Diagnostic laparoscopy and laparoscopic cecostomy for colonic pseudo-obstruction

Marked cecal dilatation due to colonic pseudo-obstruction (Ogilvie's syndrome) is most often treated by colonoscopic decompression. When this fails, cecostomy is usually indicated if the bowel is not infarcted. We describe a new technique of laparoscopy-guided percutaneous cecostomy using T-fasteners to retract and anchor the cecum to the anterior abdominal wall and using a Foley catheter as a cecostomy tube. We performed this procedure successfully in a patient with colonic pseudo-obstruction who had marked cecal dilatation that could not be decompressed by colonoscopy. Laparoscopic inspection showed that the cecum was viable, and a laparoscopic cecostomy was placed. This procedure can be performed easily and safely and with much less morbidity than laparotomy and open cecostomy.Supported in part by the Medical Research Service of the Veterans Affairs Medical Center, San Francisco, California.     

Use of gastrointestinal contrast studies in obstruction of the small and large bowel

Gastrointestinal contrast studies were performed in 96 (27 percent) of 342 patients with small-bowel obstruction including 57 upper gastrointestinal and 39 barium-enema examinations. In 34 patients, upper gastrointestinal examination disclosed either obstruction or failure of contrast to reach the cecum in 24 hours; all 34 patients required surgery. The remaining 23 patients who had upper gastrointestinal studies recovered with tube decompression. Barium enema demonstrated obstruction in 13 (33 percent) of 39 cases of suspected small-bowel obstruction and localized obstruction in the colon rather than small bowel in 9 of 13 cases. Barium enema was 100 percent predictive of surgery when obstruction was shown, but was not helpful in predicting surgery when obstruction was not demonstrated. Surgery was required in 42 percent of patients whose barium enema did not show obstruction. Barium enema also was performed in 19 of 23 patients with large-bowel obstruction and showed the level of obstruction in all cases. All patients with largebowel obstruction required surgery except for three who recovered after barium-enema reduction of intussusception or volvulus. Barium upper gastrointestinal examination is recommended in small-bowel obstruction when plain films are nondiagnostic, and in selected cases of small-bowel obstruction that do not resolve with a short trial of tube decompression. Barium enema is not recommended in suspected small-bowel obstruction but should be performed in all cases of largebowel obstruction, except when perforation is a possibility or when the cecum measures 10 cm or larger in diameter.     

Experience with colonic volvulus

Fifty-eight cases of colonic volvulus were reviewed including 30 cases of sigmoid volvulus, 27 cases of cecal volvulus, and 1 of transverse colon volvulus. Decompression procedures were attempted in 31 instances of sigmoid volvulus in 27 patients and were successful 25 times (81 percent). Seven patients with sigmoid volvulus did not undergo surgery and of those, two died of unrelated causes, one was lost to follow-up, one was well, and three had recurrent volvulus. Twenty-four operations were performed on 23 patients and there were three deaths (13 percent mortality). There was one recurrence in two patients who underwent simple detorsion. Chronic large-bowel motility disturbances were a persistent problem in 9 of 20 (45 percent) surgical survivors. Among 27 instances of cecal volvulus, one was reduced by contrast enema and ten endoscopic attempts at decompression were unsuccessful. Twenty-six operations were done and there were four operative deaths (15 percent mortality). There were no recurrences. Large-bowel motility disorders were noted in follow-up in 3 of 22 patients (14 percent). Overall there were 10 deaths in 58 patients for a 17 percent mortality rate. These data support the importance of endoscopic decompression for sigmoid volvulus but not for cecal volvulus. Definitive treatment of both forms of volvulus should include assessment of colonic motility. Read at the meeting of the American Society of Colon and Rectal Surgeons, Anaheim, California, June 12 to 17, 1988.     

