World J Surg (2008) 32:459–464 DOI 10.1007/s00268-007-9353-3
Sigmoid Volvulus in the Middle East Hussein A. Heis Æ Kamal E. Bani-Hani Æ Daher K. Rabadi Æ Mwaffaq A. Elheis Æ Bayan K. Bani-Hani Æ Tagleb S. Mazahreh Æ Ziyad A. Bataineh Æ Nabeil A. Al-Zoubi Æ Mohammed S. Obeidallah
Published online: 16 January 2008 Ó Socie´te´ Internationale de Chirurgie 2007
Abstract Little is known about sigmoid volvulus in the Middle East despite textbooks referring to the region as part of the ‘‘volvulus belt.’’ Our objectives were to assess the prevalence, clinical presentations, radiological findings, operative treatments, and postoperative outcomes of patients managed for sigmoid volvulus in Jordan as a model for the region. The medical records of patients with large bowel obstruction who were managed at King Abdullah University Hospital and its affiliated institutes, northern Jordan, over a 6-year period between January 2001 and January 2007 were retrospectively reviewed to identify patients with a confirmed diagnosis of sigmoid volvulus. Sigmoid volvulus was responsible for 9.2% of all cases of large bowel obstruction seen during the study period. There were 32 patients with sigmoid volvulus, 24 (75%) of whom were men. The median age of the patients was 59 years (range 21–83 years). Abdominal pain and distention were the main presentations. Colonoscopic detorsion was applied in 25 patients, which was achieved in 17 (68%) of them after the first attempt. Six patients had a gangrenous sigmoid colon, four of which required resection and a Hartmann procedure. Sigmoid resection with primary anastomosis was performed in 28 patients,
H. A. Heis K. E. Bani-Hani (&) D. K. Rabadi B. K. Bani-Hani T. S. Mazahreh Z. A. Bataineh N. A. Al-Zoubi M. S. Obeidallah Department of Surgery, King Abdullah University Hospital, Faculty of Medicine, Jordan University of Science and Technology, PO Box 3030, Irbid, Jordan 22110 e-mail:
[email protected] M. A. Elheis Department of Radiology, King Abdullah University Hospital, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan 22110
including 2 with a gangrenous colon. Postoperative complications were observed in five patients, including one patient with viable colon who develop an anastomotic leak. Two patients died, making the mortality rate 6%. Sigmoid volvulus is uncommon in Jordan. Resection of the sigmoid colon with primary anastomosis appears to be the preferred procedure.
The worldwide incidence of sigmoid colon volvulus (SCV) is not known, but it varies widely according to the geography and population studied. In Western countries, SCV is the most common colonic volvulus; however, it is a relatively uncommon cause of intestinal obstruction, representing approximately 8% to 10% of all cases. In the United States, SCV is the third most common cause of colonic obstruction after cancer and diverticulitis [1]. In contrast, the prevalence is much higher in other parts of the world, such as Iran, India, Bolivia, Brazil, Nigeria, West Africa, and Ethiopia, where SCV accounts for 50% to 85% of large bowel obstructions [2–8]. In the ‘‘volvulus belt’’ of South America, Africa, and southern Asia, the consumption of high-fiber diets results in a long, redundant sigmoid colon. In Brazil, Chagas’ disease, with its associated megacolon, is a major cause of SCV [5]. SCV also occurs frequently in young people in geographic areas in which roundworms are endemic [9]. Little is known about sigmoid volvulus in the Middle East, despite textbooks referring to the region as part of the ‘‘volvulus belt.’’ The aim of this study was to assess if the Middle East region is part of the ‘‘volvulus belt’’ by examining the prevalence of sigmoid volvulus in Jordan as a model for the Middle East region. Another aim of this
123
460
World J Surg (2008) 32:459–464
study was to review our experience with sigmoid volvulus, with emphasis on the prevalence, etiology, clinicopathologic features, and treatment options. Another purpose was to describe the clinical profile of patients with SCV in Jordan and highlight the diagnostic difficulties and pitfalls.
