The 5 steps model.
\\n\\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 179 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 252 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
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Syamasundar Rao"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"18918",title:"Gangrene of Large Bowel Due to Volvulus-Etiopathogenesis, Management and Outcome",doi:"10.5772/21979",slug:"gangrene-of-large-bowel-due-to-volvulus-etiopathogenesis-management-and-outcome",body:'\n\t\tLarge bowel volvulus accounts for 10-30% of all large bowel obstruction and occurs most commonly in the sigmoid colon(Asbun 1992, Bagarani 1993, Bhatnagar 2004, Oren 2007, Pahlman 1989 ). It is more common in the region of Africa, South America, Middle East and Southern Asia. The most common site of volvulus include sigmoid colon(80%), caecum(15%), transverse colon(3%), splenic flexure(2%) and ileosigmoid knotting(<1%)( Bhatnagar 2004, Oren 2007, Halliday 1993, Majeski 2005, Lord 1996). Delay in presentation and diagnosis increases the risk of gangrene particularly so among the uncommon variety because of its atypical presentation and sometimes quite scarce manifestations(Bhatnagar 2004, Halliday 1993, Majeski 2005,Lord 1996). The outcome depends on intensive and adequate resuscitation with fluids and broad spectrum antibiotics and prompt resection of the gangrenous loop of gut(Asbun 1992, Bagarani 1993, Bhatnagar 2004, Halliday 1993, Majeski 2005,Lord 1996). The mortality rate even though has improved significantly in recent years due to better perioperative management of these patients, continues to remain high when gangrene sets in. The various factors that influence the outcome include general factors like advanced age of the patient, associated comorbid conditions and local factors including perforation, peritonitis and presence of shock(Bhatnagar 2004, Halliday 1993, Majeski 2005,Lord 1996, Halliday KE 1993, Feldman D 2000). This chapter intends to discuss the etiopathogenesis, presentation, investigation and management of both common and uncommon volvulus of the colon with emphasis on those volvulus being complicated with gangrene
\n\t\tSigmoid volvulus is a leading cause of strangulation of large bowel the world over (Bhatnagar 2004, Halliday 1993, Majeski 2005,Lord 1996). It is common in Asia, Africa, Scandinavia, South America, Middle East and Eastern Europe (Bagarani 1993, Bhatnagar 2004, Oren 2007, Pahlman 1989, Halliday KE 1993, Feldman D 2000,). The incidence of gangrenous volvulus is sketchy in the world literature but the major concern is the high mortality associated with it (17 to 100%) as compared to 3-30% in non gangrenous volvulus (Bagarani 1993, Bhatnagar 2004, Oren 2007,,Pahlman 1989). Anatomic features predisposing to sigmoid volvulus include redundant sigmoid colon that has a narrow mesenteric attachment. Sigmoid volvulus is seen in elderly patients, often in institutionalized and debilitated patients with neurological and psychiatric conditions such as Parkinson’s disease and schizophrenia. The association of sigmoid volvulus with advancing age is more likely due to dysmotility rather than lengthening of the sigmoid colon and its mesentry. Other less common predisposing factors include pregnancy, post operative adhesions, internal herniations, intussusceptions, omphalomesenteric abnormalities, intestinal malrotation, appendicitis and carcinoma. (Bhatnagar 2004, Oren 2007, Pahlman 1989, Halliday KE 1993, Feldman D 2000)
\n\t\t\tThe predominant symptom of gangrenous sigmoid volvulus is abdominal pain and progressive abdominal distension (92 to 95%), constipation (92%), muscle guarding / rigidity (75%) and vomiting in 60% of the cases (Asbun 1992, Bagarani 1993, Bhatnagar 2004, Oren 2007, Pahlman 1989). A visible sigmoid loop is noted in 42% and rectal examination may reveal blood in the examination finger. The median duration of symptom on admission is 3 days (3.7±2.8 range 1-15) (Asbun 1992, Bagarani 1993, Bhatnagar 2004, Oren 2007,,Pahlman 1989). A previous attack of volvulus is recorded in 23.5% while 72.5% may develop gangrene in the first attack (Bhatnagar 2004). The incidence of preoperative shock did not differ in patients with differing pattern of gangrene but the incidence of shock is significantly higher in patient who died (Bagarani 1993, Bhatnagar 2004, Oren 2007,,Pahlman 1989, Halliday KE 1993).
\n\t\t\tGangrene of the colon may be extensive and well defined (figure 1) or at times may be patchy with ill defined limits. The pattern of gangrene can be divided into 3 groups (Bhatnagar 2004): (a) those with gangrene confined to sigmoid colon. In 73% of the cases the gangrene is confined classically to the area of constriction. (b) the gangrenous area may extend beyond the confines of the area under constriction on one or both sides (26% of the cases)( Bhatnagar 2004). More often it extends well down into the rectum lying in the hallow
\n\t\t\t\tGangrenous sigmoid volvulus-Extensive and well defined
of the sacrum(c) those with gangrene of the sigmoid with ileal knotting. In 15%, the gangrenous sigmoid may be involved in knotting with ileum. The gangrene of rectum distal to the twist is uncommon as the main vascular supply to the rectum lies proximally running in the medial limb of the sigmoid mesocolon and hence is generally not involved in the twist. However it could be involved if the vessels take a slightly aberrant lateral course in the mesocolon which is narrowed and hence can become incorporated in the twist. If the gangrene in rectum distal to the twist is not recognized, it can lead to an error in judgment of performing an anastomosis to the gut of questionable viability and with disastrous consequences (Asbun 1992, Bhatnagar 2004)
\n\t\t\tThe diagnosis could be established in approximately 60% of the cases with a plain x-ray abdomen (Bhatnagar 2004, Oren 2007,,Pahlman 1989, Halliday KE 1993, Feldman D 2000). The distended sigmoid colon appears as ahaustral collection of gas (sometimes referred as “bent inner tube” sign or “coffee bean” sign) that extends from the pelvis to the right upper quadrant as high as the diaphragm(Feldman D 2000). Distended large bowel proximal to the sigmoid colon and air fluid levels in the small bowel are often present (Asbun 1992, Bagarani 1993, Bhatnagar 2004, Oren 2007, Pahlman 1989, Ballantyne GH 1982). Presence of air in the bowel wall (pneumatosis intestinalis), free air in peritoneal cavity or in the portal vein would strongly indicate the presence of gangrenous gut. A barium enema with water soluble contrast is contraindicated when gangrene is suspected(Mellor MF 1994). A CT scan would show the typical finding of a whirl sign at the site of the twist caused by dilated sigmoid colon around its mesocolon and vessels and bird beak appearance of the afferent and efferent colonic segment (Catalano O 1996).
