Delayed perforation of the sigmoid colon after endoscopic reduction of sigmoid volvulus

Abstract

Case

An 81‐year‐old woman was diagnosed with sigmoid volvulus. As there were no signs of peritoneal irritation, emergency endoscopic reduction was attempted and achieved successfully. Although she remained stable on the following day, she suddenly developed perforative pan‐peritonitis 35 h after the procedure.

Outcome

Emergency laparotomy revealed a 10‐mm‐diameter perforation at the anti‐mesenteric wall of the top of the sigmoid loop, and sigmoid resection with Hartmann's procedure was carried out. Pathological examination revealed ischemic necrosis around the perforation site. She recovered well with intensive care, and was discharged 32 days later.

Conclusion

Delayed sigmoid perforation after endoscopic reduction of sigmoid volvulus is a rare but important and life‐threatening pitfall, and should always be considered by acute care physicians. To prevent this dangerous complication, evaluation of the viability of the entire sigmoid by direct vision and semi‐emergency operation as soon as the patient's condition is optimized after endoscopic reduction may be essential.

Introduction

Sigmoid volvulus (SV) is a characteristic condition of strangulated ileus, in which a loop of the sigmoid colon twists around its mesentery, resulting in large bowel obstruction and vascular compromise to itself.1

According to recent advances in endoscopic instruments and techniques, current optimal acute care for SV patients with no signs of peritoneal irritation has been widely recognized as emergency endoscopic reduction of the volvulus followed by elective definitive surgery.1, 2, 3, 4, 5, 6

Sigmoid perforation is a well‐known complication of SV. However, it is relatively rare,1, 2, 3, 4 and is usually already present when the patient is examined, that is, before admission.2 Here, we report a rare case of delayed sigmoid perforation, which occurred 35 h after endoscopic reduction of SV. We also review the relevant published work, and discuss the possible mechanism of this rare pattern of perforation.

Case Report

An 81‐year‐old woman with Parkinson's disease was admitted to our hospital with abdominal distension and a 7‐day history of constipation. On admission, her general condition was good, and physical examination revealed abdominal distension, normal bowel sounds, and no tenderness. Plain abdominal radiography revealed a severely dilated sigmoid loop (Fig. 1A). Plain abdominal computed tomography revealed a dilated sigmoid loop with the beak sign and no ascites (Fig. 1B). She was diagnosed with SV, and emergency endoscopic reduction was attempted because there were no signs of peritoneal irritation. The sigmoid was reached smoothly during colonoscopy, but the color of the sigmoid mucosa could not be clearly visualized because of extensive retention of feces. A large amount of gas and feces was aspirated from the sigmoid, and reduction of the volvulus was achieved successfully. After this procedure, abdominal distension markedly decreased, and sequential insertion of a transanal ileus tube was attempted under colonoscopic guidance and fluoroscopic control for bowel preparation. We considered elective definitive surgery within several days. The following day, she remained stable, and plain abdominal radiography revealed no SV recurrence or bowel perforation. However, abdominal distension suddenly recurred 35 h after the procedure. She appeared pale, with labored breathing, and her level of consciousness was deteriorated (Japan Coma Scale, II‐20). Body temperature was 36.8°C, heart rate was 114 b.p.m., respiratory rate was 28 breaths/min, and blood pressure, 68/39 mmHg. She developed oliguria with a urinary output of 18 mL/h. On physical examination, her abdomen was severely distended with muscular defense and rebound tenderness. Laboratory results revealed leukocytopenia (3,400/mm³), coagulopathy (prothrombin time, 18.7 s; fibrin degradation product, 27.5 mcg/mL; antithrombin III, 51%), elevated levels of C‐reactive protein (24.2 mg/dL) and lactate (5.0 mmol/L), and hypoxia (PaO₂, 59.0 mmHg under 8 L/min of facial O₂ mask). The systemic inflammatory response syndrome score was 3. Plain abdominal radiography revealed intraperitoneal free air (Fig. 1C). We diagnosed her condition as severe sepsis due to perforative pan‐peritonitis. Emergency endotracheal intubation followed by mechanical ventilation, fluid resuscitation, antibiotic treatment, and administration of vasopressors were initiated, and emergency operation was carried out 3 h after the onset of severe sepsis. At laparotomy, a large amount of fecal ascites was encountered. Although almost the entire sigmoid seemed to be viable, there was a local gangrenous lesion at the anti‐mesenteric wall of the top of the sigmoid loop, and a perforation with a diameter of 10 mm was observed at the center of this lesion (Fig. 2A,B). Under the diagnosis of sigmoid perforation, sigmoid resection with Hartmann's procedure, peritoneal lavage, and drainage were carried out. Pathological examination revealed ischemic necrosis around the perforation site (Fig. 2C), and Clostridium perfringens was cultured from both the blood sample and ascites. After the operation, she developed septic shock, acute respiratory distress syndrome, and disseminated intravascular coagulation. However, she recovered well with intensive care, and was discharged 32 days after the operation (Fig. 3).

Figure 1.

(A) Supine x‐ray examination on admission of an 81‐year‐old woman with abdominal distension and a 7‐day history of constipation revealed dilated bowel loops, and a severely dilated sigmoid loop. (B) Plain abdominal computed tomography revealed a dilated sigmoid loop with the beak sign (arrow) and no ascites. (C) Supine x‐ray examination 35 h after endoscopic reduction of sigmoid volvulus revealed free air (asterisks) in the abdominal cavity. White arrow, tip of the transanal ileus tube; black arrow, top of sigmoid loop, i.e., perforation site.

