Resection with Primary Anastomosis in (26.8%) of patients , two stage operative procedures resection of the volvulus sigmoid with (Hartmann and Paul-Mikulicz done in (73.2%), in caecal volvulus right hemicolectomy (with ileo-transverse Anastomosis done for (42.9%), caecopexy (28.6%) and Caecostomy for 2 patients(28.6%) patients. Postoperative complications; Wound infection in (31.3%) of cases. Anastomotic leak (12.5%). Total mortality occurs in 10 cases (20.8%).
Conclusion: In acute LBV emergency surgery is indicated, Hartmann’s procedure is the procedure of choice. The presence of cardiac, renal, or respiratory diseases has a significant impact on the complications, morbidity and mortality of patients undergoing surgery for large bowel volvulus.