Technical

Developments

Percutaneous

and

Cecostomy:

C. Morrison, MD Michael J. Lee, MD Susan A. Stafford, MD Sanjay Saini, MD Peter R. Mueller, MD

Instrumentation

Controlled

Transperitoneal

Approach’

Mary

The authors present two cases of percutaneous cecostomy performed with a modified approach previously described for percutaneous gastrostomy and cholecystostomy. T-fastener devices were used to affix the cecum to the anterior abdominal wall; thus, the potential problem of fecal spillage was prevented. In both cases, adequate fecal drainage was provided without complication. Index

terms:

dure, dure,

interventional proceinterventional procestenosis or obstruction,

Abdomen,

752.1299 752.1299

Colon, #{149} Colon, #{149}

752.721 Radiology

P

1990;

176:574-576

ROLONGED

greaten than with a significant (1,2). The ensuing a high morbidity

moved.

cecal distention of 10 cm is associated risk of perforation fecal peritonitis has and mortality. Previ-

firmly

wall

ously, surgical cecostomy, and, more recently, cobonoscopic decompression,

when possible, the treatments rupture

have been advocated of choice to prevent

(3-7).

Radiologic

as

adapted

transpenitoneal cecal dewithout the risk of fecal In this technique,

from

one

previously

used

to

The

nylon

against

the

and

filament anterior

secured.

is pulled abdominal

To adequately

affix

the cecum to the anterior abdominal wall, this is repeated at each corner of the square. Catheter insertion may proceed by means of either a trocan or Seldinger approach. Because the use of the T-fas-

tenen

percutaneous

cecostomy has been suggested as an attractive alternative to conventional sungical or endoscopic techniques (8,9). We present a new method, safely performed in two patients, that we think allows compression contamination.

Mass), previously described for use in percutaneous gastrostomy, to use in performing percutaneous cecostomy. This technique has been previously descnibed (10) but is summarized as follows. The dilated cecum is located fluoroscopically, and a small area in the middle of the cecum is identified. A bocab skin analgesic is administered at the four corners of a 2-inch square overlying the previously selected site (Figs 1, 2). A specially designed 18-gauge introducen needle is loaded with a T-fastenen, and a 5-mm syringe containing 1 mm of saline solution is attached to the introducer-needle assembly. At each corner of the square, the needle is sharply inserted with a single thrust into the bowel, and its intnaluminal position is confirmed with aspiration of air. The T-fastenen is then launched from the introducer by inserting a stylet, and the introducer needle is ne-

system

allows

immediate

ma-

nipulation of the tract, we prefer the Seldingen technique. Progressive dilation of the tract with standard dilators

and

barge

peel-away

systems enabled of up to 24-30-F

Case

introducer-sheath placement in a single

of catheters sitting.

Reports

percutaneous cholecystostomy (1 1), T-fastener devices are used to affix the cecum to the anterior abdominal wall.

Case 1.-A 71-year-old woman with end-stage cervical carcinoma had been treated previously with pelvic nadiation therapy and a urinary diversion procedure for a vesicovaginal fistula. At the time of surgery, multiple adhesions of the large and small bowels

Materials

were

perform

percutaneous

gastrostomy

(10)

and

and

Methods

We adapted a nylon T-fastenen (Brown/Mueller gastrostomy kit; Meditech/Boston Scientific, Watertown,

I

From

chusetts

the Departments General

MA02114(M.C.M., Emerson

ceived March

Hospital,

February

April

16; revision 12. Address RSNA, 1990

574

#{149} Radiology

Hospital,

of Radiology,

32 Fruit

M.J.L.,S.S., Concord,

22, 1990; received reprint

Massa-

St. Boston,

P.R.M.),and Mass

(S.A.S.).

revision

requested

April requests

11; accepted to P.R.M.

Re-

noted.

