Volvulus of the Cecum: Choice of Operation
George J. Todd, MD, New York, New York Kenneth A. Forde, MD, New York, New York
Despite the relatively infrequent occurrence of cecal vo1vulus, this condition has been the subject of several surgical studies published recently [l-6]. Although most authors present excellent discussions on etiology, symptoms, radiographic findings, morbidity, and mortality, there remains some question about the best form of treatment for cases in which there is no evidence of vascular compromise or perforation. Several authors [3,6,7] recommend colon resection in all cases of cecal volvulus because of concern over the possibility of recurrence after a lesser procedure (such as cecopexy or tube cecostomy). This study was undertaken to determine the recurrence rate of cecal volvulus after colectomy, cecopexy, and tube cecostomy.
The records of patients at Presbyterian Hospital with the diagnosis of cecal volvulus during the period 1958 to 1977 were reviewed with regard to age, sex, operative findings, operative procedure performed, recurrence of cecal volvulus, and length of follow-up. Results
Twenty patients had a diagnosis of cecal volvulus during this 20 year period. The average age of the group was 54.6 years (range 16 to 801, and 70 per cent were women. The patients were divided into two groups: those who had volvulus with perforation or gangrene (Table I) and those who had volvulus without evidence of vascular comnromise or nerfoFrom the Department of Surgery, Columbia-Presbyterian Medical Center, 622 West 168th Street. New York. New York. Reprint requests should be add&d to George J. Todd, MD. Department of Surgery, Presbyterian Hospital. 622 West 168th Street, New York, New York 10032.
632
ration (Table II). As shown in the tables, the mortality in the former group was 50 per cent (three of six), and there were no deaths in the latter group. The duration of follow-up in the group of patients without perforation or gangrene ranged from 1.5 to 14 years (mean 6.0 years) and there was no recurrence during the follow-up period, despite the fact that only one patient in this group underwent resection. Comments
Regardless of the cause of the actual twisting of the bowel (for example, recent surgery or constipation), the underlying anatomic malformation is probably the same: failure of the terminal ileum, cecum, and ascending colon to fuse to the posterior parietal peritoneum during the third stage of midgut rotation. An anatomic derangement of this nature that would allow for a 180° volvulus of the cecum has been found in 11.2 per cent of consecutive normal adult dissecting-room cadavers [8]. Review of the studies published recently indicates that the mortality associated with cecal volvulus is primarily related to the presence or absence of vascular compromise (Table III), which again emphasizes the need for early operative intervention in patients with this condition. While there is no question that gangrenous bowel must be resected, the issue of whether to resect the bowel in all cases of cecal volvulus seems to be unresolved. Meyers et al [3], Rivas and Dennison [6], and Melchior [7] recommend resection for all cases of cecal volvulus re. gardless of the condition of the bowel. The rationale for this recommendation is based on concern regarding the recurrence of volvulus after cecostomy
or cecopexy. In an effort to address this question, we
The American Journal of Surgery
Volvulus of the Cecum
TABLE I Age (yr)
Cecai Voiruius With Perforation or Gangrene Operative Findings
Operation
Follow-up
45F 77F’
Gangrene Gangrene
lleocolectomy lleocolectomy
8OF
Perforation
Cecostomy
67M 59F 77M
Perforation Gangrene Gangrene
Cecostomy lleocolectomy lleocolectomy
4.5 years Died on postop day 9f Died on postop day 12t 5.0 years 12.0 years Died on postop day 185
& Sex
TABLE ii
Age (yr) & Sex 24F 58M 70M 71F 61M 54F 50F 16F 17F 61F 38F 69M 45F 52F
Postop = postoperative. This patient had undergone detorsion of cecal volvulus and appendectomy 22 years earlier. + The cause of death was aspiration pneumonia. t The cause of death was myocardial infarction. 9 The cause of death was pneumonia. l
TABLE Ill
Cecai Voivuius Without Perforation or Gangrene
