Ileo-sigmoid knotting: The Parirenyatwa hospital experience

Abstract

Background: Ileo-sigmoid knotting is a rare cause of intestinal obstruction with a rapidly progressive course, for which expedient surgical intervention is  required to prevent mortality. The aim of this study was to determine the characteristics, presentation, morbidity and mortality associated with ileo-  sigmoid knotting at Parirenyatwa Group of Hospitals (PGH). To determine the preoperative diagnostic precision and management patterns of ileo- sigmoid knotting cases at PGH.

Methods: A retrospective analysis was performed on patients operated on at Parirenyatwa Hospital with a diagnosis of ileo-sigmoid knotting between  April 2011 and April 2018. Data inclusive of demographics, time to presentation and surgery, preoperative diagnosis, complications and in-hospital  mortality was collected. The relationship between the duration of symptoms prior to surgery and incidence of both septic shock and transfusion were  analysed.

Results: Twenty-one cases of ileo-sigmoid knotting were identified for analysis. The median age was 37 years (range 18–65 years) with a 6:1 male to  female ratio. Two of the three females included were pregnant. Twenty patients (95.2%) described an acute onset abdominal pain, with 83.3%  experiencing the pain nocturnally, while asleep. The median duration of symptoms at presentation was 12.5 hours (range 2–39 hours). At admission,  leucocytosis (WCC > 11x10³/dl) was noted in eleven patients (52.4%). Seventy-three per cent of patients were noted to have electrolyte derangements at  presentation. Seven patients (33.3%) had recorded episodes of severe hypotension (SBP < 90) prior to surgery. The most common preoperative diagnosis,  based on both clinical assessment and plain x-ray evaluation, was sigmoid volvulus (52.4%), with no preoperative diagnosis of ileo-sigmoid  knotting being made. All patients had gangrenous small bowel, with 81% having a gangrenous sigmoid colon. All cases underwent small bowel resection  and primary anastomosis plus Hartmann’s procedure. Postoperatively, eleven patients (52.4%) developed septic shock, while 62% required blood  transfusion. There was one (4.8%) early postoperative mortality.

Conclusion: To avoid mortality, the diagnosis of ileo-sigmoid knotting should be entertained and the imperative of emergency surgery recognised in the  young male or pregnant female patient with acute nocturnal onset abdominal pain, a rapidly deteriorating small bowel obstruction clinical picture and  with radiological features suggestive of both small and large bowel obstruction.