An 83-year-old woman with severe dilated cardiomyopathy and recurrent sigmoid volvulus
([Fig. 1]) who was resident in a nursing home refused to undergo surgery and instead decided
to undergo formation of a percutaneous endoscopic colostomy. A colonoscopy was performed
as far as the cecum after oral preparation, so that the left colon was detorsioned.
At 22 cm from the anal verge, which was the first part of the sigmoid colon that could
be transilluminated, a standard 22-Fr percutaneous endoscopic gastrostomy (PEG) tube
(Compat Nuport, Novartis, Basel, Switzerland) was inserted transanally using the classical
pull-through technique ([Fig. 2]). The patient recovered uneventfully and was discharged 3 days later. An initial
follow-up visit did not reveal any complications ([Fig. 3]).
Fig. 1 Abdominal radiograph in an 83-year-old woman showing the classical “coffee bean”
sign of a sigmoid volvulus.
Fig. 2 Endoscopic view showing the internal bumper of the colostomy tube within the sigmoid
colon.
Fig. 3 a Abdominal computed tomography (CT) scan showing the colostomy tube 1 month after
percutaneous endoscopic insertion. b Photograph of the colostomy tube exiting through the abdominal wall following percutaneous
endoscopic insertion.
The patient re-presented complaining of abdominal distension 7 weeks after the procedure.
Abdominal radiography was consistent with a recurrent lower gastrointestinal volvulus
([Fig. 4]). The typical spiral pattern of the mucosa could be seen at 14 cm from the anal
verge, and the bowel was detorsioned by colonoscopy. Immediately after this colonoscopy,
the patient developed severe abdominal pain and hypotension. An emergency computed
tomography (CT) scan showed a massive pneumoperitoneum and that the colostomy flange
had come loose within the colonic loop ([Fig. 5]). Emergency surgery revealed a hole about 1 cm in diameter in the sigmoid colon
with stool spillage. A resection of the rectosigmoid colon with formation of an end
colostomy was performed, but unfortunately the patient died 24 hours later from cardiopulmonary
failure.
Fig. 4 Abdominal radiograph taken on re-admission 7 weeks later showing a recurrent lower
gastrointestinal volvulus 7 – 8 cm below the sigmoid fixation.
Fig. 5 Abdominal computed tomography (CT) scan revealing a massive pneumoperitoneum and
the internal bumper of the colostomy no longer affixed to the abdominal wall.
A definitive therapy for recurrent sigmoid volvulus in high risk surgical patients
is yet to be determined. Lately percutaneous endoscopic sigmoidostomy has gained interest
as a promising minimally invasive approach [1]
[2]
[3]
[4]. This report stresses that recurrence may still occur below the sigmoid fixation,
an area that is out of reach for this endoscopic procedure because of lack of transillumination.
Furthermore, fatal peritonitis has been reported to be a serious delayed complication
[5] because a colocutaneous fistula may take longer to mature than a PEG owing to the
fragility of the colonic wall and its bacterial contents. This case emphasizes the
need for proper post-procedural care of patients following this procedure.
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