Additional experience of endoscopic T-bar sigmoidopexy

Endoscopic-Assisted Percutaneous Sigmoidopexy: New Highlights on Technique and Outcomes

Background

Sigmoid volvulus is primarily a disease of the elderly.

Case Presentation

We describe a case of recurrent sigmoid volvulus in an elderly woman who refused surgery due to the high risk posed by general anesthesia and surgical intervention. She underwent endoscopic-assisted percutaneous sigmoidopexy using only three 2-shot anchor sets. No radiographic observation was necessary during the procedure. Some puncture sites were secured using endoscopic clips.

Conclusion

Endoscopic-assisted percutaneous sigmoidopexy is increasingly used as an effective alternative to surgical sigmoidopexy when surgery under general anesthesia poses a high risk. Despite clinical improvement and resolution of the recurrent volvulus, after sigmoidopexy patients may continue to experience motility dysfunction and diffuse dilation of the colon for a few weeks, which may correlate with the episodes of obstruction experienced prior to fixation.

Percutaneous endoscopic sigmoidopexy using T-fasteners for management of sigmoid volvulus

BACKGROUND

Sigmoid volvulus (SV) is the third leading cause of large bowel obstruction after colonic neoplasms and diverticular disease. SV has traditionally been managed via endoscopic detorsion and decompression followed by non-emergent surgical resection owing to the high risk of recurrence. Most cases of SV occur in elderly debilitated patients with multiple comorbidities and may not be candidates for surgical resection. Endoscopic sigmoidopexy has been described as an alternative to surgical resection. Here, we describe our experience with endoscopic sigmoidopexy using T-fasteners.

METHODS

Three patients with recurrent SV that were identified as poor surgical candidates by our colorectal surgery team underwent endoscopic sigmoidopexy. The patients received preoperative bowel preparation. A colonoscope was inserted and the site of the volvulus was visualized and assessed for adequate decompression. Subsequently, four points of fixation were identified and T-fasteners were deployed.

RESULTS

Two patients underwent successful sigmoidopexy without any complications or recurrence on follow-up. One patient developed post procedure pneumoperitoneum that was successfully treated conservatively; however, he passed away from their underlying comorbidities.

CONCLUSION

Overall, preliminary results for sigmoidopexy using T-fasteners have been promising, offering a potential option to prevent recurrence in high risk patients unsuitable for surgical intervention.

Prospective analysis of percutaneous endoscopic colostomy at a tertiary referral centre

BACKGROUND

Percutaneous endoscopic colostomy (PEC) is an alternative to surgery in selected patients with recurrent sigmoid volvulus, recurrent pseudo-obstruction or severe slow-transit constipation. A percutaneous tube acts as an irrigation or decompressant channel, or as a mode of sigmoidopexy. This prospective study evaluated the safety and efficacy of this procedure at a single tertiary referral centre.

METHODS

Nineteen patients with recurrent sigmoid volvulus, ten with idiopathic slow-transit constipation and four with pseudo-obstruction underwent PEC. The tube was left in place indefinitely in those with recurrent sigmoid volvulus or constipation, whereas in patients with pseudo-obstruction it was left in place for a variable period of time, depending on symptoms.

RESULTS

Thirty-five procedures were performed in 33 patients. Three patients developed peritonitis, of whom one died, and ten patients had minor complications. Symptoms resolved in 26 patients.

CONCLUSION

This large prospective study has confirmed the value of PEC in the treatment of recurrent sigmoid volvulus and pseudo-obstruction in high-risk surgical patients.