Endoscopic Management of Acute Sigmoid Volvulus in High Risk Surgical Eldery Patients: A Randomized Controlled Trial.

Introduction:

Sigmoid volvulus is a surgical emergency and if untreated, it will lead to bowel ischemia & perforation with high incidence of mortality (1). Most of the patients with sigmoid volvulus are old age with many co-morbidities (2). So, the risk of surgery for those elderly patients is high and is associated with high incidence of morbidity & mortality (3) . Early intervention is required for managing the sigmoid volvulus to avoid its serious complications , so the less invasive intervention is the best for those high risk elderly patients (4) . Usually in the past after failure of deflating rectal tube to untwist the volvulus , the patients were subjected for surgical colostomy to relive the intestinal obstruction with high risk consent for elderly patients then in later session , they were subjected for definitive surgery (5) . As the emergency surgery is associated with high incidence of morbidity & mortality in elderly patients, so the endoscopic approach becomes the first line of management to resolve the obstruction in uncomplicated sigmoid volvulus in elderly patients (6). The endoscopic untwist of the acute sigmoid volvulus was first described by Bruusgaard and had the advantage of both diagnostic & therapeutic values (7) . For diagnostic value, the endoscopy evaluate the mucosa and its viability , it is also important to exclude other causes of intestinal obstruction , the length of the endoscopy is enough to reach beyond site of twist and diagnose the torsion as the site of twist appears spiral , sphincter area of the mucosa (8). For therapeutic value , it is successful in treating the acute volvulus by incidence of 75%-95% , but with high recurrence rate up to 90% (9). The elective definitive surgery few days later after the endoscopy was postponed in elderly patients for many reasons , so in our study we will try to fix the sigmoid colon also by endoscopy without needs for general anesthesia and major surgery.

Objectives:

To evaluate the advantages and safety of Endoscopic management of acute sigmoid volvulus in high risk surgical patients and its effect in reducing morbidity and postoperative hospital stay.

Patients and Methods Patients This prospective randomized controlled clinical trial included all patients who developed the manifestations of acute a cute sigmoid volvulus and referred to the Zagazig University Hospital Emergency Department between December 2020 and August 2022. The study was prospectively approved by Zagazig University Faculty of Medicine Institutional Review Board (Approval Number: 9989/23-10-2022), and was retrospectively submitted in clinicaltrials.gov in November 2022 (NCT05051683). The study was performed in accordance with the code of ethics of the World Medical Association (Declaration of Helsinki) for studies involving human subjects. Written informed consent was obtained from all participants after explaining to them all the study procedures with its benefits and hazards. Patients with age of ≥60 years-old , with acute sigmoid volvulus not managed by rectal deflating tube, with no evidence of bowel ischemia, with ASA III & IV , high risk surgical patients , with comorbidities and on sepsis but not septic shock were included and eligible for randomization. We excluded patients who were with good general condition (ASAI&II), patients with age below 60 years , patients with bowel ischemia and patients managed by rectal deflating tube.