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Percutaneous endoscopic cecostomy: A case series
Percutaneous endoscopic cecostomy: a case series Jack I. Ramage, Jr., MD, Todd H. Baron, MD, FACP Background: There are few reports of percutaneous endoscopic cecostomy in adult patients. Methods: All cases of acute colonic pseudo-obstruction (n = 2) and neurogenic bowel (n = 3) in adults in which percutaneous endoscopic cecostomy was performed were reviewed retrospectively. Observations: Percutaneous endoscopic cecostomy was a definitive treatment. In 1 of the 2 patients with acute colonic pseudo-obstruction, the percutaneous endoscopic cecostomy tube was clamped and subsequently removed 10 weeks after placement; in the other patient with acute colonic pseudo-obstruction, the percutaneous endoscopic cecostomy tube remains in place. In 2 of the 3 patients with neurogenic bowel, the percutaneous endoscopic cecostomy tube continues to function well; the third patient did well for 6 months and then died of underlying comorbid disease. There was no mortality or need for surgical intervention for any patient. Complications occurred in 2 patients; 1 developed transient fever and leukocytosis and 1 had self-limited bleeding during anticoagulation. Conclusions: Percutaneous endoscopic cecostomy is a safe and effective treatment for both acute colonic pseudo-obstruction and neurogenic bowel when aggressive albeit conservative treatment is unsuccessful.
Surgical cecostomy, including indications for the procedure and the technique, is well described, and there has been considerable experience with this operation.1 There are 2 nonsurgical alternatives to surgical cecostomy: percutaneous cecostomy and percutaneous endoscopic cecostomy (PEC). The techniques and outcomes of percutaneous cecostomy, performed by interventional radiologists, have been reported.2,3 Percutaneous endoscopic cecostomy was first described in 1986 by Ponsky et al.4 for the treatment of acute colonic pseudo-obstruction (ACPO). Subsequently, there have been only two reports describing the use of PEC for ACPO.5,6 Other reports have expanded the range of indications for PEC, including facilitation of antegrade continence enemas (ACE) in pediatric patients with chronic constipation or fecal incontinence.7,8 Treatment of adult Received September 11, 2002. For revision November 7, 2002. Accepted February 5, 2003. Current affiliations: Division of Gastroenterology and Hepatology, Mayo Clinic Foundation, Rochester, Minnesota, and Scottsdale, Arizona. Reprint requests: Todd H. Baron, MD, Mayo Clinic, 13400 E. Shea Blvd., Scottsdale, AZ 85259. Copyright © 2003 by the American Society for Gastrointestinal Endoscopy 0016-5107/2003/$30.00 + 0 doi:10.1067/mge.2003.197 752
GASTROINTESTINAL ENDOSCOPY
A
B Figure 1. A, Endoscopic view within right colon: a 19-gauge needle used to puncture the abdominal wall has entered the colon and is grasped tightly with a snare. B, Endoscopic view (different patient) after PEG tube placement. Mushroom portion of tube is located just distal to cecum seen in background.
patients with neurogenic bowel/constipation by PEC for ACE has not been reported. Experience with PEC placement within the investigators’ health system consists of 2 patients with recurrent ACPO and 3 with neurogenic bowel. PATIENTS AND METHODS Percutaneous endoscopic cecostomy technique Percutaneous endoscopic cecostomy placement was performed using a modification of the technique initially described by Ponsky et al.,4 which is modeled after the PEG pull technique. In patients hospitalized with ACPO or obstipation who underwent PEC placement, broad-spectrum antibiotics typically were being administered for other indications. Otherwise, antibiotics were given prophylactically before PEC placement—for inpatients, piperacillin/tazobactam; for a single outpatient, amoxicillin/clavulanic acid. These antibiotics were chosen to provide coverage against gram-positive (skin) and gram-negative (fecal) bacteria. Administration was continued for 24 VOLUME 57, NO. 6, 2003
Percutaneous endoscopic cecostomy: a case series
hours after the procedure, during which time patients were observed for evidence of complications. When PEC was performed electively for neurogenic bowel, patients ingested a standard polyethylene glycol solution (GoLytely, Braintree Laboratories, Braintree, Mass.) in preparation for the procedure. In patients with ACPO, preparation of the colon was not attempted. Patients fasted for at least 8 hours before the procedure. Conscious sedation was induced by intravenous administration of titrated doses of midazolam and fentanyl or midazolam and meperidine. For colonoscopy in patients with ACPO, particular attention was devoted to keeping air insufflation to a minimum to avoid perforation of the already distended colon. Colonoscopy was performed with standard adult or pediatric endoscopes. Once the cecum or right colon was intubated, the