Percutaneous endoscopic cecostomy in adults: a case series

CASE STUDIES

Percutaneous endoscopic cecostomy in adults: a case series Christopher R. Lynch, MD, Robert G. Jones, MD, Kristen Hilden, MS, Jason C. Wills, MD, John C. Fang, MD Salt Lake City, Utah, USA

Background: Percutaneous cecostomy is used to treat recurrent colonic pseudoobstruction or obstipation in children and adults with multiple medical comorbidities. Percutaneous endoscopic cecostomy is a potentially attractive alternative to surgical or fluoroscopic cecostomy placement. A few reports describe percutaneous endoscopic cecostomy for management of these problems in children, whereas there are no large series of percutaneous endoscopic cecostomy in adult patients describing the indications, complications, and outcomes. Objective: Report our experience with percutaneous endoscopic cecostomy in adults. Design: Case series. Setting: Single tertiary referral center in the United States. Patients: Five patients with recurrent colonic pseudoobstruction and 2 with chronic refractory constipation. Interventions: Percutaneous endoscopic cecostomy. Results: Eight cases of percutaneous endoscopic cecostomy were performed from May 2001 through October 2005: 6 for colonic pseudoobstruction and 2 for chronic constipation. Seven of 8 cases were successful and resulted in clinical improvement. One patient required surgical removal of the percutaneous endoscopic cecostomy tube at 4 days for fecal spillage resulting in peritonitis despite successful tube placement for chronic constipation. Removal of the cecostomy tube occurred in 3 of 6 cases of pseudoobstruction (the other 3 remain in place). In the other patient with chronic constipation, clinical improvement occurred, but the patient died of underlying illness 21 days after placement. No other serious complications occurred. Limitations: Retrospective, single-center study. Conclusions: Percutaneous endoscopic cecostomy is a viable alternative to surgically or fluoroscopically placed cecostomy in a select group of patients with recurrent colonic pseudoobstruction or chronic intractable constipation.

Percutaneous cecostomy has been used in cases of chronic intractable constipation, primarily in patients with spinal cord injury or children with severe disability, and for decompression in recurrent colonic pseudoobstruction. A number of reports have detailed the indications, complications, and outcomes of surgically placed cecostomy, primarily for the administration of antegrade continence enemas (ACE) in patients with chronic constipation.1-4 Percutaneous cecostomy placement under fluoroscopic guidance has also been described in a small number of patients with colonic pseudoobstruction.5,6 See CME section; p. 243. Copyright ª 2006 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2006.02.037

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Percutaneous endoscopic cecostomy (PEC) was first described by Ponsky et al7 in 1986 as an alternative to surgically or radiographically placed cecostomy for treatment of acute colonic pseudoobstruction (ACPO). The use of PEC has subsequently been reported for ACPO in 3 studies.8-10 Its use has also been reported for administration of ACE in children11,12 and adults10,13 with chronic intractable constipation. We report our institution’s experience with PEC in 8 cases: 2 with chronic constipation and 6 with recurrent pseudoobstruction.

PATIENTS AND METHODS Seven patients underwent 8 PEC placements between May 2001 and October 2005: 5 patients for recurrent Volume 64, No. 2 : 2006 GASTROINTESTINAL ENDOSCOPY 279

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Figure 1. Endoscopic view of PEC tube. The cecum is seen in the background.