Patients and methods The medical records of patients with large bowel obstruction who were managed at King Abdullah University Hospital and its affiliated institutes, northern Jordan, over a 6-year period between January 2001 and January 2007 were retrospectively reviewed to identify patients with a confirmed diagnosis of SCV. During the study period, 349 patients with large bowel obstruction were managed at our hospitals. The etiologies of obstruction for the whole group of patients are summarized in Table 1. SCV was identified in only 32 (9.2%) of these patients. For these 32 patients, the demographic data, clinicopathologic features, preoperative radiologic investigations, attempted endoscopic decompression, operative findings, type of surgical procedure performed, postoperative complications, mortality, and duration of hospital stay were retrospectively reviewed and analyzed. Before 2001, some of the patients with successful colonoscopic reduction were not offered surgery. Since the introduction of a specialized gastrointestinal unit at our hospitals in January 2001, we have adopted a more radical approach. According to the protocols at our hospitals, patients with SCV are first offered colonoscopic decompression for their acute colonic obstruction through careful flexible colonoscopy or sigmoidoscopy with minimum air insufflation after adequate resuscitation fluid therapy.
Table 1 Causes of large bowel obstruction among 349 patients Cause
No. of patients
Colonic carcinoma
217
62.2
Diverticular disease
51
14.6
Sigmoid colonic volvulus
32
9.2
Adhesions
19
5.4
Colonic pseudoobstruction
12
3.4
Cecal volvulus
6
1.7
Intussusception
5
1.4
Hernia Pelvic neoplasms
2 2
0.6 0.6
Fecal impaction
1
0.3
Acute toxic dilatation
1
0.3
Endometriosis
1
0.3
349
100
Total
123
%
Barium enema is not used routinely at our hospital for SCV decompression. If the colonic decompression is successful, complete bowel preparation is performed, followed by semielective laparotomy after 2 days. If colonic decompression fails, the patient is taken to theater for emergency laparotomy. During surgery, regardless of whether the sigmoid colon is gangrenous, derotation of the sigmoid colon and lysis of mesosigmoid adhesions is performed, followed by sigmoidectomy and primary tension-free endto-end colorectal anastomosis. Intraoperative colonic lavage is used selectively in cases of emergency surgery if the patient has a loaded colon and is deemed suitable for segmental resection and primary anastomosis. If the risk of anastomotic leakage is considered high in a specific case, a protective ileostomy is selectively performed. If sigmoid perforation is present, a Hartman procedure and colostomy are undertaken. All patients receive intravenous cephalosporin with metronidazole at admission, which is continued for at least 5 days following surgery.
Statistical analysis Univariate analysis was performed utilizing the v2 test and the Mann–Whitney U-test as appropriate. Statistical significance was accepted at a p \ 0.05. Statistical analyses were performed using the SPSS Statistical package for Windows version 14 (SPSS, Chicago, IL, USA).
Results During the study period, 32 patients (24 men, 8 women) with SCV were managed at our hospitals. The median age of the patients was 59 years (range 21–83 years). The SCV attack was the first episode for 19 patients, the second episode for 10 patients, and the third episode (or more) for 3 patients (these previous attacks were prior to 2001). Five patients were bedridden, and chronic constipation was a problem for 18 patients. One of our patients was pregnant at presentation. Coexisting medical illnesses, including neuropsychiatric conditions, were present in 16 patients. The main symptoms were abdominal pain (91%), distention (84%), vomiting (72%), and constipation (63%); and the main signs were abdominal tenderness (81%), absence of stool in the rectum (53%), muscular rigidity (47%), hyperkinetic bowel sounds (31%), and melanotic stool in the rectum (19%). Vomiting preceded or coincided with the onset of other abdominal symptoms in seven patients, four of whom were found to have a gangrenous sigmoid colon. Emptiness of the left iliac fossa was recorded in 10 (31%) patients. The median duration of symptoms was 46 hours (range 8–120 hours). There was one case of incarcerated
World J Surg (2008) 32:459–464
461
SCV in a right inguinal hernia (Fig. 1). The torsion was found in a clockwise direction in 15 (47%) patients, and the torsion was 360° in 14 (44%) patients. The correct preoperative diagnosis was made in 88% (28/32) of cases. In addition to the clinical picture, the diagnosis was aided by the classic radiologic signs on plain abdominal radiographs in 22 patients (Fig. 2). In six patients the diagnosis was confirmed only after computed tomography (CT) scans of the abdomen and pelvis. In the remaining four patients the diagnosis was made intraoperatively after they underwent emergency laparotomy.
