Introduction

Sigmoid volvulus is usually managed by endoscopic detorsion in the absence of complications, while surgery is reserved for severe cases. However, recurrence rates remain high, ranging from 18% to 90% (1). The guidelines from the American Society of Colon and Rectal Surgeons (1) recommend prophylactic surgery, although the optimal timing is not defined. In Europe, most cases are sporadic and affect elderly patients with comorbidities. However, large studies mainly originate from endemic regions, which limits their applicability to Western settings. Moreover, there is a lack of large-scale data focusing specifically on the endoscopic management of sigmoid volvulus.

Aims & Methods

The study aimed to evaluate the outcomes of patients with sigmoid volvulus managed by endoscopic detorsion during out-of-hours emergency endoscopy shifts across multiple centers.
We conducted a retrospective, multicenter study (8 centers), including all patients who underwent endoscopy for suspected sigmoid volvulus during on-call digestive endoscopy shifts between March 2016 and December 2023. Procedures were performed by the POET group (Parisian On-call Endoscopy Team), a mobile unit composed of an endoscopist and a nurse, covering urgent endoscopy during nights and weekends in Paris and suburbs (6.9 million inhabitants), using a portable system (2).

Results

A total of 404 patients were included. Median age was 72 years (IQR 59; 83), 69% were male, 19% institutionalized, 40% had neurocognitive disorders, 26% had anatomical abnormalities of the colon and 45% had constipation. The most common presenting symptoms were abdominal pain (53%), bowel obstruction (17%), and constipation (20%). Endoscopic detorsion was successful in 92% of cases, with a 2% perforation rate and 89% of clinical success. Predictors of technical failure included ischemia at endoscopy (OR 0,16 [0,07-0,37], p<0,0001) and history of abdominal surgery (OR=0,44 [0,2;0,99], p=0,0463). Ischemia was independently associated with initial CRP ≥ 27 mg/L (OR=2,24 [1,11-4,54], p=0,0253), time to endoscopy ≥ 10h (OR=2,38 [1,28-4,39], p=0,0058), and radiological signs of severity (OR=4,13 [1,82-9,36], p=0,0007). All 24 patients with colonic necrosis at endoscopy died without emergency surgery, regardless of the success of detorsion (58% in this subgroup). In 28% of cases, endoscopy was performed for recurrence. Among patients with a first episode, recurrence occurred in 40%, with 50% occurring within 12 days. Endoscopic success was associated with a higher risk of recurrence (OR=4,39 [1,18-16,32], p=0,0271). In-hospital and 30-day mortality was <10%; overall mortality at the latest follow-up was 31% (median follow-up : 9 months, IQR 2-31).

Conclusion

Emergency endoscopic detorsion is highly effective with low morbidity. However, in the presence of colonic necrosis, endoscopic treatment is ineffective and uniformly fatal without surgical intervention. Optimal patient selection is therefore critical, and relies on early identification of predictive factors for ischemia. Volvulus recurrence is frequent and early, highlighting the need for systematic prophylactic treatment following successful detorsion. Elective surgery during the same hospitalization should be considered whenever possible. For patients with surgical contraindications, endoscopic sigmoidopexy may offer a viable alternative.

References

1. Alavi K, Poylin V, Davids JS, Patel SV, Felder S, Valente MA, Paquette IM, Feingold DL; Prepared on behalf of the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction. Dis Colon Rectum. 2021 Sep 1;64(9):1046-1057. doi: 10.1097/DCR.0000000000002159. PMID: 34016826.
2. Camus M, Becq A, Jaïs B; Parisian On-Call Endoscopy Team; Dray X. Resource-sparing urgent endoscopies by a mobile on-call team in the Paris area during the COVID-19 outbreak. Gastrointest Endosc. 2020 Aug;92(2):447-448. doi: 10.1016/j.gie.2020.04.021. Epub 2020 Apr 16. PMID: 32305344; PMCID: PMC7161514.

Introduction

Endoscopic submucosal dissection (ESD) is an effective treatment for superficial esophageal cancer, but postoperative stenosis remains a significant concern. Particularly, probability of the stenosis is less investigated in cases with a 50%-75% circumferential mucosal defect.

Aims & Methods

This study aimed to identify influential factors for postoperative stenosis after the moderate circumferential resection in esophageal ESD. This multi-center retrospective observational study analyzed data from 513 patients across 19 institutions who underwent esophageal ESD from April 2018 to March 2022 and showed 50% to 75% of the circumferential mucosal defect. We firstly overviewed the current status on the postoperative stenosis, the steroid use, and postoperative adverse events in these patients. Subsequently, we identified influential factors for postoperative stenosis. Patients were categorized into stenosis and no stenosis groups, and univariate and multivariate analyses were performed for each parameter. We further investigated influential factors of stenosis in two cohorts: steroid and no steroid groups. Finally, the parameters were compared between the steroid and no steroid groups to assess the tendency of the steroid use in general practice.

Results

Postoperative stenosis was observed in 28 cases (5%). Univariate analysis comparing the stenosis group (n = 28) and no stenosis group (n = 485) revealed significant differences in the prior endoscopic treatment near the lesion (p = 0.02), cervical esophageal location (p = 0.04), defect circumference (p =0.01), and procedure duration (p = 0.02). There was no significant difference in the steroid use between two groups. Multivariate analyses identified history of prior endoscopic treatment close to the lesion (p = 0.01, odds ratio [OR], 5.10), cervical esophageal lesions (p = 0.03, OR, 3.97), large circumferential defect (p <0.01, OR, 3.78), and longer procedure duration (p <0.01, OR, 3.83) as independent risk factors for stenosis formation. Among the steroid group, significant associations of the postoperative stenosis were revealed with the prior endoscopic treatment near the lesion (p = 0.02), cervical esophageal location (p = 0.04), and >5/8 of defect circumference (p = 0.02). In the no steroid group, only the procedure duration (p = 0.01) showed a significant difference between the stenosis and non-stenosis groups. Comparison between the steroid (n = 223) and no steroid groups (n = 290) revealed significant differences in the prior endoscopic treatment near the lesion (p <0.01), cervical esophageal lesions (p <0.01), and resected specimen dimensions (p <0.01). The stenosis rates were 7% in the steroid group and 4% in the no steroid group, without a significant difference. No significant difference in adverse events was observed between the two groups.

Conclusion

In esophageal ESD with a 50%-75% circumferential mucosal defect, the steroid was used in over 40% of patients, and postoperative stenosis still occurred in 5%. Because wider circumference, location of the cervical esophagus, prior endoscopic treatment close to the lesion, and prolonged operative time were identified as independent risk factors on the stenosis, steroid therapy should be preferred in these cases. Particularly, lesions with a history of endoscopic treatment, on cervical esophagus, and with >5/8 of defect circumference should require more aggressive countermeasures than currently applied.