Should we recommend PEC and when?

Percutaneous endoscopic colostomy (PEC) was first described in 1986, by Jeffrey Ponski [1], who had invented percutaneous endoscopic gastrostomy a few years before that [2]. Performed by 2 operators, PEC consists of placing a tube in the colon during colonoscopy in order to provide antegrade colonic enemas (ACE) in severe constipation or fecal incontinence [3,4]. The PEC tube can also be used as a tool allowing easier and immediate colonic exsufflation in Ogilvie’s syndrome or chronic intestinal obstruction [5,6]. In the majority of PEC indications, the colostomy tube is placed in the cecum for 2 main reasons: 1) to allow pancolonic rather than distal ACE in order to (theoretically) provide more effective bowel function; and 2) cecal transillumination as a prerequisite to improve procedure ease and safety because it helps determine the most direct route to the colon. So far, whether performing PEC is safe and effective in other situations, such as sigmoid volvulus, remains largely unknown. What is the clinical problem with sigmoid volvulus and how can PEC fix it? First of all, sigmoid volvulus is not a rare disease because since it accounts for 7% of intestinal occlusions, being the third most common cause of colonic occlusion after cancer and diverticular disease [7]. Incidence of sigmoid volvulus is especially high in Africa, East Asia, and Eastern Europe, probably because of dietary habits in these countries. Besides high intake of fibers, other potential factors frequently associated with sigmoid volvulus are megacolon, age, male sex, and ethnicity. However, little is known regarding the pathophysiology of this disease, especially concerning the acute event precipitating the twist of the distal colon. In practice, the clinical symptoms often mimic small bowel obstruction but in most cases, plain abdominal radiograph is sufficient to diagnose the typical aspect of sigmoid volvulus. Emergency colonoscopy is a highly effective and safe option for untwisting the volvulus and exsufflating the proximal colon while avoiding ischemic necrosis and perforation. Indeed, the technical success of endoscopy is considered to be around 95% with a low morbidity and mortality (<5%), even in aged and frail patients [8]. In contrast, immediate surgery is associated with high mortality rates and should be considered only in cases of septic shock, peritonitis or suspicion of severe colonic ischemia. In fact, the biggest issue with sigmoid volvulus is the very high recurrence rate (40%–90%) [8,9]. The risk of recurrence can be prevented by prophylactic sigmoidectomy, but this strategy is generally proposed in a minority of cases because sigmoid volvulus is especially frequent in elderly and frail patients. Among the 83 patients with sigmoid volvulus whom we studied at Nantes University Hospital, 55% of those who refused surgery or in whom it was contraindicated went on to experience an average of 2.6 additional episodes of sigmoid volvulus over the next 18 months (personal data). Given that we will see more and more octogenarians and nonagenarians in the next decades, we should consider different strategies for preventing recurrence of sigmoid volvulus because the condition represents a burden not only for the endoscopist on call, but also for society in terms of hospital costs. In this issue of Endoscopy International Open, Frank et al. [10] report on a systematic review of PEC performed in the sigmoid colon for the treatment of sigmoid volvulus in 56 patients. Unfortunately, it is difficult to estimate the efficacy of PEC in this situation because this review could only collect heterogeneous data from 5 case series and 5 observational studies, with only 1 study performed prospectively. The number of patients was low (1–19) and the technique used for PEC was very different among studies. However, this review adds to our knowledge by providing novel and interesting insight regarding the feasibility and complications of PEC in this specific situation.