lumen was cleansed to remove any fecal material. With the patient in the supine position, a site for PEC placement was chosen by using transillumination and endoscopically observed indentation in response to pressure exerted with a finger on the abdomen. The abdominal wall was then prepped with betadine solution, and a local anesthetic was injected (1% lidocaine). The contents of standard, commercially available PEG trays with 20F tubes (MIC, Ballard Medical Products, Draper, Utah; or Microvasive Endoscopy, Natick, Mass.) were used with the exception of the snare provided with these kits, which is too short to pass through a colonoscope; a standard polypectomy snare was substituted. The snare was opened within the bowel lumen at the anticipated location of needleentry. The intermediate 19-gauge needle provided in the PEG kits was inserted through the skin into the bowel lumen and tightly grasped at its proximal portion with the snare to maintain apposition of the colon to the anterior abdominal wall (Fig. 1A). With the 19-gauge needle in place, the trocar was advanced through the abdominal wall alongside the needle in the same orientation. The snare was then released from the smaller needle and the trocar was grasped. The remainder of the procedure was as for placement of a PEG tube using the pull technique, with the tube pulled through the anus and into position (Fig. 1B). No skin incision was made, as these investigators have shown in a prospective pilot study, and it is the investigators’ experience with direct percutaneous endoscopic jejunostomy that omission of a skin incision is safe and may reduce the risk of skin infection.9 The external bumper was applied to the abdominal side of the tube and approximated to the skin, with a notation being made of the thickness of the abdominal wall. In most cases, the colonoscope was not reinserted to confirm that the tube was positioned correctly. In patients with ACPO, the PEC tube was placed to gravity drainage or low intermittent suction and flushed with 30 mL of tap water every 6 hours. For patients with neurogenic bowel, the tube was capped with the standard PEG valve and flushed with 30 mL of tap water twice daily, in addition to daily administration of a laxative beginning 4 or more hours after the procedure. For antegrade irrigation, laxative regimens were individualized based on the severity of constipation and comorbid illnesses. VOLUME 57, NO. 6, 2003
J Ramage, T Baron
A
B Figure 2. A, Plain radiograph of abdomen demonstrating colonic distention. B, Plain radiograph of abdomen (same patient as in Fig. 1A) after PEC. Colonic distention has resolved and PEC tube is seen in right lower quadrant. Case reports The review and reporting of 5 cases was approved by the investigators’ Institutional Review Board. All procedures were performed between August 2001 and June 2002. The cases are presented in chronologic order. Case 1. A 69-year-old, man with obesity (body mass index, 43) underwent removal of an infected knee prosthesis. After the procedure, the patient remained immobile and required narcotic pain medication, which resulted in ACPO. Colonoscopic decompression was performed, but ACPO recurred. Neostigmine, given intravenously,10 was effective, but ACPO reoccurred 3 days later (Fig. 2A). Placement of a PEC resulted in colonic decompression (Fig. 2B), and the patient was discharged. Six weeks later, replacement of the knee prosthesis restored mobility. The PEC tube was clamped, and thereafter bowel habits returned to normal. The tube was removed 10 weeks after placement and the residual fistula tract healed within 3 weeks. The cecostomy tube was removed by cutting it at skin level and pushing it into the cecal lumen after which it was passed in the stool. At a 12-month follow-up, the patient was well and without recurrent colonic distention. Case 2. A 37-year-old woman with quadriparesis and neurogenic bowel was hospitalized 4 times over 6 months because of obstipation and vomiting. Percutaneous endoscopic cecostomy was performed on an outpatient basis, although the patient was hospitalized for 24 hours of observation after the procedure. The cecostomy tube was irrigated once per day with polyethylene glycol 3350 (Miralax, GASTROINTESTINAL ENDOSCOPY
753
J Ramage, T Baron
Percutaneous endoscopic cecostomy: a case series
Table 1. Summary of PEC cases Case
Age (y)/gender
Indication
Tube size (F)
Complications
Follow-up (mo)
1 2 3 4 5
69/M 37/F 67/M 47/M 76/F
ACPO Neurogenic bowel Neurogenic bowel Neurogenic bowel ACPO
20 20 20 20 20
None None Leakage/fever None Bleeding
12 8 5 6 2