Two

months

later,

she pne-

sented in an extremely debilitated state with abdominal pain and a distal bowel obstruction. Because of her medical condition, surgery was not possible. On a plain radiograph of the abdomen, the cecal diameter measured 14 cm. A percutaneous cecostomy was performed under fluonoscopic guidance with use of the T-fastenen system (Fig 1). Successfub dilation of the tract allowed placement of the 24-F catheter into the

cecum

in a single

sitting.

the obstruction, and the solved. The tube effected

This

relieved

symptoms adequate

repal-

liative drainage until the patient died more than a month later. Case 2.-An 80-year-old woman with abdominal pain and distention presented 1 week after a cholecystectomy was performed, in which partial duodenal and transverse colon nesections were required due to a penicholecystic inflammatory mass. An abdominal radiograph showed an obstructed transverse colon that was thought to have been inadvertently oversewn at surgery. At this time, the patient was not thought to be in good enough medical condition to undergo surgery. A pencutaneous cecostomy was performed under fluoroscopic control. The cecum was affixed to the anterior abdominal wall with the T-fastener system. A 24-F Foley catheter was placed into the cecum by means of the Seldingen technique.

Five

liters

of fluid

stool

were

drained

during the next 72 hours. Definitive surgery was performed 1 week later on a nonemengent basis. At surgery, the anterior cecum was affixed to the fat and the anterior abdominal wall, and no fecal matter was present in the pentoneum.

Discussion Acute cecal dilatation can be due to mechanical and nonmechanicab causes; in the hospitalized patient, risk of penfonation seems most related not to the absolute cecal diameter but rather to the duration of distention (2). The cecum is the segment of the colon with the largest diameter, and in cobonic obstruction or pseudoobstruction, it is the portion of the large bowel that dilates the most. This is in accordance with the law of Laplace, which states that the pressure required to stretch the walls of a hollow viscus decreases in inverse proportion to the radius of curvature (12). If the cecum reaches a diameter of more than 10 or 12 cm, the risk of penfonation increases due to vascular compromise of the bowel wall (2). Should this occur, the mortality rate may exceed 30% (5). The traditional method of decompression has been surgical cecostomy, but since 1977 (7), cobonoscopic decompression has been performed in patients with a nonobstructed colon. Percutaneous decompression, achieved with needle (13) and catheter placement (8,9), has been reported as an altennative therapy to decompress cecab distention and prevent cecal rupture and ensuing fecal peritonitis.

August

1990

a.

b.

C.

Figure 1. Studies of a 71-year-old patient with metastases to the small and large bowels from metastatic cervical carcinoma and

postoperative study

adhesions.

demonstrates

caused

(a) Barium

a large

by obstruction

dilated

enema cecum,

in the sigmoid

colon

(arrows). (b) Collimated spot radiograph of the dilated cecum after insertion of T-fastenens into the cecum (arrows). Note the square area delimited by the T-fasteners. (c) Spot radiograph shows insertion of a 0.038-inch guide wire through the center (arrow) of the square area delimited by T-fasteners. A 24-F Foley catheter was placed after dilation of

the tract. (d) Plain radiograph men shows the Foley catheter gion

of the

the balloon. sion

of

the

cecum,

There colon.

with

(e)

cystostomy,

Volume

tomographwall of the cewall (an-

2. (a, b) Schematics of the T-fastener system used for apposing the abdominal and visceral walls. (a) An 18-gauge slotted needle arrow) is introduced into the viscera. The slot contains a stainless steel T-fastener with a suture that follows alongside the needle arrow). (b) After the T-fastener is released, the visceral and abdominal walls are apposed (arrow) by pulling on the suture. (c) Phoof the slotted needle (curved arrow) and T-fastener device (straight arrow). The proximal end of the device has a dental pledget to the skin (10).

Percutaneous cecostomy may offer a cure for patients with dilatation from an ileus and provides a temporizing measure in patients ultimately nequiring surgery to correct a mechanical obstruction. The need to develop a safe, quick approach to allow percutaneous cecal decompression led us to adapt a technique, previously described for percutaneous gastrostomy and choletomy.

in

C.

b.

