sigmoid volvulus is the third most common cause of colonic obstruction in adults and is associated with high morbidity and mortality [ 1 , 2 ] . despite this , there is significant disagreement regarding management   with a lack of randomized controlled trials to guide best practice . current consensus is  in the absence of ischaemic , gangrenous or perforated bowel requiring emergency surgery  to attempt decompression using flexible sigmoidoscopy or colonoscopy . if successful , early elective surgery may be offered , typically involving a limited sigmoid resection with primary anastomosis [ 2 , 3 , 5 ] . sigmoid volvulus is more common in elderly patients [ 5 , 6 ] , the majority with comorbidities . non - operative options include : endoscopic t - fastener fixation , tube sigmoidostomy , colon extraperitonealization , mesocoloplasty , sigmoid plication , ladd 's procedure or percutaneous endoscopic colostomy ( pec ) tube placement . although no trials have directly compared these various options , pec insertion is usually preferred due to its lower risk profile [ 7 , 8 ] . the most common complication following pec insertion is infection  occurring in up to 77% of patients  which may necessitate pec removal . here , we present the first case of asymptomatic pec tube migration and demonstrate how an appropriate trial of conservative management may be offered . a 68-year - old nursing home resident presented to the emergency department after his family noticed his pec tube was missing . the pec tube was inserted 8 months earlier following recurrent sigmoid volvulus requiring repeated flatus tube decompressions . it was intended to provide definitive , long - term management ; comorbidities including multiple strokes and poorly controlled diabetes meant more invasive options were unsuitable . the pec tube had become dislodged after a healthcare worker accidentally removed a skin clip . this led to the surgical ward nursing staff  with the family 's support  raising a  safeguarding of vulnerable adults ( sova ) concern . the only abnormal clinical finding was the absence of a pec tube from a patent periumbilical colostomy site . an initial abdominal x - ray was inconclusive . a computed tomography ( ct ) abdomen - pelvis demonstrated that the pec tube had migrated into the bowel lumen , lying at the level of the recto - sigmoid junction with no evidence of obstruction or perforation ( see figs 13 ) . at the surface pec site there was residual , iatrogenic , colocutaneous fistula which functioned as a decompressive outlet . the patient remained well and the pec tube passed spontaneously on day 12 , during a bowel motion . initial plans were made to re - site the pec during early outpatient flexible sigmoidoscopy . however , due to the unresolved sova concern , he remained in hospital for over 3 weeks . on day 21 , the pec tube was successfully re - sited via a new colostomy site , adjacent to the previous pec ( figs 4 and 5 ) . if the migrated pec tube had not passed spontaneously , plans were made to remove it during the same procedure . granulation tissue had formed over the original pec site , precluding safe access with a wire , hence the creation of a second site . all staff at the nursing home attended educational sessions , run by the community stoma care nurse , to ensure safe future pec management . our patient was unfit for major surgery and his recurrent sigmoid volvulus was managed conservatively with pec fixation . a number of clinical decisions had to be made during this admission : 
 if and how to remove the pec tube?tube migration leading to perforation and frank peritonitis has been described elsewhere . however , there are no cases of asymptomatic dislodged pec tubes . following discussion with gastroenterology and colorectal surgery , the decision was made to let the pec pass spontaneously or remove it during early follow - up flexible sigmoidoscopy . the pec tube was naturally expelled on day 12 without complication.does the pec tube need to be replaced?the literature does not give a clear answer . several case reports suggest that keeping the pec tube in situ prevents volvulus recurrence [ 8 , 10 ] and , if removed , symptomatic relapse is likely [ 7 , 8 , 10 ] . infection   or patient request   often necessitates early pec removal at a known risk of recurrence .should the bowel be fixed at one or two points ( i.e. one or two pec tubes)?as with other examples , this patient 's bowel was fixed originally with one pec . however , effective , long - term prevention typically involves the insertion of two pec tubes , ideally at each end of the sigmoid colon to reduce mesenteric mobility . this is usually well tolerated with good outcomes [ 7 , 8 , 10 ] . indeed , in a case where one of two pec tubes was removed , the patient experienced volvulus recurrence and a second tube had to be re - sited .in our case , only one pec tube was re - inserted . this was due to technical difficulties at sigmoidoscopy ; however , we were reassured by the fact that our patient had not had volvulus recurrence with a single pec previously . it was thought that the residual colocutaneous fistula tract , obliterated by granulation tissue , may affix the bowel to the anterior abdominal wall at a second location.in the 9 months since pec re - insertion , the patient has not had any further episodes