Cecal Volvulus REUVEN RABINOVICI, M.D., DAVID A. SIMANSKY, M.D., OFER KAPLAN, M.D., ELIAHU MAVOR, M.D., JONAH MANN'Z, M.D.
Rabinovici R, Simansky DA, Kaplan O, Mavor E, Manny J. Cecal volvulus. Dis Colon Rectum 1990;33:765-769.
A review of 561 cases of cecal volvulus that were published between 1959 and 1989 along with 7 new cases, was performed to characterize the clinical and laboratory profile and to evaluate the various surgical options in treating this life-threatening condition. The age and sex distribution of these patients have changed over the years and shifted toward older patients (mean, 53 years) and female predominance (female:male ratio, 1.4:1). The clinical presentation was usually of distal closed-loop small bowel obstruction. Forty-six percent of the plain abdominal radiographs were suspected for cecal volvulus, but only 17 percent were diagnostic. Barium enema had a high rate of accuracy (88 percent) and was associated with minimal complications. True volvulus was 6 times more common than bascule, and gangrenous cecum was found in 20 percent of cases. Detorsion alone and cecopexy had almost similar complications, mortality, a n d recurrence rates (15, 10, and 13 percent, respectively), whereas, resection, which was p e r f o r m e d primarily for gangrenous cecum, had higher rates. However, the highest rates of complications (52 percent), mortality (22 percent), and recurrence (14 percent) were noticed after cecostomy. These data suggest that resection should be reserved for patients with necrotic cecum and that detorsion is sufficient for patients with viable cecum. Cecostomy should be abandoned. [Key words: Cecum; Volvulus]
CECAL VOLULUS, WHICH was first d e s c r i b e d 150 years ago, 1 is a surgical e m e r g e n c y caused by the axial twist o f the cecum, distal ileum, a n d p r o x i m a l colon in the absence o f n o r m a l cecal fixation. Occasionally, the c e c u m a n d a s c e n d i n g colon m a y fold anteriorly a n d u p w a r d without an axial twist, in which case the lesion is r e f e r r e d to as "bascule. ''2 T h e clinicopathologic features o f cecal volvulus result f r o m the s u b s e q u e n t Address correspondence to Dr. Rabinovici: Department of Surgery A, Hadassah University Hospital, P.O. Box 12000, 91120 Jerusalem, Israel.
765
From the Department of Surgery, Hadassah Medical Center, Jerusalem, Sheba Medical Center, Tel Aviv, Rokach Medical Center, Tel Aviv, and Kaplan Medical Center, Rehovot, Israel
c l o s e d - l o o p o b s t r u c t i o n . T h u s , unless r e c o g n i z e d early, the lesion can p r o g r e s s to colonic ischemia, perf o r a t i o n , sepsis, a n d d e a t h . T o p r e v e n t delays in t r e a t m e n t , a n d in light o f the c o n t r o v e r s y r e g a r d i n g the o p e r a t i v e m a n a g e m e n t o f this relatively u n c o m m o n f o r m o f intestinal obstruction, t h e r e is a n e e d to characterize the clinical profile o f cecal volvulus a n d to analyze the d i f f e r e n t surgical options a n d results. T h e c u r r e n t study, which evaluates retrospectively 561 r e p o r t e d cases along with 7 new cases, was und e r t a k e n to clarify the clinical p r e s e n t a t i o n o f cecal volvulus a n d to define guidelines f o r its surgical treatment. Patients and Methods Five h u n d r e d sixty-one cases o f cecal volvulus rep o r t e d in the literature b e t w e e n 1959 a n d 19893-28 along with 7 new cases w e r e reviewed with r e g a r d to the clinical profile, precipitating factors, diagnostic w o r k - u p , surgical t r e a t m e n t , a n d results. R e v i e w e d Series: T h e m e a n age was 53.3 years a n d t h e r e was f e m a l e p r e d o m i n a n c e ( f e m a l e : m a l e ratio, 1.4:1). All b u t 2 p e r c e n t o f the patients w e r e t r e a t e d surgically. P r e o p e r a t i v e diagnosis by m e a n s o f plain a b d o m i n a l film a n d b a r i u m e n e m a was m a d e in 53 p e r c e n t o f patients. T h e o p e r a t i v e p r o c e d u r e s m o s t c o m m o n l y e m p l o y e d w e r e c e c o p e x y (32 p e r c e n t ) , d e t o r s i o n (25 percent), resection (25 percent), a n d cecostomy (16 percent).
766
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Current Series: Seven patients were treated for cecal volvulus between 1973 and 1989 in 4 university hospitals in Jerusalem and Tel-Aviv, which serve a population of 500,000. Age ranged between 4 and 90 years (mean, 43 years). There were 4 females and 3 males. All patients were operated upon, whereas the preoperative diagnosis rate was 71 percent. Cecopexy was p e r f o r m e d in 4 patients, resection in 2 patient, and cecostomy and cecopexy in 1 patient. Results Clinical Profile Reviewed Series: The clinical features, which are summarized in Figures 1A and 1C, are characteristics of distal closed-loop obstruction. No sufficient data concerning temperature and white blood count could be obtained. Possible precipitating factors of cecal volvulus such as previous abdominal surgery, pregnancy, other
September 1990
acute medical illness, and mental disorders were present in 6 to 32 percent of cases (Fig. 1B). Current Series: Symptoms, clinical signs, laboratory data, and possible precipitating factors are listed in Table 1. The most common symptoms were abdominal pain (6 of 7), vomiting (5 of 7), abdominal distention (3 of 7), and constipation (2 of 7). Four patients had 6 previous intra-abdominal operations and one patient was mentally retarded. The mean temperature was 97.7 ~ F. Four patients had abdominal signs localized to the right lower quadrant, two patients had generalized peritonitis, and one patient had diffuse tenderness. Peristaltic sounds were normal in four patients, and reduced, absent, and high pitched in one patient each. The temperature and abdominal signs correlated poorly with the presence of gangrenous cecum (patients 3 and 7). The white blood count ranged between 3700 and 21,700 with a mean of 10,700.