\n\t\t\tIt is of outmost importance to be aware that a gangrenous volvulus is an acute surgical emergency and has to be dealt expeditiously and aggressively to achieve better outcome. The management of sigmoid volvulus involves adequate and prompt fluid resuscitation, decompression of proximal bowel and urgent resection of the gangrenous segment (Asbun 1992, Bagarani 1993, Bhatnagar 2004, Oren 2007, Pahlman 1989, Ballantyne GH 1982, Kuzu MA 2002). While in the absence mucosal ischemia it would seem reasonable to attempt detorsion and decompression via sigmoidoscopic placement of soft rectal tube or occasionally barium enema(Mellor MF 1994), the presence of gangrene of colon warrants immediate laparotomy after intensive resuscitation(Bhatnagar 2004, Ballantyne GH 1982, Kuzu MA 2002). In gangrenous sigmoid volvulus, resection and primary anastomosis may be performed with acceptable mortality and morbidity rates provided that the patients is haemodynamically stable and a tension free anastomosis of well vascularised segments of the bowel is feasible. This technique when employed has a reported mortality rate of 16 to 33%( Oren 2007,,Pahlman 1989,Bhatnagar 2004, Ballantyne GH 1982, Kuzu MA 2002).On table cleaning of the proximal bowel may be added to perform the primary anastomosis with reasonable safety. When condition for primary anastomosis is not ideal then Hartmann’s operation or Mickulicz procedure with resection of gangrenous loop may be life saving particularly in unstable patients with severe fecal peritonitis((Bhatnagar 2004, Kuzu MA 2002). The drawback of adding a stoma however is that it carries the mortality and morbidity risks associated with stoma and that it requires a second operation.
\n\t\t\tThe mortality following surgery in these patients range from 19 to 66%( Asbun 1992, Bagarani 1993, Bhatnagar 2004, Oren 2007,,Pahlman 1989, Ballantyne GH 1982, Kuzu MA 2002). Experienced surgeons however could perform both primary anastomosis and stoma successfully by laparoscopic approach; the concern however is that of rupture of gangrenous loop while doing so. Exteriorisation of the gangrenous gut is another option although it is difficult to fully exteriorize a gangrenous loop and the associated mortality could be higher(Asbun 1992, Bagarani 1993, Bhatnagar 2004, Oren 2007,,Pahlman 1989, Ballantyne GH 1982, Kuzu MA 2002). While the overall mortality in nongangrenous sigmoid volvulus is 6 to 24%, in gangrenous SV it ranges from 11 to 80% (Asbun 1992, Bagarani 1993, Bhatnagar 2004, Oren 2007, Pahlman 1989, Kuzu MA 2002). The factors that influence the adverse outcome include delay in presentation or diagnosis, advanced age, fecal peritonitis due to perforation of gangrenous loop, previous episodes of volvulus, associated comorbidities including diabetes mellitus, and renal, cardiac and pulmonary insufficiency (Asbun 1992, Bagarani 1993, Bhatnagar 2004, Oren 2007, Pahlman 1989, Ballantyne GH 1982, Kuzu MA 2002). The most important cause of death however is septicaemic shock. The morbidity rate is approximately 6 to 26% and includes wound infection, intra-abdominal abscess, evisceration, anastomotic leakage, stomal complications, intestinal obstruction, respiratory complications and DVT(Asbun 1992, Bagarani 1993, Bhatnagar 2004, Oren 2007,,Pahlman 1989). The mean hospitalization period ranges from 8 to 13 days (Bhatnagar 2004). Since gangrenous SV invariably requires resection of sigmoid colon, recurrence of volvulus is unlikely (Asbun 1992, Bagarani 1993, Bhatnagar 2004, Oren 2007, Pahlman 1989).
\n\t\t\tGangrenous sigmoid volvulus invariably occurs due to delay in presentation or diagnosis. The occurrence of gangrene beyond the confines of twist is likely and awareness of this is necessary to avoid insecure anastomosis. The management includes aggressive resuscitation followed by resection of the gangrenous loop with primary anastomosis or stoma. The mortality is significantly higher than in patients with nongangrenous sigmoid volvulus. Various factors that would influence the outcome adversely is older age group, associated comorbidities, presence of shock at admission, fecal peritonitis and previous episode of volvulus.
\n\t\t\tCecal volvulus (CV) is an axial twist of the cecum ascending colon and terminal ileum around a mesenteric pedicle. CV is relatively uncommon with an incidence of 2.8 to 7.1 per million people per year(Tejler G 1988).Cecal volvulus occurs in patients who have increased cecal motility as a result of anomalous fixation of the right colon. Acquired anatomical abnormalities such as surgical adhesions can also contribute. Other conditions that have been associated with cecal volvulus include pregnancy, congenital malformations, colonoscopy, Hirschprung\'s disease and mobile cecal syndrome(Tejler G 1988, Bystrom J 1972, Madiba TE 2002). The majority of the patients with cecal volvulus have full axial rotation causing twisting of the mesentery and blood vessels (Majeski J 2005, Tejler G 1988, Bystrom J 1972). In approximately 10% of cases the cecum and ascending colon fold in the anterior cephalad direction (known as cecal bascule)(Tejler G 1988, Bystrom J 1972). Although cecal bascule does not cause torsion of the mesentery and blood vessels it can lead to intestinal gangrene due to distension and bowel wall ischemia(Tejler G 1988, Bystrom J 1972).
