Management and risk factors for colonic volvulus: retrospective national cohort study

Abstract

Background: This study evaluated the outcomes of colonic volvulus management in a national cohort, and identified risk factors for morbidity and mortality.

Methods: This was a multicentre national retrospective study of patients presenting with colonic volvulus between 2010 and 2019. Main outcome measures were 30-day and 1-year mortality. Multivariable regression and Kaplan-Meier analyses were used to study predictors of mortality and survival.

Results: Of the 559 patients presenting with sigmoid volvulus, 381 underwent surgery and 178 received conservative treatment. The 30-day mortality rates were 11.0% and 19.0%, respectively. Emergency surgery (P = 0.030), nursing home residence (P = 0.040), increased co-morbidity (P = 0.017), and male sex (P = 0.029) predicted postoperative 30-day mortality. Primary endoscopic detorsion followed by elective surgery during a subsequent hospital admission resulted in best survival. Of the 342 patients presenting with caecal volvulus, 340 underwent surgery. The 30-day mortality rate was 6.4%. Increased co-morbidity (P = 0.008), nursing home residence (P = 0.002), and necrotic caecum (P = 0.007) predicted 30-day mortality. At 1 year, the mortality rate among patients with sigmoid volvulus was 19.9% after surgery and 43.2% after conservative treatment. Emergency surgery (P = 0.023), nursing home residence (P = 0.009), and increased co-morbidity (P < 0.001) were associated with 1-year postoperative mortality. In patients with caecal volvulus the 1-year mortality rate was 13.1%. Increased co-morbidity (P < 0.001) and nursing home residence (P < 0.001) were predictive. Anastomotic leakage in patients with sigmoid volvulus was associated with an American Society of Anesthesiologists fitness grade of III (P = 0.032) and total colectomy (P = 0.012).

Conclusion: Surgery should be recommended for colonic volvulus where co-morbidity, patient preference, and functional status allows. Surgically unfit patients have poorer outcomes. Elective sigmoidectomy after endoscopic detorsion is preferred as it carries the lowest mortality risk. Necrotic bowel, dependency, and co-morbidities predict death for both sigmoid and caecal volvulus.

Fig. 1

Kaplan–Meier survival analysis comparing 30-day survival among patients with sigmoid volvulus across four treatment groups Group 1: emergency surgery; group 2: endoscopic decompression followed by emergency surgery; group 3: endoscopic decompression followed by elective surgery during the same hospital admission; group 4: endoscopic decompression followed by elective surgery during a subsequent hospital admission. Statistically significant differences in survival were observed among the groups. Overall survival curves were compared using the log rank (Mantel–Cox), Breslow (generalized Wilcoxon), and Tarone–Ware tests, all indicating significance (χ² = 10.67–10.69, 3 degrees of freedom, P = 0.014).

Fig. 2

Kaplan–Meier analysis of 30-day survival of sigmoid volvulus patients following emergency surgery, stratified by condition of bowel There were significant differences between groups (log rank, Breslow, and Tarone-Ware tests; all P < 0.001, 2 degrees of freedom). Survival was significantly better among patients with sigmoid volvulus who had elective surgery compared with those operated in an emergency setting (P = 0.01).