Introduction
Volvulus is the underlying cause of 5 % to 8 % of all bowel obstructions with sigmoid
volvulus accounting for 40 – 70 % of colonic volvulus [1]. Sigmoid volvulus occurs when the sigmoid colon twists on its mesenteric axis [2]. The patient demographic varies across the world, however, in Western populations,
patients tend to be elderly with significant comorbidities [3]. Predisposing factors for sigmoid volvulus are thought to be a long redundant loop
of sigmoid colon with an elongated mesentery [4], chronic constipation, and neurological diseases [5].
Patients present with absolute constipation and abdominal distention. The diagnosis
is usually confirmed on abdominal x-ray or, if there is diagnostic doubt, with computed
tomography [6]. Initial treatment is with endoscopic decompression but the risk of recurrence is
high (40 %-90 %) [7]
[8] as the procedure is not curative. Large bowel resection is the “gold standard” management
for recurrent sigmoid volvulus but emergency resection has been reported to carry
a mortality of up to 50 % [9]. The challenge in these patients is that recurrent sigmoid volvulus is associated
with a mortality of 7 % [5] and therefore there is a need to try and treat them definitively while avoiding
the risk of surgery. Percutaneous endoscopic colostomy provides an alternative management
option for frail and elderly patients who are felt to be too high risk for surgery.
The National Institute for Health and Clinical Excellence (NICE) guidelines published
in 2006 highlight the different options available for the treatment of sigmoid volvulus.
They also explain that open resection may be contraindicated in frail or elderly patients.
The guidelines subsequently state that percutaneous endoscopic colostomy offers an
alternative treatment option for those who are unfit for surgery or who have tried
alternatives without success [10].
This paper reviews the current literature evaluating percutaneous endoscopic colostomy
as a definitive treatment for recurrent sigmoid volvulus in patients where surgery
is felt not to be an option and assesses whether the 2006 NICE guidelines [10] are still valid.
Methods
A systematic literature search was conducted using PubMed, Web of Science, and Embase.
Only English language papers were included. The exploded search terms “Percutaneous
Endoscopic Colostomy” and “Sigmoid Volvulus” were used. Librarian support was used
to ensure that the maximum number of relevant articles were returned. Published abstracts
from meetings and letters were excluded on the basis that they provided insufficient
evidence for comparison.
The abstracts identified in the literature search were then analyzed and included
if they used percutaneous endoscopic colostomy to treat sigmoid volvulus either as
a single intervention or compared to surgery. Studies that used percutaneous endoscopic
colostomy to treat a number of conditions including sigmoid volvulus were included
if the results from sigmoid volvulus patients could be separated from the other conditions.
Backward chaining was used to identify any papers that had been missed in the original
database search. The papers were then graded according to the strength of evidence
they provided.
Results
Five observational studies and 5 case reports were identified which met the inclusion
criteria. They provided data on 56 patients with recurrent sigmoid volvulus treated
with percutaneous endoscopic colostomy placement. All the patients were considered
too high risk for resectional surgery or had repeatedly refused it. The risk of resectional
surgery was assessed using the American Society of Anesthesiologists (ASA) fitness
score or World Health Organization performance status. Significant comorbidities and
frailty were also considered when assessing fitness for surgery. The largest and only
prospective study involved 19 patients [11]. A flowchart of the search strategy used for PubMed is shown in [Fig. 1].
Fig. 1 Flowchart of PubMed search strategy. One further relevant paper identified with librarian
support.
Procedure
Where specific information on the procedure was available, all techniques for PEC
tube placement were comparable. All patients were given prophylactic intravenous (IV)
antibiotics at the time of the procedure and closely observed afterward for complications.
The patients were all given conscious sedation and the site of the PEC tube was identified
using transillumination [7]
[11]
[12] or fluoroscopy [2]. Techniques using 1 or 2 PEC tubes for fixation are both described. Full results
by paper are listed in [Table 1].
