We read with interest their studies by Atamanalp, in which the authors evaluated the clinical features in many patients with sigmoid volvulus (SV).^3,4,5 Particularly, Atamanalp demonstrated that there were 3 important factors causing unsuccessful endoscopic detorsion; a prolonged symptom period (≥24 hours), the presence of an over-rotation (volvulus degree ≥360°), and the co-occurrence of ileosigmoid knotting (ISK).

With regard to the factors pointed out by Atamanalp, we re-evaluated the clinical features of patients in our study. First, The proportion of prolonged symptom period (≥24 hours) in possible detorsion group and in impossible detorsion group were 30.8% (4/13) and 50.0% (4/8). Second, the presence or absence of an over-rotation (volvulus degree ≥360°) in all the cases were evaluated by CT. CT examinations were performed in all the 21 cases, and 9 cases showed the findings of over-rotation. The proportion of the cases with the findings of over-rotation in possible detorsion group and in impossible detorsion group were 30.8% (4/13) and 62.5% (5/8). In addition, we overviewed all the CT findings and the operative records. There were no cases presenting ISK in our study.

Taken together, our additional investigation showed that prolonged symptom period and over-rotation might be involved in unsuccessful endoscopic detorsion of SV patients. Unfortunately, our study was underpowered to demonstrate the significant difference of these factors between endoscopically successful and unsuccessful cases because of a small sample size.

In summary, we agree with Atamanalp's comments and lead to our concluding remark that in clinical practice, we should deliberately observe several factors, which was suggested by our group and Atamanalp, to approach the better clinical outcome of SV patients.