Colonoscopically guided tube decompression in Ogilvie's syndrome

Ogilvie's syndrome (pseudo-obstruction of the colon) may result in gangrene and perforation of the colon if not effectively treated. Colonoscopic decompression and endoscopically guided rectal tube placement were employed to treat five patients with this syndrome who had failed medical therapy. All patients tolerated the procedure well and required no further treatment.     

Early resolution of Ogilvie's syndrome with intravenous neostigmine

PURPOSE: Our aim was to assess the value of a parasympathomimetic drug (neostigmine) in the early resolution of acute colonic pseudo-obstruction (Ogilvie's syndrome). METHODS: A prospective study was undertaken in 18 consecutive patients (mean age, 76 (range, 31–87) years) with acute colonic pseudo-obstruction. After a varying period of conservative treatment in all cases, 16 patients with persistent, massive abdominal distention were given intravenous neostigmine. RESULTS: A rapid and satisfactory clinical and radiologic decompression of the large bowel was obtained in 12 patients (75 percent) after a single dose of the drug; another patient had complete resolution after a second dose, and the other 3 patients had only partial resolution, in one of them after a second dose of the drug. No patient required surgical decompression of the bowel. CONCLUSION: These results give support to the theory of excessive parasympathetic suppression in most cases of Ogilvie's syndrome. The treatment with intravenous neostigmine has proved very effective, preventing in many cases prolonged periods of uncomfortable and potentially hazardous conventional conservative management and avoiding surgical treatment in a consecutive series of patients.Presented in part at the XIX Congress of the European Federation of the International College of Surgeons (ICS)-National Congress of the Spanish Section of the ICS, Tenerife, Spain, October 12 to 14, 1995.     

Ogilvie's syndrome--acute colonic pseudo-obstruction. Case report and review of the literature

We present a rare entity of colonic pseudo-obstruction, characterised by severe colonic dilatation in absence of any organic obstacle. Clinical symptoms, diagnostic approach, and therapeutic measures are analysed and discussed. Many factors have been associated with this syndrome which include electrolyte imbalance, systemic infection, drugs, and occasionally, neurologic disease. Reported here is a case of acute colonic pseudo-obstruction which developed in a patient with restrictive respiratory dysfunction. Colonic decompression by means of colonoscopy, the most effective therapeutic approach for pseudo - obstruction failed, and surgical cecostomy was required. The acute colonic pseudo-obstruction, Ogilvie's Syndrome, most often appears as a complication of other clinical conditions. It is characterized by massive colonic dilatation in the absence of a mechanical cause and may lead to cecal perforation in absence of treatment. When colonic obstruction is suspected, one should always consider the possibility of the occurrence of Ogilvie's syndrome     

Cecal volvulus: outcome of management by celiotomy

This study was undertaken to evaluate the care of patients with cecal volvulus recently treated in Department of Veterans Affairs (DVA) hospitals. This large contemporary review examines the outcomes of surgical treatment and is also the largest reported series of attempted colonoscopic decompressions. All patients with the ICD-9-CM code for colonic volvulus during the period 1991–1995 were identified in the computerized national DVA database. Data on patient demographics, clinical course, and outcomes were collected. Fifty-five patients with cecal volvulus and complete medical records were identified. The average age was 68 years; all were male. Previous abdominal surgery (5 of 55 patients; 9%), and neurologic impairment (6 of 55 patients; 11%) were the most common risk factors. Diagnosis was possible by plain radiography in the majority of patients (39 of 55; 71%). Colonoscopic decompression was attempted in 20 patients (36%), but was successful in only one (5%). The mortality rate was 18% for colectomy and primary anastomosis (5 of 28 procedures), 31% for colectomy and stoma formation (5 of 16 procedures), 11% for cecopexy (1 of 9 cases), and 100% for tube cecostomy (2 procedures). Mortality was significantly correlated with emergent surgery (p < 0.01). Cecal volvulus frequently presents as a surgical emergency, and continues to be associated with a high mortality rate. Prompt diagnosis is often possible with plain radiographs, but colonoscopic decompression is typically unsuccessful. Cecopexy provides a safe alternative to resection and primary anastomosis in suitably selected patients. Received: 20 September 1999 / Accepted: 10 October 1999     

