Percutaneous Endoscopic Colostomy Research Articles

Percutaneous Endoscopic Colostomy to Relieve Malignant Bowel Obstruction.

Malignant bowel obstruction due to peritoneal carcinomatosis is a common problem. When surgery is not feasible in the context of a high intraperitoneal tumour burden, other techniques are required. We report the case of a 67-year-old female with malignant obstruction of the ascending colon. Following an unsuccessful surgical attempt, decompression was successfully achieved via percutaneous endoscopic colostomy using a lumen-apposing metal stent. The patient was able to resume a full oral diet within 2 days. However, local inflammatory complications arose due to faecal contamination of the sutures. Once the sutures were removed, no further interventions were required. Percutaneous endoscopic colostomy is a safe and viable alternative for decompression in malignant bowel obstruction when surgery is not feasible. However, limitations include the risk of local infection due to sutures and its applicability only in cases with distal stenosis. Malignant bowel obstruction is a frequent challenge in palliative care.Percutaneous colostomy with a lumen-apposing metal stent (LAMS) is a safe and effective option to relieve bowel obstruction.Percutaneous colostomy with a LAMS remains patent in the long term.

Sigmoid volvulus with 25 episodes.

We report the case of a 74-year-old male with abdominal pain, distention and obstipation for 8 hours. He had a medical history of 24 sigmoid volvulus (SV) episodes, 23 of which treated with endoscopic detorsion, while one resolved spontaneously. Physical examination revealed abdominal distention, tenderness, hyperkinetic bowel sound and an empty rectum. Abdominal X-ray radiograph revealed dilated sigmoid loops with coffee bean sign. Computed tomography demonstrated dilated sigmoid loops with air-fluid levels and mesenteric whirl sign. Flexible colonoscopy showed a spiral-like luminal obstruction of the viable sigmoid colon at 18 cm from anal verge. A successful colonoscopic detorsion was performed. Due to the poor general health status of the patient (American Society of Anesthesiologists-ASA score 4) arising from serious comorbidities including coarctation of aorta and coronary disease, percutaneous endoscopic colostomy was suggested instead of elective sigmoid colectomy. He did not approve adjunctive therapy and was discharged following 24-hour observation.

S187 Percutaneous Endoscopic Colostomy: A Systematic Review of More Than Two Decades Experience

Introduction: Percutaneous endoscopic colostomy (PEC) is a minimally invasive procedure used to treat recurrent colonic pseudo-obstruction, sigmoid volvulus, chronic intracTable constipation, and neurogenic bowel. Traditional management of these conditions involving surgical colostomy or bowel resection in many cases has been replaced by percutaneous approaches under imaging or endoscopic guidance due to high rates of technical success and low morbidity rates. We conducted a systematic literature review to summarize the use, indications, and complications of PEC in adult patients. Methods: A systematic literature review was conducted using PubMed, Medline, Google Scholar, and Embase to identify patients who had undergone PEC for any indication. The search terms used were “percutaneous endoscopic colostomy”, “percutaneous endoscopic cecostomy”, “percutaneous cecostomy”, and “percutaneous colostomy”. Exclusion criteria were colostomy tubes that were not placed endoscopically. Results: A total of 11 observational studies (3 prospective, 8 retrospective), 18 case reports, and 7 case series between 1998 and 2022 were identified. A total of 318 patients who underwent PEC were identified. The mean age was 66.4 ± 23.5 and 64% were male. The most common indication was sigmoid volvulus (n= 131) followed by pseudo-obstruction (n=43), chronic intrac table constipation (n=83), neurogenic bowel (n=45), and others (n=9). The procedure was technically successful in 311 patients (97.7%). The total complication rate was 37.6%, 83.5% (n=66) of which were minor complications such as pain, bleeding, infection, leakage, and 16.4% (n=13) of which were major complications such as peritonitis, pneumoperitoneum, and sepsis. PEC-related mortality was 1.3% (n=4). The most common locations for tube placement were the left colon (59%) followed by right colon (13%), the rest of the cases the location was not reported. The number of tubes removed was 57, 8 due to symptom resolution, 3 for planned colostomy, and 1 for pain. (Figure) Conclusion: PEC is an underutilized procedure that offers a viable treatment alternative for select patients who are deemed high risk for surgical intervention and in whom conservative therapy is unsuccessful. It can lead to durable relief of symptoms with good technical success and low risk of major complications. Further prospective studies are needed to establish the optimal placement technique, long-term efficacy, and safety.Figure 1.: Percutaneous Endoscopic Colostomy tube indications