Operation Appendectomy Appendectomy Cecopexy Cecopexy Cecostomy Appendectomy, Appendectomy, Appendectomy, Appendectomy, Appendectomy, Appendectomy, Appendectomy, lleocolectomy Cecopexy
Follow-up 11 2 2 3 1.5 4 14 9 5 7 12 2 3 9
cecopexy cecopexy cecopexy cecostomy cecostomy cecostomy cecostomy ~-
years years years years years years years years years years years years years years
Mortality in Patients With Cecai Volvulus
Author Reference No., & Year
No. of Deaths
No. of Patients
Melchior [ 71, 1949 Krippaehne et al [ 21, 1967 Grover et al [ 71,1973 Meyers et al [3], 1972 Smith and Goodwin [ 41, 1973 Andersson et al [5], 1975’ Rivas and Dennison [ 81, 1978 Present series, 1979
1 10 2 0 3 13 2 3
6 22 12 9 24 37 21 20 151
Total
No. Who Had Gangrene or Perforation/ No. of Deaths
-
l/l 714 6/l l/O 2/l 572 l/O 613
5/o 1516 6/l 8/O 2212 2716 2012 14/O
29112 (41.4%)
34 (22.5 %)
No. Who Had Viable Bowel/ No. of Deaths
117117 (14.5%)
Numbers in parentheses indicate mortality rates. The diagnosis was made at autopsy in five cases; the condition of the bowel was not specified. l
TABLE IV
Recurrence of Cecai Volvulus in Patients Treated by Colon Resection, Cecopexy, Cecostomy, or Detorsion Alone
Author & Reference No. Melchior [ 71 Krippaehne et al [ 21 Meyers et al [ 31 Smith and Goodwin [ 41 Andersson et al [ 51 Rivas and Dennison [ 61 Present Series Total
No. of Operations 6 12 13 21 26 20 18 116
No. of Recurrences 1 0 4 0 2 1 1 9 (7.8%)
No. Who Had Resection1 No. of Recurrences 5/o 5/o 8/O 3/o 4/o 8/O 3/o 3610 (0)
No. Who Had Cecostomy I No. of Recurrences l
No. Who Had Cecopexytl
No. of Recurrences
No. Who Had Detorsiontl No. of Recurrences
l/l 0 414 2/o 1012
0 4/o l/O 0 7/o
l/O
5/l
6/O
6/O
6/O
3/l
0 3/o 0 16/O 5/o
31/o (0%)
28/8 (28.5%)
21/l
(4.8%)
Numbers in parentheses indicate recurrence rates. The length of postoperative follow-up.was not specifically stated except in the studies of Meyers et al (6 months to 12 years) and Andersson et al (mean of 7 years). Cecostomy combined with cecopexy in 10 cases and with appendectomy in 6 cases. + Cecopexy combined with appendectomy in five cases. $ Detorsion alone combined with appendectomy in 10 cases. l
Volume 138. November 1878
633
Todd and Forde
reviewed several published series with the specific intention of determining the frequency of recurrent volvulus. As noted in Table IV, the overall recurrence rate is 7.8 per cent after operation for cecal volvulus. (One reported recurrence [ 71 was excluded from the tabulation because of insufficient data regarding the type of operation performed; inclusion of this recurrence would increase the overall recurrence rate to 8.6 per cent.) Of importance is the fact that there was no recurrence after either colectomy or tube cecostomy (36 and 31 cases, respectively). There was a 28.5 per cent rate of recurrence after cecopexy (28 cases). Surprisingly, the rate of recurrence after detorsion alone was only 4.8 per cent, perhaps because of the length of follow-up or some other favorable anatomic factors that influenced the surgeon to perform this minimal procedure. Summary and Conclusions
Although it is clear that there is a significant frequency of recurrent volvulus after cecopexy, there is
634
no evidence from either this series or previous reports that resection is associated with a lower recurrence rate than tube cecostomy. In the absence of data suggesting a clear superiority of colon resection, it appears that tube cecostomy should be the treatment of choice for cases of cecal volvulus that are not complicated by vascular compromise. References 1. Grover NK, Gulati SM, Tagore NK, Taneja OP: Volvulus of the cecum and ascending colon. Am J Surg 125: 672, 1973. 2. Krippaehne WW, Betto RM, Jenkins CC: Volvulus of the ascending colon. Am J Surg 114: 323, 1967. 3. Meyers JR, Heifetz CJ. Baue AE: Cecal volvulus-a lesion requiring resection. Arch Surg 104: 594, 1972. 4. Smith WR, Goodwin JN: Cecal volvulus. Am J Surg 126: 215, 1973. 5. Andersson A, Bergdahl L, Van Der Linden W: Volvulus of the cecum. Ann Surg 181: 876, 1975. 6. Rivas AA, Dennison HC: Volvulus of the cecum. Am Surg 44: 332, 1978. 7. Melchior E: Volvulus of the cecum-an appeal for primary resection. Surgery 25: 251, 1949. 8. Wolfer JA, Beaton LE, Anson BJ: Volvulus of the cecum. Surg Gynecol Obstet 74: 882, 1942.