colonic pseudoobstruction and 2 with chronic refractory constipation. One patient with recurrent pseudoobstruction underwent PEC placement twice. The PEC procedure was similar to that described for the PEG pull technique14 as modified by Ponsky et al.7 For patients with refractory constipation, a 2-day preparation of the colon was performed. On day 1, the patients ingested only clear liquids. On day 2, a standard polyethylene glycol solution (GoLYTELY; Braintree Laboratories, Braintree, Mass) or sodium phosphate solution (Phospho-soda; C.B. Fleet Co, Lynchburg, Va) was administered orally per standard protocol. On day 3, the procedure was performed. In patients whose colon was still inadequately prepared, an additional liter of GoLYTELY was administered endoscopically into the cecum, then the colonoscopy was repeated, and the procedure was completed on day 4. In those patients with colonic pseudoobstruction, no preparation was attempted, but the patients were fasting. With the patient under conscious sedation, the colonoscope was advanced to the cecum, and the abdominal wall in the right lower quadrant was transilluminated. The correct position was verified in all patients by cecal indentation with direct digital pressure on the abdominal wall and by transillumination. The abdominal wall was then prepared, draped, and anesthetized in a sterile fashion. A 19-gauge Seldinger cannula was passed through the abdominal wall and into the cecal lumen. A snare was then maneuvered around the needle and tightened over a 300-cm-long wire passed through the needle. The colonoscope, the snare, and the insertion wire were then withdrawn from the colon. The insertion wire was then affixed to a 20F gastrostomy tube (Microvasive Endoscopy, Boston Scientific Corp, Natick, Mass). The PEC tube was slowly pulled retrograde through the colon, exiting the abdominal wall, and was fixed in place with external bolsters in the first 7 cases (Fig. 1). In the most recent case, the cecum was also secured to the abdominal wall with 3 T-fasteners (Brown/ Mueller T-fastener set; Microvasive), approximately 2 cm apart in a triangular configuration around the cecostomy site. The method for T-fastener placement has been described in the radiologic literature5,6,15 and is an adaptation

of a method described in Japan by Uno16 for endoscopic cases. The wound was covered for 24 hours with a sterile dressing. Broad-spectrum intravenous antibiotics were provided before and for 24 hours after the procedure. For patients with colonic pseudoobstruction, the PEC tube was left open for 24 hours and allowed to vent. After that time, the tubes were clamped and opened 2 to 3 times daily for decompression (Fig. 2). Tap water (30-60 mL) was flushed through the tube 3 to 4 times per day. In patients with chronic constipation, daily antegrade enemas with 500 mL GoLYTELY were begun the morning after the procedure and were titrated to 2 to 3 bowel movements per week. The institutional review board at our institution approved the study.

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Figure 2. A, Plain abdominal radiograph, demonstrating colonic distention. B, Repeat plain abdominal radiograph of the same patient after PEC placement. Colonic distention is improved, and the PEC tube is visible in the right lower quadrant.

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Percutaneous endoscopic cecostomy in adults

TABLE 1. Summary of cases of PEC Case

Age (y)/gender

Indication

Procedure duration, min

1

35/F

Constipation

71

2

84/M

PO (recurrent)

3

79/F

4*

Outcome

PEC duration, mo

None

Died 21 d after PEC (malignancy)

1

68

None

PEC removed

6

PO (recurrent)

37

None

PEC removed

9

76/M

PO (recurrent)

102

None

PEC removed

4

5

67/M

PO (recurrent)

85

Peristomal infection

PEC still in use

12

6

82/M

PO (recurrent)

40

Peristomal infection

PEC still in use

8

7

51/M

Constipation

45

Peritonitis

PEC removal/ surgery day 4

d

8*

78/M

PO (recurrent)

None

PEC still in use

1

120

Complications

Constipation, Chronic refractory constipation; PO, pseudoobstruction. *These 2 cases are the same patient; after 4 months of clinical improvement, the first PEC was removed; a second PEC was placed for clinical recurrence 17 months after the first PEC was removed.

