Transverse Colonic Volvulus: A Case Report and Literature Review of a Rare Disease

A B S T R A C T

Obstructions of the large and small bowel are frequently caused by cancer, inflammation, post-surgical adhesions, hernias, and, more rarely, volvulus, representing <10% of all reported cases. Of these, volvulus of the transverse colon (TCV) is found in <5% of all instances of colonic volvulus with delayed diagnosis and treatment resulting in infarction, peritonitis, and death. Given the morbidity and the fact that TCV most often develops acutely, diagnosis of this condition is considered to be a surgical emergency. Common surgical procedures to correct this often involve urgent exploratory laparotomy, followed by either colopexy or colectomy with subsequent creation of colostomy or anastomoses. This is a review of all of the treatment and complications of transverse colonic volvulus published in the last 75 years.

Keywords

Transverse colon, volvulus, surgical management

Introduction

Obstructions of the large and small bowel are frequently caused by cancer, inflammation, post-surgical adhesions, hernias, and, more rarely, volvulus, representing <10% of all reported cases [1]. Of these, transverse colonic volvulus (TCV) is found in <5% of all instances of colonic volvulus with delayed diagnosis and treatment resulting in infarction, peritonitis, and death [2]. Given the morbidity and the fact that TCV most often develops acutely, diagnosis of this condition is considered to be a surgical emergency. Common surgical procedures to correct this often involve urgent exploratory laparotomy, followed either by colopexy or colectomy with subsequent creation of colostomy or anastamoses. The following is a case report describing the treatment of 21-year-old female with a history of mast cell disease and Ehler-Danlos syndrome who presented to the emergency department with a TCV followed by a review of all of the treatment and complications of transverse colonic volvulus published in the last 75 years.

Case Report

A 21-year-old female with a history of mast cell disease, Ehler-Danlos syndrome, gastroparesis, reflux disease, and failure to thrive presented to the emergency department with sharp abdominal pain and abdominal distension. Patient's surgical history included a Nissen fundoplication to treat her reflux disease and a gastrostomy tube to treat her failure to thrive. Patient was requiring long term steroids to treat her mast cell disease. Patient stated that she had persistent pain for greater than four hours, and her pain was steadily increasing in severity. The patient complained of nausea and retching. Vomiting was absent, likely due to her history of Nissen fundoplication. Patient denied having bowel movements or flatus since her episode of pain began. Labs showed a mildly elevated leukocyte count of 12.6, with lipase of 36 and normal metabolic panel. An acute abdominal series demonstrated severe dilation of bowel (Figure 1). Due to the patient's allergy to contrast, a non-contrasted CT scan of the abdomen and pelvis was performed and confirmed severe gaseous dilatation of the distal small bowel and proximal colon. A transition point was identified at the distal transverse colon along with a mesenteric swirl sign (Figure 2) which suggested a volvulus. An exploratory laparotomy was performed.

At operation, a right upper quadrant optical entry was attempted. Due to distension of the abdomen and lack of adequate visualization, the procedure was converted to open. A midline incision was made, and the bowel was eviscerated. The transverse colonic volvulus was identified and reduced. There was noted to be decompressed colon distal to the site of obstruction. The patient had extensive colonic mesentery, and due to the risk of recurrent volvulus, she was treated with a subtotal colectomy. An ileosigmoid anastomosis was created and the patient's abdomen was closed. The patient was admitted to the ICU following surgery. Patient was transferred to the floor on post-op day two. Full return of bowel function occurred by post-op day four. Her hospital course was complicated by a Clostridium difficile infection on hospital day eight and patient was started on Fidaxomicin due to patient's allergy to vancomycin. Patient was discharged home on hospital day nine.

Figure 1: X-ray of the abdomen of 21 year old female demonstrating distended loops of bowel secondary to transverse colonic volvulus.

Figure 2: CT scan of the abdomen of a 21 year old female demonstrating a mesenteric swirl sign highlighting the patient’s transverse colonic volvulus.