The American Journal of Surgery
George J. Todd, MD, New York, New York Kenneth A. Forde, MD, New York, New York
Despite the relatively infrequent occurrence of cecal vo1vulus, this condition has been the subject of several surgical studies published recently [l-6]. Although most authors present excellent discussions on etiology, symptoms, radiographic findings, morbidity, and mortality, there remains some question about the best form of treatment for cases in which there is no evidence of vascular compromise or perforation. Several authors [3,6,7] recommend colon resection in all cases of cecal volvulus because of concern over the possibility of recurrence after a lesser procedure (such as cecopexy or tube cecostomy). This study was undertaken to determine the recurrence rate of cecal volvulus after colectomy, cecopexy, and tube cecostomy.
The records of patients at Presbyterian Hospital with the diagnosis of cecal volvulus during the period 1958 to 1977 were reviewed with regard to age, sex, operative findings, operative procedure performed, recurrence of cecal volvulus, and length of follow-up. Results
Twenty patients had a diagnosis of cecal volvulus during this 20 year period. The average age of the group was 54.6 years (range 16 to 801, and 70 per cent were women. The patients were divided into two groups: those who had volvulus with perforation or gangrene (Table I) and those who had volvulus without evidence of vascular comnromise or nerfoFrom the Department of Surgery, Columbia-Presbyterian Medical Center, 622 West 168th Street. New York. New York. Reprint requests should be add&d to George J. Todd, MD. Department of Surgery, Presbyterian Hospital. 622 West 168th Street, New York, New York 10032.
632
ration (Table II). As shown in the tables, the mortality in the former group was 50 per cent (three of six), and there were no deaths in the latter group. The duration of follow-up in the group of patients without perforation or gangrene ranged from 1.5 to 14 years (mean 6.0 years) and there was no recurrence during the follow-up period, despite the fact that only one patient in this group underwent resection. Comments
Regardless of the cause of the actual twisting of the bowel (for example, recent surgery or constipation), the underlying anatomic malformation is probably the same: failure of the terminal ileum, cecum, and ascending colon to fuse to the posterior parietal peritoneum during the third stage of midgut rotation. An anatomic derangement of this nature that would allow for a 180° volvulus of the cecum has been found in 11.2 per cent of consecutive normal adult dissecting-room cadavers [8]. Review of the studies published recently indicates that the mortality associated with cecal volvulus is primarily related to the presence or absence of vascular compromise (Table III), which again emphasizes the need for early operative intervention in patients with this condition. While there is no question that gangrenous bowel must be resected, the issue of whether to resect the bowel in all cases of cecal volvulus seems to be unresolved. Meyers et al [3], Rivas and Dennison [6], and Melchior [7] recommend resection for all cases of cecal volvulus re. gardless of the condition of the bowel. The rationale for this recommendation is based on concern regarding the recurrence of volvulus after cecostomy
or cecopexy. In an effort to address this question, we
The American Journal of Surgery
Volvulus of the Cecum
TABLE I Age (yr)
Cecai Voiruius With Perforation or Gangrene Operative Findings
Operation
Follow-up
45F 77F’
Gangrene Gangrene
lleocolectomy lleocolectomy
8OF
Perforation
Cecostomy
67M 59F 77M
Perforation Gangrene Gangrene
Cecostomy lleocolectomy lleocolectomy
4.5 years Died on postop day 9f Died on postop day 12t 5.0 years 12.0 years Died on postop day 185
& Sex
TABLE ii
Age (yr) & Sex 24F 58M 70M 71F 61M 54F 50F 16F 17F 61F 38F 69M 45F 52F
Postop = postoperative. This patient had undergone detorsion of cecal volvulus and appendectomy 22 years earlier. + The cause of death was aspiration pneumonia. t The cause of death was myocardial infarction. 9 The cause of death was pneumonia. l
TABLE Ill
Cecai Voivuius Without Perforation or Gangrene
