Gastrointestinal: “Introducer‐to‐pull type switch” approach for long‐term percutaneous endoscopic cecostomy

Abstract

Percutaneous endoscopic cecostomy (PEC) is an uncommonly used rescue approach for refractory constipation and/or pseudoobstruction. The introducer method may, albeit no comparative data are available, increase safety by providing a cecopexy limiting risk of peritoneal soiling. By contrast, this approach hinges on balloon tube application prone to dislocation, providing a clinical rationale to switch to a standard pull-type tube after tract maturation. A 73-year-old patient suffering from diabetes mellitus type 2 and Parkinson’s disease presented for the second time for abdominal distension and constipation. Further diagnostic work-up indicated high-grade chronic colonic pseudoobstruction with a cecal diameter of up to 11 cm. Given the lack of clinical improvement under laxatives and colon prokinetics, PEC was recommended after adequate counseling. First, we performed an uncomplicated introducer-type PEC as per standard proceedings under a 3-day peri-interventional antibiotic regime with ceftriaxone. To this end, a gastropexy device from a commercially available set (Freka Pexact, Fresenius Kabi, Bad Homburg, Germany) was used to place three sutures at maximal diaphanoscopy with adequate distance from critical structures such as appendix base and/or ileocecal valve (Fig. 1a). Next, the center of sutures arranged in a triangular fashion was punctured with a large trocar with a peel-away sheath (Fig. 1b), through which a balloon tube was inserted and adequately blocked (Fig. 1c). After accidental tube dislocation 2 months later and urgent external re-insertion, a switch to a standard tube to reduce the risk of inadvertent tube removal was suggested. Therefore, another uncomplicated lower endoscopy was performed, and a wellmatured PEC tract could be confirmed in a through-the-balloon view (Fig. 1d). After insertion through the unblocked balloon tube, a nylon thread was grasped with a standard biopsy forceps and withdrawn through the anus together with the endoscope (Fig. 1e). As a last step, a standard gastrostomy tube was introduced in a pull fashion with endoscopic confirmation of optimal placement (Fig. 1e). Regular tube mobilization and avoidance of excessive traction have been recommended to limit risk of colonic buried bumper syndrome. Although the presented “introducer-to-pull type switch” approach in long-term PEC follows a sound clinical rationale, systematic study is needed to assess its true benefits and risks.