Traditionally, catheter-based percutaneous cecostomy has been utilized in the setting
of closed-looped colonic obstruction and in selected patients with fecal incontinence
in whom conservative management has failed. Although the procedure is associated with
high rates of technical success, complications including catheter migration or dislodgement
are common and occur in up to a third of patients. Catheter occlusion and leakage
from the catheter site are also common, with leakage often occurring on the skin (20 %)
or within the peritoneum (12 %) [1]
[2]
[3]
[4]
[5]. Here, we explored the option of using a percutaneous, fully covered, self-expandable,
metal stent (FCSEMS) for sequential decompression following malfunction of a percutaneous
catheter. In theory, the caliber of the stent would allow improved drainage, while
the external flange could be secured with a suture, reducing the risk of migration
or dislodgement.
A 44-year-old man with a complex medical history, including heart and kidney transplants
and recurrent urothelial cancer, presented with colonic obstruction, secondary to
metastasis from the latter, at the level of the ascending colon ([Fig. 1 a]). On computed tomography (CT), the cecum was dilated with solid fecal matter and
demonstrated pneumatosis intestinalis of the cecal wall ([Fig. 1 b, c]). As the patient was a poor surgical candidate, traditional colonic stenting was
considered; however, this was deemed unsuitable in view of the high risk of cecal
perforation secondary to gas insufflation. Therefore, we opted for placement of a
CT-guided percutaneous cecostomy tube as a temporizing measure ([Fig. 1 d]).
Fig. 1 Positron emission tomography–computed tomography (CT) scan showing: a metastatic lesion at ascending colon; b dilated cecum filled with semi-solid fecal matter (arrow); and c pneumatosis intestinalis (arrow). d CT-guided percutaneous cecostomy placement.
While technically successful, the percutaneous cecostomy tube failed to provide significant
decompression and the patient experienced both leakage onto the skin and occlusion
of the catheter. Thus, we subsequently exchanged the catheter for an FCSEMS to improve
drainage and decompression ([Video 1]).
Video 1 Percutaneous cecostomy with fully covered self-expandable metal stent for initial
management of severe malignant colon obstruction.
The procedure was performed under general anesthesia, and fluoroscopy was utilized
throughout. A long 0.035-inch Jagwire (Boston Scientific, Marlborough, Massachusetts,
USA) was placed through the original 5 Fr catheter and curled within the cecum ([Fig. 2 a, d]). The catheter was removed over the guidewire, a 1 cm skin incision was made, and
a 4 mm balloon was used to dilate the tract. Over the wire an 18 × 60 mm Niti-S esophageal
stent (Taewoong Medical, Gyeonggi-do, South Korea) was deployed, with the distal flange
fully expanded inside the cecum and the proximal flange expanded outside of the abdomen
([Fig. 2 b, e]). Stool was seen extruding out of the stent immediately after stent deployment.
The stent body was further dilated with a 10 mm dilator balloon ([Fig. 2 c, f]) and the proximal flange was sutured to the skin.
Fig. 2 Placement of a fully covered, self-expandable, metal stent (FCSEMS). a, d Guidewire inserted through the 5 Fr catheter and curled inside the cecum. b, e FCSEMS deployed under fluoroscopic and direct visualization. c, f Stent dilated with 10 mm Hurricane balloon.
The cecum was successfully decompressed following stent placement. The patient subsequently
underwent traditional endoscopic colonic stent placement 1 month later ([Fig. 3]). At follow-up, he continued to have relief of his obstructive symptoms. The percutaneous
stent was removed and the cecostomy was allowed to close spontaneously without complication.
Fig. 3 Colonic stent placed across the obstructing lesion 1 month later.
Percutaneous cecostomy with stent placement presents another minimally invasive option
in the management of high risk malignant colonic obstruction. This therapeutic modality
should be considered in appropriate high risk cases given the potential decrease in
migration, dislodgement, or occlusion when compared with catheter-based approaches.
Endoscopy_UCTN_Code_TTT_1AT_2AZ
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high quality video and all
contributions are freely accessible online.
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