A.
B.
100.
40
8060.
b.I 0
20 40.
I1.
10 20. 0
g
o
~-O
~,
._o'~ ~
~
II
N
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~,
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80,
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~,
FIG. 1. Presenting symptoms (A), precipitating factors (B), abdominal signs (C), and operative findings (D) of 561 patients reported during 1959-1989.
Volume 33 Number 9
CECAL VOLVULUS
767
TABLE 1. ClinicalProfile of Current Series (7 Patients) Sex, Age
Duration of Symptoms
F, 90
12 hrs
M, 53
10 hrs
M, 30
?
F, 17
24 hrs
M, 4
24 hrs
F, 65
7 days
F, 37
6 hrs
Medical History
Symptoms Abdominal pain, distention, vomiting Abdominal pain, vomiting, constipation Abdominal pain, vomiting Abdominal pain, distention, vomiting Abdominal pain, vomiting Abdominal pain, constipation Abdominal distention
Temperature
Hiatal hernia, hysterectomy Severe valvular heart disease, umbilical hernia Mental retardation
36.8
--
36.3
--
36.3
Appendectomy, nephrectomy Appendectomy
36.0 36.6
36.8 36.8
Abdominal Signs
WBC
KUB
Barium Enema
Diffuse tenderness, normal---P Diffuse peritonitis, distention, hypo--P
10700 diag.
diag.
3700 SBO
diag.
Diffuse peritonitis, distention, no---P RLQ--tenderness, normal--P RLQ--peritonitis, normal---P RLQ--tenderness, distention, hyper--P RLQ--tenderness, distention, normal~P
21700 susp.
diag.
14400
--
--
8600
--
--
6600 diag.
--
9100 susp.
diag.
P = peristalsis; diag = diagnostic; SBO = small-bowel obstruction; susp = suspicious; RLQ = right lower quadrant. Possible precipitating factors were previous intraa b d o m i n a l o p e r a t i o n s (6 in 4 patients) a n d m e n t a l r e t a r d a t i o n (1 patient).
Diagnosis Reviewed Series." M o r e t h a n h a l f o f the patients were d i a g n o s e d p r e o p e r a t i v e l y by m e a n s o f clinical consideration c o m b i n e d with plain a b d o m i n a l film a n d bari u m e n e m a (Fig. 2). T h e diagnosis was suspected in 46 p e r c e n t o f the plain a b d o m i n a l r a d i o g r a p h s while 30 p e r c e n t were m i s i n t e r p r e t e d as small-bowel obstruction. H o w e v e r , definitive diagnosis b a s e d o n plain a b d o m i n a l r a d i o g r a p h s alone was m a d e in only 17 p e r c e n t . B a r i u m e n e m a e x a m i n a t i o n was p e r f o r m e d in 50 p e r c e n t o f patients with an accuracy rate (true positive a n d t r u e negative) o f 88 percent.
laparotomy 47
Current Series: Five patients were d i a g n o s e d p r e o p eratively (4 b a s e d o n b a r i u m e n e m a a n d o n e based on plain a b d o m i n a l film). T h e r e m a i n i n g 2 patients were d i a g n o s e d at l a p a r o t o m y .
Operative Findings Reviewed Series: Mobile c e c u m was f o u n d in all cases. T r u e volvulus was 6 times m o r e c o m m o n t h a n bascule (Fig. 1D). Necrosis, which o c c u r r e d in 20 percent o f the patients, was p r o p o r t i o n a l l y distributed b e t w e e n t r u e volvulus a n d bascule. T w o p e r c e n t o f all cecal volvulus were r e d u c e d s p o n t a n e o u s l y a n d only mild m e s e n t e r i c a n d m u r a l congestion were f o u n d at l a p a r o t o m y . Fixation o f the c e c u m by adhesions a n d bands was o b s e r v e d in 23 p e r c e n t o f patients. Current Series: Mobile c e c u m was p r e s e n t in all patients. Five patients h a d t r u e volvulus a n d 2 patients h a d a n t e r i o r c e p h a l a d d i s p l a c e m e n t o f the cecum. G a n g r e n o u s c e c u m was f o u n d in o n e case o f volvulus a n d in o n e p a t i e n t with bascule. A d h e s i o n s as a possible fixation m e c h a n i s m o f the c e c u m w e r e r e p o r t e d in only o n e patient.
Surgical Treatment and Results
',UB 17 barium 86 FIG. 2. Means of diagnosis in 561 reported patients during 1959-1989. Data are presented as percentages.
Reviewed Series: T h e o p e r a t i v e p r o c e d u r e s a n d results are p r e s e n t e d in T a b l e 2. D e t o r s i o n alone a n d cecopexy h a d almost similar complication, mortality, a n d r e c u r r e n c e rates. H i g h e r rates w e r e o b s e r v e d after resectional operations, which w e r e p e r f o r m e d in almost all patients with necrotic cecum, w h e r e a s 9 p e r c e n t o f the resections w e r e p e r f o r m e d in patients with viable cecum. T h e r e was n o significant difference in the results o f resections p e r f o r m e d in patients with necrotic or viable colon (data not shown). T h e highest complication, mortality, a n d r e c u r r e n c e rates were r e c o r d e d a f t e r cecostomy (with or without cecopexy). T h e m e a n follow-up p e r i o d was 63 m o n t h s .
