Ileosigmoid knotting in Sub-Saharan Africa: a systematic review and meta-analysis

Abstract Background Ileosigmoid knotting (ISK) is a rare double-segment closed-loop intestinal obstruction in which the ileum and sigmoid colon entwine, frequently progressing to bowel gangrene within hours. Although rare worldwide, it is concentrated within the volvulus belt of which Sub-Saharan Africa (SSA) is a major component. No prior synthesis has quantitatively pooled the regional epidemiology, surgical management and outcomes. Methods We performed a PRISMA-2020-compliant systematic review and meta-analysis. PubMed, Scopus, Web of Science, AJOL and Google Scholar were searched from inception to January 2026. Original observational studies (≥ 5 patients) from any SSA country were eligible. Then it independently screened, extracted and appraised (adapted Newcastle–Ottawa Scale). Random-effects DerSimonian–Laird pooled proportions were generated, with subgroup, meta-regression and Egger analyses. Results Ten studies (349 patients from six countries) met inclusion criteria (1949–2025). The pooled cohort was 79.1% male, mean age 42.9 years. Abdominal distension was near-universal (85%, I² = 0%); shock at presentation was 27% (95% CI 17–37%). Both segments were gangrenous in 68% (95% CI 54–82%) and only 12% had two viable segments. Resection with primary anastomosis was performed in 53% and Hartmann’s procedure in 39%. Pooled in-hospital mortality was 20% (95% CI 8–32%; I² = 90.2%), falling from 50% pre-2000 to 11% since 2015 ( p  < 0.001); meta-regression confirmed a per-year decline (β = −0.035, p  = 0.024, R² = 70%). Pooled anastomotic leak was 6% (I² = 13.7%). Conclusion ISK in SSA affects young-to-middle-aged rural men, with bowel gangrene present in the majority of cases. Contemporary mortality has fallen five-fold to 11% but remains unacceptable. Aggressive shock reversal, individualised intraoperative decision-making and standardised reporting are priorities.