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\begin{document}

\title{Sigmoid volvulus secondary to undescended testicle, Report of first case
in the literatures}



\author[1]{Mojtaba Ahmadinejad}%
\author[2]{Alireza  Mammohammadi}%
\author[1]{Amirhossein Hajialigol}%
\author[1]{Armin Tajik}%
\author[1]{Hadi Maleki}%
\author[1]{Haleh  Pak}%
\author[1]{Javad Zebarjadi Bagherpour }%
\affil[1]{Alborz University of Medical Sciences}%
\affil[2]{Hamadan University of Medical Sciences}%


\vspace{-1em}



  
  \date{May 25, 2024}


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\textbf{Introduction}

A volvulus occurs when a segment of intestine, usually part of the
colon, twists around its mesentery. Following this rotation, initially
venous return is disturbed and causes ischemia caused by venous stasis.
With the prolongation of obstruction in the mesenteric vessels, along
with the distention of the twisted segment of the intestine due to the
progressive production of gas by the bacteria inside it, the arterial
input is also disturbed, and the mucosal ischemia gradually progresses
towards the muscular and serous layers, leading to perforation of the
entire thickness of the intestine

Sigmoid volvulus accounts for 2\% to 5\% of colonic obstructions in
Western countries and 20\% to 50\% of colonic obstructions in Eastern
countries (1). This occurs mostly in patients with lack of mobility and
a history of chronic constipation, where the sigmoid colon becomes
chronically distended and redundant.

Undescended testis (UDT) is defined as one or both testicles absent in
scrotal sac when descending processes become disturbed and testis
remains inside the peritoneal cavity (2). There are some very known
complications of a undescendent intra-abdominal testicle such as cancer,
ischemia and infertility(3); But the rotation of the colon around the
spermatic cord of one UDT, it is a very rare phenomenon that there is no
similar report.

In this article, we introduce a 67-year-old man who underwent laparotomy
with the diagnosis of sigmoid volvulus, and the intraoperative findings
were surprising.

\textbf{Case presentation}

A 67-year-old man, came to the emergency department with a complaint of
abdominal pain and obstipation from 2 days ago. In the post medical
history, he was a healthy man with 3 childs, with no comorbidities, or
history of hospitalization in the past, and he mentioned a history of
constipation. On examination, vital signs were within normal
limits(BP=100/80 mmhg,PR=84 per/min,RR=14 per/min ,T=37),and in
abdominal examination there was mild abdominal distention and mild
general tenderness .With the suspicion of intestinal obstruction, plain
abdominal x-rays were requested, and according to the appearance of
coffee beans in the X-ray (Figure 1), the diagnosis of sigmoid volvulus
was made. In the requested tests Hb was 14.5 g/dl, WBC was 9000 with
70\% PMN. The rest of the tests were within normal limits.

After fluid resuscitation, and insertion of a nasogastric tube for upper
decompression, rigid rectosigmoidoscopy was performed in the operating
room, which was unsuccessful. the patient was transferred to the
operating room for laparatomy. After induction of general anesthesia and
midline laparotomy, the sigmoid was clearly warped around the
meso-sigmoid. After manual untwisting, we noticed a tubular structure at
the base of the meso-sigmoid(Figure 2 and 3). Suspecting that the said
element is the spermatic cord, the scrotum was touched and it was found
that the left scrotum was empty. With further exploration and release of
adhesions between the spermatic cord and meso-sigmoid, the testis was
observed with a normal and non-atrophic appearance. After releasing all
adhesions, orchidectomy was performed intra-abdominally by urologist.
Then sigmoidectomy was performed by Hartmann's method by attending
surgeon. On the first day after the operation, the number of leukocytes
decreased (12000/dl) and the general condition of the patient improved.
patient passed the post-operative period without significant incident
and was discharged after 4 days. In the pathology report of the testicle
sample, no neoplasia or dysplasia was reported.

\textbf{Discussion}

Etiology of sigmoid volvulus is a redundant loop of sigmoid that twists
on its mesenteric pedicle more than 180\textsuperscript{0} which lead to
obstruction and venous outflow and arterial inflow disturbance,
respectively. Prolongation of this disturbance leads to mucosal ischemia
and infraction, and eventually, transmural perforation (4).

There are some known risk factors that have been associated with sigmoid
volvulus such as anatomical redundancies in the mesentery, malfixation
of the mesentery, chronic constipation, sedentary lifestyle, and
neurological disease (5)

Plain abdominal radiographs will show the classical coffee bean or
kidney bean sign, and often dilatation of the proximal colon. The
characteristic ''whirl' sign on CT scan corresponds with twisted
mesentery (6).

When the viability of the sigmoid colon mucosa is suspected, flexible
sigmoidoscopy is indicated to examine the colon mucosa, as well as
insufflationduring sigmoidoscopy to untwist the volvulus (7). Those
patients with failed decompression or those with complications such as
mucosal infarction or more advanced sequels need surgical intervention.
The surgery of choice is a sigmoid colectomy. Performing primary
anastomosis versus a Hartman procedure depends on intraoperative
findings and patients status .