S1957 A Percutaneous Endoscopic Colostomy (PEC) Tube to the Rescue

Introduction: Acute colonic pseudo-obstruction (ACPO) is a colonic distention without obstruction that can lead to catastrophic complications. Supportive care until spontaneous resolution is often successful whereas surgery in the acute setting is reserved for emergencies such as ischemia and/or rupture. We present a case of refractory ACPO successfully treated with a percutaneous endoscopic colostomy (PEC) tube. Case Description/Methods: A 72-year-old male presented with cellulitis. He was treated with antibiotics, during which time he developed colonic distention and a diagnosis of toxic megacolon was considered. Surgery was consulted and recommended non-operative management due to his stable clinical status and significant co-morbidities including a BMI of 53. He was started on oral vancomycin and intravenous metronidazole with overall improvement clinically. After discharge, the patient continued to have diarrhea and persistent colonic distention. Readmission occurred and the Gastroenterology team performed colonoscopic decompression twice without sustained resolution of colonic distention. The decision was made to proceed with a cecostomy tube by interventional radiology. Unfortunately, despite a patent 8.5Fr cecostomy tube, the colonic distention continued to worsen mainly in the transverse colon with the diameter reaching 22 cm. The decision was made to place a higher caliber 24 Fr PEC tube in the operation room under monitored anesthesia care. The PEC tube was successfully placed endoscopically in the transverse colon without any acute complications [Figure 1]. Fortunately, the patient’s colonic distention improved to less than 10 cm on follow-up abdominal x-rays. Discussion: Patients with ACPO are often medically complex with multiple comorbidities. Non-interventional, supportive care, including removal of offending agents, correction of fluid and electrolyte imbalances and ambulation remains the preferred treatment. Should medical therapy be contraindicated or fail, endoscopic decompression is recommended with a success rate of up to 95%. Emergent surgical management is usually only reserved for those with perforation or presumed ischemia and is associated with high rates of morbidity and mortality. In challenging cases such as this, a multidisciplinary approach is needed, which can facilitate collective decision-making regarding less well-established and less invasive treatment modalities, such as PEC.Figure 1.: Percutaneous Endoscopic Colostomy tube in the transverse colon.

A single centre 20-year retrospective cohort study: Percutaneous endoscopic colostomy.

Percutaneous endoscopic colostomy (PEC) represents an important intervention in specific patients. Limited data currently exist. We present the largest recorded study of patients undergoing PEC. Retrospective analysis of consultant logbooks highlighted all patients from 1997 to 2020. Two independent reviewers assessed records. Parameters measured were age, sex, indication, number of sites, complications, mortality and survival. Three subgroups were identified: recurrent sigmoid volvulus (RSV), pseudo-obstruction and neurogenic. ANOVA, chi-squared and Fischer's exact tests were utilized; Kaplan-Meier curves estimated survival and the log-rank test was applied. A p value of <0.05 was considered statistically significant. Ninety-six PEC insertions were done on 91 patients (five reinsertions). There were 66 men (69%) and the mean age was 73.1 years (interquartile range 23). The indications were RSV n=72, pseudo-obstruction n=13, neurogenic n=11. The 30-day complication rate was overall n=27 (28%), RSV n=23, pseudo-obstruction n=4. Nine patients leaked (9.9%) (eight RSV, one pseudo-obstruction), of whom five died. 90-day mortality was 14.6% (14 patients), 18.5% (13/72) for RSV, 7.7% (1/13) for pseudo-obstruction. Overall recurrence following PEC was 10.4%. The median follow-up was 25 months (interquartile range 4.6-62.2months). At 3, 5 and 10 years survival was 46%, 34% and 26% for RSV, 70%, 55% and 15% for pseudo-obstruction and 91%, 91% and 81% for neurogenic respectively. Recurrent sigmoid volvulus and pseudo-obstruction patients undergoing PEC compared to neurogenic patients have poorer outcomes with higher complication rates and shorter life expectancy. We advocate that high volume specialist units undertake PEC. The significant associated risks of PEC require careful consideration when determining patient suitability. Utilizing risk stratification scores may help guide shared decision making between patients, relatives and clinicians.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction.

Management of sigmoid volvulus using percutaneous endoscopic colostomy.