Discussion

TCV is a rare occurrence where delayed diagnosis and treatment can result in infarction, peritonitis, and death [2]. Additionally, TCV is more likely than other sites of volvulus in the large bowel to produce septic shock, with rates of gangrene reported to be between 16% and 60% [3]. While TCV has been reported in all ages and genders, those with developmental delays, chronic constipation, and pregnant women have shown more frequent incidences [1, 4]. TCV most often presents as abdominal pain, fever, vomiting, distension, and constipation [5]. TCV develops acutely and is considered to be a surgical emergency. Common surgical procedures to correct TCV often involve urgent exploratory laparotomy, followed by either colopexy or colectomy with subsequent creation of colostomy or anastomoses [6].

Table 1: Comprehensive Literature Review of Transverse Colonic Volvulus Cases from 1944 to 2018.

Author

Year

 

Pts

 

Age*

 

Gender

 

Procedure

Colectomy vs. Colopexy

Post-Op Complications

Hosp

Stay (Days)

Schammel

2018

1

21

F

Laparotomy with Colectomy

Colectomy

C. Difficile Infection

9

Milickovic [4]

2017

1

16

M

Ex. Lap with Colectomy and Colostomy

Colectomy

Cardiorespiratory Failure

240

Sala-Hernandez [6]

2016

1

81

M

Subtotal Gastrectomy, subtotal colectomy, Y en Roux gastrojejunostomy, ileosigmoid anastamosis

Colectomy

Anemia

13

Waluza [7]

2015

3

11

7

17

F

M
M

Laparotomy with colectomy

Colectomy

Colectomy

Colectomy

Ileus

Constipation;

Fever;

Pain

Small Bowel Obstruction

18

28

35

Walczak [3]

2013

1

76

F

Laparotomy with Colectomy

Colectomy

Cardiorespiratory Failure; Death

7

Sharma [1]

2013

1

29

F

Laparotomy with Colopexy

Colopexy

None

 

Smith [8]

2013

1

7

M

Laparotomy with Colopexy

Colopexy

None

 

Sana [2]

2013

1

39

F

Laparotomy with hemicolectomy

Colectomy

None

5

Lianos [9]

2012

1

82

F

Laparotomy with Total Colectomy

Colectomy

None

8

Kaushik [10]

2012

1

38

M

Laparotomy with Colectomy and Colostomy

Colectomy

None

 

Sage [11]

2012

1

25

F

Laparotomy with Needle Decompression and Colopexy

Colopexy

None

6

Chen [12]

2012

1

12

M

Laparotomy with Colectomy

Colectomy

 

 

Nofuentes [13]

2011

1

28

F

Laparotomy with hemicolectomy and anastamosis

Colectomy

None

9

Deshmukh [14]

2010

1

27

M

Laparotomy with Colostomy

Colectomy

None

 

Rahbour [15]

2010

1

15

M

Laparotomy with colectomy and loop defunctioning ileostomy

 

Colectomy

Small Bowel Obstruction

 

Booij [16]

2009

1

43

M

Laparotomy with subtotal colectomy and ileorectal anastamosis

 

Colectomy

Fever; Infection

9

Katsanos [17]

2009

1

83

F

Laparotomy with hemicolectomy and transversectomy

Colectomy

 

 

Ramirez-Wiella-Schwuchow† [18]

2009

1

46

F

Laparotomy with hemicolectomy and ileocoloanastamosis

Colectomy

None

4

Sparks [19]

2008

1

75

M

Laparotomy with hemicolectomy and Ileostomy

Colectomy

None

6

Hinkle [20]

2008

1

22

M

Laparotomy with Colectomy

Colectomy

None

 

Matsushima [21]

2006

1

22

F

Laparotomy with Colectomy

Colectomy

 

 

Casamayor [22]

2005

1

34

F

Laparotomy with colectomy and anastamosis

Colectomy

Dehiscence; Inflammation

 

Tobinaga [23]

2004

1

70

M

Laparotomy with Colopexy

Colopexy

Megacolon

17

El-Tawil [24]

2002

1

61

F

Laparotomy with Colectomy

Colectomy

None

 

Asabe [25]

2002

1

12

F

Laparotomy with Colectomy

Colectomy

None

 

Echenique† [26]

2002

2

59

 