\n\t\t\tThe majority of patients with cecal volvulus have similar presentation to those with small bowel obstruction (Majeski J 2005, Tejler G 1988, Bystrom J 1972, Madiba TE 2002). The major symptoms are abdominal pain, nausea, vomiting and obstipation. The pain is usually steady with superimposed colicky component associated with peristalsis. The abdomen is often diffusely distended representing the dilated right colon and small bowel. Fever, peritonitis or hypotension may indicate the presence of intestinal gangrene (Majeski J 2005, Tejler G 1988, Bystrom J 1972, Madiba TE 2002).
\n\t\t\tThe diagnosis can be established by a barium or water soluble contrast enema or CT scan(Majeski J 2005, Tejler G 1988, Bystrom J 1972, Madiba TE 2002). On plain radiography the cecum appears as a kidney shaped mass extending into the left upper quadrant. Distended loop of small bowel are common. The abdominal plain film is suggestive of diagnosis in 46% but diagnostic only in 17% of the cases(Majeski J 2005, Tejler G 1988, Bystrom J 1972). While barium study is diagnostic in 88% of the cases it is contraindicated when diagnosis is not clear or gangrene is suspected (Tejler G 1988, Bystrom J 1972). CT scan has become the preferred radiological test for establishing the diagnosis of cecal volvulus and in recognizing its variant. It can also show the signs of strangulation and or perforation (Tejler G 1988, Bystrom J 1972).
\n\t\t\tWhile the goal of nongangrenous cecal volvulus is to prevent the development of gangrene and address the anatomic abnormality, in gangrenous volvulus the need of the hour is resection of gangrenous loop immediately after adequate resuscitation (Majeski J 2005, Tejler G 1988, Bystrom J 1972, Madiba TE 2002). While several techniques may be used in dealing with nongangrenous cecal volvulus including cecopexy and cecostomy, in the presence of gangrene the surgical approach warrants resection of gangrenous gut and primary anastomosis (Madiba TE 2002). Colopexy of the remainder right colon would be required as in most instances the right colon is mobile due to failure of fusion of the cecum and ascending colon to posterior pericolic peritoneum(Madiba TE 2002). The tinea of reminder of the right colon holds sutures very well because this segment of the colon is not involved in cecal volvulus. The remainder of the distal colon must always be carefully examined intra-operatively for colonic obstruction. A proximal ileocolic anastomosis in the presence of a distal obstruction may lead to a lethal postoperative outcome (Majeski J 2005, Madiba TE 2002).
\n\t\t\tThe outcome of resection of gangrenous cecal volvulus depends on the overall fitness of the patient including the age and associated comorbid conditions. The overall mortality in gangrenous cecal volvulus range from 23 to 48% (Majeski J 2005, Tejler G 1988, Bystrom J 1972, Madiba TE 2002). The presence of preoperative shock and fecal peritonitis have adverse outcome.
\n\t\t\tThe splenic flexure volvulus is rare with an incidence of less than 2% of all colonic volvulus with approximately 32 cases being reported in the literature so far(Ballantyne GH 1985). The rarity of the splenic flexure volvulus is due to the fact that this part of large bowel has limited mobility due to its attachment to phrenocolic, gastrocolic and splenocolic ligament and intraperitoneal position of the descending colon(Ballantyne GH 1985,Mittal R 2007, Osuka A 2006). For splenic flexure volvulus to occur some or all of these anatomical factors should be congenitally absent or altered by surgery thus rendering the flexure unusually mobile. The splenic flexure volvulus has also been reported with other congenital anomalies including wandering spleen causing volvulus of the splenic flexure; this causes partial obstruction of the large intestine by the splenic pedicle(Ballantyne GH 1985,Mittal R 2007). Congenital bands and acquired adhesions due to previous surgeries could be other etiological factors (Ballantyne GH 1985, Mittal R 2007, Osuka A 2006).
\n\t\t\tThough there are reported cases of splenic flexure volvulus in children(Osuka A 2006) the median age of these patients is 53 years with a female preponderance (Ballantyne GH 1985, Mittal R 2007). The usual presentation of these patients is non acute and nonspecific and include recurrent episodes of abdominal pain, distension and vomiting and is usually not suspected because of the rarity of this condition. Acute presentation with features of gangrene is rare (figure 2) and such patients could present with severe tenderness, guarding, rigidity and shock invariably due to delay in presentation or diagnosis (Ballantyne GH 1985, Mittal R 2007, Osuka A 2006).
\n\t\t\t\tSplenic flexure volvulus- grossly distended gangrenous loop
Diagnosis of this rare condition is facilitated by radiological investigation including plain X-ray abdomen and CT scan( Ballantyne GH 1985,Mittal R 2007, Osuka A 2006). The characteristic findings include the following: 1) two widely separated air fluid levels one in the distended splenic flexure and the other in the cecum (figure 3); 2)markedly dilated air filled colon with abrupt termination at the anatomic splenic flexure; 3)an empty descending and sigmoid colon; 4) a characteristic beak at the anatomic splenic flexure on barium enema examination if performed; 5) a coffee bean appearance of the dilated splenic flexure is seen
\n\t\t\t\tPlain x-ray showing two widely separated air fluid levels in splenic flexure and cecum
CT scout film revealing dilated splenic flexure loop with concavity facing upwards and laterally
CT image showing dilated splenic flexure with whirl sign (arrow)
and in splenic flexure volvulus unlike sigmoid volvulus the concavity of the bean is facing upwards and laterally (figure4). The CT scan will reveal dilated splenic flexure with a characteristic whirl sign at the site of the twist of the mesentery6 (figure 5). The presence of gangrene is suspected when there is air in the wall of the bowel (pneumatosis intestinalis), air in portal vein or in the presence of peritonitis6.
\n\t\t\tLike in the case of sigmoid volvulus the immediate priority is aggressive resuscitation with IV fluids and appropriate antibiotics to optimize the patient for an urgent surgery (Ballantyne GH 1985, Mittal R 2007, Osuka A 2006). The broad principle of management would include resection and primary anastomosis or creation of stoma. A primary anastomosis is avoided in the presence of perforation and peritoneal soiling, preoperative shock and in the presence of dilated edematous loops of gut to be anastomosed (Ballantyne GH 1985, Mittal R 2007, Osuka A 2006).
\n\t\t\tThe overall mortality ranges from 16 to 33% and depends significantly in delay in diagnosis, presence of shock, fecal peritonitis and associated comorbidities (Ballantyne GH 1985, Mittal R 2007, Osuka A 2006).
