Dear Sir,


We thank Dr. Atamanalp and his colleagues for their insightful comments about our article “Laparoscopic fixation of volvulus by extra-peritonealization: a case series” [1, 2] We congratulate them on their impressive experience.

We certainly agree that endoscopic decompression, when applicable, is the initial management of choice, and this is our routine. We should remember, however, that in some circumstances this. modality is not readily available and in these cases, “blind” rectal tube application can be life-saving. So, globally, “best available care” is, sometimes, not the optimal care.

We agree that the most effective treatment for sigmoid volvulus is resection. This may be in contrast to cecal volvulus, for which, so far in our limited experience, no recurrences were observed after extra-peritoneal fixation, with negligible morbidity. For sigmoid volvulus, resection continues to be our default solution, but for very high-risk patients, or those who refuse to undergo resection for fear of anastomotic failure and its risks, including the need for a colostomy, fixation is a viable alternative; it does not preclude future resection in case of failure and volvulus recurrence.

When presenting the options to the patient, it is important to be familiar with the alternatives and honestly describe the pros and cons, to receive proper informed consent. Our experience adds to the surgeon’s toolbox when faced with colonic volvulus.