Gangrenous cecal volvulus with 720° torsion and prolonged intraoperative hypotension in a resource-limited setting: a case report

Abstract

Introduction and importance: Cecal volvulus is an uncommon cause of large-bowel obstruction, but when it occurs, it can rapidly become life-threatening, with ischemia and gangrene developing quickly. Explicitly quantified 720° torsion is rarely described. Case presentation: A 45-year-old man presented after 5 days of abdominal pain, distension, obstipation, fever, and vomiting. His pulse rate was 124 beats per minute, his blood pressure was 100/65 mmHg, and he demonstrated clear signs of peritonism. Based on his history, examination findings, elevated white blood cell count, and abdominal X-ray, we suspected a gangrenous large-bowel obstruction. During laparotomy, we found the cecum and ascending colon twisted 720° counterclockwise, with gangrene extending up to the hepatic flexure and involving the distal ileum. The right colon was mobilized lateral-to-medial, the ileocolic vessels were ligated, and the mesenteric division was completed using hand-tied 3-0 Vicryl ligatures. Bowel transection was performed in healthy tissue approximately 10 cm proximal to the ileocecal valve, followed by en bloc resection of the gangrenous cecum and ascending colon. He remained hypotensive intraoperatively for about 40 minutes, with a nadir of 79/51 mmHg, and required crystalloids along with norepinephrine at 0.05 μg/kg/min. Owing to his instability, an end ileostomy and proximal transverse colonic mucous fistula were created instead of a primary anastomosis. Clinical discussion: This case highlights that reconstruction in gangrenous cecal volvulus should be individualized according to bowel viability, contamination, and patient physiology. In the presence of prolonged intraoperative hypotension, vasopressor requirement, bowel edema, and severe bowel compromise, staged diversion may be safer than immediate anastomosis. The case also emphasizes the diagnostic limitations of plain radiography in distinguishing cecal from sigmoid volvulus when CT is unavailable. Conclusion: This case illustrates that urgent source control and physiology-guided staged reconstruction can achieve good outcomes in severe cecal volvulus, even in a resource-limited referral hospital without CT or pathology services.