Operation Appendectomy Appendectomy Cecopexy Cecopexy Cecostomy Appendectomy, Appendectomy, Appendectomy, Appendectomy, Appendectomy, Appendectomy, Appendectomy, lleocolectomy Cecopexy
Follow-up 11 2 2 3 1.5 4 14 9 5 7 12 2 3 9
cecopexy cecopexy cecopexy cecostomy cecostomy cecostomy cecostomy ~-
years years years years years years years years years years years years years years
Mortality in Patients With Cecai Volvulus
Author Reference No., & Year
No. of Deaths
No. of Patients
Melchior [ 71, 1949 Krippaehne et al [ 21, 1967 Grover et al [ 71,1973 Meyers et al [3], 1972 Smith and Goodwin [ 41, 1973 Andersson et al [5], 1975’ Rivas and Dennison [ 81, 1978 Present series, 1979
1 10 2 0 3 13 2 3
6 22 12 9 24 37 21 20 151
Total
No. Who Had Gangrene or Perforation/ No. of Deaths
-
l/l 714 6/l l/O 2/l 572 l/O 613
5/o 1516 6/l 8/O 2212 2716 2012 14/O
29112 (41.4%)
34 (22.5 %)
No. Who Had Viable Bowel/ No. of Deaths
117117 (14.5%)
Numbers in parentheses indicate mortality rates. The diagnosis was made at autopsy in five cases; the condition of the bowel was not specified. l
TABLE IV
Recurrence of Cecai Volvulus in Patients Treated by Colon Resection, Cecopexy, Cecostomy, or Detorsion Alone
Author & Reference No. Melchior [ 71 Krippaehne et al [ 21 Meyers et al [ 31 Smith and Goodwin [ 41 Andersson et al [ 51 Rivas and Dennison [ 61 Present Series Total
No. of Operations 6 12 13 21 26 20 18 116
No. of Recurrences 1 0 4 0 2 1 1 9 (7.8%)
No. Who Had Resection1 No. of Recurrences 5/o 5/o 8/O 3/o 4/o 8/O 3/o 3610 (0)
No. Who Had Cecostomy I No. of Recurrences l
No. Who Had Cecopexytl
No. of Recurrences
No. Who Had Detorsiontl No. of Recurrences
l/l 0 414 2/o 1012
0 4/o l/O 0 7/o
l/O
5/l
6/O
6/O
6/O
3/l
0 3/o 0 16/O 5/o
31/o (0%)
28/8 (28.5%)
21/l
(4.8%)
Numbers in parentheses indicate recurrence rates. The length of postoperative follow-up.was not specifically stated except in the studies of Meyers et al (6 months to 12 years) and Andersson et al (mean of 7 years). Cecostomy combined with cecopexy in 10 cases and with appendectomy in 6 cases. + Cecopexy combined with appendectomy in five cases. $ Detorsion alone combined with appendectomy in 10 cases. l
Volume 138. November 1878
633
Todd and Forde
reviewed several published series with the specific intention of determining the frequency of recurrent volvulus. As noted in Table IV, the overall recurrence rate is 7.8 per cent after operation for cecal volvulus. (One reported recurrence [ 71 was excluded from the tabulation because of insufficient data regarding the type of operation performed; inclusion of this recurrence would increase the overall recurrence rate to 8.6 per cent.) Of importance is the fact that there was no recurrence after either colectomy or tube cecostomy (36 and 31 cases, respectively). There was a 28.5 per cent rate of recurrence after cecopexy (28 cases). Surprisingly, the rate of recurrence after detorsion alone was only 4.8 per cent, perhaps because of the length of follow-up or some other favorable anatomic factors that influenced the surgeon to perform this minimal procedure. Summary and Conclusions
Although it is clear that there is a significant frequency of recurrent volvulus after cecopexy, there is
634
no evidence from either this series or previous reports that resection is associated with a lower recurrence rate than tube cecostomy. In the absence of data suggesting a clear superiority of colon resection, it appears that tube cecostomy should be the treatment of choice for cases of cecal volvulus that are not complicated by vascular compromise. References 1. Grover NK, Gulati SM, Tagore NK, Taneja OP: Volvulus of the cecum and ascending colon. Am J Surg 125: 672, 1973. 2. Krippaehne WW, Betto RM, Jenkins CC: Volvulus of the ascending colon. Am J Surg 114: 323, 1967. 3. Meyers JR, Heifetz CJ. Baue AE: Cecal volvulus-a lesion requiring resection. Arch Surg 104: 594, 1972. 4. Smith WR, Goodwin JN: Cecal volvulus. Am J Surg 126: 215, 1973. 5. Andersson A, Bergdahl L, Van Der Linden W: Volvulus of the cecum. Ann Surg 181: 876, 1975. 6. Rivas AA, Dennison HC: Volvulus of the cecum. Am Surg 44: 332, 1978. 7. Melchior E: Volvulus of the cecum-an appeal for primary resection. Surgery 25: 251, 1949. 8. Wolfer JA, Beaton LE, Anson BJ: Volvulus of the cecum. Surg Gynecol Obstet 74: 882, 1942.
The American Journal of Surgery
