1041 Salvage Therapy for Colonic Mechanical Obstruction With Introducer-Type Colostomy and Colopexy

Abstract

Percutaneous endoscopic colostomy (PEC) has been established as an alternative method of intestinal decompression and irrigation for functional large bowel obstruction and relapsing sigmoid volvulus. However, several cases of postoperative fecal peritonitis have been reported secondary to stool leakage. Prior fixation of the colon to the anterior abdominal wall could eventually reduce that risk. This video presents the case of a 70-year-old patient with a two-month history of diarrhea and painful abdominal distention not responding to medical treatment. He had previously undergone anterior resection for rectal cancer, radiotherapy for bladder cancer and resection of postradiation small intestinal strictures. Clinical examination revealed a cachectic patient with significant distention and high pitched bowel sounds. CT-scan disclosed a 7-cm long stricture of the neo-rectum with upstream dilation of the colon up to 10 cm. Colonoscopy with a slim endoscope revealed a long edematous stricture involving the neo-rectum and sigmoid colon. Endoscopic treatment with stenting or dilation was not feasible due to the location and length of the obstruction. In addition the patient was deemed unfit to undergo surgery. Therefore, an introducer type colostomy was suggested, combined with colopexy, using a dedicated suturing device. Prophylactic antibiotics were administrated prior to the procedure. The left colon was distended with CO2, and the site of puncture was located by means of light transillumination and finger indentation, proximally to the stenotic segment. Local anesthesia was administrated and the colon was punctured with the injection needle in order to confirm good positioning. Then, we performed colopexy with the help of the introducer needle which was inserted in the lumen of the colon. A small incision was made between the sutures, and a Trocar with a peal-away sheet was introduced through the abdominal wall into the colon. The trocar was removed, a 15 French PEG tube was progressed through the sheet, and the balloon was inflated with 5 ml of sterile water. The peal away sheath was removed, and the retaining plate was placed. The patient recovered uneventfully and was trained to use the colostomy for both decompression and irrigation as needed. The colostomy tube was definitely removed 2 months later due to progressive clinical improvement. In conclusion, PEC with the introducer method combined with colopexy, may be used as salvage therapy for colonic decompression and irrigation of selected cases of mechanical obstruction. Fixation of the colon to the abdominal wall may decrease the risk of postoperative peritonitis, secondary to stool leakage or to tube dislocation.