The aim of this systematic review was to appraise the current literature on the use of percutaneous endoscopic colostomy (PEC) as an alternative to major surgery and endoscopic decompression alone for treating sigmoid volvulus in frail, comorbid patients. A systematic literature search of literature published between April 2000 and January 2017 was carried out using the MEDLINE®, Embase™ and CINAHL® (Cumulative Index to Nursing and Allied Health Literature) databases. The search terms were "percutaneous endoscopic colostomy", "PEC", "sigmoidopexy", "sigmoidostomy" and "sigmoid volvulus". The studies identified were screened and those that did not fulfil the inclusion criteria were excluded. Seven observational studies and seven case reports (comprising eighty-one patients) were found to match our inclusion criteria. All patients had recurrent sigmoid volvulus and were treated with PEC either with a single PEC tube or with two PEC tubes inserted. Sigmoid volvulus recurred in 10 of the 81 patients; 3 of these individuals developed recurrence with PEC tubes in situ and 7 following tube removal. There were seven deaths after the procedure. The most frequent morbidity associated with PEC tube insertion was site infection (n=6). Our systematic review highlights the use of PEC as an alternative in managing recurrent sigmoid volvulus in frail, comorbid patients unfit for or refusing surgery, with the best outcomes seen in those patients where two PEC tubes were inserted and remained in situ indefinitely. Further studies are needed to improve the safety and efficacy of the procedure as well as post-procedure care.

2140 Management of Recurrent Sigmoid Volvulus Using Dual Endoscopic Modalities of Sigmoidopexy and Percutaneous Colostomy Placement

INTRODUCTION: Sigmoid volvulus (SV) occurs when the colon twists about its mesentery which can compromise vascular perfusion leading to ischemia. Mortality rate (MR) is up to 60%, requiring emergent endoscopic (ES) detorsion via flexible sigmoidoscopy (FS) with placement of a rectal tube. Recurrence is high, ultimately requiring surgical management. The mean age of presentation is 70 with high likelihood of multiple comorbidities, resulting in high surgical risk. We present a case of ES therapy of recurrent SV. CASE DESCRIPTION/METHODS: 88-year-old man with colon cancer status post left hemicolectomy (LH), coronary artery disease on antiplatelet agents, atrial fibrillation on anticoagulation, congestive heart failure, and chronic pulmonary disease, presented with abdominal pain, distention and obstipation for two days. The patient had a history of three episodes of SV requiring ES detorsion since LH. Abdominal x-ray revealed a markedly dilated sigmoid colon. Emergent FS was performed with insertion of a 36 French (Fr) catheter resulting in decompression. Computed tomography (CT) was unrevealing for other pathology. Colonoscopy showed a severely redundant, tortuous and dilated colon without other abnormalities. Subsequently, ES sigmoidopexy was performed under fluoroscopy to minimize looping and confirm SV detorsion. Six T-fasteners (TF) were placed cephalocaudally, 5-10 cm apart, with the first TF upstream to proximal region of twisting and the sixth TF downstream to distal region of twisting. A 16 Fr percutaneous endoscopic colostomy (PEC) tube was then inserted as a decompression valve. The tube was affixed to the abdominal wall with two additional TFs inserted adjacent to the third TF to create a triangle within the region of previously dilated lumen. The eight TFs and PEC tube were tightened to abdominal wall, and the tube was connected to a Foley drainage bag. Follow up CT scan confirmed resolution of SV. The patient improved clinically and was discharged home after having formed bowel movements. DISCUSSION: Due to high MR, a high index of suspicion for SV is necessary in elderly patients presenting with abdominal distention. Although several case series exist describing ES sigmoidopexy and laparoscopically-assisted PEC tube insertion, to our knowledge this is the only described case of definitive ES therapy using both surgical and ES techniques. While additional cases are required to assess safety and efficacy, this technique may be an addition to the ES armamentarium in managing SV.

When all seems lost: management of refractory constipation-Surgery, rectal irrigation, percutaneous endoscopic colostomy, and more.

While the pharmacological armamentarium for chronic constipation has expanded over the past few years, a substantial proportion of constipated patients do not respond to these medications. This review summarizes the pharmacological and behavioral options for managing constipation and details the management of refractory constipation. Refractory constipation is defined as an inadequate improvement in constipation symptoms evaluated with an objective scale despite adequate therapy (ie, pharmacological and/or behavioral) that is based on the underlying pathophysiology of constipation. Minimally invasive (ie, rectal irrigation and percutaneous endoscopic colostomy) and surgical therapies are used to manage refractory constipation. This review appraises these options, and in particular, percutaneous endoscopic colostomy, which as detailed by an article in this issue, is a less invasive option for managing refractory constipation than surgery. While these options benefit some patients, the evidence of the risk: benefit profile for these therapies is limited.

Percutaneous endoscopic colostomy for adults with chronic constipation: Retrospective case series of 12 patients.