Percutaneous endoscopic cecostomy: a case series

BACKGROUND: There are few reports of percutaneous endoscopic cecostomy in adult patients. METHODS: All cases of acute colonic pseudo-obstruction (n = 2) and neurogenic bowel (n = 3) in adults in which percutaneous endoscopic cecostomy was performed were reviewed retrospectively. OBSERVATIONS: Percutaneous endoscopic cecostomy was a definitive treatment. In 1 of the 2 patients with acute colonic pseudo-obstruction, the percutaneous endoscopic cecostomy tube was clamped and subsequently removed 10 weeks after placement; in the other patient with acute colonic pseudo-obstruction, the percutaneous endoscopic cecostomy tube remains in place. In 2 of the 3 patients with neurogenic bowel, the percutaneous endoscopic cecostomy tube continues to function well; the third patient did well for 6 months and then died of underlying comorbid disease. There was no mortality or need for surgical intervention for any patient. Complications occurred in 2 patients; 1 developed transient fever and leukocytosis and 1 had self-limited bleeding during anticoagulation. CONCLUSIONS: Percutaneous endoscopic cecostomy is a safe and effective treatment for both acute colonic pseudo-obstruction and neurogenic bowel when aggressive albeit conservative treatment is unsuccessful.     

Acute colonic pseudo-obstruction or Ogilvie's syndrome. Report of two cases treated with colonoscopic decompression and review of the literature

Acute colonic pseudo-obstruction (ACP), or Ogilvie's syndrome, is a disorder characterized by massive dilatation of the colon, and typically occurs in the critically ill or post-operative patient. The clinical presentation may be impossible to distinguish from mechanical causes of colonic obstruction. Its importance is reflected in an overall mortality of up to 30%, perforation of the cecum occurring in 14.8% of patients with a reported mortality of up to 46%. Medical therapy has had variable results. Tube cecostomy or other operative interventions can lead to much morbidity and mortality in the critically ill patient. Colonoscopy recently has proven to be highly effective in achieving colonic decompression as well as excluding a mechanical etiology for obstruction and poses minimal risk to the patient. Colonoscopy should be reserved for patients who show progressive cecal dilatation or who deteriorate clinically despite aggressive medical therapy. We report two patients with ACP treated with colonoscopy and review the literature.     

Synchronous cecal and sigmoid volvulus

Volvulus is a rare cause of intestinal obstruction in the U.S. Sigmoid colon volvulus is the most frequent, followed by cecal volvulus. The simultaneous occurrence of cecal and sigmoid colon volvulus is extremely unusual. We are reporting what to our knowledge is the third case.     

Cecal volvulus

The case records of 12 patients with cecal volvulus over a 20-year period were reviewed. The patients averaged 46.7 years old; 75 per cent were white and 67 per cent were male. Patients presented with signs and symptoms of intestinal obstruction. Pain and distention were present in more than half of the patients. X-rays assisted in making the diagnosis of cecal volvulus in only five of the patients. Diagnosis was made in the remainder at the time of surgical exploration. At operation, one cecum was necrotic and required resection. Five patients underwent cecostomy, two cecopexy, and four simple detorsion. Postoperatively, one patient developed a wound infection. There were no deaths. Follow-up for seven patients averaged 75 months each. One patient who had undergone simple detorsion developed another cecal volvulus. All who were contacted were alive and well. At St. Luke's Hospital, cecal volvulus generally occurs in middle-aged white males. Cecostomy or cecopexy adequately treats cecal volvulus when the cecum remains viable. This study demonstrates that prompt surgical intervention, before strangulation of the colon occurs, results in low mortality even in city hospital patients.     