Braintree Laboratories, Braintree, Mass.), 17 g mixed in 8 ounces of water, followed by flushing with 30 mL of tap water. Daily bowel movements occurred with this regimen, allowing the numerous medications used to regulate bowel function before PEC to be discontinued. At an 8-month follow-up, the patient was well, had not been rehospitalized, and was having nearly normal bowel movements. Case 3. A 67-year-old man with quadriplegia, autonomic dysreflexia, and multiple comorbid illnesses had neurogenic bowel, necessitating chronic use of enemas and laxatives. The patient had multiple hospitalizations for recurrent obstipation. During a hospital admission for abdominal distention with obstipation, a PEC was performed because it was felt that the patient was a poor candidate for surgical colostomy. After the procedure, he developed a fever. Treatment with broad-spectrum antibiotics was continued and within 48 hours the fever resolved. The regimen required to maintain daily bowel movements was a 600 mL bolus of normal saline solution followed immediately by 50 mL of a 50% glycerin solution (Alcon USA, Fort Worth, Tex.). The cecostomy functioned well, and there was no recurrence of obstipation for 6 months, at which time the patient succumbed to respiratory failure. Case 4. A 47-year-old man with a history of traumatic brain injury and paraplegia had neurogenic bowel. Despite treatment for constipation, he had been hospitalized on 3 occasions over the preceding year with abdominal pain, distention, and obstipation. A PEC was placed in the ascending colon because significant looping of the colonoscope in the dilated colon prevented cecal intubation. A regimen of 50 mL of sodium phosphate solution (Fleet Pharmaceutical, Inc., Lynchburg, Va.) mixed with 250 mL of tap water administered once daily resulted in daily bowel movements and all other medications used to regulate bowel function were discontinued. At a 5-month follow-up, the patient was doing well. Case 5. A 76-year-old woman with multiple comorbid illnesses and chronic constipation was confined to bed with compound fractures of both lower extremities. During the ensuing 3 months, she was hospitalized 3 times because of severe abdominal distension and inability to eat. During the third admission for ACPO, a PEC was performed. Because of an existing deep venous thrombosis, treatment with heparin was started within 24 hours of PEC placement, whereupon bleeding developed per rectum and from the cecostomy tube. Anticoagulation was discontinued and the patient was transfused with 2 units of packed red blood cells. The anticoagulation was not resumed, and there was no further bleeding. The patient was discharged 1 week later to a nursing home and has not required readmission. 754
GASTROINTESTINAL ENDOSCOPY
At 8 weeks after PEC placement there was no abdominal distension, bowel movements were described as normal, and the patient was eating well. The cecostomy tube was placed to intermittent suction nightly and is flushed with 30 mL of tap water 4 times per day.
OBSERVATIONS Data for the 5 patients who underwent PEC placement are summarized in Table 1. In 1 of the 2 patients with acute colonic pseudo-obstruction, the percutaneous endoscopic cecostomy tube was clamped and subsequently removed 10 weeks after placement; in the other patient with acute colonic pseudo-obstruction, the percutaneous endoscopic cecostomy tube remains in place. In 2 of the 3 patients with neurogenic bowel, the percutaneous endoscopic cecostomy tube continues to function well; the third patient did well for 6 months and then died of underlying comorbid disease. There was no mortality or need for surgical intervention for any patient. Complications occurred in 2 patients; 1 developed transient fever and leukocytosis and 1 had self-limited bleeding during anticoagulation. DISCUSSION al.4
Ponsky et initially described PEC in 1986 in a report of 2 patients with ACPO that did not resolve after decompressive colonoscopy. The PEC placement resulted in immediate and complete colonic decompression without procedure-related complications. Two patients with ACPO who underwent PEC placement were reported by Salm et al.5 There were no complications and the cecostomy tubes were used for venting. The underlying condition eventually improved in both patients, who resumed having normal bowel movements, and the tubes were removed. Tube cecostomy is an effective alternative to surgical and percutaneous cecostomy for patients with ACPO. Unfortunately, the optimal cecostomy technique has not been established. Although one patient with ACPO in the present series was a candidate for surgical cecostomy, a PEC was carried out during urgent decompressive colonoscopy, thereby obviating the need for additional procedures. Complications of PEC should be similar to those associated with surgical and radiologic techniques, with the possible added risk of perforation of an adjaVOLUME 57, NO. 6, 2003
Percutaneous endoscopic cecostomy: a case series
