Comments on “Percutaneous Endoscopic Sigmoidopexy: Still a Way to Go”

I read the paper written by Garrido et al. [1] on a patient with recurrent sigmoid volvulus (SV) treated with percutaneous endoscopic sigmoidopexy (PES) following second endoscopic detorsion (ED). Although ED is successful in approximately four-fifths of patients, SV tends to recur in approximately one-third of patients, and approximately one-seventh of patients are diagnosed with short- or medium-term recurrences, which generally occur during the index admission period [2, 3]. Most probably due to the relatively low incidence of the early recurrence, the treatment algorithm is not clearly identified [4]. My comments relate to the management of the early SV recurrence based on our 57-year and 1,071-case experience, which is the most comprehensive single-centre SV data over the world [5].

The treatment of primary SV is well defined. ED followed by elective surgery is preferred in uncomplicated and non-gangrenous patients, while urgent surgery is required in complicated and gangrenous cases or in whom endoscopy is unsuccessful [5]. However, there are some controversies in the management of recurrent SV, particularly in patients with early recurrence [4]. A few-hour or day interval between ED and early recurrence provides an empty colon or allows for bowel preparation, or even antibiotic prophylaxis [3]. Although these advantages lead up to perform semi-elective surgery, second endoscopic decompression allows for minimally invasive procedures such as elective laparoscopic sigmoidectomy or PES [5]. For these reasons, some practitioners prefer surgery, while some others favour second endoscopy. Among limited availability of studies, Johansson et al. [6] and Mulas et al. [7] used surgery in 4 and 3 patients, respectively, while Iida et al. [8] and Maddah et al. [9] preferred second endoscopy in six and four cases, respectively. On the other hand, Bruzzi et al. [4] reported a 22-patient series including second endoscopy in 11 cases, while surgery in the remained 11 patients.

In our series, early recurrence was determined in 33 (5.3%) of 617 cases with successful nonoperative detorsion. All patients were treated with surgery, in whom bowels were viable. Sigmoidectomy with primary anastomosis was used in 17 patients (51.5%), while other operations were mesopexy in 11 (33.3%), sigmoidectomy with stoma in four (12.1%), and detorsion in one (3.0%). Mortality and morbidity rates were 3.0% (1 case) and 12.1% (4 patients), respectively. Although there is no case treated with second endoscopy and minimally invasive procedures in our series, in my opinion, second ED followed by elective laparoscopic sigmoidectomy is the optimal choice in well-conditioned and nonelderly patients, while PES is an alternative way in bad-conditioned and elderly cases, as was demonstrated by the authors. It is clear that an unsuccessful second endoscopy requires semi-elective open surgery including sigmoid colectomy in well-conditioned and nonelderly patients, while sigmoidopexy, mesopexy, extraperitonealization, or detorsion alone are main alternatives in bad-conditioned and elderly cases. I congratulate the authors and wait for their reply on my comments.

Statement of Ethics

Written informed consent was obtained from the participants of this paper.

Conflict of Interest Statement

The author declares that he has no conflict of interests.

Funding Sources

The author has no funding sources to declare.

Author Contributions

Sabri Selcuk Atamanalp collected and analysed the data, reviewed the literature, and wrote the text. He approved the final version of the manuscript.

Funding Statement

The author has no funding sources to declare.

Data Availability Statement

Data can be obtained from corresponding author.