768
Dis. Col. & Rect.
RABINOVICI, ET AL.
September 1990
TABLE 2. Surgical Treatment and Results in 561 Patients (1959-1989) Operation
Percent
Cecopexy Detorsion Resection Cecostomy
32 25 25 16
Complications (Percent) Abdominal Wound 8 9 16 25
Mortality (Percent)
Recurrence (Percent)
10 13 22 32
13 12 -14
7 6 13 27
Current Series: The surgical treatment and results are listed in Table 3. Four patients had cecopexy, two patients underwent right hemicolectomy, and in one patient cecostomy with cecopexy were performed. There was one hospital mortality (due to severe congestive heart failure in a high-risk patient), which occurred four days after resection. There were no recurrences during a mean follow-up period of 44.2 months.
most probably reflect different stages in the pathophysiologic process of cecal volvulus at the time of admission. Although it was estimated that the diagnosis of cecal volvulus should be made with confidence from plain abdominal films in nearly 90 percent of c a s e s , 22 only 46 percent of the plain abdominal radiographs in the current review were suspected to be cecal volvulus. The plain film diagnosis was based on the combination of several findings: dilated cecum (98 percent) containing a single air-fluid level (72 percent), little or no gas in the distal colon (82 percent), abnormally positioned cecum (56 percent), and dilatation of small bowel with air-fluid levels (55 percent). The most reliable diagnostic procedure (accuracy rate of 88 p e r c e n t ) , which is r e c o m m e n d e d by m a n y authors, ~7 was the barium enema. The typical findings were obstruction at site of colonic twist (93 percent) with no filling of the cecum (79 percent). Contrast study is also important to rule out concomitant distal colonic obstruction, which might have precipitated the cecal volvulus (2 percent). The current data do not support the assumption that such studies might induce imminent perforation and needlessly delay necessary surgical treatment. However, barium enema should be administered under low pressure in case unsuspected gangrene is present and to prevent further distention of the cecum with air. The current data confirm that mobile cecum is a prerequisite for cecal volvulus. It also establishes the relatively high association between cecal volvulus and previous abdominal surgery, pregnancy, and other
Discussion
The current study shows that the age and sex distribution of cecal volvulus have changed during the last four decades. A review of 100 cases reported in 194929 concluded that the highest incidence of cecal volvulus occurred in the 25- to 30-year-old age group with a mean age of 40 years, and that there was an equal distribution between men and women, whereas the current data reveal a peak incidence in the sixth decade of life and predominance in females. Although the diagnosis of cecal volvulus is rarely made on clinical grounds alone, the current analysis points out some clinical features that may promote correct diagnosis. Distal small-bowel obstruction associated with abdominal mass, in debilitated, mentally retarded, or pregnant patients with previous abdominal operations or with other acute medical illnesses, should raise the suspicion of cecal volvulus. However, once gangrene or perforation have occurred, severe constant abdominal pain, diffuse peritonitis, and lack of peristaltic sounds may supervene. The variable descriptions of the pain and peristalsis patterns aT'ls'2s'3~
TABLE 3. Operative Findings, Surgical Treatment, and Results in Current Series (7 Patients) Operative Findings
Procedure
Bascule, adhesions, viable cecum Volvulus, viable cecum
Cecopexy
Volvulus, necrotic cecum Volvulus, viable cecum Volvulus, viable cecum Volvulus, viable cecum Bascule, necrotic cecum
Resection Cecopexy, appendectomy Cecopexy Cecostomy, Cecopexy Resection
Cecopexy
SBO = small-bowel obstruction. CHF = congestive heart failure.
Complications Paralytic ileus -Wound infection
Mortality
Follow-up
--
(18 months) Rec. SBO---conservative treatment, no recurrence --
4 postop day, severe CHF
(28 months) Uneventful (66 months) No recurrence (60 months) No recurrence Lost to follow-up (49 months) Sigmoid volvulus
Volume33 Number9
CECAL VOLVULUS
acute medical illness. The fact that gangrenous cecum was found in 20 percent of the cases points out the potential fatality of cecal volvulus and probably reflects the difficulties in its diagnosis. Our collected data support the general agreement that resection is mandatory in the presence of necrotic or perforated cecum. Also, the current study suggests that cecostomy through the perforation hole should not be performed because of its high morbidity and mortality rates. The surgical treatment of cecal volvulus in the absence of gangrene is still controversial. Detorsion, which is a simple and rapid procedure, avoids the opening of the colon but was associated in several reports with a high recurrence rate. 1~ Subsequently, cecopexy was proposed as a relatively safe procedure with a lower recurrence rate. 13'16 However, because various series reported a high rate of recurrence after cecal fixation, resection was advocated for all cases of cecal volvulus, s'31'32 Cecostomy alone, or in combination with cecopexy, which was suggested for both cecal fixation and decompression, carries a high risk of wound infection and has serious complications such as abdominal wall necrosis, cecal necrosis, and leakage. 7'16'33 The current review shows that the morbidity, mortality, and recurrence rates of detorsion alone and cecopexy were almost similar. Therefore, cecopexy, which is more time consuming, seems to be unnecessary when detorsion is used. Cecostomy, which had the highest complication, mortality, and recurrence rates, should be abandoned. Despite the elimination of possible recurrence, resection should not be performed in patients with viable colon, since it was associated with a two-fold mortality rate and increased morbidity as compared with detorsion alone or cecopexy. Nonoperative modalities for reducing cecal volvulus are still anecdotal. The current review detected only four cases of cecal volvulus, which was reduced nonintentionally by barium enema. However, deliberate attempts to reduce cecal volvulus by barium enema are not advisable because of the risk of perforation. 16,30,34 Reports of colonoscopic reduction are also few and little-tested. 2~'~5'36 References 1. Rokitansky C. Intestinal Strangulation. Arch Gen Med 1837; 14:202. 2. Weinstein M. Volvulus of the cecum and ascending colon. Ann Surg 1938; 107:248. 3. Villet DG. Volvulus of the proximal colon. Ann Surg 1959; 150:1075-85. 4. Hinshaw DB, Carter R, Joergenson EJ. Volvulus of the cecum and right colon. Am J Surg 1959;98:175-83.