Seven patients had emergent operation without prior attempts of nonoperative reduction due to the presence of peritoneal irritation signs. Colonoscopic reduction was applied in the remaining 25 patients. In 17 patients endoscopic detorsion with rectal tube placement was achieved after the first attempt. Eight patients had unsuccessful endoscopic derotation and were taken to theater for emergency laparotomy. All patients were operated on during their initial hospital stay (15 had emergency surgery and 17 patients with successful endoscopic detorsion were operated on 2 days after the deflation). During surgery, all the patients presented with the pathognomonic findings of SCV, including redundant sigmoid colon, narrow sigmoid mesenteric pedicle, and mesosigmoiditis with mesenteric fibrosis and scarring. One of our patients had ileosigmoid knotting (ISK) (Fig. 3). Sigmoid resection with Hartmann colostomy was performed in four patients with a gangrenous perforated colon. Sigmoid resection with primary anastomosis was performed in 28 patients with viable (26 patients) or gangrenous (2 patients) sigmoid colon. Four patients underwent lavage ‘‘on table’’ prior to anastomosis due to the presence of a loaded colon, and a protective defunctioning ileostomy was performed for only one patient with gangrenous sigmoid colon who underwent resection with primary anastomosis. Reoperation because of anastomotic leak was performed in one patient with a nongangrenous sigmoid colon. None of the patients had detorsion alone, sigmoidopexy,
Fig. 2 Supine radiograph of the abdomen shows a markedly distended loop of sigmoid colon with a convex superior margin projecting into the right upper abdomen. It is essentially devoid of haustral markings. Gas distends the descending colon proximal to the twist, but the rectum has emptied. The twisted loop forms two large compartments with a central double wall ending at the point of the twist ‘‘coffee bean’’ sign. A single wall forms the outer margin of the two compartments
Fig. 3 Operative photograph illustrating ileosigmoid knotting in 45year-old man. Note the counterclockwise complete twist ([ 360°) of the sigmoid colon over the narrow pedicle of its mesentery. The distal ileum twists firmly around the sigmoid colon and its mesentery. Note also the appearance of the sigmoid colon and congestion and cyanosis due to vascular compromise from the volvulus. Fortunately, early operative intervention prevented the development of necrosis, and emergent untwisting combined with resection and end-to-end anastomosis was successful
Fig. 1 Operative photograph. The patient presented with an incarcerated sigmoid volvulus in a right inguinal hernia
123
462
mesosigmoidopexy, exteriorization, or near-total colectomy. Each the four patients who underwent a Hartmann procedure and the patient who had a diverting ileostomy had a second operation performed for colostomy or ileostomy closure. Postoperative complications were observed in five patients, with sepsis and septic shock being present in two patients (including one patient with viable colon who develop an anastomotic leak) and wound infection in two patients; pneumonia developed in one patient. Two patients died because of uncontrollable sepsis despite prompt operative treatment, making the mortality rate 6%. The median length of hospital stay following surgery was 11 days (range 6–25 days). None of the patients had recurrences of volvulus after a median followup of 16 months (range 4–59 months).
Discussion The prevalence of SCV in Jordan appears low. Only 9.2% of large bowel obstructions in this study were due to SCV. This figure is similar to those from Western countries [1] and would exclude Jordan from the ‘‘volvulus belt’’; however, with increasing travel and population migration, this condition is now being seen outside its original geographic sites of origin [10]. Emergency physicians and surgeons who are from the developing countries that form the world’s ‘‘volvulus belt’’ as well as those who are working outside this belt should maintain a high index of suspicion and be aware of SCV and its variable presentation and complications to accomplish the optimal clinical outcome [11, 12]. Only two of our patients were below the age of 30 years. SCV is most common in persons older than 50 years, with pediatric patients accounting for the next largest group. As the population is aging, SCV may be more commonly encountered [12]. When SCV occurs in younger patients, the diagnosis may be delayed or missed. SCV should be considered in young patients presenting with obstructing symptoms. In such cases, further studies, such as an abdominal CT scan, should be undertaken [13]. Male subjects constituted 75% of our patients, and a slight overall male preponderance exists among SCV patients. Sex analysis showed that the sigmoid mesocolon of the females is brachymesocolic (wider than long), whereas that of males is dolichomesocolic (longer than wide). This might explain the higher incidence of SCV among males [14]. One of our patients was pregnant at presentation. In pregnant women, SCV is the most common cause of intestinal obstruction; in a combined series of patients from 10 reports, 44% of pregnant patients with bowel obstruction had an SCV [15]. One of our patients had ISK (Fig. 3). ISK, formerly a misnomer for compound volvulus or double volvulus, is a
