Sigmoid Stiffener for Decompression Tube Placement in Colonic Pseudo-Obstruction

• Introduction
• Patients and Methods
• Results
• Discussion
• Acknowledgement
• References

Background and Study Aims: Decompression tube placement improves outcome in colonic pseudo-obstruction (CP) which is refractory to conservative measures, especially if the decompression tube is placed proximal to the hepatic flexure. We evaluate the ability of a sigmoid stiffener to facilitate more proximal colonoscopy and decompression tube placement.

Patients and Methods: A sigmoid stiffener is used in the standard fashion during colonoscopic decompression for pseudo-obstruction. After cecal wire placement, the colonoscope is withdrawn, leaving the stiffener and wire in place. By passing through the stiffener, an over-wire decompression tube can avoid sigmoid looping. We compared proximal extent of colonoscopy, tube position, endoscopy time, and patient outcomes using a sigmoid stiffener, with a control group of patients treated previously. Patients with colonic ischemia were excluded.

Results: Using this technique, nine consecutive colonoscopies and decompression tube placements reached the right colon. Significantly, only three of seven control colonoscopies and two control decompression tubes did so. However, improvements in procedural time and patient outcome did not reach statistical significance. No complications occurred.

Conclusion: The use of a sigmoid stiffener during colonic decompression allows more proximal colonoscopy and decompression tube placement, with possible clinical benefit. We do not use this technique in the setting of left colon ischemia.

Introduction

A heterogeneous group of disorders can lead to colonic pseudo-obstruction, an entity which may progress to cecal ischemia and perforation. When conservative therapy fails to resolve this potentially fatal complication, it is best treated by colonoscopic decompression [1] [2] [3] [4] [5] [6]. Colonoscopic decompression is more successful when the proximal colon is reached [2] [6]. Decompression tube placement can help avoid repeat colonoscopies by facilitating and maintaining decompression [7] [8] [9] [10]. The decompression tube functions best when placed proximal to the splenic flexure [11], and may be even more effective when placed proximal to the hepatic flexure [10].

Since pseudo-obstructed colons are typically dilated, elongated, and uncleansed, proximal colonoscopy is often difficult and time-consuming. Sigmoid looping of the decompression tube during insertion is particularly frustrating [9]. Often, the colonoscope does not reach the right colon, and the decompression tube usually does not reach as proximal a position as does the colonoscope. This study evaluates the safety and success of a sigmoid stiffener in improving proximal colonoscopy and decompression tube placement in colonic pseudo-obstruction.

Patients and Methods

We compared the experience of one attending endoscopist (W.L.B.) using the stiffener technique with a set of historical controls from his own immediate prior experience. Cases were accumulated prospectively after the initiation of the technique, and consecutive, historical controls were taken from immediately preceding cases at Froedtert Memorial Lutheran Hospital. Left-sided ischemia, which precludes safe sigmoid stiffener placement, was the only exclusion criterion.

At our institution, we carry out colonoscopic decompression for colonic pseudo-obstruction with fluoroscopic guidance, and thus a sigmoid stiffener can be easily placed using a standard technique, without special effort [12]. Prior to the procedure, a stiffener (1.7 cm internal diameter, 2.0 cm outer diameter, 40 cm long, ST-C3; Olympus, Lake Success, New York, USA; Figure [1]) is lubricated and back-loaded onto a large-channel, 1.4 cm colonoscope (OES-CF-1T10L; Olympus), which is then inserted and advanced beyond the splenic flexure. During insertion, the colonic mucosa is inspected for left-sided ischemia and washed, if necessary. If no ischemia is noted, any sigmoid loops are reduced and the stiffener is positioned in the descending colon under fluoroscopy. Subsequent colonoscopy of the proximal colon allows placement of a 0.035-inch, 480-cm guide wire into the cecum using endoscopic and fluoroscopic visualization. The colonoscope is then withdrawn, care being taken to keep the sigmoid stiffener and wire in position. A 14-Fr decompression tube (CDSG-14-175; Wilson-Cook, Winston-Salem, North Carolina, USA) is placed over the wire, which guides it through the stiffener and into the proximal colon, under fluoroscopy. The stiffener prevents sigmoid loop formation, which otherwise frequently occurs as the tip of the decompression tube encounters resistance at the splenic flexure. Once the decompression tube position is confirmed fluoroscopically, the stiffener is withdrawn over the decompression tube. If the guide wire and guide catheter are first removed, the decompression tube flange passes through the stiffener with only moderate resistance.

We recorded patient age, underlying diagnosis, extent of prior conservative measures, clinical status, and medications. Endoscopic data included the extent of colonoscopic progress, initial decompression tube position, procedural duration, and success of immediate and sustained decompression. Successful immediate decompression was defined as definite improvement in the patient's clinical and radiological appearance immediately after the procedure. Successful sustained decompression was defined as avoidance of recurrent colonic pseudo-obstruction as long as the decompression tube was in use. Differences in the extent of colonoscopy, proximity of decompression tube placement, and success of immediate and sustained decompression between groups were compared using Fisher's exact test. Procedural duration was compared using the Mann¿-Whitney rank sum test.

