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Emergency Management Of Sigmoid Volvulus At Tertiary Care Nursing Essay

All the patients who met inclusion criteria were included in this study. After adequate resuscitation and investigations, all patients were operated. Following parameters were noted, biodata of patient, viability of gut, operative time, procedure performed and post operative complications (wound infection, RTI, paralytic ileus and stoma complications). All patients were followed for 6 months and recurrence rate was observed.

DATA ANALYSIS: Data was entered on specific designed proforma and analyzed by SPSS version 13.

RESULTS: A total no of 32 patients admitted through emergency department, finally diagnosed as volvulus of sigmoid colon were included in this study.

Mean age was 51.83 years +/- 10.13.Male to female ratio was 5.4:1.

Main Clinical features were abdominal pain, distention and constipation.

All patients were operated by midline incision. Gut was viable in 8 patients while non viable in remaining 24 patients. Operative procedures performed were tube decompression and sigmoidopexy, resection and Primary anastomosis with covering stoma, Hartmann’s procedure and Paul mikulicz procedures.

Mean duration of procedure was 71.25 minute +/- 10.24

26 (81%) patients were discharged on 5th POD. Wound infection was present in 5(15.6%), RTI in 3(9%), paralytic ileus in 3(9%), and.figure1

Mean hospital stay was 6.75 days+/- 3.12.

In 6 month follow up the recurrence observed in 3 (37.5%) patients in whom sigmoidopexy was done.

CONCLUSION:

In volvulus of sigmoid colon resection and primary anastomosis with covering stoma is safest procedure.

While operating on toxic patients Hartmann or Paul mikulicz can be alternative life saving procedure.

Due to high recurrence rate after sigmoidopexy, resection should be basic principle in volvulus management.

KEY WORDS:

Sigmoid volvulus, acute large bowel obstruction, Resection and primary anastomosis with covering stoma,

INTRODUCTION:

Volvulus is defined as axial rotation of gut around its mesentery. Volvulus can occur in sigmoid, caecum, small bowel and rarely in stomach. Sigmoid colon is most common site among them.1

Acute sigmoid volvulus is a well recognized cause of acute large bowel obstruction, particularly in elderly and in patients with debilitating conditions.2,3

Sigmoid volvulus is the 3rd most common cause of colonic obstruction in United States after cancer and diverticulitis. Etiological factors include the anatomical variation, chronic constipation, neurological disease and megacolon.4

Clinical presentation is of large bowel obstruction, which may initially be intermittent, followed by passage of large quantity of flatus and faeces. Other features include abdominal distention associated with hiccup and retching, vomiting and constipation.5

Plain radiograph show classic appearance of dilated loop of bowel running diagonally across the abdomen from right to left, with two air fluid levels seen, one with in each loop of bowel.

There are different ways to deal with sigmoid volvulus including endoscopic decompression, untwisting and sigmoidopexy, resection and Paul mikulicz or Hartmann’ procedure, and resection and anastomosis with or without covering stoma.

The main draw back of conservative treatment, including detorsion by barium enema, sigmoid tube decompression and laparotomy with detorsion and colopexy, is increase recurrence rate (30%).6

Laparoscopic rectosigmoidectomy post colonoscopic decompression is good option for patients with sigmoid volvulus.7 Resection of acute sigmoid volvulus and primary anastomosis after decompression can be carried out in reasonably fit patients.8

A better knowledge of physiology of fluid and electrolyte balance, improved anesthesia, careful peri operative management and better operative technique can reduce the mortality of one stage resection and anastomosis.6

This study was conducted to know the out come of emergency management of sigmoid volvulus in patients operated at surgical department.

MATERIAL & METHODS:

Study Design: Case series

Setting: Department of Surgery, Chandka Medical College Hospital Larkana

Study period: From October 1, 2007 to April 4, 2010.

Sample Size: 32 cases

Sampling technique: Non probability purposive.

Inclusion criteria: All patients with intestinal obstruction diagnosed as sigmoid volvulus and operated were included.

Exclusion criteria:

Patients with other causes of intestinal obstruction.

Patients not consented for study

Patients not visited for follow up

DATA COLLECTION:

All the patients who met inclusion criteria were included in this study.

Purpose and procedure of the study was explained to the patient in local language and informed consent was taken from the patients or 1st degree relatives.

All patients were resuscitated by passing NG tube, maintaining I/V line, catheterization done and intravenous antibiotics for aerobic and anaerobic were started. Base line investigation and X-ray abdomen (erect and supine) done. After adequate resuscitation, all patients were operated.

Following parameters were noted on specific designed proforma, including biodata of patient, viability of gut, procedure performed, operative time and post operative complications (wound infection, RTI, paralytic ileus and stoma complications). All patients were followed for a period of 6 months and recurrence rate was observed.

DATA ANALYSIS:

Data was entered and analyzed by SPSS version 13. Mean ± SD was calculated for age of the patient, operative time and post operative hospital stay.

Frequency and percentage was calculated for gender, clinical features and post operative complications.

RESULT:

32 patients admitted through emergency department and diagnosed a case of volvulus were included in this study.

Age ranged from 24 to 68 years with mean and standard deviation was 51.83 years +/- 10.13.

Majority of patients 23(72%) were in 4th and 5th decade (table 1). Among these 32 patients 27 were male and 5 were female, with male to female ratio of 5.4: 1 (table 2).

Main Clinical features were abdominal pain, distention and constipation. Other features with their frequency and percentage are given in table 3.

All patients were operated by midline incision. Gut was viable in 8 patients while non viable in remaining 24 patients. Operative procedures performed are given in table 4.

Duration of procedure ranged from 60 to 90 minutes with mean and standard deviation was 71.25 minute +/- 10.24.

