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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 8  |  Issue : 1  |  Page : 10-13

Outcomes in cecal volvulus: Does age affect outcomes in patients who undergo surgery?


1 Department of Surgery, TriHealth Hospital, Cincinnati, Ohio, USA
2 TriHealth Hatton Research Institute, TriHealth Hospital, Cincinnati, Ohio, USA

Date of Web Publication12-Mar-2019

Correspondence Address:
Dr. Ashley M Tameron
Department of Surgery, TriHealth, 375 Dixmyth Ave, Cincinnati, Ohio 45220
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/WJCS.WJCS_40_18

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  Abstract 


Background: Colonic volvulus is a rare cause of bowel obstruction with an incidence of 2%–10%. Cecal volvulus accounts for 10%–40% of cases, with a mean age of 53 years. There is a paucity of literature reporting how older patients with cecal volvulus fair relative to their younger counterparts. Objective: The goal of our study is to evaluate the outcomes after surgical resection in patients ≥50 years old with cecal volvulus. Design: The design of the study was to collect the National Surgical Quality Improvement Program (NSQIP) data and analyze primary outcomes. Settings: These data were collected from NSQIP database focusing on patients with cecal volvulus. Materials and Methods: We utilized the NSQIP database. We identified volvulus by ICD-9 code 560.2. We selected patients with cecal volvulus who underwent surgical resection by specifying the CPT codes for open and laparoscopic right hemicolectomy. Main Outcome Measures: The primary outcomes were mortality and major and minor postoperative complications. Student's t-test was used to compare continuous variables. Chi-square and Fisher's exact tests were used to compare categorical variables. Sample Size: Analyzing the NSQIP database from 2010 to 2015, 1220 patients were identified. Results: 21.8% of patients were <50 years old and 78.2% were ≥50 years old. Patients aged ≥50 years had higher rates of comorbid conditions. There was no significant difference in mortality between the two groups or major and minor complications. Patients aged ≥50 years had a longer length of total hospital stay, i.e., days from operation to discharge. Conclusion: Cecal volvulus is an uncommon reason for bowel obstruction with unclear outcomes in elderly patients in the literature. Our study demonstrates no differences in outcomes after surgical intervention for cecal volvulus. Limitations: Limitations of this study include large database collection and selection bias. As we specifically included right hemicolectomy, this excludes patients who underwent nonresection intervention.

Keywords: Cecal volvulus, large bowel obstruction, volvulus


How to cite this article:
Tameron AM, Murphy AE, Hussain LR, Lee D, Guend H. Outcomes in cecal volvulus: Does age affect outcomes in patients who undergo surgery?. World J Colorectal Surg 2019;8:10-3

How to cite this URL:
Tameron AM, Murphy AE, Hussain LR, Lee D, Guend H. Outcomes in cecal volvulus: Does age affect outcomes in patients who undergo surgery?. World J Colorectal Surg [serial online] 2019 [cited 2019 Nov 21];8:10-3. Available from: http://www.wjcs.us.com/text.asp?2019/8/1/10/254037


  Introduction Top


Volvulus of the colon is an abnormal rotation of the redundant segment of colon around its blood supply. This can lead to obstruction, ischemia, or even necrosis of the cecum, transverse colon, splenic flexure, or sigmoid colon.[1],[2],[3] Sigmoid colon is the most common site accounting for 43%–71% of all colonic volvulus, and the second most is cecum accounting for 10%–52% of all colonic volvulus.[1],[4],[5] Colon volvulus has been shown to account for 1%–3% of all bowel obstructions in the US.[1],[2],[4] Cecal volvulus accounts for only 10%–40% of these obstructions.[3] Cecal volvulus is more commonly associated with females and younger patients.[3],[4] Unlike sigmoid volvulus, it is less commonly seen with patients from skilled nursing facilities, as well as less often with mental retardation or neurologic disorders.[6]

Due to the higher likelihood of gangrene and perforation in the cecum, treatment for cecal volvulus is most often managed surgically due to poor outcomes with endoscopic decompression.[1],[6] Few reports and limited data exist about outcomes of colonic volvulus, and literature about cecal volvulus especially in elderly population is rarer.[1] Due to the urgent or often emergent nature and the significant morbidity of cecal volvulus in the elderly, this study has been formulated to identify whether surgical management in patients 50 years of age and older would be riskier than in younger populations.


