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Resumen El vólvulo de sigmoides ocurre como resultado de una torsión del eje mesentérico colónico, cuenta con una etiología multifactorial y controvertida, de fisiopatología no clara aún. Presenta un cuadro clínico de inicio inespecífico y posteriores signos y síntomas de oclusión intestinal; su diagnóstico se establece mediante tomografía computarizada, con una sensibilidad y especificidad mayor al 90%. El manejo dependerá de la condición clínica del paciente. Caso clínico: Hombre de 29 años con antecedente de síndrome de Asperger. Refirió que desde 7 días previos a su ingreso presentó dolor tipo cólico difuso, asociado a distensión abdominal e intolerancia a la vía oral. Acudió a valoración hospitalaria donde se realizóa tomografía computarizada con niveles hidroaéreos, torsión de arteria mesentérica inferior de aspecto de torbellino. Se realizó laparotomía exploradora a través de la cual se encontró sigmoides dilatado y volvulado, con perforación en la unión rectosigmoidea; se realizó sigmoidectomía con colorectoanastomosis. Al quinto día presentó datos de respuesta inflamatoria con abdomen agudo, por lo que ingresó a laparotomía exploradora donde se encontró dehiscencia de anastomosis; se realizó procedimiento de Hartmann. El paciente presentó choque séptico y falleció a las 24 horas del postquirúrgico. Discusión: La presentación de vólvulo sigmoides generalmente se presenta en personas mayores de 70 años, pocos casos se describen en personas jóvenes y están relacionados con enfermedad de dismotilidad intestinal. El paciente no contaba con factores predisponentes, el diagnóstico se estableció con imágenes características de la enfermedad, como la imagen en torbellino, se decidió manejo quirúrgico con la realización de resección con colorectoanastomosis. Conclusión: La oclusión intestinal por vólvulo sigmoides es una patología infrecuente en jóvenes y de clínica inespecífica. Ante un paciente que presente datos de oclusión intestinal deberá ser abordado de manera apropiada, sobre todo en pacientes en quienes hayan debutado con una clínica insidiosa y persistente de dolor abdominal secundario a oclusión intestinal, sean jóvenes con o sin factores de riesgo.
Abstract Sigmoid volvulus occurs due to a torsion of the colonic mesenteric axis, it has a multifactorial and controversial etiology, and its pathophysiology is not yet clear. Presenting a clinical picture of non-specific onset and later signs and symptoms of intestinal occlusion, its diagnosis is established with computed tomography with a sensitivity and specificity greater than 90%. Management will depend on the clinical condition of the patient. Clinical case: A 29-year-old man with a history of Asperger syndrome. He referred 7 days prior to admission with diffuse cramping pain, associated with abdominal distension and oral intolerance. He went to the hospital for evaluation where a computed tomography was performed with air-fluid levels, torsion of the inferior mesenteric artery with a whirlwind appearance. Exploratory laparotomy was performed, finding a dilated and volvulated sigmoid with perforation at the rectosigmoid junction. A sigmoidectomy with colorectal anastomosis was performed. On the fifth day, he presented data of inflammatory response with acute abdomen, entering exploratory laparotomy finding anastomosis dehiscence, Hartmann procedure was performed. The patient presented septic shock, died 24 hours after surgery. Discussion: The presentation of sigmoid volvulus generally occurs in people older than 70 years, few cases are described in young people and are related to intestinal dysmotility disease, the patient did not have predisposing factors, the diagnosis is established with characteristic images of the disease such as whirlwind image, surgical management is decided by performing resection with colorectal anastomosis. Conclusion: Intestinal occlusion due to sigmoid volvulus is an infrequent pathology in young people and with non-specific symptoms. When faced with a patient presenting evidence of intestinal occlusion, this should be appropriately addressed, especially in patients who have debuted with insidious and persistent symptoms of abdominal pain secondary to intestinal occlusion, whether they are young with or without risk factors.
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@#Sigmoid volvulus is rare in the pediatric population, generally occurring in the adult age group. This is a case report of sigmoid volvulus in a pediatric patient, documenting the clinical presentation, diagnostics, endoscopic and surgical management and outcome in a16 year old male presenting with crampy abdominal pain and difficulty in bowel movement. Abdominal x-ray revealed a dilated sigmoid colon in an inverted-U configuration. Emergency endoscopic detorsion was done with subsequent elective sigmoidectomy. Although sigmoid volvulus may be rare in the pediatric population, the diagnosis should always be considered in patients presenting with abdominal pain, obstruction and abdominal distension.