Figure 2.

(A) Intraoperative finding in an 81‐year‐old woman diagnosed with sigmoid volvulus revealed a local gangrenous lesion at the anti‐mesenteric wall of the top of the sigmoid loop, and a perforation (arrow) with a diameter of 10 mm at the center of this lesion. (B) Macroscopic examination of the excised specimen revealed a gangrenous lesion with a perforation (arrow) at its center. (C) Pathological examination revealed ischemic necrosis around the perforation site. (hematoxylin–eosin stain, ×4).

Figure 3.

Clinical course in an 81‐year‐old woman diagnosed with sigmoid volvulus. 1, Endoscopic reduction of sigmoid volvulus; 2, endotracheal intubation; 3, emergency operation; 4, endotracheal extubation. AT III, antithrombin III; IVIG, i.v. immune globulin; P/F, arterial partial pressure of oxygen/fraction of inspired oxygen (PaO₂/FiO₂) ratio; PLT, platelets; PSV, pressure support ventilation; SIMV, synchronized intermittent mandatory ventilation; WBC, white blood cells.

Discussion

The etiology of SV is considered to involve several factors.1, 5 Redundant sigmoid loop with a narrow and elongated mesentery is considered the anatomic basis of the condition. This anatomical feature predisposes the sigmoid to free movement, which allows it to twist around its mesentery. Sigmoid volvulus tends to occur in elderly male individuals with neuropsychiatric diseases, who are more prone to constipation. Constipation is known to be an important predisposing factor.

The current optimal strategy for the management of SV is as follows.1, 2, 3, 4, 5, 6 For patients with any sign of peritoneal irritation, who are judged as already suffering bowel gangrene, emergency operation must be attempted. In contrast, for clinically stable patients, that is, those with no signs of peritoneal irritation, endoscopic reduction is the first acute care option of choice, and has been widely accepted with a high success rate (79–95%)2, 3, 4 and low morbidity and mortality rates (0–2.4%).2, 3, 4 However, this is only a temporizing procedure, and a high recurrence rate (18–90%)1, 6 has been reported. Therefore, it is strongly recommended that endoscopic reduction should be followed by elective definitive surgery.1, 2, 3, 4, 5, 6

Sigmoid perforation caused by ischemic necrosis of the sigmoid wall is a well‐known complication of SV. However, it is relatively rare,1, 2, 3, 4 with an incidence of 1.8–3.6%2, 3 of total SV cases. In addition, sigmoid perforation associated with SV is usually already present when the patient is examined, that is, before admission.2 To the best of our knowledge, there is no other published case report of delayed sigmoid perforation after endoscopic reduction. A possible mechanism of delayed perforation in our case is as follows. Initially, we suspected iatrogenic mechanical perforation due to direct force by colonoscopy or transanal ileus tube insertion. However, we now think this is unlikely because both of these procedures were carried out smoothly and without any difficulty by a skillful endoscopic physician. The sharp tip of the transanal ileus tube can get stuck in the colon and induce iatrogenic perforation; however, in our case, the tip of the inserted transanal ileus tube was positioned in the descending colon distant from the perforation site. Furthermore, pathologically confirmed ischemic necrosis around the perforation site was compatible with vascular compromise at this site, rather than mechanical direct force. During colonoscopy, the color of the sigmoid mucosa could not be clearly visualized, and the viability of the sigmoid could not be evaluated. However, we suppose that a certain degree of vascular compromise to the sigmoid might have already occurred, caused by impaired capillary perfusion following excessive stretching of the sigmoid wall due to increased intraluminal pressure and decreased blood supply itself due to torsion of the mesenteric vessels.1, 2 After endoscopic reduction, this vascular compromise was improved almost throughout the sigmoid. However, at the anti‐mesenteric wall of the top of the sigmoid loop, the most distant site from the main sigmoid artery, this improvement was likely insufficient. As a result, local ischemic necrosis and/or ischemia–reperfusion injury might have gradually progressed, resulting in delayed perforation.

Endoscopic reduction of SV is obviously an effective and appropriate acute care option. However, delayed perforation is a rare but important and life‐threatening pitfall. Particularly when the color of the sigmoid mucosa cannot be clearly visualized during the procedure, as in our case, the potential risk of delayed perforation may be increased. Therefore, particular effort to evaluate the viability of the entire sigmoid using colonic lavage together with colonoscopy is required, and if the viability of the sigmoid is even slightly uncertain, endoscopic reduction must be immediately converted to emergency operation. Even if endoscopic reduction is achieved, the patient must be hospitalized and strictly observed, and definitive surgery should be attempted as soon as possible. Current recommendations state that a safe and optimal interval from endoscopic reduction to definitive surgery in SV is 48 h to allow bowel preparation and fluid resuscitation.4, 5 However, delayed perforation occurred 35 h after the procedure in our case. Therefore, we propose that definitive surgery following endoscopic reduction should be attempted as soon as bowel preparation and fluid resuscitation are achieved as a semi‐emergency operation.

Conclusion

Delayed sigmoid perforation after endoscopic reduction of SV is a rare but important and life‐threatening pitfall, and should always be considered by acute care physicians. To prevent this dangerous complication, evaluation of the viability of the entire sigmoid by direct vision and semi‐emergency operation as soon as the patient's condition is optimized after endoscopic reduction may be essential.

Conflict of Interest

None.