Use of trephine stoma in sigmoid volvulus

Introduction: Sigmoid volvulus is a disease of the elderly who often have severe comorbid conditions that increase their operative risk and limit treatment options. Conservative treatment with decompression via sigmoidoscopy with rectal tube placement has high success and recurrence rates. Surgical resection with primary anastomosis is the treatment of choice when decompression fails or if the volvulus recurs. Unfortunately, perioperative complications are frequent. Moreover, many patients with sigmoid volvulus are bedridden or incontinent of stool and do not benefit from extensive resection and maintenance of bowel continuity. METHODS: Twelve debilitated patients with sigmoid volvulus determined preoperatively to be poor candidates for laparotomy and reanastomosis were treated with a trephine stoma. Initially, each patient had decompression via rigid sigmoidoscopy and rectal tube placement. Surgical intervention consisted of formation of a small hole (trephine) in the left lower quadrant. Through this hole, a sigmoid resection and end colostomy were performed. No midline laparotomy was required. RESULTS: Operative times and analgesia requirements were significantly decreased (P =0.05) compared with patients who underwent formal laparotomy. Length of hospital stay, complication rates, and length of bowel resected were similar using either surgical technique. CONCLUSIONS: The trephine stoma procedure offers significantly shorter operative times, with decreased perioperative morbidity. For high operative risk or debilitated patients with sigmoid volvulus, resection with end colostomy using the trephine stoma technique is the procedure of choice.Presented at the meeting of the Zollinger Surgical Society, Columbus, Ohio, September 5 to 7, 1996.     

Effectiveness of a long intestinal tube in a one-stage operation for obstructing carcinoma of the left colon

Five consecutive patients with obstructing carcinoma of the left colon were successfully managed by long intestinal tube decompression. The tube was introduced pernasal into the duodenum on the day of admission. The tube advanced spontaneously into the ascending colon with marked abdominal decompression within several days. Thereafter, preoperative colonic irrigation through this tube was performed. In three of five patients, segmental colectomy was accomplished without intraoperative cleansing. In two patients, fecal residue was removed by intraoperative colonic irrigation using the long tube. Proximal colostomy was avoided in all patients. This treatment protocol enabled: 1) both preoperative and intraoperative colonic irrigation and cleansing; 2) elective surgery instead of emergency; 3) safe one-stage operation with secure colonic anastomosis; and 4) segmental resection rather than subtotal resection of the colon.     

Acute colonic pseudo-obstruction

Acute colonic pseudo-obstruction (ACPO) is a syndrome of massive dilation of the colon without mechanical obstruction that develops in hospitalised patients with serious underlying medical and surgical conditions. ACPO is associated with significant morbidity and mortality, and, therefore, requires urgent gastroenterologic evaluation. Appropriate evaluation of the markedly distended colon involves excluding mechanical obstruction and other causes of toxic megacolon such as Clostridium difficile infection, and assessing for signs of ischemia and perforation. Increasing age, cecal diameter, delay in decompression, and status of the bowel significantly influence mortality, which is approximately 40% when ischemia or perforation is present. The risk of colonic perforation in ACPO increases when cecal diameter exceeds 12cm and when the distention has been present for greater than 6days. Appropriate management includes supportive therapy and selective use of neostigmine and colonoscopy for decompression. Early recognition and management are critical in minimising complications.     

Ogilvie's syndrome: Colonoscopic decompression and analysis of predisposing factors