769
5. Hjelmstedt A. Volvulus of the right colon. Acta Chir Scand 1959/1960; 118-65. 6. Sawyer RB, Sawyer KC Jr, Sawyer CS. Volvulus of the colon. Am J Surg 1962; 104:468-73. 7. Krippaehne WW, Mark Vetto R, Jenkins CC. Volvulus of the ascending colon: a report of twenty two cases. Am J Surg 1967; 114:323-32. 8. Meyers JR, Heifetz CJ, Baue AE. Cecal volvulus. Arch Surg 1972; 104:594-9. 9. Bystrom J, Backman L, Dencker H, Meden-Brith G. Volvulus of the caecum. Acta Chir Scand 1972; 138:624-7. 10. Inberg MV, Havia T, Davidsson L, Salo M. Acute intestinal volvulus, a report of 238 cases. Scand J Gastroenterol 1972; 7:209-14. 11. Smith WR, Goodwin JN. Cecal volvulus. Am J Surg 1973; 126:215-22. 12. Grover NK, Gulati SM, Tagore NK, Taneja OP. Volvulus of the cecum and ascending colon. A m J Surg 1973;125:672-5. 13. Andersson A, Bergdahl L, Van Der Linden W. Volvulus of the cecum. Ann Surg 1975;181:876-880. 14. Wertkin MG, Aufses AH Jr. Management of volvulus of the colon. Dis Colon Rectum 1978;21:40-5. 15. Todd GJ, Forde KA. Volvulus of the cecum: choice of operation. Am J Surg 1979;138:632-4. 16. O'Mara CS, Wilson TH Jr, Stonesifer GL, Cameron JL. Cecal volvulus. Ann Surg 1979;189:724-31. 17. Howard RS, Catto J. Cecal volvulus. Arch Surg 1980;115: 273-7. 18. Anderson JR, Lee D. Acute cecal volvulus. Br J Surg 1980; 67:39-41. 19. Morris DM, Eisenstat T, Hall GM. Management of cecal volvulus in debilitated patients. South Med J 1982;75:1069-71. 20. Lal MM, Yadav R, Kesri V. Volvulus of the cecum caused by injury. Injury 1983;15:139-40. 21. Barrington J, Mahender PCS. Volvulus of the caecum. Br J Radiol 1984;57:842-4. 22. Anderson JR, Mills OM. Caecal volvulus: a frequently missed diagnosis? Clin Radiol 1984;35:65-9. 23. Pruett TL, Wilkins ME, Gamble WG. Cecal volvulus: a different twist for the serious runner. N Engl J Med 1985; 312:1262-3. 24. Singh G, Gupta SK, Gupta S. Simultaneous occurrence of sigmoid and cecal volvulus. Dis Colon Rectum 1985;28:115-6. 25. Johnson CD, Rice RP, Kelvin FM, Foster WL, Williford ME. The radiologic evaluation o f gross cecal distention: emphasis on cecal ileus. AJR 1985; 145:1211-7. 26. BallantyneGH, Brandner MD, Beart RW, Ilstrup DM. Volvulus of the colon. Ann Surg 1985;202:83-92. 27. FanningJF, Cross CB. Post-cesarian section cecal volvulus. Am J Obstet Gyneco 1988;1200-02. 28. Tejler G, Jiborn H. Volvulus of the cecum: report of 26 cases and review of the literature. Dis Colon Rectum 1988;31: 445-9. 29. Donhauser JL, Atwell S. Volvulus of the cecum. Arch Surg 1949;58:129-48. 30. Nelson TJ, Bowers WF. Volvulus of the cecum and sigmoid colon. Arch Surg 1956;72:469-78. 31. Rivas AA, Dennison HC. Volvulus of the cecum. Am Surg 1978;44:332. 32. Melchior E. Volvulus of the cecum--an appeal for primary resection. Surgery 1949;25:251. 33. Halvorsen JF, Semb BH. Volvulus of the right colon: a review of 30 cases with special reference to late results of various surgical procedures. Acta Chir Scand 1975;141:804-9. 34. Figiel LS, Figiel SJ. Volvulus of the cecum and ascending colon. Radiology 1953;61:496-515. 35. Anderson MJ Sr, Okike N, Spencer RJ. The colonoscope in cecal volvulus: report of three cases. Dis Colon Rectum 1978;21:71-4. 36. Ghazi A, Shinya H, Wolff WI. Treatment of volvulus of the colon by colonoscopy. Ann Surg 1976;183:263.