cent organ/vessel because there is no direct or radiologic visualization of the abdomen. This risk can be minimized by strict adherence to the principles of good transillumination and indentation, as for PEG placement. Identification of an appropriate site for PEC placement in patients with ACPO is generally not difficult because the colon is usually markedly dilated and in close proximity to the abdominal wall. Reported complications after tube cecostomy include pressure necrosis from the external bumper, development of profuse granulation tissue, cellulitis of the abdominal wall, and sepsis.1,3,11 In the present series, complications occurred in 2 patients. One developed self-limited, pericatheter leakage and fever (case 3). The other developed self-limited bleeding when anticoagulation was instituted shortly after the procedure (case 5). Important measures to help avoid complications of PEC include the administration of broad-spectrum antibiotics before and after the procedure and limited, but adequate, application of pressure to the external bumper. Percutaneous endoscopic cecostomy has been used for indications other than ACPO, including uncontrolled fecal incontinence resulting from anorectal malformation or spina bifida in children.7 Rivera et al.8 described the use of PEC for ACE in 10 children with chronic constipation and for venting in 2 children. The children and their families were extremely satisfied with the procedure and the results. The use of PEC for antegrade irrigation for treatment of neurogenic bowel in adults has not been described previously. Three adult patients with neurogenic bowel who were managed successfully with PEC-tube placement are included in the present series. As demonstrated, the type of bowel regimen used for patients with tube cecostomies placed for treatment of chronic constipation or fecal incontinence must be individualized. An advantage of PEC over surgical cecostomy is that the cecostomy tube prevents stenosis of the stoma. However, the primary advantage over surgical cecostomy is the avoidance of general anesthesia. Patients with ACPO and chronic neurogenic constipation typically have significant comorbid illnesses that increase operative risk. Additionally, endoscopic cecostomy minimizes the risk of postoperative complications because of the formation of adhesions.7 Compared with percutaneous cecostomy tube placement, the advantages of PEC are threefold: (1) the endoscopic technique allows direct visualization of the cecum to avoid inadvertent placement of the tube in the terminal ileum or less desirable colonic locations (e.g., areas of ischemic necrosis); (2) the presence of a true internal bumper prevents separation of the colonic and anterior abdominal walls that may result VOLUME 57, NO. 6, 2003
J Ramage, T Baron
in leakage of stool and peritonitis, thereby, avoiding the need for T-fasteners or sutures; and (3) the size of the initial PEC tube can be as large as 24F, whereas multiple, progressive dilations are required with percutaneous placement to achieve this caliber.12 Tube removal and fistula closure were uneventful in the single patient in the present series (case 1) in whom the tube was removed. In general, the cecostomy tube should not be removed by traction because this could result in cecal tearing or disruption of the cecostomy tract. An ostomy appliance can be placed over the tube site after removal to collect fecal drainage until the fistula closes. In a series of patients with surgically placed cecostomy tubes, the rate of persistent cecalcutaneous fistula at more than 4 weeks was 3%, although no patient required surgical closure.1 Percutaneous endoscopic cecostomy is an effective, efficient, and cost-effective treatment for patients with recurrent or refractory ACPO and neurogenic bowel. In our opinion, the use of this technique can be expanded. However, prospective trials comparing outcomes, complications, and cost-effectiveness of various cecostomy techniques would be required to fully validate this recommendation. REFERENCES 1. Benacci JC, Wolff BG. Cecostomy. Therapeutic indications and results. Dis Colon Rectum 1995;38:530-4. 2. Casola G, Withers C, van Sonnenberg E, Herba MJ, Saba RM, Brown RA. Percutaneous cecostomy for decompression of the massively distended cecum. Radiology 1986;158:793-4. 3. van Sonnenberg E, Varney RR, Casola G, Macaulay S, Wittich GR, Polansky AM, et al. Percutaneous cecostomy for Ogilvie syndrome: laboratory observations and clinical experience. Radiology 1990;175:679-82. 4. Ponsky JL, Aszodi A, Perse D. Percutaneous endoscopic cecostomy: a new approach to nonobstructive colonic dilation. Gastrointest Endosc 1986;32:108-11. 5. Salm R, Ruckauer K, Waldmann D, Farthmann EH. Endoscopic percutaneous cecostomy (EPC). Surg Endosc 1988;2:92-5. 6. Ganc AJ, Netto AJ, Morrell AC, Plapler H, Ardengh JC. Transcolonoscopic extraperitoneal cecostomy. A new therapeutic and technical proposal. Endoscopy 1988;20:309-12. 7. De Peppo F, Iacobelli BD, De Gennaro M, Colajacomo M, Rivosecchi M. Percutaneous endoscopic cecostomy for antegrade colonic irrigation in fecally incontinent children. Endoscopy 1999;31:501-3. 8. Rivera MT, Kugathasan S, Berger W, Werlin SL. Percutaneous colonoscopic cecostomy for management of chronic constipation in children. Gastrointest Endosc 2001;53:225-8. 9. Sedlack R, Pochron N, Baron T. PEG placement without a skin incision: Undercutting the competition [abstract]. Gastrointest Endosc 2002;55:AB119. 10. Ponec RJ, Saunders MD, Kimmey MB. Neostigmine for the treatment of acute colonic pseudo-obstruction. N Engl J Med 1999;341:137-41. 11. Maginot TJ, Cascade PN. Abdominal wall cellulitis and sepsis secondary to percutaneous cecostomy. Cardiovasc Intervent Radiol 1993;16:328-31. 12. Morrison MC, Lee MJ, Stafford SA, Saini S, Mueller PR. Percutaneous cecostomy: controlled transperitoneal approach. Radiology 1990;176:574-6. GASTROINTESTINAL ENDOSCOPY