Table 1
Details of studies using percutaneous endoscopic colostomy to treat recurrent sigmoid
volvulus.
|
Paper
|
Type of paper
|
No. of patients
|
Patient characteristics
|
Method of PEC
|
Type of device used
|
PEC tubes removed
|
Recurrence of volvulus?
|
Length of follow up
|
Complications
|
|
Choi and Carter (1998)
|
Case report
|
1
|
93-year-old lady, full-time nursing care, dementia, Parkinson’s disease, schizophrenia,
TIAs, heart failure, not suitable for GA
|
2 PEC tubes sited
|
Standard PEG equipment, 2 points selected 15 cm either side of the apex.
|
Both removed at 1 month
|
No
|
9 months
|
Nil
|
|
Daniels et al (2000)
|
Retrospective observational study
|
14
|
Mean age: 78 yr (Age range 53 – 99). Conventional surgery considered unsafe or inappropriate.
|
2 PEC tubes sited
|
14Fr gastrostomy tube (Freka, Frenius, Warrington,UK)
|
8 removed at 6 weeks
|
3 /8 when PEC tubes removed after 6 weeks
|
7 – 21 months (mean 12.6 months)
|
1 patient pulled PEC tube out after 24 hr and therefore underwent sigmoid resection.
|
|
Baraza et al (2007)
|
Prospective observational study
|
19
|
ASA III or more, poor candidates for surgery. Median Age 79 yr (Age range 65 – 99)
|
2 PEC tubes sited (only 1 PEC tube sited in 5 patients due to frailty and technical
difficulties)
|
Corflo® 20 Fr PEG tube
|
6 /19 patients requested tube removal between 5 and 26 months
|
1 recurrence after 2nd PEC tube was removed secondary to infection.
|
Median follow up 35 months (21 – 89 months)
|
1 /19 developed peritonitis secondary to tube migration, 7/19 minor complications
(2 abdominal wall bleeds, 4 site infections, 1 buried bumper). 1/19 failure to insert
PEC tube.
|
|
Cowlam et al (2007)
|
Retrospective observational study
|
8
|
Mean Age: 80.4 yr, Median WHO performance status: 3, Median number of comorbidities:
2
|
Single PEC tube
|
Corflo® 14Fr or 20Fr PEG tube or Corflo® 12 Fr PEC tube
|
3 removed/dislodged
|
nil
|
Mean 8.8 months with PEC tube in situ (SEM ± 2.30 months)
|
1 episode of buried bumper syndrome, 1 episode of granulation, 1 episode of fecal
leakage and 7 infective episodes per 100 patient months with PEC tube in situ.
|
|
Mullen et al (2009)
|
Case report
|
1
|
87-year-old woman, bed bound nursing home resident, previous subarachnoid and intracerebral
hemorrhage with significant motor deficit
|
Single PEC tube
|
Corflo® 16Fr PEG tube
|
nil
|
nil
|
3 months
|
Nil
|
|
Al-Alawi, 2010
|
Case report
|
1
|
93-year-old man with AF on warfarin, IHD and asthma
|
2 PEC tubes sited
|
20Fr PEG tube
|
1 of 2 removed after 20 months as had eroded through the skin.
|
1 recurrence 6 months after proximal PEC tube removed
|
2 years
|
Nil
|
|
Molina-Infante et al, 2012
|
Case report
|
1
|
83-year-old woman, severe silated cardiomyopathy and nursing home resident refused
surgery.
|
Single PEC tube
|
22Fr PEG tube
|
Nil
|
1 after 7 weeks
|
7 weeks
|
After recurrent volvulus successfully detorsioned, perforated and required laparotomy,
died 24 hours later
|
|
Toebosch et al, 2012
|
Case report
|
1
|
73-year-old woman, severe Parkinson’s disease, previous breast cancer and resection
of local recurrence.
|
Single PEC tube
|
PEC tube placed (no details of device available)
|
Nil
|
1 after 2 years
|
2 years
|
Nil
|
|
Khan et al (2013)
|
Retrospective observational study
|
8
|
Median age 88 yr (range 85 – 95)
|
2 PEC tubes sited
|
15Fr PEG tube (Freka, Frenius, Warrington,UK)
|
2
|
2 after PEC tubes removed.
|
Median 12 months (6 – 24 months)
|
1 leakage at PEC site, 1 postoperative pain
|
|
Ifverson and Kjaer (2014)
|
Retrospective observational Study
|
2
|
2 patients deemed unfit for surgery
|
No details
|
No details
|
No
|
No details
|
No details
|
In 1 patient derotation was not achieved prior to fixation. 1 patient died after 36
days and the other after 9 months.
|
One vs 2 PEC tubes for fixation
Sixteen of the 56 patients were treated with a single percutaneous endoscopic colostomy
tube while 38 patients were treated with 2 percutaneous endoscopic colostomy tubes.
