An 82-Year-Old Woman With Abdominal Pain

James J. McCombie, MB ChB

Disclosures

March 13, 2017

Primary anastomosis may be considered if there is minimal or no contamination of the abdominal cavity (no perforation or a contained perforation) and the patient is well-nourished and likely to return to near-normal physiologic status; this is rather uncommon in the patient population at risk for sigmoid volvulus. The major risk in this patient population is anastomotic failure. Anastomotic leak rates after colorectal anastomosis range from 4% to 26%[16] and are often devastating complications; the risk is higher in patients with preexisting, severe, protein-calorie malnutrition as well as functional distal obstruction. A Hartmann procedure is generally performed for all others and is particularly indicated when there is perforation, significant peritoneal soilage, malnutrition, or a high likelihood of dysmotile colon.

Patients typically fare worse when the disease has progressed to necrosis and perforation. A retrospective study found that in patients treated with derotation and sigmoidopexy, the mortality rate was 0%, whereas those with the condition who required resection had a mortality rate of 44%.[17] This probably reflects significant progression of disease that necessitated surgery involving resection as well as a systemic inflammatory state (sepsis, severe sepsis, and septic shock) rather than the anesthesia and surgery per se. To minimize the mortality of patients presenting with this disease, timely diagnosis and management are paramount. Of course, primary prevention strategies are of even greater importance in disease prevention because the therapies outlined above are reactive and not proactive.

The patient above was treated successfully with fluoroscopy-guided barium enema, and after an uneventful hospital observation, she was discharged to her nursing home 2 days later. Follow-up was arranged for consideration of an elective surgical procedure to prevent recurrence.

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