In this video, we are going to describe a novel technique of using a Blake drain to successfully decompress a patient with acute colonic pseudo-obstruction. Acute colonic pseudo-obstruction, also known as Ogilvy syndrome, is a syndrome of acute colonic dilatation without mechanical obstruction, usually in the setting of trauma, acute illness, or recent procedure. This is a high-risk syndrome, with risk of perforation between 3 and 15%, and mortality rate of perforation around 50%. Risk of perforation increases significantly when sacral diameter exceeds 12 centimeters. Conservative and pharmacologic management is preferred, but carries risk of progression of disease. Though no randomized clinical trial has supported efficacy of endoscopic or surgical decompression, it is typically considered when there is high risk of perforation and failure to respond to conservative or pharmacologic measures. Strategies include placement of a rectal tube blindly, or under direct guidance, endoscopic decompression, and open or laparoscopic sarcostomy. In retrospective studies, endoscopic decompression without placement of a decompression tube has had mixed success, as initial success rates range between 61% and 95%, but rate of recurrence is high, at about 40%, and 1 third of patients require repeat endoscopic decompression. Recursive studies suggest that placing a decompression tube can reduce recurrence. Commercially available decompression tubes carry limitations, as they are either placed blindly, carrying a risk of perforation and coiling, or via endoscopic guidance, and are therefore necessarily both long and narrow. The long length and short diameter limit the rate that a viscous fluid is able to flow through these tubes, and endoscopically placed decompression tubes are prone to clogging, even with frequent flushing. To mitigate some of these challenges, we present a novel technique for colonic decompression using a Blake drain. Our patient was a 63-year-old male with alcohol-related decompensated cirrhosis, was admitted to the hospital for respiratory distress, and found to have a large cavitary pneumonia. His hospital course was complicated by acute colonic pseudo-obstruction. By conservative measures, he developed progressive distension, with abdominal x-ray demonstrating a sacral diameter of 17 centimeters. Our team attempted endoscopic decompression with a rectal tube. Despite this, the patient's symptoms did not improve, and sacral diameter only decreased to 15 centimeters the day after the procedure, and 13.9 centimeters two days after. A second attempt for endoscopic decompression was planned. Given failure of the previously placed tube, we felt a decompression tube with a larger diameter and shorter length was warranted to allow for better drainage. We used a 24 French Blake drain. In addition to having a larger caliber and shorter length, Blake drains offer the additional advantage of having four continuous channels to allow for multiple drainage points and resist clogging. We modified our Blake drain by securing an absorbable 3-0 suture loop to the proximal aspect of the tube, and a non-absorbable 2-0 suture loop to the distal aspect of the tube. This was done so that the proximal suture loop could help secure the tube to the colonic wall and prevent premature dislodgement, while the distal loop would prevent proximal migration. A 25 millimeter snare was passed through the scope, and the proximal end of the Blake drain was grasped using the snare. The Blake drain and snare were then inserted via the rectum together. The Blake drain and scope were advanced in tandem under minimal insufflation to the maximal extent, which for our patient was the hepatic flexure. The snare was opened to release the blake drain, and a standard 16mm endoscopic clip was used to anchor the drain to the colon using the previously placed absorbable suture loop. Once the drain was secured, the scope was withdrawn while suctioning to aid decompression. There was approximately five centimeters of the 24 French Blake drain along with a silk suture left outside the patient's body. This was secured to the patient's gluteal aspect with an adhesive dressing to prevent proximal migration, and the drain was connected to a collection bag for gravity drainage. After the procedure, the patient experienced improvement in symptoms over the next 24 hours. Abdominal x-ray the morning after his procedure demonstrated improvement in sacral diameter to 9.5 centimeters. The patient passed his rectal tube on his own one day later, and he was discharged soon after. Our case demonstrates a novel technique of using a large Bohr Blake drain to facilitate colonic decompression and acute colonic pseudo-obstruction for high-risk patients. Since this index case, our team has used this technique successfully in several other cases of acute colonic pseudo-obstruction and sigmoid volvulus. It is our hope that novel techniques such as this may reduce the morbidity and mortality of acute colonic pseudo-obstruction.

Blake drain

Ogilvie syndrome

colonic pseudo-obstruction

acute colonic dilatation

endoscopic decompression