Laparotomy with Colectomy

Colectomy

Colectomy

None

 

Al-Homaidhi [27]

2001

1

15

M

Laparotomy with hemicolectomy with anastamosis

Colectomy

None

 

Rangiah [28]

2001

2

32

34

M

M

Laparotomy with Colectomy and Colostomy

Laparotomy with Colectomy

Colectomy

Colectomy

Ileus

None

 

Samuel [29]

2000

1

5

M

Laparotomy with Colectomy and Colocolic Anastamosis

Colectomy

None

 

Haque [32]

1999

1

37

F

Laparotomy with Colectomy

Colectomy

None

 

Ciraldo [31]

1999

1

75

F

Laparotomy with Colectomy

Colectomy

 

 

Houshian [33]

1998

1

9

F

Laparotomy with Colectomy and Anastamosis

Colectomy

None

 

Plorde† [34]

1996

1

64

M

Laparotomy with Decompression and Hemicolectomy

Colectomy

 

 

Loke [35]

1995

1

34

M

Laparotomy with Colectomy

Colectomy

None

 

Mercado-Deane [36]

1995

1

7

M

Laparotomy with Colopexy

Colopexy

None

 

Yaseen [37]

1994

1

50

M

Laparotomy with subtotal

colectomy

Colectomy

Bowel Perforation;

Death

23

Mellor† [38]

1994

2

2

15

 

Laparotomy with Colopexy

Colopexy

Colopexy

 

 

De Paula† [39]

1991

1

26

M

Laparotomy with

Transversectomy

Colectomy

Small Bowel Obstruction

 

Neilson [40]

1990

1

11

M

Laparotomy with Colectomy

Colectomy

None

 

Javors [41]

1986

1

56

F

Laparotomy with Colopexy

Colopexy

Inflammation

 

Gumbs [42]

1983

3

20

66

75

F

F

M

Laparotomy with Colectomy

Laparotomy with Colopexy

Laparotomy with Colopexy

Colectomy

Colopexy

Colopexy

Infection; Anemia

None

None

 

Fishman [43]

1983

4

40

83

19

73

M

F

F

M

Laparotomy with Colectomy

Laparotomy with Colectomy

Laparotomy with Colopexy

Laparotomy with Colectomy

Colectomy

Colectomy

Colopexy

Colectomy

 

 

Anderson [44]

1981

7

12

43

63

20

65

89

35

F

F

M

F

F

F

M

Transverse colectomy and

primary anastomosis

Exteriorization resection of transverse colon

Detorsion, fixation of flexures and caecopexy

Detorsion and fixation of flexures

Resection of adhesion and detorsion

Resection of adhesion and detorsion

Extended right hemicolectomy

Colectomy

Colectomy

Colopexy

Colopexy

Colopexy

Colopexy

Colectomy

 

 

Zinkin [45]

1979

1

46

F

Laparotomy with Colectomy

Colectomy

 

 

Eisenstat [46]

1977

5

28

34

79

71

15

M

F

F

M

F

Laparotomy with Colectomy

Laparotomy with Colectomy

Laparotomy with Colopexy

Laparotomy with Colectomy

Laparotomy with Colectomy

Colectomy

Colectomy

Colopexy

Colectomy

Colectomy

Small Bowel Obstruction

None

None

Cardiorespiratory Complications; Death

Cardiorespiratory Complications; Death

15

4

Dadoo [47]

1977

1

12

M

Laparotomy with Colopexy

Colopexy

 

14

Budd [48]

1977

1

52

F

Laparotomy with Colopexy

Colopexy

Constipation

 

Miller [49]

1977

1

23

M

Laparotomy with Colopexy

Colopexy

 

 

Newton [50]

1977

2

25

26

F

F

Laparotomy with Colectomy

Laparotomy with Colopexy

Colectomy

Colopexy

 

 

Howell [51]

1976

1

4

F

Laparotomy with Colectomy

Colectomy

 

 

Smith [52]

1976

1

81

F

Laparotomy with Colectomy

Colectomy

Infection; Death

 

Lapin [53]

1973

1

36

F

Laparotomy with Colectomy

Colectomy

 

18

Gibson [54]

