Volvulus obstruction of the small and large bowelsJD Wig, SM Bose, SP Kaushik
Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh-160 012, India
77 cases of intestinal volvulus seen during the last 6 years have been analysed; majority belong to 20-40 years age group. More than 50% presented after 72 hours of onset of symptoms. Small bowel was the site of volvulus in 65% of cases, transverse colon in 2.6% and sigmoid in 23.4%. 32.5% cases had strangulation obstruction. Volvulus was of primary idiopathic variety in 84.5% of cases. Resection was required in 52%. The overall mortality was 10.5% in the series.
Volvulus is defined as a twisting of a loop around its own axis. Those organs which are suspended from a narrow base and have a long mesentery most frequently undergo volvulus. Next to small intestine, sigmoid colon is the most frequently involved. , Although volvulus is comparatively rare in Britain, Western Europe and America, it is a common cause of intestinal obstruction in Eastern Europe, Scandinavia, India and Africa. ,
The present paper is a critical analysis of our experience in the management of all cases of volvulus obstruction treated in our Unit since 1968 through 1974. 300 cases of intestinal obstruction were admitted for treatment during the period under review. 77 of these (26%) were caused by volvulus of small and large bowel.
Age and Sex: There were 63 males and 14 females. The youngest patient was 15 years old and the oldest was 80 years in age. Majority of cases (41.5%) belonged to 20-40 years age group.
Presenting Signs and Symptoms
Clinical features of acute intestinal obstruction viz. central abdominal pain, vomiting, and distention of abdomen were invariably present (98%). Visible peristalsis was seen in 48%. Abdominal tenderness suggestive of internal strangulation was seen in 33%. 30% of cases presented with toxemia.
Duration of Symptoms
The duration of symptoms ranged from 6 hours to 10 days. 517c of the patients presented after 72 hours of onset of symptoms and only 14% presented in the first 12 hours.
Emergency laparotomy was performed after adequate hydration and attempts at correction of electrolytes to near normal Nasogastric suction was instituted in all the cases. Gangrenous bowel was present in 32.5% of cases. Various operative procedures carried out have been shown in [Table 1]. In two cases, volvulus of transverse colon was seen. A subtotal colectomy was performed in one and untwisting of volvulus was done in another case. In three patients of sigmoid volvulus, sigmoid colon was anastomosed to the distal third of the transverse colon to avoid recurrence. In 34 cases (43.6%), detorsior and fixation was carried out. Resection was performed in 40 cases.
Site of Volvulus
Small bowel was affected in 50 cases (65%). In the remaining 27 cases (36%), sigmoid colon was the site of volvulus in 18 and transverse colon in 2 cases. Right colon was affected in 7 cases.
In 65 cases (84.5;%), there was no obvious cause for volvulus obstruction (Idiopathic). Only in 12 instances (15.5%) the volvulus was secondary. One case of secondary volvulus was due to gall stone, one-due to Meckel's diverticulum and 10 cases had volvulus due to bands and adhesions.
Wound infection was the commonest complication in 8 cases (10.4%). Burst abdomen was seen in 4 cases. Faecal fistula occurred in 2 cases and septicemia was observed in 3 cases. Bronchopneumonia occurred in 4 cases while recurrence has only been seen in one patient.
The overall mortality was 10.5% (8 cases).
77 cases of volvulus obstruction have been reviewed. The incidence of volvulus has been found to be 26 of all cases of intestinal obstruction treated by us. The reported incidence in the literature varies from 3-65%. ,,
The factors leading to a spontaneous primary rotation of bowel are complex but a long mesentery with short attachment and sudden distention of an intestinal loop appears to be a pre-requisite for volvulus. In Indian patients sudden overloading of the intestine by a large quantity of food may precipitate irregular violent persistalsis and thus lead to volvulus. , The most frequent cause of secondary volvulus has been reported as adhesions . , In our own cases, 13% were due to adhesions. One case of volvulus was caused by a gall stone in the small bowel, an extremely infrequent complication, although such a situation has been anticipated by Deckoff. 
Volvulus of the small intestine accounts for approximately one third of the cases observed [Table 2]; strangulation obstruction tends to occur more frequently and progresses rapidly to gangrene as the twisting of the mesentery tends to be very tight leading to early vascular impairment.
Transverse colon volvulus accounts for less than 1% of all the large bowel obstructions and less than 4% of all reported cases of colonic torsions.  Mortality in such cases has been observed to be higher than either sigmoid or caecal volvulus.. Two cases of transverse colon volvulus were seen in our series. The etiological factor in both of these cases was an elongated mesentery with redundant colon. There had been no mortality in these cases.
Sigmoid colon has been reported variously as the most common site of colonic volvulus [Table 2]. While conservative management, sigmoidoscopy and passage of a rectal tube to bypass the twist has been recommended,  many observers have not favoured this type of management. The present thinking is more in favour of emergency surgery and primary resection anastomosis. , Because of high rate of recurrence, sigmoidopexy has also not been advocated as a routine. The technique of anastomosis of the sigmoid colon to transverse colon as reported by Agarwal and Misral has yet to be evaluated further.
Mortality in cases of intestinal volvulus has ranged from 2.5-70% ,, In our cases, mortality was This high mortality had partly been due to late arrival of patients, more than 50% presenting after 72 hours of onset of symptoms.
[Table 1], [Table 2]