EP484 - More Twisted Than A Pretzel: Three Episodes Of Colonic Volvulus In The Same Patient

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Purpose/Background: Colonic volvulus is the third leading cause of colonic obstruction globally. While endoscopic detorsion may be attempted for sigmoid volvulus in the absence of ischemia or perforation, surgical resection within the index admission is recommended to reduce risk of recurrence. However, recurrence after surgical therapy has also been documented. We present the case of a 69-year-old male who presented with a third episode of colonic volvulus over a 12-year period despite two prior surgical resections.

Methods/Interventions: A 69-year-old male with a prior surgical history of right hemicolectomy and sigmoid colectomy presented with abdominal pain and obstipation for 24 hours. On exam, his abdomen was distended, tympanic, with moderate diffuse tenderness to palpation without evidence of peritonitis. A CT scan revealed sigmoid volvulus without evidence of ischemia. This was the patient’s third presentation for colonic volvulus, the first being a presentation for sigmoid volvulus ten years prior at which time he underwent a sigmoid colectomy with resection of 29cm of sigmoid colon. Three years later, he presented for cecal volvulus and underwent an extended right hemicolectomy with resection of an additional 45cm of colon. He had no prior history of colonoscopy, colonic dysmotility, or familial colon cancer.

Results/Outcomes: Patient was admitted and taken for emergent decompressive sigmoidoscopy. Detorsion of volvulus was accomplished with passage of a colonoscope into the dilated portion of colon without resistance. Suture material from prior surgery was seen in this dilated area. Further scope advancement was limited by solid stool, but all visualized mucosa was healthy appearing. The colon was suctioned free of air and liquid and patient was returned to the hospital ward with plans for subsequent resection after adequate decompression. In preparation for surgery, the patient was formally prepped and underwent preoperative colonoscopy. Two surgical anastomoses were visualized, consistent with the patient’s history, with healthy appearing mucosa. Polypectomies were performed of polyps in the transverse and descending colon; pathology revealed benign tubular adenomas. The following day, patient was taken for planned sigmoid resection, at which time he was again noted to have redundant sigmoid colon with dilation both proximal and distal to his prior anastomosis. The anastomosis and an additional margin of redundant sigmoid were resected and a new side-to-side anastomosis was created with a surgical stapler. Post-operative course was briefly complicated by an ileus with subsequent return of full bowl function, nasogastric tube removal, diet advancement, and discharge. He was seen in the office following discharge and noted to be recovering as expected with normal bowel function.

Conclusion/Discussion: This case demonstrates an uncommon presentation of recurrent colonic volvulus with successful endoscopic detorsion and surgical resection.