EP614 - Open Sigmoid Resection and Hartmann Pouch Management in a 90-Year-Old with Complex Multisystem Disease

Purpose/Background: Sigmoid volvulus represents 2-5% of intestinal obstructions in Western populations. It is a significant cause of large bowel obstruction in the elderly. It arises from torsion of the sigmoid colon around its mesentery, leading to a closed-loop obstruction that can progress to ischemia or perforation if untreated. Mortality is dependent on timing elapse before intervention. Early intervention has a 10% mortality while it increases to 40% when the intervention is delayed and there are ischemic complications. Early endoscopic decompression has a success rate of 75-90%, but recurrence can recur in up to 90% of the cases, requiring surgical management for definitive treatment.

Methods/Interventions: A 90-year-old male with prior medical history of hypertension, diabetes, chronic constipation, and recent urinary tract infection (2weeks from admission) subdural hematomas (2 months from admission) reports to the emergency room with abdominal distention and 3-days of constipation. Abdominal CT scan revealed a Frimann-Dahl sign with a 9cm dilated sigmoid colon consistent with a volvulus. The patient was transferred to the endoscopy unit for an emergent colonoscopy. Decompression was improvised with a chest tube provided with transient relief for 24 hours.

During pre-surgical preparation the patient underwent a suspected heparin induced cytopenia evidence by >50% platelets. At this time, another decompression was performed while the multidisciplinary team (neurosurgery, hematology, cardiology, pulmonology and nephrology) evaluated for surgical clearance. After medical stabilization, an open sigmoidectomy with splenic flexure mobilization and colostomy (Hartmann's procedure) was performed. Despite an ARISCAT score of 34, he tolerated the surgery but evolved with a hypertensive crisis and acute kidney injury that was managed in the intensive care unit. He had a speedy recovery and was discharged with physical therapy and follow up outpatient care.

On post-operative day 45, the patient presented constipation and abdominal distention in our outpatient clinic. Abdominal CT imaging excluded abscess, fistula, or rupture of the colon but displayed a dilation of 12cm of the Hartmann pouch with air-fluid surrounding the structure at a non-dilated section. This confirmed that the dilation occurred post-operatively. Using a 28 Fr Foley catheter, the rectum was irrigated, and the stool was evacuated and the distention relieved. The patient's symptoms were resolved without complications or recurrence, and dietary modifications were recommended, physical therapy and outpatient care were scheduled.

Results/Outcomes: Herein, we report a case of a 90-year-old male with multiple-comorbidity who successfully recovered from an open sigmoidectomy highlighting the feasibility of a successful open abdominal surgery in a frail elder patient. We underscore the importance of multidisciplinary cooperation and close monitoring for delayed postoperative complications such as Hartmann pouch dilations, enteric fistulas, or abscesses,

Conclusion/Discussion: A sigmoid volvulus is surgical emergency that demands prompt recognition, cautious optimization and vigilant follow-up in frail elderly patients with multiple comorbidities. Swift multidisciplinary coordination, surgical planning, and focused postoperative care were key for this patient's favorable outcome. Open resection remains a viable option when supported by multidisciplinary evaluation and swift intervention.

Colon Resection
Imaging Xray