123
World J Surg (2008) 32:459–464
condition where the distal ileum twists firmly around the sigmoid colon and its mesentery; it is usually associated with a difficult preoperative diagnosis and poor surgical out come [16]. No cases of internal herniation concurrent with SCV were found among our patients. Concurrent association of internal herniation with ISK or SCV has been reported [11]. One of our patients presented with incarcerated SCV in a right inguinal hernia (Fig. 1). A similar case has been reported recently [17]. Patients with SCV usually present with sudden-onset abdominal pain, vomiting, and obstipation. There may be tenderness, distension, and a palpable mass. In four of our patients with gangrenous sigmoid colon, vomiting preceded or coincided with the onset of other abdominal symptoms. The pattern of vomiting may be a simple, useful predictor of prognosis in SCV cases. Raveenthiran noted that there are two patterns of vomiting in SCV: type 1 in which vomiting preceded or coincided with the onset of other abdominal symptoms; and type 2 where vomiting occurred after the onset of other abdominal symptoms. Type 1 vomiting reflected more severe disease and was associated with increased morbidity and mortality [18]. Reported risk factors for gangrenous SCV were age over 60 years, the presence of shock on admission, and a history of previous episodes of volvulus [19]. Emptiness of the left iliac fossa was recorded in 10 (31%) patients. Raveenthiran reported that the positive predictive value of this sign was 100% [20]. Rapid diagnosis and early decompression are key factors in the optimal management of SCV. The diagnosis of SCV is made by physical examination and radiographic studies. SCV can be diagnosed by plain abdominal radiography in more than 70% of cases on the basis of classic radiologic signs of SCV [9, 20]. Abdominal CT scanning has been used to rule out other etiologies of obstruction and colonic ischemia in patients with SCV. On CT scans, in addition to dilated loops of bowel with an air/fluid level, a round, soft tissue mass with a whirled configuration might be seen at the site of torsion [17]. This has been referred to as the ‘‘whirl’’ sign [9, 15, 21]. With acute SCV, the degree of torsion varies from 360° in 50% of cases, to 180° in 35% of cases, to 540° in 10% of cases [9]. The torsion is usually counterclockwise. The direction and degree of the torsion in our patients was consistent with that of other reports [22]. Sigmoid resection is the definitive treatment for SCV, but nonoperative decompression using flexible colonoscopy or sigmoidoscopy with rectal tube placement to allow for elective resection should be attempted first in patients with no evidence of peritonitis [23–25]. Colonoscopic reduction was applied in 25 of the patients in this study and was successful in 17 of them. Endoscopic reduction alone is of questionable value for preventing recurrence in most
World J Surg (2008) 32:459–464
cases. As recurrence is frequent, occurring in 40% to 60% of patients, subsequent elective definitive surgery should be the ultimate treatment as soon as the patient is a reasonable anesthetic risk, preferably during the same admission to avoid recurrence [25, 26]. If the distal level of obstruction is above the level that could be reached by rigid sigmoidoscopy to allow decompression, a flatus tube can be ‘‘lassoed’’ onto the side of a flexible endoscope, which allows accurate placement under direct vision [27]. Endoscopic reduction failed in eight of our patients. When nonoperative management fails to decompress the volvulus, complicating factors should be considered, and laparotomy is indicated to provide definitive treatment [13]. Management of SCV involves relief of obstruction and the prevention of recurrent attacks; the outcome depends on the population and selection of patients [28]. The management of SCV remains controversial. Various treatments for SCV have been reported. Treatment options depend on the absence or presence of peritonitis. Adequate resuscitation followed by early surgical intervention should be undertaken to reduce morbidity and mortality. The role