Straightening the Roller Coaster

The shortest distance between two points is a streight line.
Archimedes

What do you think if we ask you about sigmoid volvulus?

An old and frail patient with a distended abdomen… yes, that’s exactly what we (as Europeans) are used to see, but we have to bear in mind there’s an area in Africa, the Middle East, and India where the typical patient is a young and healthy male! We may encounter them in our ED!
It is true, though, that his management would be a bit easier compared to the frail patient, so let’s focus on the latter!

We will talk about the patient’s management and almost nothing more!

As always, we will explore things starting with something real…

Joan is a happy 90-year-old gentleman, sent from a nursing home to the ED due to abdominal distention, an episode of vomiting, and no bowel movements for the last 2 days (no stools or air).

He has a history of atrial fibrillation with an ejection fraction of 35%, grade 3 chronic renal failure (normal creatinine of 2.3 mg/dl), and no neurological impairments.

Treatments: Bisoprolol, Furosemide, Apixaban

Clinical situation: Barthel 30/100, Clinical Frailty Score 7

On physical examination:

150/90 mmHg, 75 bpm R, Sat 95% in room air with slight tachypnea

Dehydrated, abdominal distention, no tenderness, Blumberg negative.

Starting easy: 2 IV lines, balanced fluids, urinary catheter, blood tests, and ABG.

ABG: pH 7.34; Lac 2.1

Lab exam results: WBC 15400; Hb 11.2; CRP 56

Which kind of study shall we order?

Chest and abdominal X-Ray (AXR), Abdominal US, Abdominal CT scan, or Abdominal MRI.

According to the 2023 WSES guidelines, this is one of the few situations where a plain AXR may have a space. You know we discourage the use of AXR as a routine exam for our emergency patients, as most of the time it is inconclusive and does not add anything to the evaluation. But, if you suspect a sigmoid volvulus (and especially if the patient already had one or two episodes before), this test could give you enough information and be worthwhile.

“Plain abdominal radiographs are often diagnostic of sigmoid volvulus. Chest radiographs are also sufficient to detect the presence of free air, in cases of perforation.” (WESES Guidelines, Strong recommendation, based on low- or very-low-quality evidence, 1C)

Is this AXR image enough?

Actually, it is not… The AXR is not so conclusive; that’s why we asked for an abdominal CT scan:

The report described a sigmoid volvulus with retrograde dilatation of the colon, no signs of ischemia, and no free fluid or free air.

Another question for you, did we really need a CT scan for Joan?

According to WSES Guidelines:

“CT imaging can be used in cases where the diagnosis is in doubt, or if ischemia or perforation is suspected“

(Strong recommendation, based on low- or very-low quality evidence, 1C)

Therefore, due to the fact that Joan had elevated WBC and the AXR was not conclusive, the choice to perform a CT scan was not incorrect.

Now we have a diagnosis for him, but how can we treat him properly, apart from general support?

What is the first-line treatment?
Rectal tube, Rigid sigmoidoscopy, Flexible colonoscopy, OR?

To answer this question, we will crosslink the information from the WSES Guidelines together with the American Society of Gastrointestinal Endoscopy Guidelines from 2020.

Always remember we are speaking (at least in Europe) of highly frail patients, so ask yourself if continuing treatments is the right thing to do, or is it futile? If you think you’re in this situation, go straight to the end of the post; otherwise, keep reading.

Rectal Tube

If you voted for this, we’re very sorry, but there is no description of this possibility in either guideline. It is highly discouraged to use this as a first-line treatment!

We are speaking about a blind insertion, with a high risk of perforation, making the patient fairly uncomfortable (and we are being kind here), and you would just delay proper treatment!

Rigid Sigmoidoscopy

According to both guidelines, the rigid sigmoidoscopy is inferior to a flexible colonoscopy in assessing a sigmoid volvulus: “Rigid sigmoidoscopy can fail to diagnose sigmoid volvulus and miss ischemia in up to 24% of cases.”

Flexible Colonoscopy

Finally, this is our way to go! The flexible colonoscopy should be the first-line treatment in the case of sigmoid volvulus without perforation, transmural ischemia, or physiological instability!

It is effective in 60-95% of the cases (according and depending on the literature), it can assess the mucosa viability, and it has a low rate of complications (mobility 4% and mortality 3%).

And here comes the drama… We say colonoscopy is the first treatment we must offer the patient. The mucosa is at risk of ischemia, and the procedure should be performed as soon as possible. But what if the endoscopist is at home? Should we wake him/her up? Can the patient safely wait until the next morning? How many hours can we reasonably delay? And in the meantime, if something happens to the patient – say, a perforation – who is the responsible?