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Surgical cecostomy, including indications for the procedure and the technique, is well described, and there has been considerable experience with this operation.1 There are 2 nonsurgical alternatives to surgical cecostomy: percutaneous cecostomy and percutaneous endoscopic cecostomy (PEC). The techniques and outcomes of percutaneous cecostomy, performed by interventional radiologists, have been reported.2,3 Percutaneous endoscopic cecostomy was first described in 1986 by Ponsky et al.4 for the treatment of acute colonic pseudo-obstruction (ACPO). Subsequently, there have been only two reports describing the use of PEC for ACPO.5,6 Other reports have expanded the range of indications for PEC, including facilitation of antegrade continence enemas (ACE) in pediatric patients with chronic constipation or fecal incontinence.7,8 Treatment of adult Received September 11, 2002. For revision November 7, 2002. Accepted February 5, 2003. Current affiliations: Division of Gastroenterology and Hepatology, Mayo Clinic Foundation, Rochester, Minnesota, and Scottsdale, Arizona. Reprint requests: Todd H. Baron, MD, Mayo Clinic, 13400 E. Shea Blvd., Scottsdale, AZ 85259. Copyright © 2003 by the American Society for Gastrointestinal Endoscopy 0016-5107/2003/$30.00 + 0 doi:10.1067/mge.2003.197 752
GASTROINTESTINAL ENDOSCOPY
A
B Figure 1. A, Endoscopic view within right colon: a 19-gauge needle used to puncture the abdominal wall has entered the colon and is grasped tightly with a snare. B, Endoscopic view (different patient) after PEG tube placement. Mushroom portion of tube is located just distal to cecum seen in background.
patients with neurogenic bowel/constipation by PEC for ACE has not been reported. Experience with PEC placement within the investigators’ health system consists of 2 patients with recurrent ACPO and 3 with neurogenic bowel. PATIENTS AND METHODS Percutaneous endoscopic cecostomy technique Percutaneous endoscopic cecostomy placement was performed using a modification of the technique initially described by Ponsky et al.,4 which is modeled after the PEG pull technique. In patients hospitalized with ACPO or obstipation who underwent PEC placement, broad-spectrum antibiotics typically were being administered for other indications. Otherwise, antibiotics were given prophylactically before PEC placement—for inpatients, piperacillin/tazobactam; for a single outpatient, amoxicillin/clavulanic acid. These antibiotics were chosen to provide coverage against gram-positive (skin) and gram-negative (fecal) bacteria. Administration was continued for 24 VOLUME 57, NO. 6, 2003
Percutaneous endoscopic cecostomy: a case series
hours after the procedure, during which time patients were observed for evidence of complications. When PEC was performed electively for neurogenic bowel, patients ingested a standard polyethylene glycol solution (GoLytely, Braintree Laboratories, Braintree, Mass.) in preparation for the procedure. In patients with ACPO, preparation of the colon was not attempted. Patients fasted for at least 8 hours before the procedure. Conscious sedation was induced by intravenous administration of titrated doses of midazolam and fentanyl or midazolam and meperidine. For colonoscopy in patients with ACPO, particular attention was devoted to keeping air insufflation to a minimum to avoid perforation of the already distended colon. Colonoscopy was performed with standard adult or pediatric endoscopes. Once the cecum or right colon was intubated, the lumen was cleansed to remove any fecal material. With the patient in the supine position, a site for PEC placement was chosen by using transillumination and endoscopically observed indentation in response to pressure exerted with a finger on the abdomen. The abdominal wall was then prepped with betadine solution, and a local anesthetic was injected (1% lidocaine). The contents of standard, commercially available PEG trays with 20F tubes (MIC, Ballard Medical Products, Draper, Utah; or Microvasive Endoscopy, Natick, Mass.) were used with the exception of the snare provided with these kits, which is too short to pass through a colonoscope; a standard polypectomy snare was substituted. The snare was opened within the bowel lumen