In 5 patients insertion of 2 PEC tubes was planned but due to “frailty and technical
difficulties,” only 1 tube was sited [11]. For 2 patients there was no information about the number of PEC tubes or the method
of insertion [5].
Complications
Despite administration of prophylactic antibiotics, each observational study described
a number of complications secondary to PEC tube placement, the most common of which
was wound infection; a number of patients developed major complications including
peritonitis. Cowlam et al [12] published their complication data as complications per 100 patient-months with PEC
tube in situ, which meant that it was not possible to directly compare their complication
rate with that from other studies in which absolute figures were published.
Major Complications
Five of 56 patients developed major complications following PEC tube insertion. Two
patients with cognitive impairment (1 with learning difficulties, 1 with dementia)
pulled their PEC tubes out, 1 24 hours after insertion [7] and the other after 1 year. One patient developed peritonitis after 4 days, due
to fecal contamination secondary to tube migration. This was managed conservatively
due to the patient’s ASA and the patient died 7 days post-procedure [11]. Two further patients died following PEC tube insertion, 1 after 36 days and the
other after 9 months [5].
Minor Complications
Nine patients developed minor complications following the procedure. The most commonly
reported minor complication was infection at the PEC site, which occurred in 4 patients
and was resolved with antibiotics in all but 1 patient [11]. Two instances of abdominal wall bleeds were described. One patient developed buried
bumper syndrome (managed conservatively due to frailty) [11]. Khan et al [2] described 2 other minor complications: leakage at the PEC site in 1 patient and
significant postoperative pain in another patient. Cowlam et al [12] described 1 episode of buried bumper, 1 episode of granulation, and 1 of fecal leakage
per 100 patient-months with PEC tube in situ. They also reported that infection was
the most common complication, with 7 infective episodes per 100 patient-months with
PEC tube in situ.
Recurrence of Volvulus and Removal of PEC tubes
Four of 56 patients developed a recurrent sigmoid volvulus with a PEC tube in situ
[11]
[13]
[14]
[15]. The first occurred 7 weeks after insertion of a single PEC tube below the level
of fixation. Although the volvulus was successfully detorsioned at colonoscopy, the
patient developed severe abdominal pain and a massive pneumoperitoneum was shown on
computed tomography. At laparotomy a 1-cm hole was seen on the sigmoid colon with
stool spillage. The patient underwent a Hartmann’s procedure but died 24 hours later
[14]. Two other patients developed recurrent sigmoid volvulus when 1 of their 2 PEC tubes
was removed. Both patients were successfully treated by reinserting a second PEC tube
[11]
[15]. The final patient developed a recurrent sigmoid volvulus 2 years after a single
PEC tube was successfully used to treat his recurrent sigmoid volvulus. No complications
were described in the intervening period [13].
Choi and Carter [16] removed both PEC tubes after 1 month with no complications. However, when Daniels
et al [7] removed the colostomy tubes at 6 weeks in the first 8 patients that they treated,
3 patients developed recurrent sigmoid volvulus, so subsequent tubes were left in
situ indefinitely. Three patients in the Cowlam et al [12] study had their PEC tubes removed or dislodged, 1 patient underwent definitive surgery,
1 patient died from fecal peritonitis, and 1 patient remained symptom free.
In the Baraza et al [11] study, 6 of 19 patients requested that tubes be removed between 5 and 26 months
with no subsequent relapse. However, 2 patients in the Khan study [2] developed recurrent sigmoid volvuluses when their PEC tubes were removed and had
to undergo a further procedure to have them reinserted.
Follow up
In all the studies there were a significant number of deaths from unrelated causes
during the follow-up period. The length of follow up described was variable, the shortest
being 3 months [3] and the longest 89 months [11].