In the reported articles, there are few intestinal complications
associated with cryptorchidism. Most of these articles considered the
mechanical obstruction caused by the adhesion of the undescended testis
or the compressive effect of the gubernaculum as the main cause of the
mechanical obstruction of the small intestine.

Nik Hamidi et al reported A 22-year-old man with typical symptoms and
imaging findings reported a small bowel obstruction that was caused by
adhesions from an undescended testis (8). Kim et al and Bassiouny et al
reported such cases of small bowel obstruction due to twisting of small
bowel around gubernaculum of an undescendent testis (9),(10)

Despite the existence of reports of small bowel mechanical obstruction
due to undescended testis, no report of colonic volvulus was found in
the literature, and to our knowledge, this is the first report of such a
case.

Sigmoid volvulus is one of the common cases that surgeons frequently
encounter. The case scenarios are often the same, and from experience,
most cases result from a long meso and an elongated sigmoid secondary to
prolonged constipation. Therefore, it is clear that a scrotal
examination would not be part of the routine examination of a patient
with sigmoid volvulus. In this article, by reporting a very rare
etiology for a very common pathology, we tried to point out the
importance of head to toe examination in all patients.

\textbf{Consent}

Informed consent was obtained from the patient for publication of this
case report and accompanying images. A copy of the written consent is
available for review by the Editor-in-Chief of this journal on request.

\textbf{Provenance and peer review}

Not commissioned, externally peer-reviewed.

\textbf{Ethical approval}

This is a case report paper.

\textbf{Funding}

There is no funding for this work.

\textbf{Guarantor}

The corresponding author is Dr. Javad Zebarjadi Bagherpour who accepts
full responsibility for the work and/or the conduct of the study, had
access to the data, and controlled the decision to publish.

\textbf{Research registration number}

None.

\textbf{CRediT authorship contribution statement}

All authors had same contribution on this work.

\textbf{Declaration of competing interest}

All authors confirm that there is no conflict of interest.

\textbf{Acknowledgement}

The authors would like to thank to Clinical Research Development Unit
(CRDU) of shahid Madani Hospital, Alborz University of Medical Sciences
for their support, cooperation and assistance throughout the period of
study

1. S.S. Atamanalp, Sigmoid volvulus, Eur J Med, 42 (3) (2010 Dec), pp.
142-147, 10.5152/eajm.2010.39

2. L.H. Braga, A.J. Lorenzo, Cryptorchidism: a practical review for all
community healthcare providers, Canadian Urological Association journal
= Journal de l'Association des urologues du Canada, 11 (1-2Suppl1)
(2017), pp. S26-S32

3. K\selectlanguage{ngerman}üçük HF, Dalkiliç G, Kuroglu E, Altuntas M, Barisik NO, Gülmen M.
Massive bleeding caused by rupture of intra-abdominal testicular
seminoma: case report. J Trauma. 2002 May;52(5):1000-1.

4. Saba M., Rosenberg J., Wu G., Hinika G. A case of sigmoid volvulus in
an unexpected demographic. Surg. Case Rep. 2021;7(1):3--7.
doi:~10.1186/s40792-020-01105-3.

5. Salas S., Angel C.A., Salas N., Murillo C., Swischuk L. Sigmoid
volvulus in children and adolescents. J. Am. Coll. Surg.
2000;190(6):717--723.

6. Xiang H, Han J, Ridley WE, Ridley LJ. Horseshoe sign: Sigmoid
volvulus. J Med Imaging Radiat Oncol. 2018 Oct;62 Suppl 1:85-86.

7. Garfinkle R, Morin N, Ghitulescu G, Vasilevsky CA, Boutros M. From
Endoscopic Detorsion to Sigmoid Colectomy-The Art of Managing Patients
with Sigmoid Volvulus: A Survey of the Members of the American Society
of Colon and Rectal Surgeons. Am Surg. 2018 Sep 01;84(9):1518-1525.

8 . amdi NHN, Raj K, Khairy AM., A rare cause of mechanical obstruction:
case report of, cryptoorchidsm in adult. Int Surg J 2020;7:3790-1.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

9. Chang Woo Kim,\textsuperscript{1,2}Gyeong Eun Min,\textsuperscript{3}
and Suk-Hwan Lee, Small bowel obstruction caused by cryptorchidism in an
adult, Ann Surg Treat Res. 2017 Nov; 93(5): 281--283.

10. Ibrahim E. Bassiouny, Tariq O. Abbas, \textsuperscript{*}Amani N.
Alansari, and Mansour A. Ali, Unique Presentation of Intra-Abdominal
Testis: Small Bowel Obstruction, ISRN Urol. 2011; 2011: 579153.

\textbf{Figure legends:}

Figure 1:typical coffie bean sign in abdominal X-ray

Figure 2-3:intraoperative finding

\textbf{Hosted file}

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