Percutaneous endoscopic colostomy (PEC) is a technique derived from percutaneous endoscopic gastrostomy. When conservative treatment of chronic obstipation fails, colon irrigation via PEC seems less invasive than surgical interventions. However, previous studies have noted high complication rates of PEC, mostly related to infections. Our aim was to report our experiences with PEC in patients with chronic refractory constipation. Retrospective analysis of all patients who underwent PEC for refractory constipation in our secondary referral hospital between 2009 and 2016. Twelve patients received a PEC for chronic, refractory constipation. Short-term efficacy for relief of constipation symptoms was good in 8 patients and moderate in 4 patients. Two patients had the PEC removed because of spontaneous improvement of constipation. Three patients, who initially noticed a positive effect, preferred an ileostomy over PEC after 1-5years. One PEC was removed because of an abscess. Long-term efficacy is 50%: 6 patients still use their PEC after 3.3years of follow-up. No mortality occurred. PEC offers a technically easily feasible and safe treatment option for patients with chronic constipation not responding to conventional therapy. Long-term efficacy of PEC in our patients is 50%.

69-Year-Old Man With Abdominal Pain and Obstipation

69-Year-Old Man With Abdominal Pain and Obstipation

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

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.

Use of percutaneous endoscopic colostomy (PEC) to treat sigmoid volvulus: a systematic review.

Background and aim: Percutaneous endoscopic colostomy provides an alternative management option for patients with recurrent sigmoid volvulus who are considered too high risk to undergo surgery. We reviewed the literature to assess whether the National Institute for Health and Clinical Excellence guidelines published in 2006 supporting the use of percutaneous endoscopic colostomy are still valid. Methods: A systematic literature search was conducted using PubMed, Web of Science, and Embase. The exploded search terms “Percutaneous Endoscopic Colostomy” and “Sigmoid Volvulus” were used. Librarian support was used to ensure the maximum number of relevant articles were returned. Identified abstracts were then analyzed and included if they met the inclusion criteria. Results: Five observational studies and 5 case reports were identified that met the inclusion criteria. They provided data on 56 patients with recurrent sigmoid volvulus treated with percutaneous endoscopic colostomy placement. Sixteen of the 56 patients were treated with a single percutaneous endoscopic colostomy (PEC) tube while 38 patients were treated with 2 PEC tubes. For 2 patients the details of the procedure were unknown. Five patients developed major complications following the procedure: 1 patient developed peritonitis after 4 days, due to fecal contamination secondary to tube migration and 2 patients with cognitive impairment pulled their PEC tubes out. Two other patients died following PEC insertion. Nine patients developed minor complications following the procedure. The most commonly reported minor complication was infection at the PEC site. Four of 56 patients developed a recurrent sigmoid volvulus with a PEC tube in situ. Conclusion: Although in these case series there is a 21 % risk of morbidity and 5 % risk of mortality from the use of a PEC, this is favorable compared to the mortality risk of 6.6 % to 44 % reported with operative intervention. This review of contemporary literature therefore supports the use of PEC in frail and elderly patients.

Should we recommend PEC and when?

Percutaneous endoscopic colostomy (PEC) was first described in 1986, by Jeffrey Ponski 1, who had invented percutaneous endoscopic gastrostomy a few years before that 2. Performed by 2 operators, PEC consists of placing a tube in the colon during colonoscopy in order to provide antegrade colonic enemas (ACE) in severe constipation or fecal incontinence 3 4. The PEC tube can also be used as a tool allowing easier and immediate colonic exsufflation in Ogilvie’s syndrome or chronic intestinal obstruction 5 6. In the majority of PEC indications, the colostomy tube is placed in the cecum for 2 main reasons: 1) to allow pancolonic rather than distal ACE in order to (theoretically) provide more effective bowel function; and 2) cecal transillumination as a prerequisite to improve procedure ease and safety because it helps determine the most direct route to the colon. So far, whether performing PEC is safe and effective in other situations, such as sigmoid volvulus, remains largely unknown.

Percutaneous endoscopic colostomy: a useful technique when surgery is not an option.

Percutaneous endoscopic colostomy (PEC) is a minimally invasive endoscopic procedure that offers an alternative treatment for high-risk patients with sigmoid volvulus or intestinal pseudo-obstruction who have tried conventional treatment options without success or those who are unfit for surgery. The procedure acts as an irrigation or decompressing channel and provides colonic ‘fixation’ to the anterior abdominal wall. The risk of complications highlights the importance of informed consent for patients and relatives.

