DIAGNOSIS AND TREATMENT OF VOLVULUS OF THE SIGMOID FLEXURE, WITH REPORT OF A CASE.

C. O. Thienhaus, Milwaukee, Wis.

HILE I have taken the liberty of bringing before you today a brief review of the clinical picture of volvulus of the sigmoid flexure and methods of operation, I have been induced to do so by the observation of the following case:

Mr. B., aged 56 years, frcin P., Mich., was sent to the Post-Graduate Hospital for operation by his physician, Dr. W, four months ago. The anamnesis shows that he has been a sufferer from chronic constipation for many years. Three days before admission he was suddenly seized with sharp pains in the abdomen, followed by intense bloating and cessation of flatus and stools. The pain, colicky in character, recurred at intervals. The abdominal bloating increased and was followed by belching of large quantities of gas. His family physician, Dr. W., in consultation with Dr. G. from E., made a diagnosis of ileus. After futile attempts to relieve the obstruction by high enemata, immediate operation was decided upon, and the patient was sent to the Post-Graduate Hospital. After his arrival, physical examination presented the following status: The lower left quadrant of the abdomen was bloated out of all proportions to the remainder of the abdominal region. In fact there was a circumscribed tympanitic area which could be easily made out by percussion. During an attack of colicky pain it was possible to detect some peristalsis in the bloated coil of intestines. Considerable belching of gas was present, but no vomiting. No flatus. Temperature 99; pulse 85.

During operation, which was performed immediately upon his arrival, it was found that the sigmoid flexure, distended to an encrmous degree, was twisted upon its mesentery for about 180 degrees, in a manner indicated by the accompanying diagram. The descending colon and rectum were contracted to the size of an index finger at and near the point of twisting. After untwisting the volvulus it was found that the mesentery of the sigmoid measured 22 cm. in length, and was somewhat thickened. As the twisted portion of the mesentery and the sigmoid itself were in apparently good condition, the distended sigmoid was emptied into the rectum by gentle pressure, and, after its reposition in the abdomen, the sigmoid flexure, for a distance of 15 cm., was sutured to the abdominal wall parallel to the incision for the purpose of preventing a recurrence of the volvulus. The abdomen was closed in the usual manner. The patient made an uneventful recovery, and left the hospital three weeks after operation. He has been perfectly well since the operation (four

months).

Volvulus of the sigmoid flexure is by no means rare. In fact among the cases of volvulus of the intestines cited in literature it seems to be the most common. As far back as 1888 Leichtenstern, collecting seventysix cases of volvulus of the intestines, points out that among these seventy-six cases forty-five were volvulus of the sigmoid flexure, twenty-three were vovulus of a part of the ileum, and eight were volvulus of the entire small intestines. The coditio sine qua non for the occurrence of volvulus of the sigmoid is an elongation of its mesentery. This may be congenital,

Courtesy New York Post-Graduate.

NEW HARVARD MEDICAL SCHOOL BUILDINGS

(From photograph taken during one of the receptions tendered the members of the American Medical Association in Boston, June, 1906.)

but usually it is produced by chronic constipation. When, in cases of chronic constipation, large conglomerates of fecal matter are retained within the sigmoid, an elongation of the mesentery, produced by traction, may easily take place, thereby paving the way for twisting of the mesentery. This may be for 180 degrees, as in our case, or even from 360 to 450 degrees.

Ries believes (Annals of Surgery, October, 1904) that an inflammation of the mesosigmoid is always present in such cases and is essential for the occurrence of a volvulus. This, however, is still sub judice. In regard to diagnosis of volvulus of the sigmoid flexure the following points must be borne in mind:

Volvulus of the sigmoid flexure usually occurs in old people (males seem to be more often afflicted than females), who have been suffering from chronic constipation for a long period of time.

2d. The onset is sudden and sharp. Colic like pains, recurring at intervals usually originate in the left iliac fossa or sub-umbilical region. The pain is almost always followed by more or less meteorism. Sometimes the distended sigmoid can be outlined by palpation and percussion of the abdomen. That vomiting occurs very late is quite natural when we take into consideration that the obstruction is in the lower portion of the intestinal tract. Rise of temperature and pulse is not present in the beginning, but may set in later in neglected cases, when gangrene and infection are imminent.