Subject(s)
Adolescent , ConstipationABSTRACT
Ovarian torsion results from twisting of the ovary about the suspensory ligament, which contains the ovarian artery and vein, lymphatic’s, and nerves. Volvulus is a torsion of a segment of the alimentary tract, that often leads to intestinal obstruction. Ovarian torsion leading to sigmoid volvulus is the rarest complication which authors found in this case. Hence the case was presented. A 28-year-old women presented with acute pain in abdomen since 14 hours, followed by 2 episodes of vomiting, abdominal distension since 10 hours. Plain X-ray Abdomen erect was done which showed ‘Coffee bean’ sign with multiple air fluid levels suggestive of sigmoid volvulus. On laparotomy, after opening the peritoneum, large right ovarian cyst around 12×11×10 cm with solid and haemorrhagic content with long pedicle around 8 cm with 3 turns of torsion was noted. Abutting the ovarian mass, sigmoid colon was seen twisted around its mesentery including the twisted ovarian pedicle. Hence, the twisted component included the twisted ovarian pedicle and twisted sigmoid mesentery. Stepwise detorsion of ovarian pedicle followed by oophorectomy was done. For sigmoid volvulus, resection of vascular compromised sigmoid colon and descending colon stoma was done. Reanastomosis was done later after 3 months post operatively.
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Background: The objective of the study was to discuss the appropriate course of action in cases of sigmoid volvulus. It becomes important due to its high morbidity and mortality and its acute emergency presentation.Methods: This is a retrospective study of sigmoid volvulus admitted in the department of surgery at Late SBRKM Government Medical College, Jagdalpur. The study period was from January 2017 to August 2019. A total of 27 cases were under study. On admission, they were examined, investigated and treated surgically and the outcome noted.Results: Out of 27 patients 25 were male and 2 cases were female. The mean age group was 65 years. The co-morbidities consisted of previous abdominal surgeries, diabetes mellitus, hypertension, and renal complications. The common factor was chronic constipation and purgative abuse. All underwent a definitive surgical procedure like sigmoidectomy and colorectal anastamosis or sigmoidectomy and colostomy. In the second group colostomy closure and end to end anastamosis carried on at a later date. We have lost 5 patients in the post-operative period.Conclusions: The sigmoid volvulus presents with the features of intestinal obstruction. The real danger is the gangrene of the bowel, as a consequence of ischaemia. It requires an early surgical intervention for the maximum benefit of the patient.
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Introducción: Las pruebas de diagnóstico por imagen se han convertido en una pieza crucial en el diagnóstico del abdomen agudo en la urgencia, sin embargo, la conducta médica deberá basarse en los hallazgos iconográficos contextualizados. El signo tomográfico del remolino constituye un paradigma por su asociación con el vólvulo intestinal. Objetivos: Registrar pacientes con diagnóstico de abdomen agudo en busca del "signo del remolino" en la tomografía computada e identificar quiénes requirieron intervención quirúrgica. Métodos: Estudio analítico de corte transversal evaluándose 115 tomografías computadas de abdomen agudo obstructivo en búsqueda del signo del remolino. Resultados: 15 tomografías fueron excluidas por tratarse de estudios solicitados en posoperatorios. El signo del remolino se presentó en el 5%. Los diagnósticos fueron de mal rotación intestinal (2%), vólvulo de intestino delgado (1%), vólvulo de sigma (1%) y enterocolitis (1%). Sólo el 60% de los pacientes requirieron cirugía. Discusión: La presencia del signo del remolino no siempre obedece a una resolución quirúrgica. No es patognomónico de una sola entidad puntual, pudiendo representar un hallazgo en el contexto de otra patología aguda, por lo que se debería reconocer sus variantes para instaurar el tratamiento adecuado, sea quirúrgico o médico.