at the anticipated location of needleentry. The intermediate 19-gauge needle provided in the PEG kits was inserted through the skin into the bowel lumen and tightly grasped at its proximal portion with the snare to maintain apposition of the colon to the anterior abdominal wall (Fig. 1A). With the 19-gauge needle in place, the trocar was advanced through the abdominal wall alongside the needle in the same orientation. The snare was then released from the smaller needle and the trocar was grasped. The remainder of the procedure was as for placement of a PEG tube using the pull technique, with the tube pulled through the anus and into position (Fig. 1B). No skin incision was made, as these investigators have shown in a prospective pilot study, and it is the investigators’ experience with direct percutaneous endoscopic jejunostomy that omission of a skin incision is safe and may reduce the risk of skin infection.9 The external bumper was applied to the abdominal side of the tube and approximated to the skin, with a notation being made of the thickness of the abdominal wall. In most cases, the colonoscope was not reinserted to confirm that the tube was positioned correctly. In patients with ACPO, the PEC tube was placed to gravity drainage or low intermittent suction and flushed with 30 mL of tap water every 6 hours. For patients with neurogenic bowel, the tube was capped with the standard PEG valve and flushed with 30 mL of tap water twice daily, in addition to daily administration of a laxative beginning 4 or more hours after the procedure. For antegrade irrigation, laxative regimens were individualized based on the severity of constipation and comorbid illnesses. VOLUME 57, NO. 6, 2003
J Ramage, T Baron
A
B Figure 2. A, Plain radiograph of abdomen demonstrating colonic distention. B, Plain radiograph of abdomen (same patient as in Fig. 1A) after PEC. Colonic distention has resolved and PEC tube is seen in right lower quadrant. Case reports The review and reporting of 5 cases was approved by the investigators’ Institutional Review Board. All procedures were performed between August 2001 and June 2002. The cases are presented in chronologic order. Case 1. A 69-year-old, man with obesity (body mass index, 43) underwent removal of an infected knee prosthesis. After the procedure, the patient remained immobile and required narcotic pain medication, which resulted in ACPO. Colonoscopic decompression was performed, but ACPO recurred. Neostigmine, given intravenously,10 was effective, but ACPO reoccurred 3 days later (Fig. 2A). Placement of a PEC resulted in colonic decompression (Fig. 2B), and the patient was discharged. Six weeks later, replacement of the knee prosthesis restored mobility. The PEC tube was clamped, and thereafter bowel habits returned to normal. The tube was removed 10 weeks after placement and the residual fistula tract healed within 3 weeks. The cecostomy tube was removed by cutting it at skin level and pushing it into the cecal lumen after which it was passed in the stool. At a 12-month follow-up, the patient was well and without recurrent colonic distention. Case 2. A 37-year-old woman with quadriparesis and neurogenic bowel was hospitalized 4 times over 6 months because of obstipation and vomiting. Percutaneous endoscopic cecostomy was performed on an outpatient basis, although the patient was hospitalized for 24 hours of observation after the procedure. The cecostomy tube was irrigated once per day with polyethylene glycol 3350 (Miralax, GASTROINTESTINAL ENDOSCOPY
753
J Ramage, T Baron
Percutaneous endoscopic cecostomy: a case series
Table 1. Summary of PEC cases Case
Age (y)/gender
Indication
Tube size (F)
Complications
Follow-up (mo)
1 2 3 4 5
69/M 37/F 67/M 47/M 76/F
ACPO Neurogenic bowel Neurogenic bowel Neurogenic bowel ACPO
20 20 20 20 20
None None Leakage/fever None Bleeding
12 8 5 6 2
Braintree Laboratories, Braintree, Mass.), 17 g mixed in 8 ounces of water, followed by flushing with 30 mL of tap water. Daily bowel movements occurred with this regimen, allowing the numerous medications used to regulate bowel function before PEC to be discontinued. At an 8-month follow-up, the patient was well, had not been rehospitalized, and was having nearly normal bowel movements. Case 3. A 67-year-old man with quadriplegia, autonomic dysreflexia, and multiple comorbid illnesses had neurogenic bowel, necessitating chronic use of enemas and laxatives. The patient had multiple hospitalizations for recurrent obstipation. During a hospital admission for abdominal distention with obstipation, a PEC was performed because it was felt that the patient was a poor candidate for surgical colostomy. After the procedure, he developed a fever. Treatment with broad-spectrum antibiotics was continued and within 48 hours the fever resolved. The regimen required to maintain daily bowel movements was a 600 mL bolus of normal saline solution followed immediately by 50 mL of a 50% glycerin