\n\t\t\tSplenic flexure volvulus is a rare cause of intestinal obstruction. Gangrene is usually associated with the acute form of presentation. Rarity of the condition and protean manifestation may lead to delay in the diagnosis. Radiological investigations could however guide to a prompt surgical treatment after adequate resuscitation. Resection and primary anastomosis is often feasible failing which the patient my require resection with colostomy.
\n\t\t\t\tAs the manifestation of transverse colon volvulus is to a large extent similar to splenic flexure volvulus it would not be further discussed.
\n\t\t\tIleosigmoid knotting is a rare cause of intestinal obstruction that rapidly progresses to gangrene of ileum as well as the sigmoid colon(Shepherd JJ 1967,Puthu D 1991, Alver O 1993). Preoperative diagnosis is difficult because of its infrequency and atypical radiographic findings (Shepherd JJ 1967). It is essential to differentiate it from sigmoid volvulus because endoscopic reduction is a contraindication in ISK(Raveenthiran V 2001). In recent years CT has been useful in making a preoperative diagnosis (Raveenthiran V 2001). Generalized peritonitis and sepsis are the main cause of poor outcome (Shepherd JJ 1967, Puthu D 1991, Alver O 1993). After hemodynamic stabilization, immediate surgical intervention is need of the hour. Three factors are responsible for ileosigmoid knotting (Shepherd JJ 1967): 1) a long small bowel mesentery and freely mobile small bowel 2) a long sigmoid colon on a narrow pedicle and 3) ingestion of high bulk diet in the presence of empty small bowel as would happen during the fasting month of Ramadan among Muslims. When a semi liquid bulk meal progresses into the proximal jejunum it increases the mobility of the intestine and the heavier segments of the proximal jejunum fall into the left lower quadrant(Shepherd JJ 1967). The empty loop of ileum and distal jejunum twist in a clockwise rotation around the base of the narrow sigmoid colon. Further peristalsis form an ileosigmoid knot with 2 closed loop obstruction; one in the small bowel and the other in the sigmoid colon. Ileo sigmoid knotting is categorized into 3 types (Shepherd JJ 1967 ). In type 1, the ileum (active component) wraps itself around the sigmoid colon (passive component) in a clockwise or anticlockwise direction. In type 2 the sigmoid colon (active component) wraps itself around a loop of ileum (passive component) in a clockwise or anticlockwise direction and in type3 the ileocecal segment (active component) wraps itself around the sigmoid colon (passive component)
\n\t\t\tIleosigmoid knot rapidly progresses to gangrene of ileum as well as the sigmoid colon. (Figure 6). Generalized peritonitis,sepsis and dehydration are the principal complications (Shepherd JJ 1967, Puthu D 1991, Alver O 1993, Raveenthiran V 2001). The predominant symptom and signs of presentation include abdominal pain and tenderness (100%), abdominal distension (94 to 100%), nausea and vomiting (87 to 100%), rebound tenderness (69%) and shock (0 to 60%)( Shepherd JJ 1967, Puthu D 1991, Alver O 1993, Raveenthiran V 2001). Despite the critical condition the preoperative diagnosis is not easy. The diagnostic difficulty is partly caused by the unfamiliarity of this rare entity and the confusing and self contradicting feature of the disease. While the clinical feature of vomiting suggests small bowel obstruction the radiographic findings are that of colonic distension which is uncommon in small bowel obstruction. In 73 to 79.5% of cases the bowel is gangrenous (Shepherd JJ 1967,Puthu D 1991, Alver O 1993, Raveenthiran V 2001). Both sigmoid colon and small bowel are involved in 52 to 60% of the cases. Paradoxically the incidence of bowel gangrene was 90% in those who presented early within 24 hours of their symptoms, presumably reflecting the fulminating clinical deterioration of patients due to early and extensive infarction of the bowel involved in a tight knot(Horgan PG 1992). In patients who present after 24 hours of the initial symptoms the bowel gangrene was noted in 57% of the cases.(Shepherd JJ 1967, Puthu D 1991, Alver O 1993, Raveenthiran V 2001).
\n\t\t\t\tIleosigmoid knot- Gangrenous ileum and sigmoid colon seen along with the Meckel’s diverticulum
The diagnosis could be achieved following radiological investigations. The plain X-ray findings include a double loop of dilated sigmoid colon and multiple air fluid levels in the small intestine(Shepherd JJ 1967,Puthu D 1991, Alver O 1993, Raveenthiran V 2001)). The CT scan findings suggestive of Ileo sigmoid knot include the whirl sign created by the twisted intestine and sigmoid mesocolon in the ileosigmoid knot, medial deviation of cecum and ascending colon (Alver O 1993, Raveenthiran V 2001).
\n\t\t\tThe initial management would involve aggressive resuscitation with fluid, appropriate antibiotics and correction of acid base imbalance if any (Shepherd JJ 1967,Puthu D 1991, Alver O 1993, Raveenthiran V 2001). After hemodynamic stabilization, laparotomy is performed without any delay. The outcome would depend significantly in early and adequate resuscitation and prompt resection of the gangrenous loop. Various surgical procedures have been employed in these patients. The initial attempt to untie the knot may be feasible when both sigmoid and ileum are viable or sigmoid colon alone is viable (Shepherd JJ 1967, Puthu D 1991, Alver O 1993, Raveenthiran V 2001). When both sigmoid and ileum are gangrenous there is difficulty in untying the knot with the potential risk of rupture of the gangrenous loop in doing so leading to peritoneal spillage of the toxic bowel contents (Shepherd JJ 1967,Puthu D 1991, Alver O 1993, Raveenthiran V 2001). Intestinal clamps hence should be applied before dissection or resection of the knot and the loops.