Forty-eight cases of Ogilvie's syndrome, colonic pseudoobstruction, presenting between 1983 and 1989 were retrospectively reviewed to assess the results of colonoscopic decompression and to identify potential etiologic factors. Three patients had spontaneous resolution with medical treatment. Forty-five patients required 60 colonoscopic decompressions: 38 (84 percent) were successfully treated using colonoscopy; five (11 percent) required an operation; and two died within 48 hours of colonoscopy from medical causes. No complications or deaths were the result of colonoscopy. Twenty-nine patients (64 percent) were successfully treated with a single colonoscopy. One-third of patients required serial decompressions. Average cecal diameter in patients with successful colonoscopic decompression was 12.4 cm but was larger for patients requiring more than one colonoscopy (13.3 cm) and for those who failed colonoscopic therapy (13.4 cm). The spine or retroperitoneum had been traumatized or manipulated in 52 percent of patients. Patients with Ogilvie's syndrome were being treated with narcotics (56 percent), H-2 blockers (52 percent), phenothiazines (42 percent), calcium-channel blockers (27 percent), steroids (23 percent), tricyclic antidepressants (15 percent), and epidural analgesics (6 percent) at diagnosis. Electrolyte abnormalities included hypocalcemia (63 percent), hyponatremia (38 percent), hypokalemia (29 percent), hypomagnesemia (21 percent), and hypophosphatemia (19 percent). Colonoscopic decompression in Ogilvie's syndrome is safe and effective management. Multiple pharmacologic and metabolic factors, as well as spinal and retroperitoneal trauma, appear to alter autonomic regulation of colonic function, resulting in colonic pseudo-obstruction.Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, April 29 to May 4, 1990.     

Colonic pseudo-obstruction: the dilated colon in the ICU

Acute colonic pseudo-obstruction is a syndrome of massive dilation of the colon without mechanical obstruction that develops in hospitalized patients with serious underlying medical and surgical conditions. Increasing age, cecal diameter, delay in decompression, and status of the bowel significantly influence mortality, which is approximately 40% when ischemia or perforation is present. Evaluation of the markedly distended colon in the intensive care unit setting involves excluding mechanical obstruction and other causes of toxic megacolon such as Clostridium difficile infection, and assessing for signs of ischemia and perforation. The risk of colonic perforation in acute colonic pseudo-obstruction increases when cecal diameter exceeds 12 cm and when the distention has been present for greater than 6 days. Appropriate management includes supportive therapy and selective use of neostigmine and colonoscopy for decompression. Early recognition and management are critical in minimizing complications.     

Prophylactic ureteral catheterization in colon surgery

PURPOSE: The preoperative placement of prophylactic ureteral catheters in operations of the distal colon is both commonplace and controversial. We assessed the frequency, safety, and effectiveness of their use over a five and one-half-year period in a teaching hospital. METHODS: The charts of 561 consecutive patients who underwent sigmoid or rectosigmoid colectomy from 1986 to 1991 were analyzed for age, sex, diagnosis, type of colectomy, placement of ureteral catheters, and ureteral complications. RESULTS: Ureteral catheterization was attempted in 92 patients (16.4 percent); it was successful bilaterally in 80 patients (87 percent) and unilaterally in an additional 10 patients (98 percent). Four (0.71 percent) transmural ureteral injuries were identified. Two surgical injuries (0.43 percent) occurred in the 469 patients without prophylactic catheter placement (95 percent confidence interval = 0.00549–0.0153). Two injuries (2.2 percent), consisting of one surgical injury and one iatrogenic injury directly related to catheter placement, occurred in the 92 patients with prophylactic catheters (95 percent confidence interval = 0.00262–0.0764). This latter injury resulting from catheter placement represents a rate of 1.1 percent per patient and 0.55 percent per ureteral catheterization attempted. Using a 24-hour staged removal, these catheterizations were associated with a 0 percent incidence of reflux anuria. CONCLUSIONS: Experienced surgeons requested prophylactic ureteral catheter placement in 16.4 percent of their sigmoid and rectosigmoid colectomies. The risk of ureteral injury (1.1 percent) as a direct result of catheter insertion is small, but not insignificant. Prophylactic ureteral catheters do not assure the prevention of transmural ureteral injuries, but may assist in their immediate recognition.     