Introduction: The imaging test have become an important piece on the diagnosis of the acute abdomen in emergency, nevertheless medical conduct should be based on contextualized iconographic findings. The tomographic "whirlpool sign" establishes a surgical paradigm for its association with the bowel volvulus. Objetive: To register patients with diagnosis of acute abdomen looking for the "whirlpool sign" in the computed tomography and identify who needed surgical intervention. Methods: Analytical cross-sectional study. 115 tomographies of acute obstructive abdomen have being evaluated. Results: 15 tomographies were excluded. The prevalence of the whirlpool sign was 5%. Diagnoses were intestinal malrotation (2%), midgut volvulus (1%), sigmoid volvulus (1%) and enterocolitis (1%). Only 60% of the patients required surgery. Discussion: The presence of the "whirlpool sign" not always determines a surgical resolution. It is not a pathognomonic sign of a punctual entity; it could represent an ordinary finding in the context of several pathologies. To apply the correct treatment, surgical or medical, for these patients it was important to recognize "whirlpool sign" variants.
Subject(s)
Humans , Male , Female , Adult , Middle Aged , Aged , Aged, 80 and over , Tomography, X-Ray Computed , Intestinal Volvulus/diagnostic imaging , Abdomen, Acute/diagnostic imaging , Signs and Symptoms , Cross-Sectional Studies , Intestinal Volvulus/surgeryABSTRACT
Worldwide incidence of sigmoid volvulus varies from 6-30%. In India the incidence varies from 11.8% in the west to 1.5 - 9.4 % in north and south India respectively, depending on the dietary constituents. The management of sigmoid volvulus varies depends on the timing of presentation and the condition of the large bowel
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El vólvulo de sigmoides es causa de oclusión intestinal, su frecuencia es muy baja en edades tempranas de la vida, produce cuadro de oclusión intestinal o suboclusión intestinal repetida, no es objeto de diagnóstico diferencial en el abdomen agudo y su diagnóstico requiere de un interrogatorio profundo, estudio radiológico de abdomen simple en posición erecta y estudio de colon por enema. Se presentó paciente de 15 años que se operó de vólvulo de sigmoides en el Hospital Provincial Pediátrico Docente Hermanos Cordové de Manzanillo, provincia Granma.
Sigmoid volvulus is a cause of intestinal obstruction whose frequency is very low in the early years of life, producing intestinal obstruction or intestinal repeated subocclusions, in the Surgery service it is not considered a disease for differential diagnosis as cause of acute abdomen for diagnosis, and always need a good examination, plain abdominal radiographic study in an erect position, which is the initial imaging study and should be performed in a case of suspected intestinal obstruction, and its certainty study of colon by enema. A 15- year- old patient who underwent a surgery of sigmoid volvulus was presented in this paper, which contributes to the small number of cases recorded worldwide. The elements of diagnosis made and the treatment given to this patient were declared.
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Aims: To determine the incidence of sigmoid volvulus in Northern Uganda. Study Design: A cross-sectional (2 years retrospective and one year prospective) study design was conducted on patients’ medical records and those admitted, surgically managed or referred from the 19 hospitals in Northern Uganda. Place and Duration of the Study: This study was conducted in 19 hospitals in Northern Uganda from January 2010 to December 2012. Methodology: A cross sectional study design with a two year retrospective and one year prospective studies were conducted to determine the incidence of sigmoid volvulus in Northern Uganda. All patients’ records with a diagnosis of sigmoid volvulus in 19 hospitals were included in the study. Ethical approval was obtained from the IRB of Gulu University Medical School and Uganda National Council for Science and Technology (UNCS&T). Data analysis was conducted using STATA/IC version 12.1. Results: The incidence of sigmoid volvulus in Northern Uganda was 251.8 per 100,000 surgical populations in 2 years. Most cases occurred in the dry season particularly from December to April and least observed from May to November. Middle aged and elderly male were the most commonly affected. Conclusion: The incidence of sigmoid volvulus in Northern Uganda was 251.8 per 100,000 surgical populations in 2 years. The proportion of bowel obstructions due to sigmoid volvulus in Northern Uganda was 23.4% and similarly comparable with the proportion found in other African countries and higher than those in developed countries.
