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Another Place for an ACE?

Braegger, Christian M.D.

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Journal of Pediatric Gastroenterology and Nutrition: October 2002 - Volume 35 - Issue 4 - p 586-587
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Sigmoid Irrigation Tube for the Management of Chronic Evacuation Disorders M.W.L. Gauderer, J.M. DeCou, J.T. Boyle J Pediatr Surg 2002;37:348–51.

Summary:

In this report, Drs. Gauderer, DeCou, and Boyle from the Children's Hospital in Greenville, South Carolina, briefly describe the selection, surgical technique, and clinical response of four patients who received a sigmoid button device for antegrade perfusion of the sigmoid colon and rectum. The four patients all had severe, medically recalcitrant constipation and fecal incontinence resulting from pelvic dyssynergia (1), myelodysplasia (2), and high imperforate anus repair (1). Preoperative evaluation in the first three patients included an assessment (radio-opaque markers were mentioned in one) of colon transit time which indicated that transit time in the proximal colon was normal. After prepping the colon, the procedure was performed under general anesthesia. Under laparoscopic surveillance, a rigid sigmoidoscope was advanced into the sigmoid colon to the level of the junction of sigmoid and descending colons. By twisting the sigmoidoscope, the sigmoid wall was held against the abdominal wall in the left lower quadrant. A needle was then passed via a small left lower quadrant skin incision, through the abdominal wall, the sigmoid wall and into the lumen of the sigmoidoscope. A standard percutaneous gastrostomy guide wire was passed through the cannula into the sigmoidoscope, grasped and pulled out the anus with a rigid forcep. The sigmoidoscope was then removed. A percutaneous gastrostomy tube with a rubber disc as the luminal anchor was attached to the guide wire and was pulled into the anus and out the abdominal wall by traction on the abdominal end of the guide wire. Although not identified, the author's drawing of the tube looks like a Genie gastrostomy device (Bard Endoscopic Tenchnologies, Billerica, MA). In 3 to 27 months of follow up, the four patients all were “socially continent” and were able to defecate within 5 to 15 minutes of perfusing the sigmoid button device with 300 to 500 mL of saline. One child still required intermittent laxatives post operatively. One child whose gastrostomy tube may have been cut a bit short in transforming it to a skin-level device, developed cellulitis, which responded to a tube change and antibiotics.

Comment:

The authors clearly state at the end of their report that patient selection was key to the success they encountered with this new technique. They selected only patients with distal fecal retention, avoiding patients who appeared to have more generalized dilation and dysmotility of the colon. Their preoperative evaluation of colon motility was reported very briefly, but appeared to be a fairly simple evaluation of the colon size and the speed of barium passage. Colon transit time appears to have been formally assessed in only one patient by tracking the passage of orally administered radio-opaque markers. The distal location of the colon perfusion catheter was associated with a more rapid evacuation of the recto-sigmoid using smaller infused volumes than routinely reported in patients with standard antegrade perfusion procedures using the cecum. One of their patients developed peristomal cellulitis, a complication seen in all of the antegrade colon perfusion techniques requiring a foreign body. The potential drawbacks of the procedure mentioned by the authors included the need to use a foreign body rather than a biologic conduit in the sigmoid colon, the narrower lumen of the sigmoid colon compared with the cecum (presumably making cramps worse and/or initial insertion more difficult?), and mild “pulling” on the tube caused by the powerful sigmoid contractions after perfusion (presumably causing more severe cramps and/or possibly increasing the risk of dislodging the button?).

I had other concerns about this procedure, which the authors did not address. I would venture that there are few pediatric gastroenterologists or surgeons under 45 years old who regularly use or have used a rigid sigmoidoscope. Since I am well over 45, I know that finding one's way through a mega-rectum may be difficult or impossible with a standard 25-cm rigid sigmoidoscope. Advancing the tip of the sigmoidoscope to the junction of the sigmoid and descending colon as suggested by the drawings in this paper would require experience with the maneuvers necessary to advance the rigid scope around the turns of the recto-sigmoid colon and a generous helping of good luck. Running out of scope while still in the rectum seems like a potential complication. Even with the aid of laparoscopy, confirming that the scope really is at the junction of the sigmoid and descending colon before cannulation may be difficult if the recto-sigmoid is massively dilated or elongated. In an obese patient, there may be difficulty with transillumination of the abdominal wall or palpation of the tip of the sigmoidoscope, which might prevent the operator from accurately hitting the lumen of the rigid scope with the needle. In the patient with pelvic floor dysfunction, I wondered whether simply resecting the mega-rectum and sigmoid might have been an alternative approach, which would have obviated the need for a button device and daily infusions. I also wondered whether tacking down the enlarged sigmoid colon at its proximal end might increase the risk of sigmoid volvulus. My surgical colleagues in Denver did not feel that this posed a serious risk, but more procedures will need to be safely done before I would stop worrying.

Dr. Gauderer is the innovative surgeon who introduced and refined the technique of percutaneous gastrostomy 20 years ago. This report describes a modification of the antegrade enema technique, which looks simpler and more to the point for some selected patients. I look forward to seeing further reports from this group describing their experience with more patients and outlining refinements in technique and equipment which may in time make the procedure as standard as a percutaneous gastrostomy is today. I would hope that some piece of equipment similar perhaps to a tripod grasper could be developed which could be threaded through a flexible colonoscope. The purpose of this accessory would be to stabilize the sigmoid wall against the abdominal wall during percutaneous cannulation of the sigmoid lumen. If such a device could be constructed, then those who never have and never will use a rigid sigmoidoscope could deal with this procedure!

Judith M. Sondheimer

Chief of Pediatric Gastroenterology, Hepatology and

Nutrition

University of Colorado Health Sciences Center and The

Children's Hospital

Denver, Colorado, U.S.A.

© 2002 Lippincott Williams & Wilkins, Inc.