  Materials and Methods Top


We utilized the National Surgical Quality Improvement Program (NSQIP) database. We identified volvulus by ICD-9 code 560.2. We then selected patients with cecal volvulus who underwent surgical resection by specifying the CPT codes: 44,160 for open right hemicolectomy and 44,205 for laparoscopic right hemicolectomy. We compared the demographic data, perioperative and short-term postoperative outcomes, and complications of those over the age of 50 to patients under the age of 50 years old. Our primary outcomes were mortality and major and minor postoperative complications. The Student's t-test was utilized to compare continuous variables. Chi-square and Fisher's exact tests were used to compare categorical variables. All P values were two-sided, and P < 0.05 was considered statistically significant. Statistical analysis was performed using IBM SPSS Statistics for Windows, version 22.0 (Armonk, NY, USA).


  Results Top


Analyzing the NSQIP database from 2010 to 2015, a total of 1220 patients were identified who underwent surgical intervention for cecal volvulus. Demographic data as shown in [Table 1] describe the preoperative characteristics of both groups. Of these, 266 (21.8%) patients were <50 years old and 954 (78.2%) patients were ≥50 years old. The group had 76% women and 24% men. Both the elderly and young groups had more women represented. Patients 50 years and older had statistically significantly higher rate for comorbid conditions, including diabetes mellitus (DM, 3.8% vs. 9.1%; P = 0.004), chronic obstructive pulmonary disease (COPD, 0.8% vs. 11.6%; P < 0.00010), and hypertension (8.3% vs. 50.6%; P < 0.0001). The older cohort also had a lower mean albumin (4.1 vs. 3.9 g/dL; P = 0.001) and was more likely to be on chronic steroids (1.9% vs. 3.8%; P = 0.034).
Table 1: Demographics and patient comorbidities

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Preoperative status [Table 2] explains the American Society of Anesthesiologist (ASA) Classification of each patient. There were a higher proportion of patients with lower ASA scores in the young patient cohort. The majority of the younger group was in ASA Class 2 (51.9%) which means that they had mild disease without substantive functional limitations. The group 50 and older had the majority of patients in ASA Class 3 (47%) which means that they had substantive functional limitations with one or more moderate-to-severe disease. They also had 13.2% with severe, systemic disease with a constant threat to life, ASA Class 4.
Table 2: Preoperative complications

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The majority of patients with cecal volvulus underwent open surgery [Table 3]. Patients younger than 50 years old had a higher rate of laparoscopic surgery (22.1% vs. 10.9%; P < 0.001). The rate of nonelective operations was equivalent in both groups (87.3 vs. 90.4; P = 0.157). The average time to surgery was also equivalent in both groups (0.5 vs. 0.7 days; P = 0.11). The operative time was longer in the younger group with mean operative time of 97.5 vs. 89.1 min (P = 0.004).
Table 3: Intraoperative factors

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The primary outcome of mortality was not significantly different between the two groups (1.1% vs. 3.4%; P = 0.061). When patients were further subdivided by age decade, there was not a significant difference in 30-day mortality among the surgical groups [Figure 1]. There were no significant differences in major or minor complications between the two groups, based on Clavien–Dindo classification system.[7] As shown in [Table 4], there was no difference in superficial site infections (8.3% vs. 7.8%; P = 0.783), deep incisional site infections (0.4% vs. 0.9%; P = 0.364), organ space infections (3.8% vs. 4.5%; P = 0.597), or return to the operating room (OR) (5.3% vs. 7.3%; P = 0.23). The total hospital stay was longer in the older group (7.4 vs. 9.6 days; P = 0.005).
Figure 1: Mortality ≤30 days by decade