Cecostomy is a useful surgical procedure

PURPOSE: There is a large choice of treatment for obstructing carcinoma of the left colon. We report our experience of tube cecostomy as the initial treatment for obstructing colonic carcinoma followed by elective resection. METHODS: From 1975 to 1995, 113 patients presenting with colonic obstruction caused by cancer were initially treated by tube cecostomy. RESULTS: The cecostomy was performed under local anesthesia in 26 cases (23 percent) and general anesthesia in 87 cases (77 percent). In the postoperative period 15 patients died (13 percent) and 26 (23 percent) had wound infection in the area around the cecostomy. A second operation performed on the 98 surviving patients comprised 74 left colonic resections with anastomosis, 9 without anastomosis (Hartmann's operation), 1 right colectomy, 3 total colectomies eliminating the cecostomy, 3 internal bypasses, and 8 proximal lateral colostomies. Surgical closure of the cecostomy was performed during six of the second operations. No deaths occurred from any of the second operations. The cecostomy closed spontaneously in 78 patients (89 percent). In ten cases (11.4 percent) a third operation was performed to close the cecostomy, without mortality. CONCLUSIONS: Comparison our cecostomy results with published studies of proximal diverting loop colostomies for the same indications showed comparable mortality after the first operation. Cecostomy decrease mortality of the second operation. This retrospective study suggests that cecostomy is a useful and less invasive surgical procedure for patients presenting with colonic obstruction caused by cancer.     

Laparoscopic-assisted bowel surgery

The use of laparoscopic surgical techniques is now being applied to a variety of operations traditionally performed in an open fashion. Twenty patients underwent laparoscopic-guided large and small bowel surgery at our institution from March 1991 to April 1992. The indications for surgery included polyps, obstruction, bleeding, and perforation, and pathologic diagnoses included benign polyps, lipomas, inflammatory bowel disease, perforation of a jejunal diverticulum, colonic arteriovenous malformations, and adenocarcinoma. Mobilization of the colon, ligation of the mesentery, and closure of the mesenteric defect were performed using the laparoscopic equipment. One trocar site was enlarged to 3 cm to deliver the bowel through the abdominal wall. All anastomoses were hand-sewn. Postoperative hospitalization ranged from 2 to 31 days (median, five days). No mortality was noted, and morbidity was 20 percent. We conclude that laparoscopic-guided bowel surgery is technically feasible and should translate into shorter hospitalization and less patient discomfort.     

True and false large bowel obstruction

Acute large bowel obstruction can be the result of mechanical causes (such as colorectal cancer) or motility disturbances, the latter being termed colonic pseudo-obstruction.Whatever the aetiology, the pathophysiology of large bowel obstruction has clinical significance. Changes in motility augmented by increased colonic blood flow may play a role in dissemination of tumour cells and/or bacteria. Intravascular fluid depletion, especially shortly after intestinal decompression, has important haemodynamic implications.The diagnosis is often confirmed on plain abdominal X-ray, but water-soluble contrast studies are important in distinguishing a mechanical obstruction (which almost always requires an operation) from a pseudo-obstruction (which can usually be managed without surgery).Mortality and morbidity may be reduced by optimization of the patient's condition both before and after the operation using intensive care facilities and by careful timing of surgery.The surgical management of malignant large bowel obstruction is best directed by a senior surgeon. For tumours up to and including the splenic flexure, an extended right hemicolectomy is advisable since it offers adequate removal of the tumour and allows an immediate safe ileocolic anastomosis. More distal tumours should be resected if possible, and there is much to recommend on-table irrigation and immediate anastomosis, although a colostomy with a mucous fistula or Hartmann's procedure still have a place.Endoscopic diagnosis and decompression enables definitive surgery to be undertaken electively and several techniques are being evaluated.Non-operative reduction of sigmoid volvulus by rigid or flexible endoscopy is achieved with high success rates, but is not recommended for caecal volvulus. Resection is usually necessary in both to prevent recurrence. Mortality of colonic volvulus is closely related to bowel viability.Uncomplicated colonic pseudo-obstruction may be managed medically or by endoscopic decompression. It often occurs in association with systemic medical conditions, which need to be treated vigorously. Surgery is indicated if there are signs of impending or frank perforation, or if non-operative measures fail.