Volvulus Management Medical Slides

Present the stepwise approach: (1) If peritonitis, sepsis, or perforation suspected → emergent laparotomy with resection (Hartmann procedure usually, though primary anastomosis is acceptable in fit patients without perforation). (2) If no signs of peritonitis → endoscopic decompression: rigid sigmoidoscopy with rectal tube insertion (75-90% success rate), or flexible sigmoidoscopy. Endoscopic reduction should be abandoned if mucosal ischemia/necrosis is visualized. (3) After successful decompression → semi-elective sigmoidectomy during same admission (recurrence without surgery is 40-60%). ASCRS 2021 guidelines recommend definitive surgery during index admission when feasible, as readmission for recurrence carries higher morbidity, especially in the elderly frail population.

Present the key differences: Cecal volvulus has much lower endoscopic decompression success (30% vs 75-90% for sigmoid), higher ischemia/perforation risk, and does not have the redundant mesentery amenable to detorsion. Therefore: (1) Urgent surgery is generally indicated — do not delay for endoscopic attempts in most cases. (2) Right hemicolectomy is the preferred operation (recurrence rate <5%) with primary ileocolic anastomosis if bowel is viable and patient is stable. (3) Cecopexy (fixation without resection): lower morbidity but recurrence rate 10-20%, considered only for viable cecum in high-risk surgical patients. (4) Cecostomy tube: associated with high complication rates (40%) and recurrence — generally discouraged. Special case: cecal bascule (anterior fold without axial twist) may be amenable to cecopexy as there is less vascular compromise.

Present midgut volvulus as a surgical emergency: caused by malrotation (failure of normal 270° counterclockwise rotation during embryogenesis) with narrow mesenteric root allowing the entire midgut to twist around the SMA. Presentation: typically neonate with bilious vomiting (bilious emesis in a neonate = malrotation with volvulus until proven otherwise). Diagnosis: upper GI series showing abnormal position of DJ junction (gold standard), or "whirlpool sign" on ultrasound. Treatment: emergent Ladd procedure — (1) eviscerate and detorse bowel counterclockwise, (2) divide Ladd bands (peritoneal bands compressing duodenum), (3) widen mesenteric root by separating SMA from SMV, (4) appendectomy (appendix will be in LLQ), (5) place duodenum on right and cecum on left. Time sensitivity is extreme — delays lead to massive midgut necrosis and short gut syndrome.