The National Institute for Health and Clinical Excellence is examining percutaneous endoscopic colostomy and will publish guidance on its safety and efficacy to the NHS in England, Wales and Scotland. The Institute's Interventional Procedures Advisory Committee has considered the available evidence and the views of Specialist Advisors, who are consultants with knowledge of the procedure. The Advisory Committee has made provisional recommendations about percutaneous endoscopic colostomy.
This document summarises the procedure and sets out the provisional recommendations made by the Advisory Committee. It has been prepared for public consultation. The Advisory Committee particularly welcomes:

• comments on the preliminary recommendations
  
• the identification of factual inaccuracies
  
• additional relevant evidence.

Note that this document is not the Institute's formal guidance on this procedure. The recommendations are provisional and may change after consultation.

The process that the Institute will follow after the consultation period ends is as follows.

• The Advisory Committee will meet again to consider the original evidence and its provisional recommendations in the light of the comments received during consultation.
  
• The Advisory Committee will then prepare draft guidance which will be the basis for the Institute's guidance on the use of the procedure in the NHS in England, Wales and Scotland.

For further details, see the Interventional Procedures Programme manual, which is available from the Institute's website (www.nice.org.uk/ipprogrammemanual).

Closing date for comments: 20 December 2005
Target date for publication of guidance: March 2006

Note that this document is not the Institute's guidance on this procedure. The recommendations are provisional and may change after consultation.

Current evidence on the safety and efficacy of percutaneous endoscopic colostomy appears adequate to support the use of this procedure in elderly and frail patients with recurrent sigmoid volvulus and colonic motility problems provided that the normal arrangements are in place for audit and clinical governance.

Patients and/or their parents should be fully informed about the potential risk of peritonitis. They should be provided with clear written information. In addition, use of the Institute's Information for the public is recommended (available from www.nice.org.uk/IPGXXXpublicinfo [details to be available at publication]).

Percutaneous endoscopic colostomy offers an alternative treatment for patients who have tried conventional treatment options without success or who are unfit for surgery.

Percutaneous endoscopic colostomy (PEC) is a minimally invasive procedure. PEC tubing is placed in position using a colonoscope, which is inserted into the left colon through the rectum. A wire is passed through a small skin incision and pulled back through the anal canal via the colonoscope. The PEC tube is tied to the wire, pulled back through the bowel and abdominal wall, and secured against the abdominal wall. The colonoscope is re-inserted to check the final position of the PEC tube. The tube is then attached to a drainage bag, which is usually flushed twice a day. Prophylactic antibiotics are administered for a few days.

The published evidence on this procedure is limited. The largest published case series includes 15 children with refractory constipation, of whom 14 underwent the procedure and 6 were followed up for 12 months. All children evaluated at 12 months were socially clean (mostly clean with occasional accidents, or no soiling) and two children were able to have the tube removed. In another case series of 14 patients with recurrent sigmoid volvulus, five patients whose tubes had been left in situ remained recurrence free at a mean follow-up of 12.6 months. For more details, refer to the sources of evidence (see Appendix).

The Specialist Advisors stated that outcomes seemed to be better in patients with sigmoid volvulus than in those with incontinence or constipation.

The most common complications reported were granuloma formation (6/15 and 4/6 in two case series) and infection (3/15 and 2/6). Other reported complications included pain associated with the administration of an enema (1/15), colonic leakage (5/6) and tube erosion (1/6). Preliminary unpublished data from a multicentre UK audit reported a 12% infection rate (13/105 patients) following the procedure. Two deaths attributed to late tube dislodgement were reported in patients treated for recurrent sigmoid volvulus. For more details, refer to the sources of evidence (see Appendix).

The following document, which summarises the evidence, was considered by the Interventional Procedures Advisory Committee when making its provisional recommendations.

• Interventional procedure overview of percutaneous endoscopic colostomy, August 2005.

Available from: www.nice.org.uk/ip74overview