Safe percutaneous endoscopic colostomy for severe constipation with use of the introducer method.

Percutaneous endoscopic colostomy (PEC) has been established as an alternative method of intestinal decompression and irrigation for chronic intestinal pseudoobstruction, relapsing sigmoid volvulus, neurogenic bowel, and constipation [1]. However, the thin, distended colonic wall can easily be torn during creation of the PEC with the pull method, and inadvertent traction of the PEC tube and colonic peristalsis can occur. By using an introducer method, we successfully prevented these complications. A 92-year-old man had relapsing slowtransit constipation (●" Fig.1a) without constant care by the medical staff. Hoping to be able to manage defecation convenientlywith nonmedical care, he underwent PEC (●" Fig.2): (i) full distension of the working space in the sigmoid colon; (ii) four-point square fixation of the colon to the peritoneal wall by four sutures made with the Funada percutaneous endoscopic gastrostomy (PEG) kit (Create Medic Co., Kanagawa, Japan) under colonoscopic transillumination; and (iii) puncture of the needle introducer of the tube in the center of the fixation and replacement of the PEC tube with a button-type gastrostomy (●" Fig.3). Computed tomography revealed the collapsed sigmoid colon without unnatural stretching andbending, and without the migration of visceral organs (●" Fig.1b,c). Thus, PEC effectively achieved colonic decompression and irrigation for more than 10months. There are several contraindications to PEC that are similar to the contraindications to PEG, such as inability to pass the colonoscope, failure of transillumination, and the presence of bulky ascites [2]. Several reports have described frequent minor and several severe complications, such as bleeding and fecal leakage [3]; these occur during retraction of the colon from the abdominal wall [4] owing to the fragility of the distended colonic wall and the formation of a PEC tract by the pull method. Our use of the introducer PEG kit, which can attach the colonic wall to the peritoneal wall around the insertion hole of the PEC tube, resulted in resistance to tearing stress during the PEC procedure, traction of the tube, and peristalsis.