Rabinovici R, Simansky DA, Kaplan O, Mavor E, Manny J. Cecal volvulus. Dis Colon Rectum 1990;33:765-769.
A review of 561 cases of cecal volvulus that were published between 1959 and 1989 along with 7 new cases, was performed to characterize the clinical and laboratory profile and to evaluate the various surgical options in treating this life-threatening condition. The age and sex distribution of these patients have changed over the years and shifted toward older patients (mean, 53 years) and female predominance (female:male ratio, 1.4:1). The clinical presentation was usually of distal closed-loop small bowel obstruction. Forty-six percent of the plain abdominal radiographs were suspected for cecal volvulus, but only 17 percent were diagnostic. Barium enema had a high rate of accuracy (88 percent) and was associated with minimal complications. True volvulus was 6 times more common than bascule, and gangrenous cecum was found in 20 percent of cases. Detorsion alone and cecopexy had almost similar complications, mortality, a n d recurrence rates (15, 10, and 13 percent, respectively), whereas, resection, which was p e r f o r m e d primarily for gangrenous cecum, had higher rates. However, the highest rates of complications (52 percent), mortality (22 percent), and recurrence (14 percent) were noticed after cecostomy. These data suggest that resection should be reserved for patients with necrotic cecum and that detorsion is sufficient for patients with viable cecum. Cecostomy should be abandoned. [Key words: Cecum; Volvulus]
CECAL VOLULUS, WHICH was first d e s c r i b e d 150 years ago, 1 is a surgical e m e r g e n c y caused by the axial twist o f the cecum, distal ileum, a n d p r o x i m a l colon in the absence o f n o r m a l cecal fixation. Occasionally, the c e c u m a n d a s c e n d i n g colon m a y fold anteriorly a n d u p w a r d without an axial twist, in which case the lesion is r e f e r r e d to as "bascule. ''2 T h e clinicopathologic features o f cecal volvulus result f r o m the s u b s e q u e n t Address correspondence to Dr. Rabinovici: Department of Surgery A, Hadassah University Hospital, P.O. Box 12000, 91120 Jerusalem, Israel.
765
From the Department of Surgery, Hadassah Medical Center, Jerusalem, Sheba Medical Center, Tel Aviv, Rokach Medical Center, Tel Aviv, and Kaplan Medical Center, Rehovot, Israel
c l o s e d - l o o p o b s t r u c t i o n . T h u s , unless r e c o g n i z e d early, the lesion can p r o g r e s s to colonic ischemia, perf o r a t i o n , sepsis, a n d d e a t h . T o p r e v e n t delays in t r e a t m e n t , a n d in light o f the c o n t r o v e r s y r e g a r d i n g the o p e r a t i v e m a n a g e m e n t o f this relatively u n c o m m o n f o r m o f intestinal obstruction, t h e r e is a n e e d to characterize the clinical profile o f cecal volvulus a n d to analyze the d i f f e r e n t surgical options a n d results. T h e c u r r e n t study, which evaluates retrospectively 561 r e p o r t e d cases along with 7 new cases, was und e r t a k e n to clarify the clinical p r e s e n t a t i o n o f cecal volvulus a n d to define guidelines f o r its surgical treatment. Patients and Methods Five h u n d r e d sixty-one cases o f cecal volvulus rep o r t e d in the literature b e t w e e n 1959 a n d 19893-28 along with 7 new cases w e r e reviewed with r e g a r d to the clinical profile, precipitating factors, diagnostic w o r k - u p , surgical t r e a t m e n t , a n d results. R e v i e w e d Series: T h e m e a n age was 53.3 years a n d t h e r e was f e m a l e p r e d o m i n a n c e ( f e m a l e : m a l e ratio, 1.4:1). All b u t 2 p e r c e n t o f the patients w e r e t r e a t e d surgically. P r e o p e r a t i v e diagnosis by m e a n s o f plain a b d o m i n a l film a n d b a r i u m e n e m a was m a d e in 53 p e r c e n t o f patients. T h e o p e r a t i v e p r o c e d u r e s m o s t c o m m o n l y e m p l o y e d w e r e c e c o p e x y (32 p e r c e n t ) , d e t o r s i o n (25 percent), resection (25 percent), a n d cecostomy (16 percent).
766
Dis. Col. & Rect.
RABINOVICI, ET AL.
Current Series: Seven patients were treated for cecal volvulus between 1973 and 1989 in 4 university hospitals in Jerusalem and Tel-Aviv, which serve a population of 500,000. Age ranged between 4 and 90 years (mean, 43 years). There were 4 females and 3 males. All patients were operated upon, whereas the preoperative diagnosis rate was 71 percent. Cecopexy was p e r f o r m e d in 4 patients, resection in 2 patient, and cecostomy and cecopexy in 1 patient. Results Clinical Profile Reviewed Series: The clinical features, which are summarized in Figures 1A and 1C, are characteristics of distal closed-loop obstruction. No sufficient data concerning temperature and white blood count could be obtained. Possible precipitating factors of cecal volvulus such as previous abdominal surgery, pregnancy, other
September 1990
acute medical illness, and mental disorders were present in 6 to 32 percent of cases (Fig. 1B). Current Series: Symptoms, clinical signs, laboratory data, and possible precipitating factors are listed in Table 1. The most common symptoms were abdominal pain (6 of 7), vomiting (5 of 7), abdominal distention (3 of 7), and constipation (2 of 7). Four patients had 6 previous intra-abdominal operations and one patient was mentally retarded. The mean temperature was 97.7 ~ F. Four patients had abdominal signs localized to the right lower quadrant, two patients had generalized peritonitis, and one patient had diffuse tenderness. Peristaltic sounds were normal in four patients, and reduced, absent, and high pitched in one patient each. The temperature and abdominal signs correlated poorly with the presence of gangrenous cecum (patients 3 and 7). The white blood count ranged between 3700 and 21,700 with a mean of 10,700.