\n\t\t\t\tPrimary anastomosis of the small bowel loop after resection is preferable( Raveenthiran V 2001). When the terminal ileum is gangrenous within 10 cms of the ileocecal valve an end to end anastomosis is avoided(Raveenthiran V 2001). The distal stump is then closed and end to side ileocecostomy is performed. Resection of the sigmoid colon is often advised even when it is viable to prevent recurrent volvulus and recurrent knotting(, Alver O 1993, Raveenthiran V 2001). Primary anastomosis following colonic resection could be carried out safely particularly when the history is short and the remaining bowel is clean, well vascularalised and undistended and a tension free anastomosis is feasible. In the absence of an ideal situation and significant preoperative shock or peritoneal contamination a Hartmann procedure or covering colostomy may be advocated to avoid the risk of fecal leak from colonic anastomosis (Shepherd JJ 1967,Puthu D 1991, Alver O 1993, Raveenthiran V 2001).
\n\t\t\tThe operative mortality from ileo sigmoid knot varies from 0 to 48% (mean 35.5%). The mortality figures are generally related to duration of the symptom, preoperative shock, the presence or absence of gangrene and the general status of the patient(Shepherd JJ 1967,Puthu D 1991, Alver O 1993, Raveenthiran V 2001).
\n\t\t\tIleo sigmoid knot is a rare cause of intestinal obstruction. Unfamiliarity and diagnostic difficulties have contributed to the mortality and morbidity of this condition in the past. Better understanding of the problem and increased possibility of preoperative diagnosis following CT scan have facilitated early diagnosis and intervention. Aggressive fluid resuscitation, preoperative antibiotics, prompt laparotomy and effective surgery including resection of gangrenous loop and primary anastomosis and better perioperative care of the shocked patient have optimized the survival of these patients
\n\t\t\tWhile an obviously gangrenous bowel is easy to detect, operative evaluation to determine the viability of borderline ischemia may not be precise(Horgan PG 1992). The use of intraoperative doppler examination and use of intravenous administration of fluroscein with visual examination using ultraviolet light are standard methods to determine bowel viability(Horgan PG 1992). These intraoperative tests are not absolutely accurate. Moreover both tests require detorsion of the bowel and reperfusion of the bowel. Reperfusion of ischemic or gangrenous bowel can produce metabolic acidosis, intestinal bacterial and toxin translocation and possible irreversible septic shock(Patel A 1992, Zimmerman BJ 1992). Reperfusion of ischemic intestine results in extensive microvascular and parenchymal cell injury by release of proteases and physical disruption of the endothelial barrier resulting in eventual cell death(Zimmerman BJ 1992). To avoid reperfusion of the ischemic volvulus and reperfusion injury the gangrenous bowel loop should be resected without detorsion (Alver O 1993, Raveenthiran V 2001)
\n\t\tGangrene is a potential complication of colonic volvulus. It is of outmost importance that a clinician avoids this complication in a patient with a colonic volvulus by an early diagnosis, adequate resuscitation and prompt surgical intervention. Once gangrene has set in the outcome is adversely effected. The surgical intervention would involve resection with primary anastomosis or creation of stoma. Primary anastomosis is generally avoided in the presence of shock, significant peritonitis, and inability to create anastomosis between two well vascularised loops in a tension free manner. The factors that seriously affect the outcome include general factors including advanced age and associated comorbid conditions and local factors including fecal peritonitis and shock
\n\t\tOriginating from Toyota production system (TPS), lean production (LP) or lean manufacturing (LM) has now become a well-known and widely adopted philosophy all over the world. Its first usages were limited with the production industry and therefore its initial applications emerged in the manufacturing businesses. As time passes, the service industry has begun to utilize from the LP philosophy and/or techniques. As the adaptation of lean expanded from production sector to service sector, its concept transformed from LP to lean thinking (LT).
Historical evolution of the “lean” started with TPS and continued as LP/LM, and finally became LT. No matter what anyone says, each of these terms indicates the same concept. Eliminating or at least minimizing the waste (Japanese: muda) in a system is the basic philosophy of lean and to produce the maximum output by using minimum resources is the main goal of it. Lean seeks for a system that tries to detract non-value added things from the processes and bring the value-added things into the forefront. These efforts become meaningful if the value is defined correctly and the system is designed and conducted truly. Value must be defined by the customer since he/she is the end user of the product and/or service. Thus, to give exactly what the customer wants, businesses must take into consideration the concepts of efficiency and quality. It is clear that an efficient and quality focused system uses the resources exactly as needed and produces products and/or services that satisfy the customers.
Many organizations from production or service sectors implement lean production as its main system or apply lean principles partially in its specific activities. These organizations utilize from LT with the aims of becoming more efficient, more competitive, and more quality oriented. Furthermore, in recent years LT spread from a single business to supply chains of multiple businesses. It is possible to say that LT attracts many businesses and these businesses want to transform into a lean business. Lean transformation process is an important inflection point for a business and it must be carefully initiated, designed and managed. The starting point of this transformation process is crucial and right method(s) must be used during the phase. Value stream mapping (VSM), one of the methods of LT, is the most suitable method that can be used in the first step. VSM is a paper and pencil based method that focuses on the current state of a process, makes all value and non-value added activities visible, and proposes a lean future state. VSM is dealt with in this chapter in a detailed way.
The rest of the chapter is organized as follows. Section 2 focuses on lean philosophy. Lean techniques are examined in Section 3, and VSM is explained in Section 4. In Section 5, there are VSM examples from the service and production sector for a better understanding of the subject. Finally, this chapter ends with discussion and conclusion.
Businesses should be recognized the importance of customer and value concepts. Customers do not want features that do not create value in products or services. All sectors, both product and service sector, should pay attention to this situation in order to compete with their competitors. This is because customers are not willing to pay extra for features that do not create value. Value can be categorized into three types: value added, non-value added and necessary non-value added operations [1]. Value added operations are processes that please the customer and must be in the process. Necessary non-value added operations are wasteful but necessary. Lastly, non-value added operations are completely wasteful and must be eliminated.
Lean philosophy is defined by Radnor et al. [2] as “Lean as a management practice based on the philosophy of continuously improving processes by either increasing customer value or reducing non-value adding activities (muda), process variation (mura), and poor work conditions (muri).” As can be seen from the definition, lean philosophy has emerged within the framework of some elements, especially waste (muda). Lean production is typically believed to be 7 types of waste [3]. These wastes are over production, waiting, transportation, over processing, inventory, unnecessary motions and defects (Figure 1).
Seven types of waste.