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Table 4: Major and minor complications

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  Discussion Top


Colonic volvulus is the result of abnormal rotation of a segment of colon around the mesentery.[1],[2],[3] Often this is due to a redundant colon with a long and free mesentery on a narrow base.[1],[2],[3] Colon volvulus can occur in the cecum, transverse colon, splenic flexure, or sigmoid colon.[1] Cecal volvulus has been thought to have two etiologies. The first is congenital where the colonic mesentery of the ascending colon has failed to fuse to the posterior peritoneum, leading to excessive mobility of the cecum around the base. In studies of autopsies, 10%–25% of the population has this failed fusion, leading to sufficient mobility to develop a volvulus.[8] The second etiology is acquired. These acquired causes include adhesions, pregnancy, colonic atony, colonoscopy, and Hirschsprung's disease.[9] The complications of volvulus include ischemia due to compromised blood supply, gangrene, and perforation, leading to concern of mortality for these patients.[1],[2],[4],[10],[11]

Demographics for cecal volvulus match our group with incidence peak in women in their mid-50s. This may be due to previous surgery or mobilization and elongation of the cecal mesentery with pregnancy.[1] Other risk factors, which we were not able to obtain from the NSQIP, described in the literature include adynamic ileus, chronic constipation, inflammation of the peritoneum, pelvic tumors or cysts, blows to the abdomen, and laxative abuse.[12]

Treatment for volvulus ranges from nonoperative options to surgical intervention. Cecal volvulus is different than sigmoid volvulus due to 20%–25% of patients who have associated necrosis, which could develop into perforation if nonoperative management is pursued.[1],[3],[13] Nonoperative reduction with either colonoscopy or even barium enema is rarely successful, and it ultimately could lead to perforation.[14] Surgical management, first and foremost, is used to describe the viability of the involved bowel without unvolvulizing the bowel. Surgical intervention can be classified as resective or nonresective procedures.[1],[15],[16] In older patients, some have tried to perform cecostomy; however, there were high rates of complications including gangrene, necrosis, leak, and fistulas, with 2%–14% recurrence. This option leads to the highest mortality rate and complications. Another option is detorsion and cecopexy, but the recurrence rate was between 20% and 30%. Resection consisting of a right hemicolectomy is the surgery of choice for cecal volvulus.[1],[3] Typically, these do not require proximal diversion, unlike sigmoid volvulus. Decision for diversion depends on patient condition and the condition of the bowel.[3] The current guidelines from the American Society of Colon and Rectal Surgeons recommend avoiding endoscopic decompression with first-line therapy being surgical resection with primary anastomosis.[4] Even though the patient population of cecal volvulus is usually younger than sigmoid counterparts, the median age is over 50 years old. There are limited data specifically discussing the morbidity and mortality of patients presenting with cecal volvulus in patients over 50 years old. As the population ages, it will be important to know how to educate these patients in regard to risk when they require surgical intervention.

This study demonstrates that the majority of patients presenting with cecal volvulus are women (76.0%) with a mean age of 68.5 years. These patients do have more comorbid conditions, including DM, COPD, and medically treated hypertension. Furthermore, they have poorer nutrition status as demonstrated by their albumin level. The older group had 60.6% with an ASA Class 3 or more compared to the younger group who had only 27.8% with ASA Class 3 or greater. Although it could be expected that older patients would have worse outcomes after surgery with all these compounding factors, using the NSQIP data, it was demonstrated that older patients have comparable outcomes to their younger cohort both in terms of mortality and postoperative complications. One possible explanation is that patients underwent emergent surgery (90.4%) within less than a day of presentation (0.7 days). Most of these were open laparotomies (89.1%), similar to younger patients. The average length of time in the OR and in the hospital was, however, significantly longer in the older group.

Patients 50 years or older did not have any significant increase in minor or major postoperative complications. This includes wound complications, pneumonia, acute kidney failure, unplanned intubations, pulmonary emboli, prolonged ventilator requirements, and strokes. There was also no statistically increased mortality in the older age group. Mortality does trend, per decade, up from 2% in patients from 50 to 59 years old to 5.4% in patients ≥80 years old, but this is not statistically significant. We can conclude that patients presenting with cecal volvulus 50 years old or older will be safe to undergo surgical intervention when required.