A.
B.
100.
40
8060.
b.I 0
20 40.
I1.
10 20. 0
g
o
~-O
~,
._o'~ ~
~
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-
~,
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D.
80,
100.80..
w 0 n,, ILl ilL.
60.
~,20,
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-6
9,--~
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0
n_H -
~,
FIG. 1. Presenting symptoms (A), precipitating factors (B), abdominal signs (C), and operative findings (D) of 561 patients reported during 1959-1989.
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767
TABLE 1. ClinicalProfile of Current Series (7 Patients) Sex, Age
Duration of Symptoms
F, 90
12 hrs
M, 53
10 hrs
M, 30
?
F, 17
24 hrs
M, 4
24 hrs
F, 65
7 days
F, 37
6 hrs
Medical History
Symptoms Abdominal pain, distention, vomiting Abdominal pain, vomiting, constipation Abdominal pain, vomiting Abdominal pain, distention, vomiting Abdominal pain, vomiting Abdominal pain, constipation Abdominal distention
Temperature
Hiatal hernia, hysterectomy Severe valvular heart disease, umbilical hernia Mental retardation
36.8
--
36.3
--
36.3
Appendectomy, nephrectomy Appendectomy
36.0 36.6
36.8 36.8
Abdominal Signs
WBC
KUB
Barium Enema
Diffuse tenderness, normal---P Diffuse peritonitis, distention, hypo--P
10700 diag.
diag.
3700 SBO
diag.
Diffuse peritonitis, distention, no---P RLQ--tenderness, normal--P RLQ--peritonitis, normal---P RLQ--tenderness, distention, hyper--P RLQ--tenderness, distention, normal~P
21700 susp.
diag.
14400
--
--
8600
--
--
6600 diag.
--
9100 susp.
diag.
P = peristalsis; diag = diagnostic; SBO = small-bowel obstruction; susp = suspicious; RLQ = right lower quadrant. Possible precipitating factors were previous intraa b d o m i n a l o p e r a t i o n s (6 in 4 patients) a n d m e n t a l r e t a r d a t i o n (1 patient).
Diagnosis Reviewed Series." M o r e t h a n h a l f o f the patients were d i a g n o s e d p r e o p e r a t i v e l y by m e a n s o f clinical consideration c o m b i n e d with plain a b d o m i n a l film a n d bari u m e n e m a (Fig. 2). T h e diagnosis was suspected in 46 p e r c e n t o f the plain a b d o m i n a l r a d i o g r a p h s while 30 p e r c e n t were m i s i n t e r p r e t e d as small-bowel obstruction. H o w e v e r , definitive diagnosis b a s e d o n plain a b d o m i n a l r a d i o g r a p h s alone was m a d e in only 17 p e r c e n t . B a r i u m e n e m a e x a m i n a t i o n was p e r f o r m e d in 50 p e r c e n t o f patients with an accuracy rate (true positive a n d t r u e negative) o f 88 percent.
laparotomy 47
Current Series: Five patients were d i a g n o s e d p r e o p eratively (4 b a s e d o n b a r i u m e n e m a a n d o n e based on plain a b d o m i n a l film). T h e r e m a i n i n g 2 patients were d i a g n o s e d at l a p a r o t o m y .
Operative Findings Reviewed Series: Mobile c e c u m was f o u n d in all cases. T r u e volvulus was 6 times m o r e c o m m o n t h a n bascule (Fig. 1D). Necrosis, which o c c u r r e d in 20 percent o f the patients, was p r o p o r t i o n a l l y distributed b e t w e e n t r u e volvulus a n d bascule. T w o p e r c e n t o f all cecal volvulus were r e d u c e d s p o n t a n e o u s l y a n d only mild m e s e n t e r i c a n d m u r a l congestion were f o u n d at l a p a r o t o m y . Fixation o f the c e c u m by adhesions a n d bands was o b s e r v e d in 23 p e r c e n t o f patients. Current Series: Mobile c e c u m was p r e s e n t in all patients. Five patients h a d t r u e volvulus a n d 2 patients h a d a n t e r i o r c e p h a l a d d i s p l a c e m e n t o f the cecum. G a n g r e n o u s c e c u m was f o u n d in o n e case o f volvulus a n d in o n e p a t i e n t with bascule. A d h e s i o n s as a possible fixation m e c h a n i s m o f the c e c u m w e r e r e p o r t e d in only o n e patient.
Surgical Treatment and Results
',UB 17 barium 86 FIG. 2. Means of diagnosis in 561 reported patients during 1959-1989. Data are presented as percentages.
Reviewed Series: T h e o p e r a t i v e p r o c e d u r e s a n d results are p r e s e n t e d in T a b l e 2. D e t o r s i o n alone a n d cecopexy h a d almost similar complication, mortality, a n d r e c u r r e n c e rates. H i g h e r rates w e r e o b s e r v e d after resectional operations, which w e r e p e r f o r m e d in almost all patients with necrotic cecum, w h e r e a s 9 p e r c e n t o f the resections w e r e p e r f o r m e d in patients with viable cecum. T h e r e was n o significant difference in the results o f resections p e r f o r m e d in patients with necrotic or viable colon (data not shown). T h e highest complication, mortality, a n d r e c u r r e n c e rates were r e c o r d e d a f t e r cecostomy (with or without cecopexy). T h e m e a n follow-up p e r i o d was 63 m o n t h s .
