Comments on "Sigmoid volvulus management, only endoscopic devolvulation?"

We are grateful our case has aroused such interest from our Turkish colleagues, and we thank them for their kind reply. Sigmoid volvulus (SV) is the third leading cause of colonic obstruction in the world. Is it widely known there is a progressive aging of the population. Prevention with lifestyle habits and early treatment of cardiovascular risk factors has led to an increase of pluripatologic chronic conditions. A higher incidence of neurodegenerative diseases is also a proven fact. Their intestinalinvolvementcan be ina direct form, withneuronal destruction in myenteric plexus leading to chronic constipation, and alsodue to secondary drug effects (laxatives causing fecal overloading, increased intracolonic pressure, dolichocolon…), all favouringweakness in colonic wall, and therefore the appearance of sigmoid volvulus. We don´t have specific data about SV incidence and recurrence in our centre.However, literature reviews show recurrence is the norm in the majority of cases after colonic decompression. Data reported from our colleagues in Turkey represents a single centre cohort and a broad spectrum over time (from 1960s until now), so recurrence rate should not be generalized to global population. The continuous improvement in endoscopic procedures since their beginning might have despair results of colonic decompression and need of surgery among years. Nowadays we have more sophisticated and high-resolution endoscopes, as well as better trained endoscopists with more advanced therapeutic techniques. This might overlap with surgical development of less invasive techniques, lower rates of complication and shorter postoperative recovery. We suggest the authors to examin in their database the different outcomes through decades in their cohort since we believe medical/endoscopic/surgical approach has changed from 1960s until now. Finally, we agree elective surgery must be the final treatment in SV cases with American Society of Anesthesiologists (ASA) scores 1-3. Endoscopic or laparoscopic colopexychoice for ASA > 3 patients should be made based on each centre´s experience. We believe endoscopic approach with endoscopic colostomy or sigmoidopexy might be the first approach for fragile patients since it is an easily performed technique, with low rate of complications and acceptable long-term results preventing a recurrence of SV. Further studies are needed to compare minimally invasive surgery to endoscopic approach.