Shinban Liu, DO, Nicholas Morin, DO, Vadim Meytes, DO, George Ferzli, MD. NYU Langone Hospital – Brooklyn
Introduction: Cecal volvulus is a rare form of obstruction that occurs when there is torsion or rotation of mobile cecum or ascending colon. It accounts for only 1-3% of all adult intestinal obstructions and is believed to have three main subtypes: clockwise axial rotation, loop torsion of the cecum with the terminal ileum, and anterior-superior folding without rotation—known as a cecal bascule. Cecal bascule presents less commonly, is less likely to create vascular compromise, and more frequently occurs in younger female patients. While abdominal plain film may reveal a characteristic “coffee bean” shaped cecum, computed tomography remains more specific in identifying cecal volvulus, differentiating between subtypes, and risk stratifying patients for operative management. We present the case of a 41 year old female with a cecal bascule treated with laparoscopic cecopexy and incidental appendectomy.
Case Presentation: 41 year old female with surgical history of abdominoplasty and caesarean section presents with 3 days of severe right lower quadrant abdominal pain with multiple episodes of nausea and vomiting. CT demonstrated cecal bascule formation without features of ischemic change or perforation. Patient was brought to the operating room and a redundant right colon with floppy cecum was identified. Multiple interrupted sutures were placed between the colonic tenia and lateral peritoneum to restrict the mobility of the cecum. Due to the retrocecal location of the appendix following cecopexy, an incidental appendectomy was performed. The patient had an uncomplicated postoperative course with unremarkable outpatient follow up.
Discussion: Cecal bascule is an uncommon form of cecal volvulus with anterior folding that can lead to obstructive symptoms. Initial diagnostic imaging may include abdominal plain film; however CT is more sensitive and assists with diagnostic specificity and operative planning. Nonsurgical treatment of cecal volvulus via endoscopy is limited, relatively ineffective, and associated with increased ischemia. Thus, surgical management should be the primary treatment modality. If nonviable bowel is encountered intraoperatively, resection is mandatory. With viable bowel, surgical management includes detorsion and fixation with cecopexy or hemicolectomy. Studies have shown increased risk of recurrence with cecopexy so many advocate for hemicolectomy as a definitive procedure. However, hemicolectomy is comparatively associated with increased mortality. Ultimately the choice of operation should be based on patient risk stratification, viability of the involved bowel segment, and operator experience.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 92229
Program Number: P316
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster