Dear Editor,

With interest I read the paper titled “Endoscopic Management of Sigmoid Volvulus in a Debilitated Population: What Relevance?” written by da Rocha et al. [¹], who reported the results of endoscopic and surgical management of sigmoid volvulus (SV) in 52 elderly and debilitated patients. Although SV, the wrapping of the sigmoid colon around its mesentery causing a closed-loop colonic obstruction, is a rare disease worldwide, it is relatively common in Eastern Anatolia, where I practice. My colleagues and I have the largest single-center SV series in the world [²] including 1,030 cases treated in a 54-year period from June 1966 to July 2020. In light of this experience, my comments relate to the pathogenesis and treatment of SV in the elderly and debilitated patients.

First, although the pathogenesis of SV is not clearly defined in detail, the role of advanced age and neuropsychiatric diseases is not a mystery [³, ⁴]. Dolichosigmoid, a long and dilated sigmoid colon with an oblong mesentery, is the most common anatomical predisposition causing SV [⁵]. Fiber-rich diet habits and chronic constipation - the latter of which common among elders - cause chronic distention, which extends the colonic transit period and worsens the elastogenesis of the colon over time, resulting in dolichosigmoid. Similarly, some of the anti-Parkinsonian and psychotropic drugs used for the medication of Parkinson’s disease or mental retardation may cause a delay in transportation through the colon. Additionally, excessive use of some laxatives and enemas, arising from the irregular defecation habits of such patients, may lead to damage to myenteric neurons, again resulting in dolichosigmoid [⁶, ⁷]. As a result, dolichosigmoid and related SV are seen more commonly in elderly and debilitated populations. In our series, 405 patients (39.3%) were older than 60 years, while there were 127 septuagenarians (12.3%), 74 octogenarians (7.2%), and 7 nonagenarians (0.7%). On the other hand, 7 (0.7%) of our patients had Parkinson’s disease and 5 (0.5%) had mental retardation.

Second, the basic treatment rules are well defined for SV. Uncomplicated and nongangrenous cases are treated with endoscopic decompression, while complicated and gangrenous cases require emergency surgery [⁸]. Although elective sigmoid resection is suggested in some selected patients with successful endoscopic decompression to prevent SV recurrence, which occurs in a mean of 25% of cases, the patient selection criteria for elective surgery, which is the most critical point in decision-making, are not well defined [⁹]. In my experience and practice, patients younger than the local life expectancy (in Turkey, 75 years) and those with American Society of Anesthesiologists (ASA) scores below or equal to III, whose expected operative mortality rate is lower than 4.3%, are potential candidates for elective surgery [¹⁰]. In our series, endoscopic decompression was tried on 752 patients (73.0%) with 82.8% success, 0.7% mortality, 2.3% morbidity, and 5.5% early recurrence rates, while emergency surgery was applied in 476 cases (46.2%) with 16.8% mortality, 34.2% morbidity, and 0.6% late recurrence rates. On the other hand, we treated 114 patients with elective surgery, and their mortality, morbidity and late recurrence rates were 0.0, 11.4, and 0.0%, respectively.

I congratulate the authors and look forward to their reply on my comments.

We would like to express our appreciation for the comments and observations made by Dr Sabri Atamanalp regarding the article entitled “Endoscopic Management of Sigmoid Volvulus in a Debilitated Population: What Relevance?” [¹].

In line with what you have stated, we were also able to identify predisposing factors for dolichosigmoid, namely chronic constipation, advanced age and care dependence. However, unlike in your report, neuropsychiatric disorders were frequent comorbidities reported in 59% of our patients. From the 31 patients reported, 16 (52%) had previous stroke and 11 (35%) had advanced dementia (one of them due to Parkinson’s disease).

In our cohort, the population was older and more debilitated, with a median age of 84 years (75% were more than 70 years old), mean Charlson comorbidity score of 6 and more than half were caregiver dependent. Nevertheless, the outcomes of endoscopic and surgical management of sigmoid volvulus in our cohort were similar to your series and to current literature [²-⁴].

Despite the efficacy of the endoscopic treatment in the emergency setting, most of the sigmoid volvulus patients will recur, and, therefore, elective surgery should be considered. There is lack of data or recommendations regarding who and when to refer for surgery, especially in the elderly and patients with multiple comorbidities.

As you stated, we also agree that elective surgery should be considered for patients with ASA score ≤3, but we do not make the decision based on age. In our opinion, it will depend on case-by-case analysis, and all patients with a life expectancy of over 10 years should be referred for surgery. Our data and the current literature indicate that elective surgery is effective and safe in selected patients and may obviate later emergency surgery, reducing morbidity and mortality [⁵]. Nevertheless, in our cohort, only 9 patients underwent elective surgery, showing that the severe comorbidities limited the use of this surgical approach.