of endoscopic intervention alone versus surgery is still debated. Despite the fact that SCV is frequently successfully managed initially by endoscopic decompression, the principal therapy of this condition is surgery due to the high recurrence rate after endoscopic treatment [29]. Altogether, 28 of our patients underwent single-stage resection and primary anastomosis. There is also still debate regarding treatment of SCV using a single-stage resection and anastomosis versus a two-stage approach. In patients without perforation or gangrene, sigmoid resection with primary anastomosis is feasible and should be the basic principle when managing SCV; single-stage procedures did not increase morbidity or mortality rates, and patients require a shorter hospital stay than those who undergo two-stage operations [30, 31]. Initial nonoperative decompression and a subsequent semielective operation is a common strategy for managing SCV. However, the optimal interval between decompression and operation is still unclear. A 2-day interval seems adequate for bowel preparation and optimization of the patient’s condition [32]. Emergency resection and primary anastomosis of the unprepared left colon is a controversial subject. Raveenthiran33 studied the feasibility of restorative resection of unprepared left colon in gangrenous versus viable SCV. Among 57 patients with acute SCV; there were 27 with gangrenous colon and 30 with viable colon. All of them had undergone emergency resection and primary anastomosis without on-table lavage or cecostomy. The median hospital stay, overall anastomotic leak rate, and mortality did not differ significantly between the groups. However, the rate of wound infection was higher in patients with gangrenous SCV. The author suggested that
463
one-stage restorative resection without on-table lavage or cecostomy appears to be a promising alternative for emergency management of acute SCV [33]. Emergency surgery is needed when there is evidence of strangulation or an inability to derotate the SCV. In all, 15 of our patients underwent emergency surgery mainly due to late presentation. Patients in whom bowel gangrene or peritonitis is present or nonoperative treatment is unsuccessful should be subjected to emergency surgery [23]. Among the various options of surgical treatment, resection and primary anastomosis should be the first choice, as it can be performed with acceptable mortality and morbidity rates provided the patient is stable and a tension-free anastomosis can be performed [23]. Nondefinitive procedures have high recurrence rates; thus, surgical resection is mandatory to prevent recurrence [23]. Considering that patients with SCV often are elderly and chronically ill, the laparoscopic or laparoscopically assisted elective approach for the treatment of SCV in a selected group of patients after successful colonoscopic decompression is feasible and is being reported with increasing frequency. It offers a good choice in terms of minimal surgical complications and quick convalescence [34, 35]. Other novel procedures reported include laparoscopic fixation of the redundant loop [36] and fixation of the sigmoid loop using a percutaneous and endoscopically placed sigmoidostomy tube [37]. Mortality rates depend on the interval between diagnosis and treatment. Therefore, rapid recognition of SCV is important. Our mortality rate is similar to the 6% mortality rate reported from South Africa [38]. The highest reported mortality occurred in cases of resection and primary anastomosis of gangrenous SCV. A mortality rate of 5.9% for elective operations versus a rate of 40% for emergency operations was reported [29]. Mortality due to gangrenous SCV has considerably declined over the last four decades from over 50% in an earlier time to 20% in the later 20 years of the last century [39].
Conclusions Sigmoid colon volvulus comprises an acute surgical emergency that may result in significant morbidity and mortality. Prompt surgical intervention is necessary to minimize morbidity and mortality. The need for swift operative intervention is emphasized.
References 1. Ballantyne GH, Brandner MD, Beart RW Jr, et al (1985) Volvulus of the colon: incidence and mortality. Ann Surg 202:83–92
123