768
Dis. Col. & Rect.
RABINOVICI, ET AL.
September 1990
TABLE 2. Surgical Treatment and Results in 561 Patients (1959-1989) Operation
Percent
Cecopexy Detorsion Resection Cecostomy
32 25 25 16
Complications (Percent) Abdominal Wound 8 9 16 25
Mortality (Percent)
Recurrence (Percent)
10 13 22 32
13 12 -14
7 6 13 27
Current Series: The surgical treatment and results are listed in Table 3. Four patients had cecopexy, two patients underwent right hemicolectomy, and in one patient cecostomy with cecopexy were performed. There was one hospital mortality (due to severe congestive heart failure in a high-risk patient), which occurred four days after resection. There were no recurrences during a mean follow-up period of 44.2 months.
most probably reflect different stages in the pathophysiologic process of cecal volvulus at the time of admission. Although it was estimated that the diagnosis of cecal volvulus should be made with confidence from plain abdominal films in nearly 90 percent of c a s e s , 22 only 46 percent of the plain abdominal radiographs in the current review were suspected to be cecal volvulus. The plain film diagnosis was based on the combination of several findings: dilated cecum (98 percent) containing a single air-fluid level (72 percent), little or no gas in the distal colon (82 percent), abnormally positioned cecum (56 percent), and dilatation of small bowel with air-fluid levels (55 percent). The most reliable diagnostic procedure (accuracy rate of 88 p e r c e n t ) , which is r e c o m m e n d e d by m a n y authors, ~7 was the barium enema. The typical findings were obstruction at site of colonic twist (93 percent) with no filling of the cecum (79 percent). Contrast study is also important to rule out concomitant distal colonic obstruction, which might have precipitated the cecal volvulus (2 percent). The current data do not support the assumption that such studies might induce imminent perforation and needlessly delay necessary surgical treatment. However, barium enema should be administered under low pressure in case unsuspected gangrene is present and to prevent further distention of the cecum with air. The current data confirm that mobile cecum is a prerequisite for cecal volvulus. It also establishes the relatively high association between cecal volvulus and previous abdominal surgery, pregnancy, and other
Discussion
The current study shows that the age and sex distribution of cecal volvulus have changed during the last four decades. A review of 100 cases reported in 194929 concluded that the highest incidence of cecal volvulus occurred in the 25- to 30-year-old age group with a mean age of 40 years, and that there was an equal distribution between men and women, whereas the current data reveal a peak incidence in the sixth decade of life and predominance in females. Although the diagnosis of cecal volvulus is rarely made on clinical grounds alone, the current analysis points out some clinical features that may promote correct diagnosis. Distal small-bowel obstruction associated with abdominal mass, in debilitated, mentally retarded, or pregnant patients with previous abdominal operations or with other acute medical illnesses, should raise the suspicion of cecal volvulus. However, once gangrene or perforation have occurred, severe constant abdominal pain, diffuse peritonitis, and lack of peristaltic sounds may supervene. The variable descriptions of the pain and peristalsis patterns aT'ls'2s'3~
TABLE 3. Operative Findings, Surgical Treatment, and Results in Current Series (7 Patients) Operative Findings
Procedure
Bascule, adhesions, viable cecum Volvulus, viable cecum
Cecopexy
Volvulus, necrotic cecum Volvulus, viable cecum Volvulus, viable cecum Volvulus, viable cecum Bascule, necrotic cecum
Resection Cecopexy, appendectomy Cecopexy Cecostomy, Cecopexy Resection
Cecopexy
SBO = small-bowel obstruction. CHF = congestive heart failure.
Complications Paralytic ileus -Wound infection
Mortality
Follow-up
--
(18 months) Rec. SBO---conservative treatment, no recurrence --
4 postop day, severe CHF
(28 months) Uneventful (66 months) No recurrence (60 months) No recurrence Lost to follow-up (49 months) Sigmoid volvulus
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CECAL VOLVULUS
acute medical illness. The fact that gangrenous cecum was found in 20 percent of the cases points out the potential fatality of cecal volvulus and probably reflects the difficulties in its diagnosis. Our collected data support the general agreement that resection is mandatory in the presence of necrotic or perforated cecum. Also, the current study suggests that cecostomy through the perforation hole should not be performed because of its high morbidity and mortality rates. The surgical treatment of cecal volvulus in the absence of gangrene is still controversial. Detorsion, which is a simple and rapid procedure, avoids the opening of the colon but was associated in several reports with a high recurrence rate. 1~ Subsequently, cecopexy was proposed as a relatively safe procedure with a lower recurrence rate. 13'16 However, because various series reported a high rate of recurrence after cecal fixation, resection was advocated for all cases of cecal volvulus, s'31'32 Cecostomy alone, or in combination with cecopexy, which was suggested for both cecal fixation and decompression, carries a high risk of wound infection and has serious complications such as abdominal wall necrosis, cecal necrosis, and leakage. 7'16'33 The current review shows that the morbidity, mortality, and recurrence rates of detorsion alone and cecopexy were almost similar. Therefore, cecopexy, which is more time consuming, seems to be unnecessary when detorsion is used. Cecostomy, which had the highest complication, mortality, and recurrence rates, should be abandoned. Despite the elimination of possible recurrence, resection should not be performed in patients with viable colon, since it was associated with a two-fold mortality rate and increased morbidity as compared with detorsion alone or cecopexy. Nonoperative modalities for reducing cecal volvulus are still anecdotal. The current review detected only four cases of cecal volvulus, which was reduced nonintentionally by barium enema. However, deliberate attempts to reduce cecal volvulus by barium enema are not advisable because of the risk of perforation. 16,30,34 Reports of colonoscopic reduction are also few and little-tested. 2~'~5'36 References 1. Rokitansky C. Intestinal Strangulation. Arch Gen Med 1837; 14:202. 2. Weinstein M. Volvulus of the cecum and ascending colon. Ann Surg 1938; 107:248. 3. Villet DG. Volvulus of the proximal colon. Ann Surg 1959; 150:1075-85. 4. Hinshaw DB, Carter R, Joergenson EJ. Volvulus of the cecum and right colon. Am J Surg 1959;98:175-83.