Results

All patients had enlargement of the cecum (diameter > 11 cm), failure of prior conservative measures (e. g. enemas, position changes, rectal and nasogastric tube placement), and clinical judgment indicating the need for urgent decompression. Table [1] displays patient characteristics. Nine cases using the stiffener technique and seven control cases were analyzed. Three potential control cases were excluded because of colonic ischemia. No cases were eliminated on account of missing data or aberrant technique. The results are summarized in Table [2].

The stiffener technique was significantly more effective in achieving proximal colonoscopy and decompression tube placement, but the mean procedural time did not significantly differ. Placement of the decompression tube proximal to the hepatic flexure produced immediate and sustained decompression in both groups. In the control group, two decompression tubes did not reach the right colon, and neither of these achieved immediate decompression.

Discussion

Those colonoscopists routinely called upon to deal with colonic decompression can attest to the difficulty encountered in achieving complete and sustained colonic decompression in these very ill patients. Any technique that expedites the procedure, improves outcome, and precludes the need for repeated intervention is desirable. Other methods of facilitating proximal passage of the colonoscope in these elongated colons (for instance, through-the-scope stiffeners or the new generation of stiffening scopes) may be helpful in reaching the cecum, but would not prevent coiling of the decompression tube in the sigmoid. We have not found the use of stiffer wires or biliary stent “pushers” to be as effective as the sigmoid stiffener in preventing sigmoid looping of the decompression tube. Although the need for decompression tube placement to the cecum has been questioned [11], there is evidence that decompression proximal to the hepatic flexure clearly gives better and more sustained results. In the experience of Fausel & Goff, effective cecal decompression often required passage into the ascending colon [2]. Nakhgevany [6] and Lavignolle et al. [10] all reported that decompression of the transverse and left colon alone can be inadequate for the reduction of cecal size. By preventing loops in the sigmoid colon, the stiffener technique promises more proximal decompression tube placement.

In 1948, Ogilvie [13] described colonic pseudo-obstruction in two patients with metastasis to the celiac plexus, leading him to postulate an autonomic neuropathic cause. Today the pathogenesis remains incompletely understood. Colonic pseudo-obstruction probably represents a common clinical manifestation of a variety of diseases. Therefore, a very large and complex trial would be required to provide statistically significant conclusions about clinical outcomes in colonic pseudo-obstruction.

We limited our study to evaluating the safety and success of this procedural modification. Defining a control group for this feasibility study was difficult. A prospective, randomized study could not be blinded. Unfortunately, we found large differences in available procedural information and in endoscopic technique among different attending endoscopists. Final decompression tube positions and procedural times were often not recorded, and some endoscopists routinely aborted the procedure in the left colon. This variability precluded the use of a historical group control. Thus, we chose to examine the experience of a single endoscopist, who provided consistent technique and data quality. The use of one endoscopist's immediate prior experience, however, raises the question of improvement due to enhanced expertise and skill, rather than due to the benefits of the new technique. We felt that the experience of this gastroenterologist, which included the 7th through the 11th year of his endoscopic practice, was enough to ensure that any significant improvement was more probably due to the technique rather than to the endoscopist. In addition, three procedures carried out by this endoscopist during the study period occurred when a stiffener was temporarily unavailable. Two of these three decompression tubes did not reach the right colon, but in one of these two instances the procedure was immediately repeated with a stiffener and did intubate the cecum. This nonblinded observation is consistent with our study results.

Because complication rates of 0.2 % to 2 % have been cited for colonoscopic decompression [14], and especially since this procedure is performed on very sick patients, safety is a major concern. We had no complications in our small series. Many reported complications are related to colonic ischemia, often right-sided, which is seen in approximately 10 % of cases [15]. It is notable that three patients were excluded from our control group on account of ischemia. On follow-up, these patients did not do well clinically. Of the five cases in which decompression tubes were prematurely withdrawn prior to return of adequate colonic motility, three developed recurrent colonic pseudo-obstruction. There was no recurrence in any patient who had good immediate decompression and subsequently passed the decompression tube spontaneously.

We use a stiffener in selected cases of difficult colonoscopy or right-sided disease requiring multiple reinsertions, but we recognize that sigmoid stiffeners seem to have fallen out of favor [12]. We have heard it said that this is due to reported or experienced complications, but we find scant evidence for either. Perhaps it is more a case of inconvenience than safety. At our institution, the quality assurance files and a poll of the staff revealed no stiffener-related complications over the past 10 years or more. This new application, specifically for the treatment of colonic pseudo-obstruction, seems an appropriate and useful addition to our therapeutic arsenal.

