Mini Laparotomy for Sigmoid Volvulus
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We want to command Dr van der Naald and colleagues on their published series on surgical treatment for uncomplicated volvulus .
We have the following comments:
First, we appreciate the rural setting in Zambia and the unavailability of flexible sigmoidoscopy for decompression. In our hospital, we do not have this service out of hours (after 5 pm). However, we find tube decompression by rigid sigmoidoscopy very helpful and usually have dramatic results. This can give longer time for fluid resuscitation and electrolyte correction. It can also change an urgent situation to a “semi-elective” one—with all the advantages associated. Additionally, it helps us to assess acutely whether there is any tissue necrosis. Atamanalp reported 35.3% morbidity and 16.1% mortality for emergency procedures versus 12.5 and 0% for elective procedures, respectively, for sigmoid volvulus .
Second, a median stay of 4 days is impressive; however, this might pose a potential problem in such a rural setting, and loss of follow-up. We believe, in such rural setting where transport is difficult, it might be perilous to discharge the patients early knowing the potential lack of post-discharge support to manage any leaks which might happen post day 4. Short hospital stay should be a means to an end, not an end in itself. In fact, hospital stay was not one of the key elements that affected the outcome in ERAS in emergency surgery as shown by Gonenc et al. . We do not agree that low septic complications rate in this series can be correlated to the median stay as was alluded to in the discussion. The small number of patients, the loss of follow-up and other confounding variables make it difficult to conclude this.
Third, smaller incisions are desirable, but sometimes such small incisions might fail to remove the entire length of redundant colon and, therefore, increase the risk of post-resection recurrence. Hence, the surgeon should never hesitate to extend the incision if needed. This is even more valid for the young age population as opposed the old and frails.
Fourth, we wonder in what situations the authors would elect to perform a proximal diversion when performing the anastomosis.