464 2. Saidi F (1969) The high incidence of intestinal volvulus in Iran. Gut 10:838–841 3. De U (2002) Sigmoid volvulus in rural Bengal. Trop Doct 32:80– 82 4. Asbun HJ, Castellanos H, Balderrama B, et al (1992) Sigmoid volvulus in the high altitude of the Andes: review of 230 cases. Dis Colon Rectum 35:350–353 5. Gama AH, Haddad J, Simonsen O, et al (1976) Volvulus of the sigmoid colon in Brazil: a report of 230 cases. Dis Colon Rectum 19:314–320 6. Udezue NO (1990) Sigmoid volvulus in Kaduna, Nigeria. Dis Colon Rectum 33:647–649 7. Schagen van Leeuwen JH (1985) Sigmoid volvulus in a West African population. Dis Colon Rectum 28:712–716 8. Astini C, Falaschi CF, Mariam M, et al (1988) The management of sigmoid volvulus: report of 39 cases. Ital J Surg Sci 18:127–129 9. Khan AN, Howat J, Macdonald S (2007) Sigmoid volvulus. http://www.emedicine.com/radio/topic636.htm/. Accessed April 22, 2007 10. Mallick IH, Winslet MC (2004) Ileosigmoid knotting. Colorectal Dis 6:220–225 11. Alver O, Oren D, Apaydin B, et al (2005) Internal herniation concurrent with ileosigmoid knotting or sigmoid volvulus: presentation of 12 patients. Surgery 137:372–377 12. Tiah L, Goh SH (2006) Sigmoid volvulus: diagnostic twists and turns. Eur J Emerg Med 13:84–87 13. Salinas NL, Carr SR, Han D, et al (2007) A surprising twist to an old problem: sigmoid volvulus in a 19-year-old man. Am Surg 73:284–286 14. Bhatnagar BN, Sharma CL, Gupta SN, et al (2004) Study on the anatomical dimensions of the human sigmoid colon. Clin Anat 17:236–243 15. Devine RM (2006) Colonic volvulus. ASCRS core subject. http://www.fascrs.org/ displaycommon.cfm?an=1&subarticlenbr=62. Accessed April 22, 2007 16. Kotisso B, Bekele A (2006) Ilio-sigmoid knotting in Addis Ababa: a three-year comprehensive retrospective analysis. Ethiop Med J 44:377–383 17. Sicklick JK, Weiss CR, Ahuja N (2007) Image of the month: incarcerated sigmoid volvulus in a right inguinal hernia. Arch Surg 142:199–200 18. Raveenthiran V (2004) Observations on the pattern of vomiting and morbidity in patients with acute sigmoid volvulus. J Postgrad Med 50:27–29 19. Bhatnagar BN, Sharma CL, Gautam A, et al (2004) Gangrenous sigmoid volvulus: a clinical study of 76 patients. Int J Colorectal Dis 19:134–142 20. Raveenthiran V (2000) Emptiness of the left iliac fossa: a new clinical sign of sigmoid volvulus. Postgrad Med J 76:638–641 21. Matsumoto S, Mori H, Okino Y, et al (2004) Computed tomographic imaging of abdominal volvulus: pictorial essay. Can Assoc Radiol J 55:297–303
123
World J Surg (2008) 32:459–464 22. Atamanalp SS, Yildirgan MI, Basoglu M, et al (2004) Sigmoid colon volvulus in children: review of 19 cases. Pediatr Surg Int 20:492–495 23. Oren D, Atamanalp SS, Aydinli B, et al (2007) An algorithm for the management of sigmoid colon volvulus and the safety of primary resection: experience with 827 cases. Dis Colon Rectum 50:489–497 24. Turan M, Sen M, Karadayi K, et al (2004) Our sigmoid colon volvulus experience and benefits of colonoscope in detortion process. Rev Esp Enferm Dig 96:32–35 25. Martinez Ares D, Yanez Lopez J, Souto Ruzo J, et al (2003) Indication and results of endoscopic management of sigmoid volvulus. Rev Esp Enferm Dig 95:544–548 26. Lau KC, Miller BJ, Schache DJ, et al (2006) A study of largebowel volvulus in urban Australia. Can J Surg 49:203–207 27. Gatenby PA, Elton C (2006) Endoscopic placement of flatus tube using ‘‘lasso’’ technique with snare wire. World J Gastroenterol 12:5902–5903 28. Lal SK, Morgenstern R, Vinjirayer EP, et al (2006) Sigmoid volvulus an update. Gastrointest Endosc Clin N Am 16:175–187 29. Safioleas M, Chatziconstantinou C, Felekouras E, et al (2007) Clinical considerations and therapeutic strategy for sigmoid volvulus in the elderly: a study of 33 cases. World J Gastroenterol 13:921–924 30. Akcan A, Akyildiz H, Artis T, et al (2007) Feasibility of singlestage resection and primary anastomosis in patients with acute noncomplicated sigmoid volvulus. Am J Surg 193:421–426 31. Agaoglu N, Yucel Y, Turkyilmaz S (2005) Surgical treatment of the sigmoid volvulus. Acta Chir Belg 105:365–368 32. Tsai MS, Lin MT, Chang KJ, et al (2006) Optimal interval from decompression to semi-elective operation in sigmoid volvulus. Hepatogastroenterology 53:354–356 33. Raveenthiran V (2004) Restorative resection of unprepared leftcolon in gangrenous vs. viable sigmoid volvulus. Int J Colorectal Dis 19:258–263 34. Liang JT, Lai HS, Lee PH (2006) Elective laparoscopically assisted sigmoidectomy for the sigmoid volvulus. Surg Endosc 20:1772–1773 35. Mehendale VG, Chaudhari NC, Mulchandani MH (2003) Laparoscopic sigmoidopexy by extraperitonealization of sigmoid colon for sigmoid volvulus: two cases. Surg Laparosc Endosc Percutan Tech 13:283–285 36. Miller R, Roe AM, Eltringham WK, et al (1992) Laparoscopic fixation of sigmoid volvulus. Br J Surg 79:435 37. Chiulli RA, Swantkowski TM (1993) Sigmoid volvulus treated with endoscopic sigmoidopexy. Gastrointest Endosc 39:194– 196 38. Bhuiyan MM, Machowski ZA, Linyama BS, et al (2005) Management of sigmoid volvulus in Polokwane-Mankweng Hospital. S Afr J Surg 43:17–19 39. Bhatnagar BN, Sharma CL, Gautam A, et al (2006) The changing survival scenario in gangrenous sigmoid volvulus: a four-decade study. J Indian Med Assoc 104:294–297
