Interventional procedure consultation document - percutaneous endoscopic colostomy
NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE
Interventional Procedure Consultation Document
Percutaneous endoscopic colostomy
The National Institute for Health and Clinical Excellence is examining percutaneous endoscopic colostomy and will publish guidance on its safety and efficacy to the NHS in England, Wales and Scotland. The Institute's Interventional Procedures Advisory Committee has considered the available evidence and the views of Specialist Advisors, who are consultants with knowledge of the procedure. The Advisory Committee has made provisional recommendations about percutaneous endoscopic colostomy.
Note that this document is not the Institute's formal guidance on this procedure. The recommendations are provisional and may change after consultation.
The process that the Institute will follow after the consultation period ends is as follows.
For further details, see the Interventional Procedures Programme manual, which is available from the Institute's website (www.nice.org.uk/ipprogrammemanual).
Closing date for comments: 20 December 2005
Note that this document is not the Institute's guidance on this procedure. The recommendations are provisional and may change after consultation.
Current evidence on the safety and efficacy of percutaneous endoscopic colostomy appears adequate to support the use of this procedure in elderly and frail patients with recurrent sigmoid volvulus and colonic motility problems provided that the normal arrangements are in place for audit and clinical governance.
|1.2||Evidence on the use of percutaneous endoscopic colostomy in children is limited. The care of children with chronic refractory constipation is complex and further evidence on the efficacy of the procedure and its place in the management of children would be useful. Patient selection in children is particularly important and should involve a multidisciplinary team that includes a paediatric gastroenterologist and colorectal surgeon. This procedure should be performed in specialist paediatric units.|
Patients and/or their parents should be fully informed about the potential risk of peritonitis. They should be provided with clear written information. In addition, use of the Institute's Information for the public is recommended (available from www.nice.org.uk/IPGXXXpublicinfo [details to be available at publication]).
|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 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 frail, elderly patients or the severely immunocompromised.|
Percutaneous endoscopic colostomy offers an alternative treatment for patients who have tried conventional treatment options without success or who are unfit for surgery.
|2.2||Outline of the procedure|
|2.2.1||Percutaneous endoscopic colostomy has evolved from percutaneous endoscopic gastrostomy (PEG).|
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.
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. In another case series of 14 patients with recurrent sigmoid volvulus, five 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 (see Appendix).
The Specialist Advisors stated that outcomes seemed to be better in patients with sigmoid volvulus than in those with incontinence or constipation.
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 (see Appendix).
|2.4.2||The Specialist Advisors listed the potential complications as infection, perforation leading to peritonitis, and bleeding.|
Chairman, Interventional Procedures Advisory Committee
|Appendix:||Sources of evidence|
The following document, which summarises the evidence, was considered by the Interventional Procedures Advisory Committee when making its provisional recommendations.
Available from: www.nice.org.uk/ip74overview
This page was last updated: 04 February 2011