Su1679 Does Percutaneous Endoscopic Colostomy Help in Spinal Cord Injury Bowel Dysfunction?

Bowel Dysfunction (BD) affects medical care and Quality of Life (QoL) in more than 1/3 of patients after Spinal Cord Injury (SCI). Such difficulty with evacuation, fecal incontinence, and visceral symptoms commonly cause persons with SCI to avoid travel, work, and other activities outside the home. Surgical and radiological irrigating colostomy tubes have been successfully used for bowel control. Ponsky, reported Percutaneous Endoscopic Colostomy (PEC) in 1986 for a case of non-obstructive colonic dilation, and we previously reported a retrospective pediatric PEC series in 2001.

Percutaneous endoscopic colostomy (PEC): an effective alternative in high risk patients with recurrent sigmoid volvulus.

Treatment of recurrent sigmoid volvulus is a major challenge in frail and elderly patients with multiple co-morbidities. Early management involves endoscopic decompression with high success rate, however, its recurrence make it a real challenge as most of these patients are not suitable for major colonic resection. The aim of this study was to assess the role of percutaneous endoscopic colostomy (PEC) in the treatment of recurrent sigmoid volvulus in these patients. Twelve PEC procedures were performed in 8 patients under our care. This prevented major colonic resection in 7 patients. One patient underwent sigmoid resection and died with postoperative complications. Two patients experienced minor complications. Three patients required repeat procedures for permanent PEC tube placement. Six patients managed permanently with PEC procedure. PEC is an effective treatment for recurrent sigmoid volvulus in high-risk elderly patients.

Treatment of recurrent sigmoid volvulus in Parkinson's disease by percutaneous endoscopic colostomy

The exact aetiology of sigmoid volvulus in Parkinson's disease (PD) remains unclear. A multiplicity of factors may give rise to decreased gastrointestinal function in PD patients. Early recognition and treatment of constipation in PD patients may alter complications like sigmoid volvulus. Treatment of sigmoid volvulus in PD patients does not differ from other patients and involves endoscopic detorsion. If feasible, secondary sigmoidal resection should be performed. However, if the expected surgical morbidity and mortality is unacceptably high or if the patient refuses surgery, percutaneous endoscopic colostomy (PEC) should be considered. We describe an elderly PD patient who presented with sigmoid volvulus. She was treated conservatively with endoscopic detorsion. Surgery was consistently refused by the patient. After recurrence of the sigmoid volvulus a PEC was placed.

A valid treatment option for critically ill and debilitated patients: percutaneous endoscopic colostomy

GIRIS Gauderer ve Ponsky (1), 1980 yilinda ilk kez perkutan endoskopik gastrostomi islemini tanimlamislar ve bu islemi, yetersiz gida alimi olan bir cocuk hastanin palyasyonunu saglamak amaciyla kullandiklarini bildirmislerdir. Ponsky, perkutan endoskopik gastrostomiden ilham alarak, konservatif tedaviye direncli bir akut kolonik psodoobstruksiyon olgusunda Perkutan Endoskopik Kolostomi (PEK) islemini uygulamistir (2). Tanimlandigi gunden bu yana, PEK’in gerek kullanimi gerekse endikasyonlari giderek artmistir.

Endoscopic-assisted Colopexy and Push Percutaneous Colostomy in the Transverse Colon for Refractory Chronic Intestinal pseudo-Obstruction

Percutaneous endoscopic colostomy (PEC), using the classic pull-through technique in the ascending or the descending colon, has been proven useful to treat chronic intestinal pseudo-obstruction. We report the case of a high-surgical risk 70-year-old male with refractory chronic intestinal pseudo-obstruction, in whom the ascending colon could not be reached due to tortuous left dolichocolon. Endoscopic-assisted colopexy and push colostomy in the proximal transverse colon was decided accordingly. Colopexy was performed under direct endoscopic vision in the proximal transverse colon using 3 preloaded T-fasteners surrounding the intended stoma site. The stoma tract was created with an introducer needle, allowing the advance of the 24 Fr 4-sleeve dilator over a guidewire. Afterwards, the dilator was removed and the peel-away sheath was left in place. Over the guidewire, a 20-Fr gastrostomy tube was advanced into the colon lumen through the covering, which was finally removed. The patient recovered uneventfully, despite postprocedure pneumoperitoneum, which was related to the technique. He died a month later due to unrelated comorbidities, without further abdominal complaints after discharge. This is the first report of PEC both using a push technique, and the first report in a different location than the ascending or the descending colon. We believe this novel push technique may be feasible for PEC, avoiding the need of reinsertion in patients with difficult colonoscopy.