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Aims: To determine the factors that influence outcome of management of sigmoid volvulus in Northern Uganda Study Design: A prospective observational study was conducted on 103 sigmoid volvulus patients admitted and surgically managed in 19 hospitals in northern Uganda and followed-up postoperatively for 30 days. Place and Duration of the Study: This study was conducted in 19 hospitals in Northern Uganda from January 2012 to December 2012. Methodology: One hundred and three patients with sigmoid volvulus were consecutively recruited and admitted in 19 of the 20 hospitals in Northern Uganda and were surgically managed by resection and primary anastomosis or Hartmann’s procedure or double barrel colostomy. Patients 13 years and above with sigmoid volvulus and who had consented/Assented were included in the study and followed up to the 30th postoperative day. Ethical approval for the study was obtained from the Institutional Review Committee of Gulu University Medical School. Data analysis was carried out using STATA/IC version 12.1. The outcome events observed were uneventful recovery morbidity and mortality. Results: Eighteen patients (17.48%) developed complications including wound sepsis 10(9.7%); wound dehiscence 8(7.7%) and anastomotic leak 8(7.7%). There were 8 deaths, thus giving a mortality rate of 7.7%. The factors associated with a high risk of morbidity and mortality were hypernatraemia (RR=14.9; 95% CI: 1.46-152.9) and ileosigmoid knotting (RR=4.94; 95% CI: 1.30- 18.78). Resection and primary anastomosis had a better outcome compared to the Hartmann’s procedure (RR=0.15; 95% CI: 0.02-0.099). Conclusion: The risk factors associated with morbidity and mortality of sigmoid volvulus management were preoperative hypernatraemia and ilio-sigmoid knotting. Hartmann’s procedure was associated with a higher risk of morbidity and mortality than resection and primary anastomosis.
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Pneumatosis Cystoides Intestinalis (PCI) is an uncommon but well recognised clinical entity in which gas-filled cysts appear in the intestinal wall.PCI can be an incidental finding or it may be detected during radiography or laparotomy. We came across two cases of PCI with characteristic morphological features associated with perforation peritonitis in and sigmoid volvulus respectively. In both cases PCI was not suspected pre-operatively.Both patients underwent urgent surgical exploration for the abdominal emergencies and were discharged in good general condition. It is imperative that the imaging finding of PCI is carefully correlated with the findings of physical examination, clinical history, and laboratory test results to determine which patients can be managed medically by treating the underlying disease and which will require emergency surgery. This decision can be difficult because the origin of the gas is often unclear and the patient's symptoms can be volatile, presenting a major dilemma for the surgeon.
Subject(s)
Pyloric StenosisABSTRACT
We report the case of a 34-year-old Malay, admitted for constipation and abdominal pain at 35 weeks of gestation. Initially, she was diagnosed to have paralytic ileus and was managed conservatively. As her condition did not improve, emergency laparotomy was performed for suspected intestinal obstruction. She delivered a baby boy weighing 2.84kg with good Apgar score through a caesarean section. Intra-operatively, she was noted to have sigmoid volvulus and sigmoidopexy was performed. Post-partum, colonoscopy and bowel decompression was performed. She recovered well and was discharged on day 5. This case illustrates the need to diagnose or suspect volvulus in pregnant woman presenting with severe constipation as early surgical intervention can reduce morbidity to both mother and fetus.
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Sigmoid volvulus may cause acute or subacute colonic obstruction. Excessive length of the sigmoid colon may be a contributing factor. Typically, the patient develops bilious vomiting and marked gaseous abdominal distension. We report a case of sigmoid volvulus in a 9-year-old boy who presented with recurrent, sudden onset abdominal pain, abdominal distension, and vomiting for 1 year, which was diagnosed by simple abdominal X-ray, barium enema, computed tomography, and colonoscopic examination. Colonoscopic reduction failed and a sigmoid colectomy with primary repair was performed. The intra-operative findings showed that the sigmoid colon was noted to be dilated, and redundant with a lax mesentery. Two clear areas of compression (proximal and distal) were present. After sigmoidectomy, the symptoms resolved. After 5 years of follow-up, he had no new symptoms.
Subject(s)
Child , Humans , Abdominal Pain , Barium , Colectomy , Colon , Colon, Sigmoid , Enema , Follow-Up Studies , Intestinal Volvulus , Mesentery , VomitingABSTRACT
Sigmoid volvulus may cause acute or subacute colonic obstruction. Excessive length of the sigmoid colon may be a contributing factor. Typically, the patient develops bilious vomiting and marked gaseous abdominal distension. We report a case of sigmoid volvulus in a 9-year-old boy who presented with recurrent, sudden onset abdominal pain, abdominal distension, and vomiting for 1 year, which was diagnosed by simple abdominal X-ray, barium enema, computed tomography, and colonoscopic examination. Colonoscopic reduction failed and a sigmoid colectomy with primary repair was performed. The intra-operative findings showed that the sigmoid colon was noted to be dilated, and redundant with a lax mesentery. Two clear areas of compression (proximal and distal) were present. After sigmoidectomy, the symptoms resolved. After 5 years of follow-up, he had no new symptoms.