OBSERVATIONS PEC placement was successful in 8 of 8 attempts (6 men, 2 women) (Table 1). One patient with recurrent pseudoobstruction underwent PEC placement twice, the second was placed for symptom recurrence 17 months after having the first one removed for stable clinical improvement. Procedure duration averaged 71 minutes (range, 37-120 minutes; median, 70 minutes). Two cases were performed on an outpatient basis. Five patients were discharged 2 days after PEC placement, and 1 inpatient remained in the hospital, where she died 21 days later of unrelated causes. No intraprocedural or immediate postprocedural complications occurred. One patient with chronic constipation developed peritonitis 4 days after PEC placement and underwent surgical removal. During surgery, the PEC was noted to be in the appropriate position. A 4-cm hematoma was seen to have developed during PEC placement by inadvertent puncture of a cecal vein. It is believed that as the hematoma resolved, the cecal wall was free to retract from the abdominal wall, thus leading to transient leakage of fecal contents into the intraperitoneal space, resulting in peritonitis. This patient had an uncomplicated postoperative course. The only other complications noted were 2 cases of peristomal infection successfully treated with oral antibiotics. The other patient with chronic constipation died 21 days after PEC placement of unrelated comorbidities. Her life expectancy was 1 to 3 months, and constipation was the most significant impairment in her quality of life. Her palliative PEC functioned well, and ACE resolved her constipation until her death from underlying malignancy. www.giejournal.org

The remaining 5 patients (all with pseudoobstruction) were followed an average of 7.8 months (range, 1-17 months). In patients whose PEC tubes were removed, follow-up lasted through PEC removal and ostomy closure. In those patients still using a PEC tube, follow-up continues at present. They all experienced significant improvement in subjective and objective abdominal bloating, discomfort, and bowel hygiene. None required further treatment except for the patient previously described who required repeat placement. The original PEC tubes were removed uneventfully by direct traction in 3 patients after an average of 6.3 months (range, 4-9 months), once venting was not needed after clamping the tube for at least 4 weeks. The remaining 2 patients with pseudoobstruction continue to use their original PEC tubes for colonic venting with good results. Their PECs have been in place for 11.4 and 7.7 months.

DISCUSSION To our knowledge, our retrospective case series represents the largest series to date describing experience with PEC in adults with colonic pseudoobstruction or chronic constipation. Ponsky et al7 first described its use in 1986 in 2 patients with ACPO who were unsuccessfully treated with colonoscopic decompression. In both cases, PEC successfully and rapidly led to colonic decompression without complications. Salm et al8 reported 2 cases of uncomplicated PEC used for venting in adult patients with colonic pseudoobstruction. Ramage and Baron10 were the first to report the use of PEC for neurogenic bowel in adults, describing their experience with PEC in Volume 64, No. 2 : 2006 GASTROINTESTINAL ENDOSCOPY 281

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3 patients with neurogenic bowel and an additional 2 with ACPO. There were no serious complications, and each patient improved clinically with PEC. We reported our initial experience with PEC in 1 adult patient with chronic constipation,13 who was included in the present series. In the present case series, PEC was a well-tolerated alternative to surgically or fluoroscopically placed cecostomy. Our patients each experienced subjective and clinical improvement. One of our 8 patients experienced a significant complication of peritonitis that required surgical PEC removal. This was felt to be caused by resolution of a space-occupying hematoma that resulted from inadvertent cecal-vein laceration. As a result, we have since modified our procedure so that 3 T-fasteners are placed in a triangular fashion around the PEC tube to affix the cecal wall tightly against the abdominal wall. We remove the T-fasteners 2 to 4 weeks later. Our overall procedural success, outcomes, and complication rates are comparable with those previously described when performed surgically, radiologically, or endoscopically.2,7-12,17,18 Compared with surgical cecostomy, endoscopic placement offers a number of advantages. General anesthesia is avoided in these patients, who may have increased surgical risk because of comorbidities. The presence of a cecostomy tube maintains stoma patency, and endoscopically placed cecostomy is reversible after improvement of the primary disease process. Cecostomy placement under endoscopic visualization rather than fluoroscopic guidance minimizes the risk of tube placement in the terminal ileum or other unfavorable sites, does not subject the patient to radiation, and may even be performed at the bedside. We suggest replacement with either standard or balloon-type replacement tubes should PEC malfunction occur, but, in our case series, no replacement was necessary. In our experience, PEC is a safe and effective option in the management of acute or chronic/recurrent colonic pseudoobstruction and chronic refractory constipation. Specific situations in which PEC may be useful for constipation include refractoriness or intolerance to medical management or an inability to undergo surgical colectomy because of comorbidity or patient preference. Further study in a prospective fashion needs to be performed to further outline its clinical indications, therapeutic possibilities, and potential complications.

