Colonic volvulus. Etiology and management

Colonic volvulus accounts for 1-7% of cases of large bowel obstruction in the United States and Western Europe. It is, however, a much commoner condition in parts of Africa, South Asia and South America. Volvulus is thought to be an idiopathic condition, probably with an anatomical basis, particularly in cecal volvulus. Some cases are, however, secondary to a known condition such as Chagas' disease. The sigmoid colon is involved in 65-80% of cases and the right colon in 15-30%. Transverse colon and splenic flexure volvulus are rare. Emergency surgery has in the past been associated with a high mortality. Nonoperative, tube decompression of sigmoid volvulus has been the single most important advance in the management of the condition--this has allowed surgery to be deferred to an elective schedule and performed on a fitter patient with a prepared bowel. Emergency surgery is still required for a minority of patients--those in whom tube decompression is unsuccessful; in those with signs of gangrenous bowel and patients with volvulus proximal to the sigmoid. When the bowel is not viable, resection is mandatory. In patients with a viable colon, there are several options. Sigmoid resection and colostomy for sigmoid volvulus and detorsion, cecopexy and tube cecostomy as a combined procedure for cecal volvulus are the usually recommended procedures.