22 (69%) patients were discharge on 5th POD. 10 (31%) patients stayed more than 5 days because of complications.

Wound infection was observed in 5(15.6%), RTI in 3(9%), paralytic ileus in 3(9%), and stoma complications in 6(18%) patients.figure1

Hospital stay in this study, ranged from 5 to 15 days with mean and standard deviation was 6.75 days+/- 3.12.

In 6 month follow up the recurrence observed in 3 (37.5%) patients in whom sigmoidopexy was performed.

TABLE NO: 1

AGE DISTRIBUTION

AGE GROUP

NO: OF PATIENTS

%

21 - 30

1

3

31 - 40

4

12.5

41 - 50

8

25

51 - 60

15

47

61 – 70

4

12.5

TABLE NO: 2

SEX DISTRIBUTION

SEX

NO: OF PATIENTS

MALE

27

FEMALE

5

M:F

5.4:1

TABLE NO: 3

CLINICAL FEATURES

Clinical features

No of Patients

%

Abdominal pain

32

100

Abdominal distention

32

100

Absolute constipation

28

87.5

Vomiting

13

40

Diarrhea

3

9

Abdominal tenderness

25

78

Visible peristalsis

12

37.5

TABLE NO: 4

PROCEDURE PERFORMED

Procedure

No of Patients

%

Paul mikulicz procedures

11

34

Sigmoidopexy

8

25

Hartmann’s procedure

7

22

Resection and primary anastomosis with covering stoma

6

18

FIGURE: 1

POST OPERATIVE COMPLICATIONS

DISCUSSION:

Sigmoid volvulus is the common cause of large gut obstruction in developing countries. This condition is quite common here as compared to western world as large no of patients employed in local studies 3.

Sigmoid volvulus is common in western world among the elderly and the institutionalized2 but in our country it is more common in middle age group. In this study age ranges from 24 to 68 years with mean of 51.83 years. Majority of patients 23 (72%) were in 4th and 5th decade. In other studies age ranged from 35 -80 years (mean 55y)10, 48-70 years11,12, 16 to 86 years( mean 47.3)13, 61-87 years 14 and 7-8015.

Among 32 patients 27 (84%) were male and 5 (16%) were female with ration of 5.4:1. In other studies ratio observed was 6.5:110, 11.5:16, 8.7:111, 7:112, 29.3:113, 1.91 14, 9:115.

Patients with sigmoid volvulus belong to low socioeconomical class and also common among the inhabitant of mountaineous areas.6 In our set up it was common in patients belong to balouchistan, taluka shahdadkot and its surrounding areas, specially in brohi tribe. Study conducted at Peshawar and quetta, described it most common in pathan tribe.6,16 chronic constipation was present in all patients because their diet was mainly contain rice and high fiber products and low water consumption.

Main clinical features were abdominal pain, distention and constipation.

Variety of approaches has been described to treat the viable gut like endoscopic decompression alone or followed by elective sigmoid resection. Other option is percutanous deflation prior to emergency tube decompression, followed by elective colopexy with banding.6,16 and per-operative tube decompression after distorsion of sigmoid colon followed by colopexy.

Non operative management of acute sigmoid volvulus potentially obviate the surgical morbidity in high risk elderly and frail patients, but because of high recurrence rate (40%) conservative treatment should be followed by definitive procedure.2

All the patients diagnosed as sigmoid volvulus on the basis of history, clinical examination and investigations were resuscitated followed by surgery.

The operative procedure depends upon general status of the patient, viability of gut and experience of surgeon.

In this study in 8 (25%) patients loop was found viable and treated with tube decompression and colopexy. In 24 patients gut was non viable, these patients were presented with delay of more than 4 days. These were toxic and frail. These were treated by different method like resection and primary anastomosis with covering stoma, Hartmann’s procedure and Paul mikulicz procedures. In none of these patients we did resection and primary anastomosis alone without covering because of patient’s poor general condition and non-viability of gut. According to other studies sigmoid resection with primary anastomosis and defunctioning colostomy is safest, it obviate the need of second laparotomy. For junior surgeon while operating on toxic and frail patients Hartmann’s procedures and Paul mikulicz procedures are safe alternate.6,16

Some author describe the resection and anastomosis as a safe and cost effective procedure in non complicated volvulus sigmoid 8,12,17,18,19 .Even some describe it a safe procedure in complicated gangrenous colon10, while some describe the high mortality rate in cases of resection and primary anastomosis of gangrenous sigmoid colon.15

In this study Post operative complications were wound infection in 5 (15.6%) patients, RTI 3(9%), paralytic ileus in 3(9%), and stoma complications in 6(18%) patients. In other studies wound infection is, 20%6, 9.5%8, 13.3%9,15% 10, , 2.7%11, 18%12, 19%17 , respiratory tract infection 20%6, Paralytic ileus is 8%11.

Hospital stay in this study ranged from 5 to 15 days with mean of 6.75 days. In other studies it is 7 days6,10.3 days8, 7.5dyas9, 4 days11and 11days13 .

Mortality rate in our study is 3.12% which can be justified by other studies, 3.3%9,13, 4%6,12, 6%2,15, some author also describe the high mortality rate of 9%16 and 15.8%20.

In 6 months follow up the recurrence rate of 37.5% in the patients in which sigmoidopexy was done .in other studies recurrence rate is 40%2, 30%16, 6%21, 7%21. No recurrence was observed after resection. Other studies are also in favour of sigmoidectomy in volvulus management.14,16

CONCLUSION:

In sigmoid volvulus, resection of gut, primary anastomosis with covering stoma is safest procedure.

While operating on toxic patient Hartmann or Paul mikulicz can be alternative life saving procedure.

Due to high recurrence rate after sigmoidopexy resection should be basic principle in volvulus management.

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