Ambiguities in Sigmoid Volvulus Management: Developing a Framework for Optimal Management Strategies

Introduction Sigmoid volvulus (SV) accounts for 10-15% of all large bowel obstructions. Endoscopic decompression remains the first-line management, with a success rate of >80%, but recurrence rates are high (45-71%). To date, ambiguity exists regarding definitive management, particularly when deciding between elective surgery and repeated endoscopic decompression. This study aimed to develop guidelines for the management of SV within our trust. Methods This retrospective study was conducted over three years at Pilgrim Hospital, Boston, United Kingdom. Data were collected from online clinical records and case notes. The study was registered with the trust audit department before commencement. Comorbidities were analyzed using the Charlson Comorbidity Index (CCI). Outcome measures included diagnostic modality, success of endoscopic decompression, complications of conservative management, length of hospital stay, definitive surgery, mortality, and recurrence. Descriptive statistics summarized patient demographics, comorbidities, diagnostic tests, and management modalities. Categorical variables are presented as frequencies and percentages, while continuous variables are reported as medians. Kaplan-Meier analysis was used to assess recurrence-free survival from the index admission. Results A total of 42 patients with SV were identified, 31 (73.8%) of whom were male. The median age was 77 years. Based on CCI, 32 (76.2%) patients had moderate or severe comorbidities. Twenty-nine patients (69%) received both an abdominal X-ray (AXR) and a CT scan, suggesting limited additional value of AXR, especially since CT is preferred in many centers and is essential for identifying potential complications. Fourteen patients (33%) had previous recurrent SV, including two patients with six prior recurrences. Eighteen (43%) underwent rigid sigmoidoscopy, 12 (28.5%) had flexible sigmoidoscopy, and seven (16.6%) had both, all achieving successful decompression. Four patients (9.5%) experienced spontaneous resolution before endoscopic decompression. Emergency surgery was required in only one patient after failed decompression. The median hospital stay was three days. Fifteen patients (35.7%) experienced further recurrences after the index admission. Overall mortality was two patients (4.8%): one due to perforation after endoscopic decompression and one from perforation secondary to recurrent volvulus, both deemed unfit for surgery. Only five patients (11.9%) underwent definitive surgery, typically after multiple recurrences, with one patient receiving surgery after the 11th recurrence. Kaplan-Meier analysis showed that recurrences commonly occurred within 90 days of the index admission, supporting consideration of early definitive surgery. Conclusions Based on this study, we developed local guidelines for expedited management of SV tailored to NHS resources and consistent with World Society of Emergency Surgery recommendations. Optimal management requires a holistic approach integrating early surgical intervention with comorbidity assessment. Early decisions regarding definitive surgery can reduce recurrences, readmissions, morbidity, and healthcare costs.