Subject(s)
Child , Humans , Abdominal Pain , Barium , Colectomy , Colon , Colon, Sigmoid , Enema , Follow-Up Studies , Intestinal Volvulus , Mesentery , VomitingABSTRACT
The laparoscopic approach to the treatment of sigmoid volvulus has been challenging because of the different anatomy of the colon and the mesentery. We report a case of a laparoscopic sigmoidectomy and anastomosis for a patient with sigmoid volvulus for whom endoscopic reduction had failed. A 68-year-old man with sigmoid colon volvulus underwent laparoscopic surgery. The laparoscopic surgery was difficult because of the tortuous and dilated bowel and the many fibrous bands. We performed an intraoperative decompression by using a rectal tube through the anus and a primary anastomosis without on- table preparation. The patient was discharged six days later without complications. We assumed that laparoscopic resection and anastomosis is a safe, effective procedure for the management of sigmoid volvulus.
Subject(s)
Aged , Humans , Anal Canal , Colon , Colon, Sigmoid , Decompression , Intestinal Volvulus , Laparoscopy , MesenteryABSTRACT
The case of sigmoid volvulus combined with a transomental hernia is reported. A 70-year-old man was admitted to our hospital with mild abdominal pain and distension. Although no signs of peritoneal irritation were apparent, a plain abdominal X-ray showed a markedly dilated loop of the sigmoid colon, and CT revealed a whirl pattern of the sigmoid mesentery. These findings suggested sigmoid volvulus. Colonoscopic reduction was attempted as an initial nonoperative treatment, and an urgent laparotomy was performed after the reduction failed. The sigmoid loop was herniated through the great omentum, with torsion in the clockwise direction. The colon was manually untwisted in the counter-clockwise direction, and the sigmoid loop was released by dividing the great omentum. During this one-stage operation, intraoperative colonic irrigation, sigmoid resection, and primary anastomosis were performed. The postoperative course was uneventful. Although sigmoid volvulus combined with a transomental hernia is rare, urgent surgical intervention is essential on failure of endoscopic reduction.
Subject(s)
Aged , Humans , Abdominal Pain , Colon , Colon, Sigmoid , Hernia , Intestinal Volvulus , Laparotomy , Mesentery , OmentumABSTRACT
A volvulus of the colon is a twisting of a redundant segment of the colon at its narrow mesentery. A sigmoid volvulus is the most common type. This disorder may spontaneously reduce and recur as a chronic problem. However, it more frequently becomes acute as a result of an obstruction, which can lead to strangulation and gangrene with a high mortality if not treated promptly. Colonoscopic reduction and decompression is the preferred initial treatment for patients with a sigmoid volvulus who show no signs of bowel strangulation, which may be the cause of the high mortality associated with emergency surgery. We experienced 2 cases of a sigmoid volvulus in a 44-year-old female and a 51-year-old male. The sigmoid volvulus was diagnosed by simple abdominal film and treated successfully by an emergency colonoscopic reduction. We report our experience on the use of colonoscopy to treat sigmoid volvulus with a reviews of the relevant literlature.
Subject(s)
Female , Humans , MortalityABSTRACT
An intestinal obstruction is a common cause of acute abdominal diseases which need emergency measures. Sigmoid volvulus is one of rare causes of colonic obstruction and occupies 2~3% of its causes in Korea. Volvulus requires a prompt diagnosis and decompression in order to prevent its progression to strangulation and gangrene. Although 90% of sigmoid volvulus can be diagnosed just by plain abdominal x-ray, computed tomography or barium enema can be done for more accurate diagnoses. For the successful treatment, accurate early examination, endoscopic reduction and surgical colonic resection are required. Endoscopic reduction has low mortality but is liable to recur, whereas emergency colonic resection has little recurrence rate but a high mortality. We experienced a case of a sigmoid volvulus in a 55-year-old male who companied of sudden abdominal pain. After diagnosed as sigmoid volvulus through plain abdominal x-ray and abdominal computed tomography, endoscopic reduction was done in the early period of development, and the sigmoid resection was performed after 7 days. We report our experience with a review of the literature regarding the diagnosis and treatment of sigmoid volvulus.