solution (Alcon USA, Fort Worth, Tex.). The cecostomy functioned well, and there was no recurrence of obstipation for 6 months, at which time the patient succumbed to respiratory failure. Case 4. A 47-year-old man with a history of traumatic brain injury and paraplegia had neurogenic bowel. Despite treatment for constipation, he had been hospitalized on 3 occasions over the preceding year with abdominal pain, distention, and obstipation. A PEC was placed in the ascending colon because significant looping of the colonoscope in the dilated colon prevented cecal intubation. A regimen of 50 mL of sodium phosphate solution (Fleet Pharmaceutical, Inc., Lynchburg, Va.) mixed with 250 mL of tap water administered once daily resulted in daily bowel movements and all other medications used to regulate bowel function were discontinued. At a 5-month follow-up, the patient was doing well. Case 5. A 76-year-old woman with multiple comorbid illnesses and chronic constipation was confined to bed with compound fractures of both lower extremities. During the ensuing 3 months, she was hospitalized 3 times because of severe abdominal distension and inability to eat. During the third admission for ACPO, a PEC was performed. Because of an existing deep venous thrombosis, treatment with heparin was started within 24 hours of PEC placement, whereupon bleeding developed per rectum and from the cecostomy tube. Anticoagulation was discontinued and the patient was transfused with 2 units of packed red blood cells. The anticoagulation was not resumed, and there was no further bleeding. The patient was discharged 1 week later to a nursing home and has not required readmission. 754
GASTROINTESTINAL ENDOSCOPY
At 8 weeks after PEC placement there was no abdominal distension, bowel movements were described as normal, and the patient was eating well. The cecostomy tube was placed to intermittent suction nightly and is flushed with 30 mL of tap water 4 times per day.
OBSERVATIONS Data for the 5 patients who underwent PEC placement are summarized in Table 1. In 1 of the 2 patients with acute colonic pseudo-obstruction, the percutaneous endoscopic cecostomy tube was clamped and subsequently removed 10 weeks after placement; in the other patient with acute colonic pseudo-obstruction, the percutaneous endoscopic cecostomy tube remains in place. In 2 of the 3 patients with neurogenic bowel, the percutaneous endoscopic cecostomy tube continues to function well; the third patient did well for 6 months and then died of underlying comorbid disease. There was no mortality or need for surgical intervention for any patient. Complications occurred in 2 patients; 1 developed transient fever and leukocytosis and 1 had self-limited bleeding during anticoagulation. DISCUSSION al.4
Ponsky et initially described PEC in 1986 in a report of 2 patients with ACPO that did not resolve after decompressive colonoscopy. The PEC placement resulted in immediate and complete colonic decompression without procedure-related complications. Two patients with ACPO who underwent PEC placement were reported by Salm et al.5 There were no complications and the cecostomy tubes were used for venting. The underlying condition eventually improved in both patients, who resumed having normal bowel movements, and the tubes were removed. Tube cecostomy is an effective alternative to surgical and percutaneous cecostomy for patients with ACPO. Unfortunately, the optimal cecostomy technique has not been established. Although one patient with ACPO in the present series was a candidate for surgical cecostomy, a PEC was carried out during urgent decompressive colonoscopy, thereby obviating the need for additional procedures. Complications of PEC should be similar to those associated with surgical and radiologic techniques, with the possible added risk of perforation of an adjaVOLUME 57, NO. 6, 2003
Percutaneous endoscopic cecostomy: a case series
cent organ/vessel because there is no direct or radiologic visualization of the abdomen. This risk can be minimized by strict adherence to the principles of good transillumination and indentation, as for PEG placement. Identification of an appropriate site for PEC placement in patients with ACPO is generally not difficult because the colon is usually markedly dilated and in close proximity to the abdominal wall. Reported complications after tube cecostomy include pressure necrosis from the external bumper, development of profuse granulation tissue, cellulitis of the abdominal wall, and sepsis.1,3,11 In the present series, complications occurred in 2 patients. One developed self-limited, pericatheter leakage and fever (case 3). The other developed self-limited bleeding when anticoagulation was instituted shortly after the procedure (case 5). Important measures to help avoid complications of PEC include the administration of broad-spectrum antibiotics before and after the procedure and limited, but adequate, application of pressure