Clinical History
Acute colonic pseudo- obstruction, refractory to conservative treatment and endoscopic decompression
Imaging Findings
Patient was admitted for peritonitis and underwent surgery which revealed a perforated appendix. His previous medical history included insulin- dependent diadetes mellitus, small cell lung carcinoma, and chronic lung insufficiency secondary to post- radiation pulmonary fibrosis and pleural effusions. The post operative period was characterized by difficulty in weaning the patient from mechanical ventilation as well as progressive colonic dilatation over a two-week period that was refractory to naso-gastric aspiration and fluid-electrolyte correction. Mechanical colonic obstruction was excluded with an X-ray enema and a preliminary diagnosis of colonic pseudo-obstruction was made.
Endoscopic decompression was attempted three times at three to four days intervals but colonic aspiration could not be left in the dilated colon endoscopically. A surgical drainage was not considered because of the poor general status of the patient. Since the last colonoscopy did not show signs of severe colonic ischemia, a fluoroscopic cecostomy with pexy was attempted the same day than CT (Fig1).
The percutaneous cecostomy (PCC) with pexy utilized four T- fasteners (Brown- Mueller, gastrostomy kit ; Meditech/ Boston Scientific, Watertown, Mass. USA) with light traction, allowing for the ventral part of the cecum to adhere to the deep portion of the abdominal wall before tube insertion (Fig 2).
A 18 Gauge introducer needle, with a T- shaped single piece of stainless steel positioned within the lumen at the tip of the needle and attached to a thread, was introduced into the colon through the abdominal wall (Fig2a). A guidewire was then put through the needle to push the T- bar into the colon. Finally, the needle was taken out and the T- fastener was pulled to bring the colonic wall against the abdominal wall. A cotton bolster lays against the outside of the abdominal wall, and two small aluminium crimps keep the T- bar in place.
Four T-fasteners are introduced, one at each corner of a 3-in. square, and then pulled up against the cecal wall so that it is apposed to the anterior abdominal wall (Fig2ab, 3a). PCC is then performed at the center of the square using the Seldinger technique. A skin incision large enough to accomodate the 17F- peel away sheath catheter to be used is made. The anterior part of the cecum is punctured, a guide wire introduced and the tract enlarged with a series of dilators (11F and 17F- peel away-Fig3b) prior to inserting the Malecot 17 French drainage catheter (Malecot ; Meditech/ Boston Scientific, Watertown, Mass.) into the cecum (Fig2c-3c).
Follow- up
Colonic dilatation did regress over two days (Fig4) and the T- fasteners were removed after ten days. Two months later, the aspiration catheter was still in place but the patient died secondary to bronchopulmonary septicemia. No complication related to the percutaneous cecostomy was noted during this period.
Discussion
Since its original description in 1948 by Sir Ogilvie, the pathophysiology of colonic pseudo- obstruction remains unknown. It has been hypothetized that an interruption of the sacral parasympathetic innervation (via the lumbar nerves from spinal segments S2 to S4) could play a role (1). This neural interruption could lead to a distal colonic distension, clinically similar to acquired Hirschprung's disease, except that autopsy results of patients with Ogilvie's syndrome reveal histologically normal ganglion cells in the colon.
The initial therapeutic of Ogilvie's syndrome is based on supportive care and nasogastric suction followed by endoscopic decompression if necessary.
The endoscopic approach, described in the late seventies (2), is not successful in 18% to 27% of cases, secondary to poor colonic preparation, a critically ill patient, or if duskiness of the mucosa suggests severe ischemia. After successful endoscopic decompression, a relapse occurs in 15% to 22% of cases while colonic perforation secondary to colonoscopy is around 20% of cases.
If a decompression catheter can be inserted endoscopically in the right colon, the recurrence rate drops dramatically (1). In addition, endoscopic percutaneous cecostomy has been rarely reported (3).
If these endoscopic maneuvers are unsucessfull and the cecum remains dilated up to 10-12 cm, most authors advocate surgical decompression. Such decompression is successful in 90% of cases but is accompagnied by high mortality (30%) and morbidity (6%) rates (1).
Percutaneous cecostomy (PCC) has been previously described in cases of colonic dilatation secondary to tumoral obstruction, cecal volvulus, pseudo- membranous colitis or in cases of fecal incontinence in children. PCC has also been reported in seventeen Ogilvie's syndrome cases. In all reported cases, colonic decompression was obtained with simple 22G needle- aspiration or after insertion of an 8- to 30- French catheter, with either the Seldinger or the trocar techniques. All catheters were left in place for 11 to 27 days. During follow- up, one case of transient back leakage along the catheter and one case of abdominal wall cellulitis resulting in severe sepsis and death were noted.
Some investigators favor a posterior approach, under CT- guidance, for colonic drainage with a retention catheter introduced through the retroperitoneum, in order to avoid fecal spillage from the cecum and the resultant peritonitis (4).
However, the majority of reported cases of PCC used an anterior approach without development of peritonitis. In addition, a posterior route is not always strictly into the retroperitoneum due to a potential posterolateral extension of the peritoneum around the cecum.
Pexy with nylon T- fasteners (Fig3), used in percutaneous gastrostomies (5) may reduce the potential for peritoneal spillage by joining the colonic wall to the parietal peritoneum and may facilitate drainage of fecal contents by allowing the insertion of large catheters.
On the other hand, as it was described for retention catheters, nylon T- fasteners may result in a focal ischemia with resulting necrosis and fecal leakage, especially in an inflated and weakened colonic wall. Interestingly, the risk of perforation appears to be more strongly related to the duration of cecal distension than the diameter of the cecum. Therefore, symptomatic treatment has to be initiated without delay, including endoscopic decompression after 48 hours if necessary. Percutaneous cecostomy is the next step after failure of the endoscopic treatment, and should be performed under fluoroscopy or CT guidance.
Algorythm:
OGILVIE's Syndrome: Duration of cecal distension ? Diameter of the cecum ?
-Conservative treatment:
--If negative: Endoscopic Decompression (66% success rate):
---If negative: 2 nd Endoscopic Decompression (75% success rate):
----If negative: Colonoscopy (ischemia?) + Percutaneous Cecostomy or Surgery
In case of Ogilvie's syndrome, the two main questions to answer to (after having diagnosed the absence of colonic obstruction) are:
1.what is the duration of cecal distension ?
2.What is the diameter of the cecum ?
1 and 2 are important prognostic factors to define the risk of cecal perforation.
When conservative treatment has failed, early endoscopic decompression of the colon is mandatory, leading to a 66% success rate, and needs to be repeated in case of initial failure (leading to a 75% success rate).
When endoscopic treatments have failed,colonoscopy is mandatory in order to exclude any ischemic area and to perform percutaneous cecostomy or surgery (ischemia).
CONCLUSION
In case of Ogilvie's Syndrome, anterior transperitoneal cecostomy decompression, with controlled pexy, may be a safe and successful alternative treatment to Surgery, after conservative and endoscopic treatments have failed. CT/ Fluoroscopy are useful for guidance.
Differential Diagnosis List
Percutaneous cecostomy decompression in Ogilvie's Syndrome
Final Diagnosis
Percutaneous cecostomy decompression in Ogilvie's Syndrome