Limitations of this study include large database collection and selection bias. As we specifically included right hemicolectomy only, this excludes patients who underwent nonresection intervention. This could significantly limit the number of patients in the analysis, limiting the power of the study. The NSQIP also keeps their data generic, so further surgical details of each case cannot be reviewed further.


  Conclusion Top


Cecal volvulus is an uncommon reason for bowel obstruction with unclear outcomes in elderly patients in the literature. Our study confirms high rates of comorbidities in patients 50 years old or older; however, there are no differences in major or minor morbidity or mortality after surgical intervention for cecal volvulus.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Halabi WJ, Jafari MD, Kang CY, Nguyen VQ, Carmichael JC, Mills S, et al. Colonic volvulus in the United States: Trends, outcomes, and predictors of mortality. Ann Surg 2014;259:293-301.  Back to cited text no. 1
    
2.
Brothers TE, Strodel WE, Eckhauser FE. Endoscopy in colonic volvulus. Ann Surg 1987;206:1-4.  Back to cited text no. 2
    
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Akinkuotu A, Samuel JC, Msiska N, Mvula C, Charles AG. The role of the anatomy of the sigmoid colon in developing sigmoid volvulus: A case-control study. Clin Anat 2011;24:634-7.  Back to cited text no. 3
    
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Swenson BR, Kwaan MR, Burkart NE, Wang Y, Madoff RD, Rothenberger DA, et al. Colonic volvulus: Presentation and management in Metropolitan Minnesota, United States. Dis Colon Rectum 2012;55:444-9.  Back to cited text no. 5
    
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Consorti ET, Liu TH. Diagnosis and treatment of caecal volvulus. Postgrad Med J 2005;81:772-6.  Back to cited text no. 6
    
7.
Dindo D, Demartines N, Clavien PA. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205-13.  Back to cited text no. 7
    
8.
Pousada L. Cecal bascule: An overlooked diagnosis in the elderly. J Am Geriatr Soc 1992;40:65-7.  Back to cited text no. 8
    
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Delabrousse E, Sarliève P, Sailley N, Aubry S, Kastler BA. Cecal volvulus: CT findings and correlation with pathophysiology. Emerg Radiol 2007;14:411-5.  Back to cited text no. 9
    
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Madiba TE, Thomson SR. The management of cecal volvulus. Dis Colon Rectum 2002;45:264-7.  Back to cited text no. 10
    
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Vogel JD, Feingold DL, Stewart DB, Turner JS, Boutros M, Chun J, et al. Clinical practice guidelines for colon volvulus and acute colonic pseudo-obstruction. Dis Colon Rectum 2016;59:589-600.  Back to cited text no. 11
    
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Pulvirenti E, Palmieri L, Toro A, Di Carlo I. Is laparotomy the unavoidable step to diagnose caecal volvulus? Ann R Coll Surg Engl 2010;92:W27-9.  Back to cited text no. 12
    
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Donhauser JL, Atwell S. Volvulus of the cecum with a review of 100 cases in the literature and a report of six new cases. Arch Surg 1949;58:129-48.  Back to cited text no. 13
    
14.
Schwab FJ, Glick SN, Teplick SK. Reduction of cecal volvulus by multiple barium enemas. Gastrointest Radiol 1985;10:185-7.  Back to cited text no. 14
    
15.
Kasten KR, Marcello PW, Roberts PL, Read TE, Schoetz DJ, Hall JF, et al. What are the results of colonic volvulus surgery? Dis Colon Rectum 2015;58:502-7.  Back to cited text no. 15
    
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Katoh T, Shigemori T, Fukaya R, Suzuki H. Cecal volvulus: Report of a case and review of Japanese literature. World J Gastroenterol 2009;15:2547-9.  Back to cited text no. 16
    


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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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