to the external bumper. Percutaneous endoscopic cecostomy has been used for indications other than ACPO, including uncontrolled fecal incontinence resulting from anorectal malformation or spina bifida in children.7 Rivera et al.8 described the use of PEC for ACE in 10 children with chronic constipation and for venting in 2 children. The children and their families were extremely satisfied with the procedure and the results. The use of PEC for antegrade irrigation for treatment of neurogenic bowel in adults has not been described previously. Three adult patients with neurogenic bowel who were managed successfully with PEC-tube placement are included in the present series. As demonstrated, the type of bowel regimen used for patients with tube cecostomies placed for treatment of chronic constipation or fecal incontinence must be individualized. An advantage of PEC over surgical cecostomy is that the cecostomy tube prevents stenosis of the stoma. However, the primary advantage over surgical cecostomy is the avoidance of general anesthesia. Patients with ACPO and chronic neurogenic constipation typically have significant comorbid illnesses that increase operative risk. Additionally, endoscopic cecostomy minimizes the risk of postoperative complications because of the formation of adhesions.7 Compared with percutaneous cecostomy tube placement, the advantages of PEC are threefold: (1) the endoscopic technique allows direct visualization of the cecum to avoid inadvertent placement of the tube in the terminal ileum or less desirable colonic locations (e.g., areas of ischemic necrosis); (2) the presence of a true internal bumper prevents separation of the colonic and anterior abdominal walls that may result VOLUME 57, NO. 6, 2003
J Ramage, T Baron
in leakage of stool and peritonitis, thereby, avoiding the need for T-fasteners or sutures; and (3) the size of the initial PEC tube can be as large as 24F, whereas multiple, progressive dilations are required with percutaneous placement to achieve this caliber.12 Tube removal and fistula closure were uneventful in the single patient in the present series (case 1) in whom the tube was removed. In general, the cecostomy tube should not be removed by traction because this could result in cecal tearing or disruption of the cecostomy tract. An ostomy appliance can be placed over the tube site after removal to collect fecal drainage until the fistula closes. In a series of patients with surgically placed cecostomy tubes, the rate of persistent cecalcutaneous fistula at more than 4 weeks was 3%, although no patient required surgical closure.1 Percutaneous endoscopic cecostomy is an effective, efficient, and cost-effective treatment for patients with recurrent or refractory ACPO and neurogenic bowel. In our opinion, the use of this technique can be expanded. However, prospective trials comparing outcomes, complications, and cost-effectiveness of various cecostomy techniques would be required to fully validate this recommendation. REFERENCES 1. Benacci JC, Wolff BG. Cecostomy. Therapeutic indications and results. Dis Colon Rectum 1995;38:530-4. 2. Casola G, Withers C, van Sonnenberg E, Herba MJ, Saba RM, Brown RA. Percutaneous cecostomy for decompression of the massively distended cecum. Radiology 1986;158:793-4. 3. van Sonnenberg E, Varney RR, Casola G, Macaulay S, Wittich GR, Polansky AM, et al. Percutaneous cecostomy for Ogilvie syndrome: laboratory observations and clinical experience. Radiology 1990;175:679-82. 4. Ponsky JL, Aszodi A, Perse D. Percutaneous endoscopic cecostomy: a new approach to nonobstructive colonic dilation. Gastrointest Endosc 1986;32:108-11. 5. Salm R, Ruckauer K, Waldmann D, Farthmann EH. Endoscopic percutaneous cecostomy (EPC). Surg Endosc 1988;2:92-5. 6. Ganc AJ, Netto AJ, Morrell AC, Plapler H, Ardengh JC. Transcolonoscopic extraperitoneal cecostomy. A new therapeutic and technical proposal. Endoscopy 1988;20:309-12. 7. De Peppo F, Iacobelli BD, De Gennaro M, Colajacomo M, Rivosecchi M. Percutaneous endoscopic cecostomy for antegrade colonic irrigation in fecally incontinent children. Endoscopy 1999;31:501-3. 8. Rivera MT, Kugathasan S, Berger W, Werlin SL. Percutaneous colonoscopic cecostomy for management of chronic constipation in children. Gastrointest Endosc 2001;53:225-8. 9. Sedlack R, Pochron N, Baron T. PEG placement without a skin incision: Undercutting the competition [abstract]. Gastrointest Endosc 2002;55:AB119. 10. Ponec RJ, Saunders MD, Kimmey MB. Neostigmine for the treatment of acute colonic pseudo-obstruction. N Engl J Med 1999;341:137-41. 11. Maginot TJ, Cascade PN. Abdominal wall cellulitis and sepsis secondary to percutaneous cecostomy. Cardiovasc Intervent Radiol 1993;16:328-31. 12. Morrison MC, Lee MJ, Stafford SA, Saini S, Mueller PR. Percutaneous cecostomy: controlled transperitoneal approach. Radiology 1990;176:574-6. GASTROINTESTINAL ENDOSCOPY
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