The importance given to the service sector is increasing day by day. The lean production mentality continues to be implemented in the service sector. Lean philosophy, both production and service sector value, optimization, quality, standardization and simplification principles are common [4]. However, the wastes defined as 7 types in lean production are 10 types (Figure 2) in the service sector [5].
Ten types of waste (service sector).
If the wastes are eliminated and the costs of waiting in stock are reduced, customer satisfaction and related sales will increase. Therefore, the purpose of both customers, employees and business partners will be achieved through the adoption of lean philosophy. On the other hand, in order to ensure continuous improvement, the wastes in the process must be converted to value. Furthermore, due to the rapid change in customer expectations, it is important to achieve perfection. Thus, Womack and Jones [6] proposed a The 5 Steps Model to help transform from value to perfection [7]. Table 1 contains the 5 steps model and explanations of the expressions [6, 7, 8, 9, 10, 11].
The steps | Explanations |
---|---|
1. Value | Value is the source of the pleasure and needs of the customers who buy the product or service. It is the starting point of lean philosophy. It is necessary to understand the needs of the customers, to define the value correctly, and to implement this in all processes |
2. Value stream | The value stream is all the activities needed during the generating of the product or service. These activities may be activities that add or do not add value to the product or service. Additionally, with all activities being seen, wastes that non-value adding will be recognized |
3. Flow | Continuous flow can be achieved by detecting and eliminating the wastes in the process. Furthermore, it is necessary to implement this throughout the value chain to ensure full flow, not just one process |
4. Pull | The pull system means that production or service will not be commenced without a customer approval. This is the exact opposite of the push system. Production will be tailored to the customer in this system. In addition, over production and unnecessary inventory are prevented by JIT applications |
5. Perfection | Perfection is the last step that separates value and waste. This step regulates the flow, ensures the continuity of the flow and initiates the pull system. Perfection is maintained by continuous improvement. Perfection means that lean thinking is adopted and implemented |
The 5 steps model.
A number of lean methods are used in the realization of these steps (detailed descriptions in the next section). JIT and Kaizen, in particular, are the main philosophies in achieving continuous improvement and in reaching perfection [12]. Besides, lean philosophy has many benefits for businesses, employees and customers. These benefits are, reduced lead time, less rework, financial savings, increased process understanding, reduced inventory, less process waste, satisfied customer, standardized processes, improved knowledge management [3, 13].
There are some principles to apply the lean philosophy successfully in a organization [14]. It is a pyramid with 4P of lean way formed by the Liker’s 4P of the Toyota way [15]. The 14 principles are represented by 4P [16]: philosophy, process, people and partner, problem solving (Figure 3).
The 4P of the lean way [10].
Koskela [17] also defined the principles (11 principles) adopted in lean thinking as Liker [10]. The main theme of the lean principles proposed by the two authors is similar to that of Womack and Jones [6] in the 5-step model. This theme consists of defining the value, providing the flow, solving problems with lean techniques and aiming to reach perfection.
Within the scope of lean thinking, there are numerous methods used to reach the targets and minimize the wastes. Some of the lean methods for becoming lean as a system are crucial in the lean systems such as value stream mapping (VSM), single minute exchange of dies (SMED), the 5S system, one piece flow, just in time (JIT), pull system (Kanban), Poka-Yoke, total productive maintenance, Kaizen, visual controls/management, 5 whys (5N), standardized work, spaghetti diagram, DMAIC, PDCA and so on [12] and they will be briefly described in this section.
SMED method is developed by Shingo in the 1950s and later perfected by Toyota over the years [18]. SMED has become the best practice to simplify and reduce the time spent on set up. Time is very important in lean systems and is not expected to be wasted. That’s why, this method has an important place in lean techniques. Thanks to SMED method, changeover time is reduced from hours to minutes. In simple terms, it is attempted to decrease the preparation time on a machine or any process to less than 10 minutes [12]. Perhaps the best example of the application of this method is automobile racings.
Set up times is separated as internal and external. The activities performed by stopping the machine are called the internal set up time, while the activities carried out around the machine without stopping the activity are called external set up time [19]. In this point, some of the internal tasks may need to be converted to external tasks without stopping the machine [20]. Thus, continuous flow can be achieved and processes become faster and more efficient. With the improvements in internal set up time, labor savings are achieved and the downtimes of the machine decrease. Moreover, improvements to external set up times do not have a direct impact on stopping time, but may give operators the freedom to take time for other activities.
The 5S system is a visual communication technique that enables the working area to be well organized [11]. It also helps to reduce waste in the working area through general cleaning. This method is preferred when it is aimed to ensure cleanliness and organized workplace layout, to improve processes, to ensure transparency and to rise up employee satisfaction. Five Japanese words, starting with the letter S, are used to create this method. These words are seiri-sort, seiton-straighten, seiso-shine, seiketsu-standardize and shitsuke-sustain [13]. Buesa [21] stated that some experts add two new terms are safety and security. Lastly, with the implementation of the 5S cycle, it is possible to change the working environment with low costs. Moreover, employees respect to their organizations and themselves, and inventory and material costs are decreased.
By the one-piece flow technique, it is intended to move a single piece at a time between operations. The one-piece flow method takes into account factors such as sorting jobs, calculating installation time, and determining job shop production policy [19]. Therefore, these factors need to be examined during production planning. Planning a production according to one-piece flow is an important component of lean production strategy. The installation time, the stock levels and the delivery time are directly affected by the lot size. In view of these situations, it is very important to be an agile business to respond to customer needs without creating inventory [12]. This can be achieved by reducing the lot size in lean production.
The just in time philosophy adopted by Toyota is a system that regulates the stock level and optimizes the flow of materials. According to the JIT production strategy, what is needed is produced in the desired amount and time [22]. In this concept, the production of more than the amount needed and stocking are considered as waste. Thus, wastes in processes are eliminated by using the JIT philosophy. Furthermore, the quality-related problems are easily identified thanks to the low level of inventory. In addition to these advantages, JIT offers businesses the flexibility and speed required to keep up with global competition.
