Anterograde colonic irrigations by percutaneous endoscopic caecostomy in refractory colorectal functional disorders.

PURPOSE: In case reports or small studies, percutaneous endoscopic caecostomy (PEC) has been proposed as an alternative to the Malone intervention to perform antegrade colonic enemas. Our goal was to assess the feasibility, efficacy, and tolerance of PEC in a large group of patients with refractory colorectal functional disorders. METHODS: From September 2006 to April 2014, all patients undergoing PEC for constipation, fecal incontinence, and incontinence after rectal resection in two expert centers were studied. The PEC procedure consisted in anchoring the caecum to the abdominal wall (caecopexy) and placing a specifically designed tube in the colonic lumen to perform antegrade enemas. The quality of life (GIQLI), constipation (Kess), and incontinence (Cleveland) scores were assessed before PEC and at 3, 6, 12, and 24 months. RESULTS: A total of 69 patients were included. GIQLI scores were significantly improved in constipation group (n = 43), incontinence group (n = 19), and rectal resection group (n = 10). In the constipation group, Kess score decreased from 25.9 before PEC to 20.6 at 2 years (p = 0.01). In the incontinence and post-rectal resection groups, Cleveland scores decreased from 14.3 before PEC to 2.7 at 6 months (p = 0.01) and to 10.4 at 2 years (p = 0.04). Overall, PEC was considered successful by patients in 58%, 74%, and 90% of cases, in constipation, incontinence, and rectal resection groups, respectively. Chronic pain (52%) at the catheter site was the most frequent complication. CONCLUSIONS: Percutaneous endoscopic caecostomy for antegrade colonic enemas improves significantly the quality of life of patients with colorectal disorder refractory to medical treatment.

Colonic endoscopic full-thickness biopsies: from the neuropathological analysis of the myenteric plexus to the functional study of neuromuscular transmission.

BACKGROUND: Better understanding of the pathophysiological mechanisms involved in severe dysmotility disorders is crucial to improve patient management and identify novel therapeutic targets. Recent studies suggested that endoscopic full-thickness biopsies (eFTBs) could be developed as an alternative to surgical biopsies. However, currently it remains unknown whether eFTBs would allow myenteric plexus analysis on whole mounts and the evaluation of neuromuscular transmission. OBJECTIVE: To determine with eFTB specimens the ability to analyze on whole mounts the key parameters of the myenteric plexus, ie, ganglia and neurons, and to perform functional evaluation of neuromuscular transmission. DESIGN: An experimental pilot study in 6 pigs was conducted in accordance with French institutional guidelines. INTERVENTION: Under general anesthesia, pigs underwent a rectosigmoidoscopy. In each pig, an eFTB was performed at 25, 30, and 35 cm from the anal margin with an EMR-based technique. Tissue specimens were immediately processed for immunohistochemical and/or functional ex vivo analysis of neuromuscular transmission. In 2 pigs, over-the-scope clips were used to seal the perforation. MAIN OUTCOME MEASUREMENTS: Feasibility of obtaining specimens containing myenteric plexus and muscularis propria, quantitative and standardized immunohistochemical evaluation of ganglia and myenteric neurons, ex vivo assessment of neuromuscular transmission and its pharmacology, and closure rate (ancillary study). RESULTS: Adequate tissue specimens were obtained in 100% of the procedures, on average, in 6±2 minutes. Immunohistochemical analysis of a whole mount of the myenteric plexus showed that each eFTB contained 14±5 ganglia and 1562±1066 myenteric neurons. In circular muscle strips, electrical field stimulation or exposure to a pharmacological agent induced a specific tissue response. A successful closure was achieved in 50% of cases. LIMITATIONS: Nonsurvival study; safety of the procedure needs to be specifically assessed and compared with recently published data. CONCLUSIONS: We demonstrate, for the first time, that full-thickness biopsy specimens obtained by using an endoscopic approach allow the performance of a precise study of the ENS phenotype on whole mounts of the myenteric plexus and the performance of functional studies such as evaluation of neuromuscular transmission. However, further studies are warranted to identify the optimal and safest endoscopic procedure before application of eFTB in humans.