Discussion
The data available on percutaneous endoscopic colostomy to treat sigmoid volvulus
are limited. There is no level 1 or level 2 evidence available and the current published
studies are small and predominantly retrospective in nature, leading to inferential
uncertainty of the results.
This review supports the view that 2-point fixation and permanent PEC improves outcome
[2] as there were no episodes of recurrent sigmoid volvulus with 2 PEC tubes in situ.
Four of 16 patients (25 %) developed recurrent sigmoid volvulus with a single PEC
tube in situ. Interestingly in 2 patients with PECs in situ, that occurred when 1
of the PEC tubes was removed and no further recurrences occurred once the second PEC
tube had been replaced [11]
[15]. Daniels et al [7] demonstrated that there was no residual fixation between the colon and abdominal
wall when the PEC tubes were removed after 6 weeks. Baraza et al [11] removed 6 PEC tubes on patient request after a minimum of 5 months. This did not
result in any subsequent relapse, perhaps suggesting that adhesions slowly form between
the sigmoid colon and the anterior abdominal wall to prevent further episodes of sigmoid
volvulus even after PEC tube removal. The majority of patients found having a long-term
PEC tube in situ acceptable [3]
[7] and, therefore, from the current evidence we would recommend keeping 2 PEC tubes
in situ indefinitely.
One challenge with percutaneous endoscopic colostomy is the technical difficulty associated
with insertion. Five patients in the Baraza study [11] only had 1 PEC tube sited “because of frailty and technical difficulties.” Khan
et al [2] described 3 patients who needed multiple PEC procedures due to “failure, technical
reasons or poor bowel prep.” Baraza et al [10] also highlighted the potential for misidentifying the location of the colonoscope
using transillumination alone as these patients often have long redundant loops of
sigmoid. They therefore recommended using a scope guide to check positioning prior
to PEC siting.
Two patients complained about the position of their PEC tubes [11]. The scope guide may help to rectify this issue although it may be necessary to
involve specialist nurses in a similar manor to pre-operative stoma siting to ensure
that the PEC tubes are in a convenient position for both patients and carers if they
are to remain in situ indefinitely.
One patient with learning difficulties and 1 patient with dementia inadvertently pulled
their PEC tubes out, 1 underwent sigmoid resection and the other developed peritonitis
and it was felt was unsuitable for surgical intervention [7]
[12]. These 2 cases suggest that PEC tubes are not safe in patients with cognitive impairment
due to the need for the PEC tube to remain in situ for a prolonged period of time.
Cowlam et al [12] argued that the complication rate was too high to support the widespread use of
PEC. The complication rate, however, has to be considered in the context of treating
patients who were ASA III or IV with significant comorbidities. In these case series
there is a 21 % risk of morbidity and 5 % risk of mortality from the use of a PEC,
which is favorable compared to the mortality risk of 6.6 % to 44 % reported with operative
intervention [17].
Infection was the most commonly reported complication. Baraza et al [11] reported infections in 4 out of 19 patients, which is similar to the infection rate
described in the NICE guidelines [10]. Cowlam et al [12] reported 1 or more episodes of infection in 77 % patients. That is much higher than
reported in previous studies, although the reason for it was unclear. Routinely giving
IV antibiotics for 24 hours post procedure could help lower the infection rate, especially
as many of these patients are vulnerable to infections.
Prolonged follow up of these patients is challenging due to the high death rate from
unrelated causes. Sixteen patients died from unrelated causes during follow up. This
high death rate demonstrates the frailty of these patients. It is therefore important
to focus outcomes on recurrence of volvulus and complications as these have a significant
impact on quality of life.
Conclusions
Three observational studies and 4 case studies have been published since issuance
of the 2006 NICE guidelines on percutaneous endoscopic colostomy to treat recurrent
sigmoid volvulus. Overall these studies add to the evidence base to support the use
of PEC in frail and elderly patients. The current evidence suggests that placement
of 2 PEC tubes reduces the risk of recurrent sigmoid volvulus. PEC tubes should be
left in situ indefinitely due to the risk of recurrent symptoms once they are removed.
Larger studies with a longer follow-up period are needed to identify the longer-term
risks and benefits of this procedure.