769
5. Hjelmstedt A. Volvulus of the right colon. Acta Chir Scand 1959/1960; 118-65. 6. Sawyer RB, Sawyer KC Jr, Sawyer CS. Volvulus of the colon. Am J Surg 1962; 104:468-73. 7. Krippaehne WW, Mark Vetto R, Jenkins CC. Volvulus of the ascending colon: a report of twenty two cases. Am J Surg 1967; 114:323-32. 8. Meyers JR, Heifetz CJ, Baue AE. Cecal volvulus. Arch Surg 1972; 104:594-9. 9. Bystrom J, Backman L, Dencker H, Meden-Brith G. Volvulus of the caecum. Acta Chir Scand 1972; 138:624-7. 10. Inberg MV, Havia T, Davidsson L, Salo M. Acute intestinal volvulus, a report of 238 cases. Scand J Gastroenterol 1972; 7:209-14. 11. Smith WR, Goodwin JN. Cecal volvulus. Am J Surg 1973; 126:215-22. 12. Grover NK, Gulati SM, Tagore NK, Taneja OP. Volvulus of the cecum and ascending colon. A m J Surg 1973;125:672-5. 13. Andersson A, Bergdahl L, Van Der Linden W. Volvulus of the cecum. Ann Surg 1975;181:876-880. 14. Wertkin MG, Aufses AH Jr. Management of volvulus of the colon. Dis Colon Rectum 1978;21:40-5. 15. Todd GJ, Forde KA. Volvulus of the cecum: choice of operation. Am J Surg 1979;138:632-4. 16. O'Mara CS, Wilson TH Jr, Stonesifer GL, Cameron JL. Cecal volvulus. Ann Surg 1979;189:724-31. 17. Howard RS, Catto J. Cecal volvulus. Arch Surg 1980;115: 273-7. 18. Anderson JR, Lee D. Acute cecal volvulus. Br J Surg 1980; 67:39-41. 19. Morris DM, Eisenstat T, Hall GM. Management of cecal volvulus in debilitated patients. South Med J 1982;75:1069-71. 20. Lal MM, Yadav R, Kesri V. Volvulus of the cecum caused by injury. Injury 1983;15:139-40. 21. Barrington J, Mahender PCS. Volvulus of the caecum. Br J Radiol 1984;57:842-4. 22. Anderson JR, Mills OM. Caecal volvulus: a frequently missed diagnosis? Clin Radiol 1984;35:65-9. 23. Pruett TL, Wilkins ME, Gamble WG. Cecal volvulus: a different twist for the serious runner. N Engl J Med 1985; 312:1262-3. 24. Singh G, Gupta SK, Gupta S. Simultaneous occurrence of sigmoid and cecal volvulus. Dis Colon Rectum 1985;28:115-6. 25. Johnson CD, Rice RP, Kelvin FM, Foster WL, Williford ME. The radiologic evaluation o f gross cecal distention: emphasis on cecal ileus. AJR 1985; 145:1211-7. 26. BallantyneGH, Brandner MD, Beart RW, Ilstrup DM. Volvulus of the colon. Ann Surg 1985;202:83-92. 27. FanningJF, Cross CB. Post-cesarian section cecal volvulus. Am J Obstet Gyneco 1988;1200-02. 28. Tejler G, Jiborn H. Volvulus of the cecum: report of 26 cases and review of the literature. Dis Colon Rectum 1988;31: 445-9. 29. Donhauser JL, Atwell S. Volvulus of the cecum. Arch Surg 1949;58:129-48. 30. Nelson TJ, Bowers WF. Volvulus of the cecum and sigmoid colon. Arch Surg 1956;72:469-78. 31. Rivas AA, Dennison HC. Volvulus of the cecum. Am Surg 1978;44:332. 32. Melchior E. Volvulus of the cecum--an appeal for primary resection. Surgery 1949;25:251. 33. Halvorsen JF, Semb BH. Volvulus of the right colon: a review of 30 cases with special reference to late results of various surgical procedures. Acta Chir Scand 1975;141:804-9. 34. Figiel LS, Figiel SJ. Volvulus of the cecum and ascending colon. Radiology 1953;61:496-515. 35. Anderson MJ Sr, Okike N, Spencer RJ. The colonoscope in cecal volvulus: report of three cases. Dis Colon Rectum 1978;21:71-4. 36. Ghazi A, Shinya H, Wolff WI. Treatment of volvulus of the colon by colonoscopy. Ann Surg 1976;183:263.