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for Astra-Zeneca and Novartis. None of the remaining authors have disclosures to make.

REFERENCES 1. Benacci JC, Wolff BG. Cecostomy. Therapeutic indications and results. Dis Colon Rectum 1995;38:530-4. 2. Malone PS, Ransley PG, Kiely EM. Preliminary report: the antegrade continence enema. Lancet 1990;336:1217-8. 3. Chait PG, Shandling B, Richards HF. The cecostomy button. J Pediatr Surg 1997;32:849-51. 4. Fonkalsrud EW, Dunn JC, Kawaguchi AI. Simplified technique for antegrade continence enemas for fecal retention and incontinence. J Am Coll Surg 1998;187:457-60. 5. vanSonnenberg E, Varney RR, Casola G, et al. Percutaneous cecostomy for Ogilvie syndrome: laboratory observations and clinical experience. Radiology 1990;175:679-82. 6. Morrison MC, Lee MJ, Stafford SA, et al. Percutaneous cecostomy: controlled transperitoneal approach. Radiology 1990;176:574-6. 7. Ponsky JL, Aszodi A, Perse D. Percutaneous endoscopic cecostomy: a new approach to nonobstructive colonic dilation. Gastrointest Endosc 1986;32:108-11. 8. Salm R, Ruckauer K, Waldmann D, et al. Endoscopic percutaneous cecostomy (EPC). Surg Endosc 1988;2:92-5. 9. Ganc AJ, Netto AJ, Morrell AC, et al. Transcolonoscopic extraperitoneal cecostomy. A new therapeutic and technical proposal. Endoscopy 1988;20:309-12. 10. Ramage JI, Baron TH. Percutaneous endoscopic cecostomy: a case series. Gastrointest Endosc 2003;57:752-5. 11. DePeppo F, Iacobelli BD, DeGennaro M, et al. Percutaneous endoscopic cecostomy for antegrade colonic irrigation in fecally incontinent children. Endoscopy 1999;31:501-3. 12. Rivera MT, Kugathasan S, Berger W, et al. Percutaneous colonoscopic cecostomy for management of chronic constipation in children. Gastrointest Endosc 2001;53:225-8. 13. Wills JC, Trowbridge B, DiSario JA, et al. Percutaneous endoscopic cecostomy for management of refractory constipation in an adult patient. Gastrointest Endosc 2003;57:423-6. 14. Ponsky JL, Gauderer MW. Percutaneous endoscopic gastrostomy: a nonoperative technique for feeding gastrostomy. Gastrointest Endosc 1981;27:9-11. 15. Ryan JM, Hahn PF, Boland GW, et al. Percutaneous gastrostomy with T-fastener gastropexy: results of 316 consecutive procedures. Radiology 1997;203:496-500. 16. Uno Y. Neurogenic bowel and antegrade continence enema by cecostomy. Tokyo (Japan); 2005. 17. Chait PG, Shandling B, Richards HM, et al. Fecal incontinence in children: treatment with percutaneous cecostomy tube placement: a prospective study. Radiology 1997;203:621-4. 18. Chait PG, Sclomovitz E, Connolly BL, et al. Percutaneous cecostomy: updates in technique and patient care. Radiology 2003;227:246-50.

Received December 12, 2005. Accepted February 20, 2006.

DISCLOSURE J. C. Fang receives grant support from Novartis, is a consultant for In-scope, and is in the speaker’s bureau

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Current affiliations: Department of Internal Medicine (Dr Lynch), Division of Gastroenterology, Hepatology, and Nutrition (Dr Jones, Ms Hilden, Dr Wills, and Dr Fang), University of Utah Health Sciences Center, Salt Lake City, Utah, USA. Reprint requests: Reprints are not available from the authors.

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