1972

1

71

M

Laparotomy with Colopexy

Colopexy

Cardiorespiratory Complications; Death

 

Singh [55]

1970

1

40

M

Laparotomy with Colopexy

Colopexy

 

 

Ponka [56]

1969

1

54

F

Laparotomy with Colopexy

Colopexy

 

10

Fischer [57]

1964

1

77

F

Laparotomy with Colectomy

Colectomy

 

18

Perdue [58]

1963

1

21

M

Laparotomy with Colopexy

Colopexy

Infection

29

Weir [59]

1959

1

18

F

Laparotomy with Colectomy

Colectomy

 

10

Boley [60]

1958

2

82

68

F

M

Laparotomy with Colopexy

Laparotomy with Colopexy

Colopexy

Colopexy

Infection

Dehiscence

21

27

McGowan [61]

1957

1

29

F

Laparotomy with Colopexy

Colopexy

 

8

Zaslow [62]

1954

1

69

M

Laparotomy with Colopexy

Colopexy

 

 

Figiel [63]

1953

1

56

F

Laparotomy with Colopexy

Colopexy

 

 

Murray [64]

1950

1

22

F

Laparotomy with Colopexy

Colopexy

 

26

Martin [65]

1944

1

22

M

Laparotomy with Colectomy

Colectomy

 

 

*Age at diagnosis; †indicates that the article was not available in English and thus the information was retrieved from review articles or is missing; greyed boxes indicate variables that case studies or reviews did not address


While rare, TCV has been described in 86 cases in the literature, including the case presented here (1990 to 2018; Table 1). Most reports are individual case reports or small case series. From the literature, the mean age of patients with TCV was 40 years (range 2-89) with 51 percent of the reported cases involving females (44; 38 males at 44%). All cases reported performing a laparotomy, with 65 percent of patients receiving a colectomy and 35 percent treated with colopexy. Of the 30 patients who received colopexy, only seven experienced complications following the procedure, a complication rate of 23 percent. Comparatively, 18 of the patients who received colectomies experienced complications, a rate of 32 percent. Overall, 29 percent of the patients reviewed had no complications following the procedure (28). Although a large percentage of patients experienced no problems in the aftermath of surgery, the most common post-op issues involved were cardiorespiratory complications (6; 7%) followed by infection (5, 6%) and bowel obstruction (4; 5%). Patients did experience a mortality rate of 7 percent as six of the cases in the literature review died. In general, with the toll of the surgery and high complication rate, TCV patients spent an average of 23 days (range 4-240) in the hospital following their operation.

The patient in our report presented to the Emergency Department complaining of abdominal pain, distension, and nausea (symptoms of a bowel obstruction). Pre-operative diagnosis of a TCV requires imaging studies (such as a CT scan), with the patient’s imaging demonstrating severe gaseous dilation and a mesenteric swirl sign. Every patient in the literature received an urgent exploratory laparotomy, followed by either colopexy or colectomy depending on the surgeon’s evaluation of the vasculature and condition of the bowel. In this patient’s case, she received a colectomy with primary anastomosis with consideration to the healthy condition of her bowel but increased likelihood of recurrence as a result of her redundant mesentery. In the review of the literature, colectomies were far more widely utilized than colopexies. Although there were more complications seen in colectomy patients overall compared to those who received colopexies, there was no statistical difference in complication rates between the two groups (p = 0.241, significance level 0.05). Therefore, based on the results of the literature review, there is no significant benefit to performing a colectomy compared to a colopexy in patients suffering from the disease with regards to complications post-operatively.

Conclusion

TCV is a rare form of bowel obstruction that must be quickly and appropriately managed to reduce morbidity and mortality. The treatment of a TCV is to operatively reduce the volvulus followed by either a colopexy or colectomy to prevent recurrence. Although colopexy allows the surgeon to save the affected region of the colon by untwisting and securing the bowel instead of performing a colostomy or anastomoses, there is no identifiable benefit between the two procedures when regarding risk of complications following surgery. Therefore, choosing one procedure over another depends on an intraoperative determination of bowel viability and risk for future volvulus rather than on potential risk for problems in the post-operative setting.