Overview
Definition:
Cecopexy is a surgical procedure aimed at fixing the cecum to the abdominal wall, typically the parietal peritoneum, to prevent recurrence of cecal volvulus
Cecal volvulus is a surgical emergency characterized by the twisting of the cecum on its mesentery, leading to intestinal obstruction and potential ischemia
Recurrent cecal volvulus poses a significant challenge due to its propensity for repeated episodes and associated morbidity.
Epidemiology:
Cecal volvulus is less common than sigmoid volvulus, accounting for about 1-5% of all intestinal obstructions
It is more prevalent in certain populations, including the elderly, those with high mobility diets, and individuals with congenital abnormalities of intestinal fixation
Recurrence rates can be high if not adequately addressed surgically, necessitating definitive management.
Clinical Significance:
Recurrent cecal volvulus can lead to repeated episodes of severe abdominal pain, distension, nausea, and vomiting
Missed or delayed diagnosis can result in bowel ischemia, perforation, peritonitis, sepsis, and even death
Understanding the role of cecopexy in preventing recurrence is crucial for surgical residents preparing for examinations and for providing optimal patient care.
Clinical Presentation
Symptoms:
Sudden onset of severe, colicky abdominal pain, often localized to the right lower quadrant
Abdominal distension
Nausea and vomiting, which can become feculent in complete obstruction
Constipation or obstipation, though a bowel movement or flatus may precede symptoms
In recurrent cases, symptoms may be intermittent and less severe initially.
Signs:
Abdominal distension with tympany
Tenderness to palpation, which may be localized or generalized depending on the severity and presence of ischemia
Absent or hypoactive bowel sounds in cases of complete obstruction
Guarding and rigidity may indicate peritonitis or ischemia
Vital signs may show tachycardia and hypotension in severe cases or with complications.
Diagnostic Criteria:
Diagnosis is primarily based on clinical suspicion confirmed by imaging
There are no formal diagnostic criteria sets akin to inflammatory conditions
rather, it is a clinical-radiological diagnosis
Key features include a history of similar episodes, characteristic symptoms, and radiographic evidence of a dilated, twisted cecum.
Diagnostic Approach
History Taking:
Detailed history of abdominal pain: onset, character, duration, radiation
Previous episodes of similar symptoms and their resolution
History of constipation or bowel habit changes
Previous abdominal surgeries or known congenital anomalies
Dietary habits and mobility
Presence of risk factors like pregnancy or neurological conditions affecting bowel motility
Red flags: persistent vomiting, severe pain, signs of peritonitis, fever.
Physical Examination:
A thorough abdominal examination, including inspection for distension and scars
Auscultation for bowel sounds
Palpation for tenderness, masses, and signs of peritoneal irritation (rebound tenderness, guarding)
Percussion to assess tympany
Digital rectal examination to rule out distal obstruction or assess rectal vault.
Investigations:
Plain abdominal X-ray: may show a dilated cecum, often with a characteristic "coffee bean" or "inverted U" shape, and air-fluid levels
CT scan of the abdomen and pelvis with IV and oral contrast: the investigation of choice, demonstrating cecal position, the twist of the mesentery (whirlpool sign), degree of distension, and signs of ischemia or perforation
Laboratory tests: complete blood count (leukocytosis may indicate inflammation or ischemia), electrolytes, renal function tests, and lactate (elevated in ischemia).
Differential Diagnosis:
Other causes of acute abdominal pain and obstruction: sigmoid volvulus, small bowel obstruction from adhesions or hernia, appendicitis, diverticulitis, inflammatory bowel disease exacerbation, ischemic colitis, ovarian torsion in females.
Management
Initial Management:
Immediate resuscitation with intravenous fluids
Nasogastric tube insertion for decompression and to reduce vomiting
Analgesia
Broad-spectrum antibiotics if peritonitis or sepsis is suspected
Correction of electrolyte imbalances.
Surgical Management:
Surgical intervention is indicated for recurrent cecal volvulus, suspected ischemia/perforation, or failure of conservative management in a first episode
The goal is to detorse the volvulus and prevent recurrence
Surgical options include:
1
Cecopexy: This is the primary procedure for recurrent volvulus
The cecum is mobilized and fixed to the posterior parietal peritoneum
Various techniques exist, including sutures, tacking the cecal base, or creating a serosal tunnel
The aim is to eliminate any mobility of the cecum
2
Cecostomy: Creating a stoma from the cecum to the abdominal wall
Less common for primary volvulus management but can be used in severely ill patients or as a salvage procedure
3
Cecal resection with anastomosis: Indicated if there is significant ischemia or gangrene of the cecum
This may involve an ileocolic anastomosis or a staged approach with an ileostomy if the patient is unstable.
Postoperative Care:
Close monitoring of vital signs and fluid balance
Nasogastric tube decompression until bowel function returns
Gradual reintroduction of oral intake
Pain management
Mobilization to prevent deep vein thrombosis
Monitoring for complications like anastomotic leak, wound infection, or ileus
Early ambulation is encouraged.
Complications
Early Complications:
Bowel ischemia or gangrene leading to perforation
Peritonitis
Sepsis
Wound infection
Intra-abdominal abscess
Anastomotic leak (if resection is performed).
Late Complications:
Recurrence of volvulus (less common after successful cecopexy)
Adhesions and small bowel obstruction
Incisional hernia
Chronic abdominal pain.
Prevention Strategies:
Prompt diagnosis and surgical intervention are key
For recurrent volvulus, definitive fixation via cecopexy is the primary prevention strategy
Ensuring adequate mobilization and fixation of the cecum during the procedure is critical to avoid recurrence.
Prognosis
Factors Affecting Prognosis:
Timeliness of diagnosis and intervention
Presence and extent of bowel ischemia or perforation
Patient's comorbidities
Appropriateness of the surgical procedure
Skill of the surgeon.
Outcomes:
With timely surgical management, particularly cecopexy for recurrent volvulus, the prognosis is generally good, with a low recurrence rate and resolution of symptoms
Patients who develop gangrene or perforation have a higher risk of morbidity and mortality.
Follow Up:
Postoperative follow-up typically involves assessment of wound healing, resolution of symptoms, and return of bowel function
Patients are advised to report any new or recurrent abdominal pain promptly
Long-term follow-up may be less frequent but is important for monitoring for late complications.
Key Points
Exam Focus:
Cecal volvulus is a surgical emergency
Recurrent volvulus requires operative intervention, with cecopexy being the preferred method for prevention
CT scan is the diagnostic modality of choice
Early diagnosis and treatment reduce the risk of ischemia and perforation.
Clinical Pearls:
Always consider cecal volvulus in patients presenting with acute right lower quadrant pain and distension, especially if they have had previous similar episodes
The whirlpool sign on CT is pathognomonic for volvulus
Cecopexy aims to eliminate cecal mobility and prevent recurrence.
Common Mistakes:
Delaying surgical intervention in suspected cecal volvulus, leading to ischemia
Inadequate fixation of the cecum during cecopexy, resulting in recurrence
Misinterpreting plain X-rays and delaying CT scan
Not considering cecal volvulus in the differential for right lower quadrant pain.