Subject(s)
Humans , Male , Middle Aged , Abdominal Pain , Barium , Colon , Colon, Sigmoid , Decompression , Diagnosis , Emergencies , Enema , Gangrene , Intestinal Obstruction , Intestinal Volvulus , Korea , Mortality , RecurrenceABSTRACT
Megacolon is an uncommon condition in which the bowel is persistently of increased diameter and it is always associated with long-standing constipation. Two main groups are recognized according to whether or not ganglia are present in the intermuscular plane of the rectal wall. Their complete absence, even along a short segment of rectum, denotes Hirschspurung's disease. If ganglia are present, the dilated bowel may be secondary to some predisposing factor such as a stricture, a congenital anorectal abnormality, a cauda equina lesion etc. In other instances, however, there may be no apparent organic reason as to why the bowel should be so dilated. This latter condition is termed "idiopathic megacolon". We report the case of one female patient with idiopathic megacolon. During medical treatment, she was complicated with a sigmoid volvulus, we performed subtotal colectomy and cecorectal anastomosis and she improved without any complication.
Subject(s)
Female , Humans , Cauda Equina , Causality , Colectomy , Colon, Sigmoid , Constipation , Constriction, Pathologic , Ganglia , Intestinal Volvulus , Megacolon , RectumABSTRACT
Sigmoid volvulus is a unfrequent cause of colon obstruction in Korea. Colonoscopic reduction and decompression is the preferred initial treatment of patients with sigmoid volvulus who do not have signs of bowel strangulation because of the high mortality associated with emergency surgery. We experienced a case of sigmoid volvulus in a 60-year-old male who presented with constipation, abdominal distension and abdominal pain. Sigmoid volvulus was diagnosed by simple abdominal film and he had taken successful emergency colonoscopic reduction of sigmoid volvulus. We report our experience & reviews the literature on the use of the colonoscope to treat sigmoid volvulus.
Subject(s)
Humans , Male , Middle Aged , Abdominal Pain , Colon , Colon, Sigmoid , Colonoscopes , Constipation , Decompression , Emergencies , Intestinal Volvulus , Korea , MortalityABSTRACT
PURPOSE: The standard treatment for sigmoid volvulus has been considered as a resection of involved segment after nonoperative decompression. This study was performed to investigate the clinical characteristics and compare the results of managements in patients with sigmoid volvulus. METHODS: We recruited twelve patients with sigmoid volvulus registered and treated at Asan Medical Center during 1989 and 1999. The medical records were reviewed retrospectively. Telephone inerviews were performed to inquire recent status. We analyzed clinical variables including symptoms on admission, physical findings, findings of radiologic studies, managements and their outcomes. The median age was 64 years (range:45 to 84 years). The median follow-up period was 46 months (range:2 to 94). RESULTS: Nine patients among twelve were male. Presenting symptoms were abdominal pain (92%), abdominal distension (67%), constipation (50%) and hematochezia. The diagnostic modalities utilized included plain film of the abdomen, CT scan and sigmoidoscopy. Nine cases (75%) were correctly diagnosed prior to operation, of which eight (67%) were diagnosed by plain film. The remaining three cases were by operation. In these cases, preoperative diagnoses were ischemic colitis and obstruction due to colonic malignancy. In seven cases, only nonoperative managements were employed. Nonoperative management included decompression by nasogastric tube or rectal tube insertion and use of bulk forming agents and stool softner afterwards to improve bowel habits. Five patients underwent anterior resection. We couldn't perform surgery in seven cases because of high operative risk due to underlying serious medical conditions such as bronchial asthma, malignancies and refusal by the patients after clinical improvement in 4 and 3cases, respectively. Three of them were died of underlying disease or sepsis. Recurrence occurred in two patients (50%) who underwent nonoperative management only and none in patients who underwent surgical intervention. CONCLUSIONS: In patients with sigmoid volvulus, elective surgery after appropriate nonoperative management is mandatory to prevent recurrence and fatal outcome, especially in good surgical risk patients. Considerable patients, however, did not undergo surgery due to poor physical status or refusal of surgery.