In lean thinking, workflows are usually applied with the pull system. The pull system is defined as the system by which the customer decides to start production or service [23]. In this system, since the production is started when there is demand, the wastes like excess inventory and overproduction is prevented. In addition, the companies that decide to implement the pull system must fulfill their customer demands within a certain time frame. For this purpose, it is inevitable to use Kanban cards. Kanban cards is a Japanese term given to cards used to control the flow in the process such as inventory control [19]. Additionally, control of the variations in demand and production can be provided with Kanban cards [24].
A Japanese word, Poka-Yoke, means mistake proofing and error avoidance [25]. In this way, errors are detected at the source and prevented from passing to the next step. The basic principle of the technique is to reduce the cost by reducing the number of defective parts that can occur during the production process to zero [26]. Poka-Yoke is preferred for quality at the source. Moreover, the Andon technique, which consists of lights that make it appear when errors occur, are also used.
Lean systems attach importance to continuous flows. The businesses want to avoid as much as possible the failures and machine errors that may occur during the process. For this reason, total productive maintenance (TPM) technique, should be implemented as routine preventive maintenance with the participation of all employees. TPM is an approach that requires the participation of all the employees within the daily production activities, which also brings the necessity of the maintenance of the equipment that it works on, prevents the errors and maximizes the efficiency of the equipment [27]. However, it is necessary to provide interdepartmental trainings to employees for this maintenance.
The main philosophy of lean system is the adoption of continuous flow and improvement. All other lean methods try to achieve this philosophy to perfection [28]. Kaizen, based on the concept of continuity, is a process improvement program that will never end. In order to make improvements in the existing production system and to find solutions to the problems identified, employees from different disciplines must come together in the Kaizen activities. In this meeting, wastes are defined and attempts are made to prevent the occurrence of other wastes. Lastly, the main basis of continuous improvement is undoubtedly the fact that top management believes the lean philosophy and provides full support to employees.
The spaghetti diagram is the visualization of the movement and transportation of the product or service in the value stream [29]. Employees can collect the data via this method [13]. Because the movements of products and services are clearly visible with this activity. Thus, the wastes during the flow can be easily determined. Besides, the problem determination and solution suggestions for eliminating non value added work steps and distances can be collected with the help of the opinions of the employees.
The 5N method is briefly the process of defining and writing specific problems. As it is understood from this definition, it is questioned why the problems arise and their answers are written under the determined problem. If the answer is not the root cause of the problem [13, 30], the evaluators will continue to ask until the root cause is determined. In the 5N method, it is tried to eliminate the wastes by asking the questions of the cause and the reason causing this problem [31]. In this way, the root of the problem is determined and solved not to occur again.
The standardization of works and processes has been developed based on the kaizen philosophy [32]. In order to ensure continuous flow, it is necessary to repeat the processes with the same quality every time. By using the standardized work method for repetitive tasks, employees will be trained in the steps of the processes according to the predetermined standards, which will allow quality improvement. Moreover, as employees know exactly what to do, their work satisfaction and motivation increase.
Visual control is a method based on organizing the working area so that management and workers can understand whether there is something going wrong in a way. The use of visual control method wherever the process takes place and its adoption can be evaluated as visual management. By using simple visual schemes, the communication between the employees becomes clear and the areas of responsibility of the employees can be determined by ground lines. In this way, processes can be viewed visually, employees are not forced and errors are prevented.
DMAIC and PDCA are cycles that monitor and examine business processes from start to finish. DMAIC (define-measure-analyze-improve-control) is an integral part of the six sigma method. This method is a systematic and result oriented. If there is flexibility during the processes, the most effective results can be obtained from this method. In addition, steps that do not add value are eliminated [33].
The PDCA (plan-do-check-act) cycle was first developed by Shewhart [12]. This method is more effective than the philosophy of doing it right the first time. Because, by using the PDCA cycle, better improvement methods are sought [33]. PDCA cycle consist of for stages: planning for improvement, doing improvement actions, checking the implications of improvement actions, and making effective permanent actions toward improvement. In these methods, precise measurements of product and process variability are made. In addition, all processes focus on statistical control [34].
Thanks to these lean tools and methods, to adopt the lean philosophy becomes easier; at the same time the philosophy is ensured to become permanent. These techniques are also thought to eliminate waste in production and service processes. Moreover, the lean methods are divided into three categories by Radnor et al. [2] as assessment, improvement and monitoring. In addition, these methods that frequently preferred in the literature are classified by Costa and Filho [35] the frame of three categories (Table 2).
Classification | Lean tools & methods |
---|---|
Assessment | Value stream mapping, 5 Whys (5N), A3, Ishikawa diagram, process mapping, Gemba walking |
Improvement | 5S’s, spaghetti diagram, continuous flow, Kaizen, pull system/Kanban, one-piece-flow, Poka-yoke, team approach to problem solving, workload balancing, Andon, Jidoka, process redesign, Heijunka, physical work setting redesign, standardized work |
Monitoring | Visual control |
Assessment/improvement/monitoring | DMAIC (define-measure-analyze-improve-control), PDCA (plan-do-check-action) |
Lean tools and methods and their classifications [35].
VSM is the most important and most widely used method. In addition, since VSM forms the main framework of this chapter, it is examined in more detail in the next section.
As a result of increasing interest in lean thinking, executives strive to transform their processes into a lean system. Lean techniques help ensure the lean in processes. One of the commonly applied lean methods is the value stream mapping (VSM) method introduced by Rother and Shook [36].
VSM is a demonstration of whole activities that value added and non-value added in processes by using a pen and paper [36]. VSM; a technique that helps determine and understand the resource and information flow of a product or service throughout the process. It is desirable to eliminate the wastes in the value stream in this method [29].
The aim of the method is to identify activities that non-value added to the product or service in the eyes of the customer and to improve the process by eliminating the wastes. The steps of the VSM method created to accomplish this aim are shown in Figure 4 [36, 37, 38]:
The value stream mapping process.
The first step in VSM is the selection of product family with common features or similar processes to avoid complexity. Then, the current state map showing the current process is drawn. What is important here is that the entire process from supplier to customer is included in the map. In the third step, the situations necessary for the development of the process that is dealt with the future state map are mapped. The color of the third step is different because VSM has no meaning if improvements are not recommended after the current state map [36]. In the last step, based on the elements identified on the map, it is discussed and applied what needs to be done, how much time is needed, who should take responsibility in each field and what the expected outcome from each activity is.