If you’re an endoscopist and you’re not happy about these words, we feel sorry for you, but you should direct your hate towards your scientific societies and not surgeons…

Operating Room

There is always space for the OR here, as we mentioned before, we should go directly to the theatre in the case of perforation, transmural ischemia, or physiological instability. That would be an emergent operation, but we must consider surgery in the case of unsuccessful endoscopic detorsion of the sigma.

“Urgent sigmoid resection is indicated when endoscopic detorsion of the sigmoid colon is not successful and in cases of non-viable or perforated colon.”

(Strong recommendation, based on low- or very-low-quality evidence, 1C.)

Please remember, and it is crucial: DO NOT DE-ROTATE THE COLON!

“…resection of infarcted bowel should be performed without detorsion and with minimal manipulation to prevent release of endotoxin, potassium, and bacteria into the general circulation and to avoid perforation of the colon…”

To paraphrase: your patient is already in theatre for this volvulus; if you could avoid making him worse, do not de-rotate the colon. He’ll thank you for it later!!!

The operation should be done with open surgery, laparoscopic, or robotic. To date, we have to individualize our surgical approach to the patient’s status, our skills, and the hospital’s situation.

And now? What shall we do after the sigmoidectomy? Shall we do a primary anastomosis or a Hartmann procedure (end colostomy)?

We have to remember that this decision is not so simple. Doing a Hartmann procedure could be easy in the OR, but then, going back into that abdomen will be a nightmare! More than 60% of Hartmann procedures will never be reconstructed! On the other hand, doing an anastomosis has its risks (dehiscence, drainage, back to OR, end colostomy, sepsis, death), and we must have local and general favourable conditions to perform a “safe” anastomosis.

Sometimes the abdominal environment and the patient are not at their best moment, and we have to think of just saving their life first, doing a damage control surgery, leaving the abdomen open, and thinking about the feasibility of doing an anastomosis during the relook surgery.

In our help, Dr Awedew performed a literature review in 2023, collecting more than 720 patients operated for gangrenous sigmoid volvulus, showing no differences in mortality (15% vs. 19%) and morbidity between primary anastomosis vs. Hartmann’s procedure.

In conclusion: “Choice of the intervention for gangrenous sigmoid volvulus should be individualised with consideration of different detrimental factors.”

Luckily for Joan, the endoscopic detorsion was successful, and a colonic tube was left in place to avoid early recurrence (yes, endoscopists should leave a tube with the proximal end in the transverse colon).

And now what? Can Joan be sent home?

The recurrence rate of sigmoid volvulus within one year is 45-71%, so discharging Joan without a plan could not be the best option.

According to what we have in the literature so far (i.e. 2025), the best treatment for sigmoid volvulus to avoid recurrence is surgery: sigmoidectomy with primary anastomosis.

When to offer this to a patient, that’s another point though…

If we look at the WSES Guidelines, we should operate (or at least offer) surgery as soon as possible, also during the index admission. This means that after a successful endoscopic detorsion, we should offer our patients an elective sigmoidectomy before discharging them home.

Nice, but we have to consider multiple points:

First, the OR availability; sometimes, the first free spot in the OR is not available for weeks.

Secondly, we have to think about which kind of patient we are treating. Is he/she young in the first episode, or is it already a recurrence? Is the patient frail? Is this his/her only possibility due to possible worsening comorbidities? Does the patient need a little time to recover from the volvulus? Are there any frailty factors we can improve with prehabilitation?

Again, we find ourselves forced to individualise our treatment to the patient, interesting eh…

Now, getting back to our poor Joan, during his first day of hospitalisation, he is evaluated by a multidisciplinary team, and he is considered to have prohibitive risks for surgery. So, what might we offer him?

Looking back again to the WSES guidelines, we find some possible alternatives:

Percutaneous Endoscopic Sigmoidopexy
Percutaneous Endoscopic Colostomy
Endoscopic derotation
Palliation

Before deciding, let’s see what they are:

Percutaneous Endoscopic Sigmoidopexy

Endoscopic procedure where the sigma is fixed to the abdominal wall with percutaneous stitches in multiple points to prevent volvulation.

In the study published by Dr Negm (2022), high-risk surgical patients were randomised into 2 arms: a surgical arm and an endoscopic one (9 vs. 9 patients).

Some results are no surprise: shorter length of procedure time and shorter length of stay for the endoscopic arm. No differences in post-procedure complications (even though they had one death in the surgical arm due to anastomotic leak). But the real deal of this study is the evaluation of the quality of patients’ life after 9 months: it was considered excellent in 8/9 endoscopic arm patients against only 3/9 in the surgical arm.