3d. In most cases of volvulus of the sigmoid flexure it is impossible to inject large quantities of salines or water into the rectum, because of the occlusion of the descending colon. This symptom has been considered of great diagnostic value

In operating for volvulus of the sigmoid flexure two conditions bave to be borne in mind: First, the state of affairs found in the twisted mesentery and distended sigmoid; and, second, the prevention of a future recurrence of the volvulus. If, after opening the abdomen, the sigmoid is in a state of beginning gangrene, or if the gut at the point of twisting is so badly damaged that its future nutrition is seriously interfered with, then there is only one rational surgical procedure at our disposal, namely, resection of the entire loop. If, however, after emptying the distended loop by means of a rectal tube, manual pressure, or direct incision, it is found that resection is unnecessary, we may have the choice of the following procedures to prevent recurrence of the volvulus:

(a) Sigmoidopexy, i.e., anchoring of the sigmoid to the anterior abdominal wall.

(b) Senn's method of shortening the mesosigmoid by reefing. (c) Roux's method of anchoring the sigmoid to the anterior and lateral abdominal wall by sutures passed through the mesentery.

(d) Philippowitz's method of anastomosing the cecum with the efferent limb of the sigmoid flexure.

(e) Resection of the entire sigmoid with end to end union.

Moschcowitz, in the New York Medical Journal, July 14th, 1906, gives a very interesting critical review on these methods of procedure. He cites that he has performed sigmoidopexy for volvulus of the sigmoid flexure five times during the past four years. In four cases the results were perfect and no recurrence took place. In one case, however, which he de

scribes in detail, ileus recurred, and the operation revealed that some coils of small intestine were apparently incarcerated in a pocket between the anchored sigmoid and the lateral abdominal wall. The sigmoid was therefore freed from the abdominal wall, exposing a number of coils of small intestines which were adherent in the space above mentioned. These adhesions were liberated and the intestines replaced into their normal position. He, however, furthermore, states that both the local and the general condition of the patient at the time of operation did not allow an exact determination as to whether the intestines were kinked over the attached sigmoid, or whether they had become strangulated in the pocket formed by the attached loop. As he states that a number of coils of small intestines were adherent in the space before mentioned, I believe a third possibility could be taken into consideration in his case, and that is the kinking of a coil of small intestine by these adhesions. We all know that in any part of the abdominal cavity, where there exists a chronic inflammatory process, such an occurrence may take place. Al. though many authors have pointed out the possible danger of incarceration of a loop of intestine in the pocket between the anchored sigmoid flexure and the lateral abdominal wall, there is not one case on record in the literature where such an accident took place.

In some cases recurrence of volvulus of the sigmoid flexure took place after sigmoidopexy or fixation of the mesentery of the sigmoid had been performed. Here, however, not the method itself, but the technique seems to have been at fault. Such a case is cited by Roux, Cent. Blatt. fuer Chir., 1894, p. 864, Roux himself admitting that the recurrence took place because he did not make his line of attachment long enough. Another case in which the same principles of faulty technic seem to have been the underlying cause for the recurrence is cited by Moynihan in his excellent work on "Abdominal Operations," 1905, p. 498, case No. 4. This case was operated by Dr. Ward. To use Moynihan's words: "The apex of the lumen of the sigmoid was stitched to the middle line to prevent retwisting." Two days later, as neither feces nor flatus had passed, the sigmoid was opened in the median line and an artificial anus established. The wound gradually closed and the patient was discharged. Two years later again ileus set in, which necessitated surgical interference. Moynihan, after opening the abdomen, found the following condition: "The apex of the sigmoid flexure was adherent at the middle line. The upper part of the sigmoid loop-that portion between the end of the descending colon and the part of the loop adherent to the anterior abdominal wall -had become enormously distended and had fallen into the pelvis of the lower portion of the loop. A kink had thus been produced in the gut at the upper part of the abdominal incision. Moynihan removed the whole sigmoid in this case. The patient recovered.

In my opinion three points are essential for the future success in the technic of sigmoidopexy:

First. The line of attachment of the sigmoid, or mesosigmoid, to the abdominal wall must be sufficiently long to avoid a further recurrence. The extent to which it should be attached must be determined by the relative length of the mesentery of the sigmoid and the base of the sigmoid loop. In our case I fixed the sigmoid flexure for a distance of 15 cm.