Standard symbols are accepted for demonstrating material flow, information flow and general information in VSM [23]. Some icons representing these symbols are provided in Figure 5.
Value stream mapping icons.
The use of the VSM method has several advantages. Advantages of VSM method are listed below [18, 39]:
ensures that the examined process is handled from beginning to end
provides visuality thanks to symbolic representation
procure the identification of the resources causing waste during the process.
shows the relationship between information flow and material flow
includes different application steps and implementation plan for continuous improvement
In addition, VSM method determines the system’s takt time, lead time and cycle times. In this way, the result of improvements in the future state map can be revealed. The terms here are briefly defined (see [19, 40]):
Takt time is the speed at which goods or services must be produced to meet customer demand. Takt time is calculated by dividing the daily total production time by daily customer demand.
Lead time (in days) is calculated by dividing the number of inventories between the processing steps into the daily demand.
Cycle time is expressed as the maximum time spent on a unit in each station. Cycle time is calculated with a simple formula: 1/output rate per hour in units.
For a better understanding of the subject, it will be useful to support the VSM method with examples. In line with this purpose, two examples, one of them from service sector and other from production sector are given.
The first example is from the service sector. The graduation, specifically the exmatriculation process of university students is selected. As aforementioned earlier in this chapter, the first stage of the VSM method is the identification of the product/service family. Here; the exmatriculation process of a university is determined as the product family. Then, the current situation of the flow in this process is observed and the current state map (CSM) is created (Figure 6). As seen in Figure 6, there are 12 steps in this process. The flow starts with “transcript control” step and ends with “completion of process”. In this map, various wastes stand out. For instance, unnecessary motions (meeting with advisor step), defects (meeting with advisor step), over processing (paper-work and head of department steps), waiting (head of department and filling out the survey steps), and inventory between processes (between department secretary and filling out the survey steps). A future state map (FSM) is drawn in order to eliminate these wastes (Figure 7). The first suggestion is that, student information system should be used actively. Moreover, various lean methods are proposed to eliminate the wastes generated during the processes. These lean methods are 5S, Poka-Yoke, quality at the source, kaizen, balanced work flow, standardized work, SMED, inventory reduction and visual controls. If the CSM (Figure 6) and FSM (Figure 7) are compared simultaneously, it is possible to see the wastes and how to eliminate them. As a result, while continuous flow is achieved, the total time is reduced from 363.5 to 276.5 minutes. This indicates an improvement of 0.24% in the process. In addition, resources are used efficiently and customer (student) satisfaction is ensured.
Current state map (service sector).
Future state map (service sector).
For the production sector application, a furniture factory is chosen. One of the sofa model (model A) produced in the furniture company is examined under VSM method (this example is derived from study of Dogan and Takcı [41]). Model A is now the product family of this example. As the second stage of VSM, the steps in the production phase of Model A are focused. The current state map (CSM) demonstrating this process is shown in Figure 8. There are eight production steps in CSM (Figure 8). Production flow starts with “crocking” and ends with “packaging”. When the current state map is analyzed, it is seen that the total time is 1.49 days and the processing time is 594 seconds. By drawing the CSM, some problems have emerged in the production area. The main problems are as follows: intermediate inventories between the processes; unbalanced workload; time losses due to the inadequate supply of the material and time losses cause quality errors (average 9.62%); time losses due to layout problem, unnecessary transportation and deficiencies like material identification. Then, to eliminate the problems identified with the CSM, a future state map (FSM) is drawn (Figure 9). In the FSM, the Kanban system is established, the pull system is applied to prevent accumulated intermediate inventories between the processes and the material transfer is controlled by FIFO. In addition, Yamazumi is proposed for balancing the workload and minimizing the quality errors and establishment of the Kanban system makes it possible to prevent time losses in production due to the lack of timely supply of the materials. Finally, it may be preferable to use 5S and physical work redesign in order to prevent the time losses due to the layout problem and the deficiencies in the material identification. Analysis of the production process of model A by VSM method showed that continuous flow is achieved; a decrease of approximately 53% in the total time, a decrease of 30% in the processing time and a 36% improvement in the quality error rate. As in the example of the service sector, when the CSM (Figure 8) and FSM (Figure 9) for production process of model A are examined simultaneously, the wastes, errors, defects and at the same time, improvements in the processes can be clearly seen.
Current state map (production sector).
Future state map (production sector).
Lean thinking is the general framework of the implementation of the lean philosophy in the production and service sectors [42]. As stated by Womack and Jones [8] “lean thinking is lean because it provides a way to do more and more with less and less—less human effort, less equipment, less time, and less space—while coming closer and closer to providing customers with exactly what they want.” LT is an endless process and implementation of continuous improvement. For continuous improvement, researchers and professionals prefer various lean methods like VSM, 5S, SMED, balanced work flow, standardized work etc. The primary purpose of these methods is to eliminate waste and ensure continuous flow.
Value stream mapping is one of the most preferred methods in literature. This is the mapping of the whole process. Mapping the stages of a process, will assist to discover the opportunities for improvement and prevent the loss of time and money of stakeholders [43]. VSM applications, with the aim of eliminating waste are not restricted to a single business; it can also be applied to the supply chain by focusing on all the steps from the first supplier to the end customer. The essence of the matter is that, VSM can be effectively used in all processes if a product or service flow exists.
This chapter has focused on lean philosophy and lean methods, especially the VSM. The motive for the detailed examination of the VSM method is that VSM is the first step to overcome how the lean production will be applied. The reason why this method is first preferred is that the whole operation is seen as a holistic approach, and at the same time, it proposes a prescription to eliminate errors and/or wastes. On the other hand, like many other methods, this method has also some limitations. Mapping complex systems with VSM can sometimes be difficult. At this point, large wastes or resources of wastes may be unnoticed. This can be a major problem in VSM, whose main goal is revealing and eliminating waste. Moreover, rather than using the VSM method alone, using with other lean methods will increase the reliability and efficiency of the results. To overcome these weaknesses, it is recommended to benefit from other methods together with the VSM method. For instance, theory of constraints, flowcharts, artificial intelligence and simulation are some of the methods that can be used with VSM.
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