Percutaneous Endoscopic Colostomy (PEC)

Again, we are speaking about something endoscopic (sedation will be needed) where a double cone device will be applied to connect the colon to the skin (something similar to a percutaneous endoscopic gastrostomy (PEG)). As a result, the patients will have to wear a colostomy bag because air and some faeces will come out. Moreover, in recent literature, it is advised to place at least 2 colostomy devices to stabilize the colon better and avoid a recurrent volvulus (meaning 2 bags for the patient).

One of the widest experiences with this procedure comes from Dr Farkas:

96 insertions on 91 patients;
28% 30-day complication rate;
9.9% leak rate;
5.2% death rate;
14.6% 90-day mortality;
10.4% overall recurrence rate;
46%, 34%, and 26% survival rate at, respectively, 3, 5, and 10 years.

With these results, we like to copy-paste the conclusions from the same authors:

«The significant associated risks of PEC require careful consideration when determining patient suitability.”

With both of these treatments – percutaneous sigmoidopexy and endoscopic colostomy – we need to make it clear to patients, and even more to their families, that these are symptomatic treatments. We’re not treating them – the elongated sigmoid is still there – and there’s still the risk of recurrence and of complications. So if anything goes wrong later, it’s important that everything has been properly understood to make sure the patient gets the best care.

Endoscopic Derotation and Palliation

This chapter is always thought for surgeons, facing the situation where the scalpel can create more damage than improvement. Also, the other endoscopic options are not a panacea for the volvulus. Therefore, here we are, with a highly frail patient who cannot be submitted to any of our treatment options (or maybe does not want to).

We consider that you have to sit down properly with the patient and the family and discuss the treatment’s limits, you will consider all together:

If you’re still in an acute setting and it has been considered the futility of endoscopic treatment (as for the surgical one), palliation could be your way. Stop active treatments and change mindset, death is coming, and prolonging the inevitable will only add more pain to it. We have to be strong and sensible to accompany the patient and the family through this passage.

If you’re already after an endoscopic derotation, you may have to face the same situation, just in a less stressful setting. Discuss in depth the pros and cons of each procedure and write the limits the patient wants. Offer real expectations for each scenario (we are really comfortable with the “best case vs. worst case scenario methodology), consider a multidisciplinary evaluation for the patient to see if there is any possibility of prehabilitation to improve her/his status.
In the end, you could find yourself in two possible scenarios: offering an endoscopic derotation (as top treatment) each time the patient presents again in the ED, or just offering palliation when a new recurrence appears. Whatever the decision will be, write it down properly in the patient’s medical record (for your colleagues and especially for the patient).

You’re gone far, friend! We’re very happy to see you down here!
Down here, there’s a summary flow-chart of what we discussed:

Here we are, finally at the end of this post.
Thank you so much!
As always, we hope this was of some help.
See you next time!

Namasté

References

Naveed M, et al. American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in the management of acute colonic pseudo-obstruction and colonic volvulus. Gastrointestinal Endoscopy 2020;91:228-35.
Farkas N, et al. A single centre 20-year retrospective cohort study: Percutaneous endoscopic colostomy. Colorectal Dis 2022;24:1390-6.
Awedew AF, et al. Comparing Resection and Primary Anastomosis versus Hartmann’s Stoma on the Mortality and Morbidity of Gangrenous Sigmoid Volvulus: Systematic Review and Meta-Analysis. Ethiop J Health Sci 2023;33:1087-96.
Loria A, et al. Sigmoid volvulus: Evaluating identification strategies and contemporary multicenter outcomes. Am J Surg 2023;225:191-7.
Negm S, et al. Endoscopic management of acute sigmoid volvulus in high risk surgical elderly patients: a randomized controlled trial. Langenbecks Arch Surg 2023;408:338.
Tian BWCA, et al. WSES consensus guidelines on sigmoid volvulus management. World J Emerg Surg 2023;18:34.
Al Manasra AR, et al. Endoscopic-Assisted Percutaneous Sigmoidopexy: New Highlights on Technique and Outcomes. CEG 2024;17:25-9.
Atamanalp SS. A nightmare: Sigmoid volvulus. Am J Surg 2025;239:115883.

How to Cite This Post

Marrano E, Tapiolas I, Cioffi PB, Bellio G. Straightening the Roller Coaster. Surgical Pizza. Published on November 9, 2025. Accessed on November 9, 2025. Available at [https://surgicalpizza.org/emergency-surgery/straightening-the-roller-coaster].