Abstract

Background: A volvulus is a rotation of a loop of bowel usually on its mesenteric axis, most commonly occurring in the sigmoid colon in the adult. Since its description in 1836 by Von Rokitansky¹ volvulus of sigmoid colon has remained a formidable disease fraught with innumerable complications and responsible for many death despite advances in surgical treatment, mortality rate have remained distressingly high. Compression of the blood vessels in the twisted pedicle compromises the blood supply to the loop and this, added to the effect of distension, leads to a high risk of strangulation and the danger of gangrene of the affected loop of large bowel necessitating immediate surgical intervention.

But with improvement in preoperative care, early surgical intervention with better suturing technique, post operative care and timely management of complication like faecal fistula reduces morbidity and mortality.

Aims: This prospective observational study has been deviced to evaluate effectiveness of single layer non absrable suture technique in sigmoid volvulus surgery to reduce post operative complication like faecal fistula and its management.

Materials and Methods

Type of study: Hospital based observational prospective study.

Out of total 198 patients diagnosed case of sigmoid volvulus,132 patients underwent resection of volvulus segment with end to end colo colic, single layer anastomosis with nonabsorbable suture ( silk 2-0), from November 2015 to October 2017 in the department of general and laparoscopic surgery of V.S.S. medical college and hospital, Burla, Sambalpur, Odisha with best possible available resources. With prior approval from VIMSAR ethical committee.

Result: In this series a total number of 74 gangrenous volvulus, 103 cases of non-gangrenous, 5 compound volvulus and 2 cases of perforated sigmoid volvulus were studied. All of them (183 cases) had undergone operations. The 5 types of operations done are as follows.

• Resection of sigmoid colon volvulus and end to end colo colic anastomosis with interrupted single layer non absorbable suture(silk 2-0) (RA)
• Hartman’s operation (HP)
• Paul mickulicz operation
• Modified (lateral) mesocoloplasty.
• HP with ileo-transverse anastomosis

Out of 102 cases of viable bowel resection and anastomosis, 6 patients (5.88%) developed faecal fistula. Out of 30 cases of gangrenous bowel resection anastomosis, 2 (6.66%) developed faecal fistula. Overall development in 8 cases (6.06%) out of 132.

Faecal fistula developed in 8 cases after resection and anastomosis. Mean day of detection of fistula was 8.5% day. Maximum no. of fistula developed on 8^th day i.e. 3.

All the 8 cases of fistula were of low output i.e. less than 500 ml for 24 hours out of which 3 patietns had output < 100ml and rest 5 patitns had output > 100ml. all patients with output < 100 ml were treated conservatively and out of 5 patients with output > 100ml, 4 were treated conservatively and 1 underwent re-laparotomy due to presence of features of diffuse peritonitis.

Conclusion: Resection of the sigmoid colon volvulus with end to end anastomosis with single layer non-absorbable suture (silk 2-0) may be considered as the treatment of choice as it offers the following advantages.

1. It has got a low mortality rate as compared to any other method of treatment.
2. It reduces the rate of anastomotic leak and formation of faecal fistula.

• In our country specially where there is always an acute shortage of hospital beds and most of the poor patients do not agree for the second selective operation, immediate curative measures should be the treatment of choice.

Keywords: sigmoid colon volvulus, RA (resection and anastomosis), faecal fistula.