PTH-105 Sigmoidopexy-assisted Percutaneous Endoscopic Colostomy (PEC) – a stepwise improvement in safety

Abstract

<h3>Introduction</h3> Percutaneous endoscopic colostomy (PEC) is an established alternative to surgery for recurrent sigmoid volvulus or pseudo-obstruction. Tube migration resulting in peritonitis remains a serious safety concern. Endoscopic sigmoidopexy allows fixation of the colon to the abdominal wall prior to PEC insertion, reducing the risk of tube migration or faecal leakage. We present our initial experience of sigmoidopexy-assisted PEC. <h3>Methods</h3> After endoscopic decompression of the colon, a suitable place for sigmoidopexy is identified (usually mid-sigmoid), using trans-illumination and/or finger indentation. A triangulated 3-point sigmoidopexy is then performed with a Pexact suturing device. A 15Fr Freka gastrostomy tube is then inserted within the sigmoidopexy points using a standard pull-through technique, to act as the PEC. A flatus bag is attached to the PEC and left on free drainage for 24 hours. Antibiotics are administered peri-procedurally. The sigmoidopexy sutures are removed after 14 days, and the PEC tube is left in situ for a minimum of 3 months. <h3>Results</h3> Over an 18 month period 12 patients had sigmoidopexy-assisted PEC (recurrent sigmoid volvulus 9, pseudo-obstruction 3) after MDT case selection. All cases were considered unsuitable for surgery after surgical review. There were no procedural complications and no episodes of faecal peritonitis or other significant sepsis. Of patients treated for volvulus (median follow up 10 months), 5 (55%) had PEC removal after 3 months without recurrence to date, whilst 2 (22%) had recurrent volvulus following PEC removal requiring further intervention (surgery 1, further PEC 1). One patient required regular venting from the PEC, hence tube not removed. Two patients with pseudo-obstruction have ongoing venting via their PEC tube, whereas one patient removed their PEC 3 weeks post insertion. Despite forcible removal, there was no observed faecal peritonitis. <h3>Conclusions</h3> Sigmoidopexy-assisted PEC appears to be a safe and effective technique, with no significant post-procedural complications in this case series. Two patients developed recurrent sigmoid volvulus after tube removal, suggesting a need to leave tubes in situ for longer than the 3 months used in our initial protocol.