(curved (straight tograph protect

Computed the abdominal

material

decompres-

rows).

e.

Figure

contrast

is significant

ic (CT) scan demonstrates cum “apposed” to the

of the abdoover the re-

for By

using

176

percutaneous

cecos-

T-fasteners

#{149} Number

to

2

ensure

fixation of the cecum to the anterior abdominal wall before tube insertion, we think that one not only greatly diminishes the likelihood of intrapenitoneal fecal spillage during or after the procedune but also allows for single-step placement of a large catheter. Others report

the

use

of

a retropenitoneal

route

to prevent the problem of intrapenitoneal contamination, but this requires turning the patients on their side, as well as using a CT-guided approach

(9,13). In addition, the subset of patients with cecal dilatation who are at most risk of perforation (2) are those with focal cecal ileus in whom the cecum is displaced anteriorly and medially

because

of

a long

cecab

mesentery.

In

these patients, a retnopenitoneal approach may be difficult, if not impossible. In debilitated patients, fluoroscopic guidance via an anterior route may be performed with the patient supine. This

approach

is not

only

easier

Radiology

but

#{149} 575

may be the only route to the cecum. Similarly, we speculate that the use of the T-fastener system provides adequate additional security and that fecal spillage will not occur in association with percutaneous cecostomy. This systern also allows placement of drainage catheters larger (up to 24-30 F) than previously reported. The importance of large-bore catheters and vigorous mngation has been emphasized in the sungery literature on tube cecostomy (4,6).

Because

of the

of the

fecab

thickness

stream,

are more likely In summary,

and

smaller

to clog. cecal distention

Intraoperative with Transrectal C. Fleischer, S. Burnett, J. Murray, W. Jones

terms:

854.12981 Ultrasound 854.32

Gynecology,

(US) Uterine

#{149}

854.12981

From

guidance neoplasms, US

the

Nashville,

TN

1, 1990;

revision

#{149} Uterine

neoplasms,

US studies,

studies,

Departments

854.12981

March

#{149} Radiology

of Radiology

and Gynecology (A.C.F., Radiation Oncology University Medical Center,

37232-3274.

reprint requests , RSNA, 1990

576

studies, intraoperative.

1990; 176:576-577

(A.C.F.), Obstetrics L.S.B., H.W.J.), and (M.J.M), Vanderbilt

received

(US),

#{149} Uterus,

Radiology

I

US

#{149} Ultrasound

requested 19; accepted

Received

March April

anterior

This

abdominal

insertion, is likely allows

we think to be great-

a direct

6.

anterior

as the larger

im-

7.

U

8.

1.

ly distended

Jackson PP. Baird RM. Cecostomy: an analysisof l02cases. AmJSurg 1967; 114:297-301. Johnson CD, Rice RP, Kelvin FM, Foster WL, Williford ME. The radiologic evaluation of gross cecal distension: emphasis on cecal ileus. AJR 1985; 145:1211-1217. Bode WE, Beart RW, Spencer RJ, CuIp CE, Wolff BC, Taylor BM. Colonoscopic decompression for acute pseudoobstruction of the colon (Ogilvie’s syndrome): report of 22 cases and review of the literature. Am J Surg 1984; 147:243-245. Goldstein SD, Salvati EP, Rubin RJ, Eisenstat TE. Tube cecostomy with cecal extraperitonealization in the management of obstructing left-sided carcinoma of the large intestine. Surg Gynecol Obstet 1986; 162:379-380. Groff W. Colonoscopic decompression and

2.

3.

4.

5.

Intrauterine

9.

10.

11

.

12.

13.

cecum.

Radiology

sonography (TRS) is used extensively for evaluation of the prostate. Its use in women, howeven, has not been fully described, except in a few reports involving a small numben of patients (1,2). We describe the use of TRS for intnaoperative placement of an intrauterine tandem for the purpose of intracavitary radiation thenapy for cervical carcinoma and as guidance for directed dilation and curettage in

complicated

BIPLANE TRANSRECTAL

cases.