In conclusion, we report a new approach to colonoscopic tube decompression, which significantly improves proximal decompression tube placement in patients with colonic pseudo-obstruction. We advocate initial conservative measures [16] such as maximizing physical activity, withholding oral intake, initiating positional changes and enemas, placing gastric and rectal decompression tubes, treating underlying electrolyte abnormalities and infections, as well as removing any potentially contributing medications. In addition, the response to neostigmine of some patients is intriguing and may provide a clinically useful approach [17]. Nevertheless, when these fail and colonoscopic decompression is required, decompression tube placement is clearly indicated. The stiffener technique improves proximal decompression tube placement and, potentially, outcome. Lastly, we would reemphasize that a stiffener should not be used if there is any evidence of left-sided colonic ischemia.

Acknowledgement

Preliminary data published as an abstract in Gastrointestinal Endoscopy 1997; 45: AB25.

References

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F.A.C.P. M.D. W. L. Berger

Division of Gastroenterology and Hepatology Froedtert Memorial Lutheran Hospital

9200 West Wisconsin Avenue

Milwaukee, Wisconsin 53226

USA

Phone: +1-414-456-6214

Email: wberger@mcw.edu

References

• 1 Kurkora J S, Dent T L. Colonic decompression of massive nonobstructive cecal dilation.  Arch Surg. 1977;  112 512-517
  PubMedSearch in Google Scholar
• 2 Fausel C S, Goff J S. Nonoperative management of acute idiopathic colonic pseudo-obstruction (Ogilvie's syndrome).  West J Med. 1985;  143 50-54
  PubMedSearch in Google Scholar
• 3 Starling J R. Treatment of nontoxic megacolon by colonoscopy.  Surgery. 1983;  94 677-681
  PubMedSearch in Google Scholar
• 4 Strodel W E, Nostrant T T, Eckhauser F E, Dent T L. Therapeutic and diagnostic colonoscopy in nonobstructive colonic dilatation.  Ann Surg. 1983;  197 416-421
  PubMedSearch in Google Scholar
• 5 Bode W E, Beart R W, Spencer R J, et al. Colonoscopic decompression for acute pseudo-obstruction of the colon (Ogilvie's syndrome).  Am J Surg. 1987;  147 243-245
  PubMedSearch in Google Scholar
• 6 Nakhgevany K B. Colonoscopic decompression of the colon in patients with Ogilvie's syndrome.  Am J Surg. 1984;  148 317-320
  CrossrefPubMedSearch in Google Scholar
• 7 Bernton E, Myers R, Reyna T. Pseudo obstruction of the colon: case report including a new endoscopic treatment.  Gastrointest Endosc. 1982;  28 90-92
  PubMedSearch in Google Scholar
• 8 Nano D, Prindiville T, Pauly M, et al. Colonoscopic therapy of acute pseudo-obstruction of the colon.  Am J Gastroenterol. 1987;  82 145-148
  PubMedSearch in Google Scholar
• 9 Harig J M, Fumo D E, Loo F D, et al. Treatment of acute nontoxic megacolon during colonoscopy: tube placement versus simple decompression.  Gastrointest Endosc. 1988;  34 23-27
  CrossrefPubMedSearch in Google Scholar
• 10 Lavignolle A, Jutel P, Bonhomme J, et al. Syndrome d'Ogilvie: resultants de l'exsulfation endoscopique dans une série de 29 cas.  Gastroenterologie Clinique et Biologique. 1986;  10 147-151
  PubMedSearch in Google Scholar
• 11 Geller A, Petersen B T, Gostout C J. Endoscopic decompression for acute colonic pseudo-obstruction.  Gastrointest Endosc. 1996;  44 144-150
  CrossrefPubMedSearch in Google Scholar
• 12  Technology Assessment Committee. Overtube use in gastrointestinal endoscopy.  Gastrointest Endosc. 1997;  43 767-770
  PubMedSearch in Google Scholar
• 13 Ogilvie H. Large-intestine colic due to sympathetic deprivation.  Br Med J. 1948;  2 671
  CrossrefPubMedSearch in Google Scholar
• 14 Earnest D L, Hixson L J. Other diseases of the colon and rectum. In: Sleisenger MH, Fordtran JS (eds). Gastrointestinal disease: pathophysiology/diagnosis/management. 5th edn.  Philadelphia; WB Saunders, 1993: 1552
  Search in Google Scholar
• 15 Vanek V W, Al-Salti M. Acute pseudo-obstruction of the colon (Ogilvie's syndrome). An analysis of 400 cases.  Dis Colon Rectum. 1986;  29 203-210
  CrossrefPubMedSearch in Google Scholar
• 16 Henry M J. Management of Ogilvie's syndrome.  Gastrointest Endosc. 1997;  45 (6) 540
  PubMedSearch in Google Scholar
• 17 Ponec R J, Saunders M D, Kimmey M B. Neostigmine for treatment of acute colonic pseudo-obstruction: a randomized, double-blind, controlled trial.  Gastroenterology. 1998;  114 (4) 34
  PubMedSearch in Google Scholar

F.A.C.P. M.D. W. L. Berger

Division of Gastroenterology and Hepatology Froedtert Memorial Lutheran Hospital

9200 West Wisconsin Avenue

Milwaukee, Wisconsin 53226

USA

Phone: +1-414-456-6214

Email: wberger@mcw.edu