2 The procedure

2.1 Indications

2.1.1 Percutaneous endoscopic colostomy is indicated primarily for recurrent sigmoid volvulus (twisting of the section of the bowel above the rectum) and colonic pseudo-obstruction. It may also be indicated in the treatment of children with constipation that is refractory to all medical treatments.

2.1.2 Sigmoid volvulus is more common in people older than 60 years, and in those with Hirschsprung's disease. It is also particularly common in people with chronic constipation. Sigmoid volvulus can be life threatening and must be promptly diagnosed and treated. Emergency treatment usually involves untwisting the bowel using a flatus tube or colonoscope. Subsequently, surgery may be considered to prevent recurrence, especially in patients who have suffered repeated episodes of sigmoid volvulus.

2.1.3 Existing surgical techniques include sigmoidopexy, sigmoidoplasty, sigmoid colectomy and primary anastomosis. These treatment options have varying success rates and open resection may be contraindicated for elderly and frail patients or severely immunocompromised patients.

2.1.4 Percutaneous endoscopic colostomy offers an alternative treatment for patients who have tried conventional treatment options without success or those who are unfit for surgery.

2.2 Outline of the procedure

2.2.1 Percutaneous endoscopic colostomy has evolved from percutaneous endoscopic gastrostomy (PEG).

2.2.2 Percutaneous endoscopic colostomy (PEC) is a minimally invasive procedure. PEC tubing is placed in position using a colonoscope, which is inserted into the left colon through the rectum. A wire is passed through a small skin incision and pulled back through the anal canal via the colonoscope. The PEC tube is tied to the wire, pulled back through the bowel and abdominal wall, and secured against the abdominal wall. The colonoscope is re-inserted to check the final position of the PEC tube. The tube is then attached to a drainage bag, which is usually flushed twice a day. Prophylactic antibiotics are administered for a few days.

2.3 Efficacy

2.3.1 The published evidence on this procedure is limited. The largest published case series includes 15 children with refractory constipation, of whom 14 underwent the procedure and 6 were followed up for 12 months. All children evaluated at 12 months were socially clean (mostly clean with occasional accidents, or no soiling) and two children were able to have the tube removed.

2.3.2 In another case series of 14 elderly patients with recurrent sigmoid volvulus, 5 patients whose tubes had been left in situ remained recurrence free at a mean follow-up of 12.6 months. For more details, refer to the Sources of evidence section.

2.3.3 The Specialist Advisors stated that outcomes seemed to be better in patients with sigmoid volvulus than in those with incontinence or constipation.

2.4 Safety

2.4.1 The most common complications reported were granuloma formation (6/15 and 4/6 in two case series) and infection (3/15 and 2/6). Other reported complications included pain associated with the administration of an enema (1/15), colonic leakage (5/6) and tube erosion (1/6). Preliminary unpublished data from a multicentre UK audit reported a 12% infection rate (13/105 patients) following the procedure. Two deaths attributed to late tube dislodgement were reported in patients treated for recurrent sigmoid volvulus. For more details, refer to the Sources of evidence section.

2.4.2 The Specialist Advisors listed the potential complications as infection, perforation leading to peritonitis, and bleeding.

2.5 Other comments

2.5.1 It was noted that there was an additional death resulting from peritonitis following a PEC procedure.

Andrew Dillon
Chief Executive
March 2006