Figure

Before

and

Methods

the transnectal

probe

was in-

serted, it was sterilized with a bacteniostatic and vinustatic spray (Sporocidmn International, Rockville, Md). A condom was secured over the probe with rubber bands, and gel was spread on the outer condom surface for adequate coupling. After the probe was in place within the rectum, approximately 30 mL of water was introduced within the condom for adequate transmission. TRS was then performed, initially in the sagittal plane, followed by confirmation in the axial plane (Fig 1). The procedune was observed in real time with both the longitudinally and axially onented transducers contained within a biplanar, 5.0-MHz tnansrectal probe (Toshiba America Ultrasound, Tustin, Cabif).

Representative

Cases

17. Address

old

158:793-

RANSRECTAL

Materials

to A.C.F.

1986;

794. Haaga JR. Bick RJ, Zollinger RM. CT-guided percutaneous catheter cecostomy. Gastrointest Radiol 1987; 12:166-168. Brown AS, Mueller PR, Ferrucci JT. Controlled percutaneous gastrostomy: nylon Tfastener for fixation of the anterior gastric wall. Radiology 1986; 158:543-545. Cope C. Percutaneous subhepatic cholecystostomy with removable anchor. AJR 1988; 151:1129. Schwartz SI, Storer EH. Principles of surgery. 4th ed. New York: McGraw-Hill, 1984; 1037. Crass JR. Simmons RL, Frick MP, Maile CW. Percutaneous decompression of the colon using CT guidance in Ogilvie syndrome. AJR 1985; 144:475-476.

Procedures

February

12; revision

intubation of the cecum for Ogilvie’s syndrome. Dis Colon Rectum 1983; 26:503-506. Hoffmann J, Jensen HE. Tube cecostomy and staged resection for obstructing carcinoma of the left colon. Dis Colon Rectum 1984; 27:2432. Kukora JS, Dent TL. Colonoscopic decompression of massive nonobstructive cecal dilation. Arch Surg 1977; 112:512-517. Casola C, Withers C, vanSonnenberg E, Herba MJ, Saba RM, Brown RA. Percutaneous cecostomy for decompression of the massive-

References

T

MD MD MD III, MD

the

abdominal approach, as well mediate insertion of catheters than previously described.

Guidance for Sonography’

Transrectal sonography was used for intraoperative guidance in intrauterine tandem placement for intracavitary radiation therapy and in dilation and Curettage procedures. The authors describe the method and three representative cases in which it was applied. It is concluded that the technique may prevent complications such as uterine perforation or bladder injury in tandem placement, and that it can facilitate dilation and curettage in complicated cases. Index

to

by reduced.

to a di-

to surgical or endoscopic When the cecum is sim-

Arthur Lonnie Michael Howard

affixed

wall before catheter the risk of spillage

viscosity catheters

ameter of greater than 10 or 12 cm is a common problem in hospitalized patients and may lead to bowel rupture. Percutaneous cecostomy is an attractive

alternative management.

ply

Case 1.-The patient woman with stage

was “b

a 72-yearsquamous

ly oriented

Diagram

shows

scanning

planes

transducer.

carcinoma of the cervix who had meceived a dose of 4,000 cGy of external irradiation

before

being

admitted

for

tandem and ovoid placement. Initial attempts at sounding the cervical canal were unsuccessful (Fig 2a, 2b). The cenvix had been replaced by a necrotic ulcerative tumor that extended into the upper vagina, night parametnium, and uterosacral ligament. TRS guided initial sounding of the cervix and, after dilation of the cervical canal, final placement of the tandem (Fig 3a, 3b). TRS helped confirm the central location of the tandem in both long and short axes. Case 2.-The patient was a 78-yearold

cell

1.

used for biplanar TRS of the uterus. Since the axially oriented transducer is mounted at the end of the probe, the probe must be withdrawn slightly to obtain a similar area of interest to that depicted with the sagittal-

vulva

woman

and

with

Paget

postmenopausal

disease

of

the

bleeding.

August

1990