of volvulus.after how many episodes of sigmoid volvulus should prophylactic pec placement be offered?the literature is inconclusive . one study ( of six patients ) reported that the mean number of episodes before pec placement was 3.5 , but no larger trials have been conducted . typically , intervention is offered on a case - by - case basis with emphasis on patient preference in those unsuitable for operative intervention . if and how to remove the pec tube?tube migration leading to perforation and frank peritonitis has been described elsewhere . following discussion with gastroenterology and colorectal surgery , the decision was made to let the pec pass spontaneously or remove it during early follow - up flexible sigmoidoscopy . tube migration leading to perforation and frank peritonitis has been described elsewhere . however , there are no cases of asymptomatic dislodged pec tubes . following discussion with gastroenterology and colorectal surgery , the decision was made to let the pec pass spontaneously or remove it during early follow - up flexible sigmoidoscopy . does the pec tube need to be replaced?the literature does not give a clear answer . several case reports suggest that keeping the pec tube in situ prevents volvulus recurrence [ 8 , 10 ] and , if removed , symptomatic relapse is likely [ 7 , 8 , 10 ] . infection   or patient request   often necessitates early pec removal at a known risk of recurrence . several case reports suggest that keeping the pec tube in situ prevents volvulus recurrence [ 8 , 10 ] and , if removed , symptomatic relapse is likely [ 7 , 8 , 10 ] . infection   or patient request   often necessitates early pec removal at a known risk of recurrence . should the bowel be fixed at one or two points ( i.e. one or two pec tubes)?as with other examples , this patient 's bowel was fixed originally with one pec . however , effective , long - term prevention typically involves the insertion of two pec tubes , ideally at each end of the sigmoid colon to reduce mesenteric mobility . this is usually well tolerated with good outcomes [ 7 , 8 , 10 ] . indeed , in a case where one of two pec tubes was removed , the patient experienced volvulus recurrence and a second tube had to be re - sited .in our case , only one pec tube was re - inserted . this was due to technical difficulties at sigmoidoscopy ; however , we were reassured by the fact that our patient had not had volvulus recurrence with a single pec previously . it was thought that the residual colocutaneous fistula tract , obliterated by granulation tissue , may affix the bowel to the anterior abdominal wall at a second location.in the 9 months since pec re - insertion , the patient has not had any further episodes of volvulus . as with other examples , however , effective , long - term prevention typically involves the insertion of two pec tubes , ideally at each end of the sigmoid colon to reduce mesenteric mobility . this is usually well tolerated with good outcomes [ 7 , 8 , 10 ] . indeed , in a case where one of two pec tubes was removed , the patient experienced volvulus recurrence and a second tube had to be re - sited . in our case , only one pec tube was re - inserted . this was due to technical difficulties at sigmoidoscopy ; however , we were reassured by the fact that our patient had not had volvulus recurrence with a single pec previously . it was thought that the residual colocutaneous fistula tract , obliterated by granulation tissue , may affix the bowel to the anterior abdominal wall at a second location . in the 9 months since pec re - insertion after how many episodes of sigmoid volvulus should prophylactic pec placement be offered?the literature is inconclusive . one study ( of six patients ) reported that the mean number of episodes before pec placement was 3.5 , but no larger trials have been conducted . typically , intervention is offered on a case - by - case basis with emphasis on patient preference in those unsuitable for operative intervention . one study ( of six patients ) reported that the mean number of episodes before pec placement was 3.5 , but no larger trials have been conducted . typically , intervention is offered on a case - by - case basis with emphasis on patient preference in those unsuitable for operative intervention . this is the first published report of pec migration into the large bowel without obstruction or perforation . we demonstrate that an appropriate trial of conservative management may be offered whilst decisions are made as to long - term prophylaxis . to what extent the residual tract may help to affix the bowel to the abdominal wall remains unknown .
a 68-year - old male nursing home resident presented following dislodgement of a percutaneous endoscopic colostomy ( pec ) tube originally sited to prevent recurrent sigmoid volvulus . computed tomography demonstrated tube migration into the lumen of the recto - sigmoid junction , where it remained for 12 days before passing spontaneously . during this period , the patient remained asymptomatic ; the residual colocutaneous fistula functioned as a decompressive valve . 
 originally , the patient was due to be discharged with early flexible sigmoidoscopy follow - up . 
 however , complex social issues delayed discharge . during his admission , a second pec tube was successfully inserted next to the previous colostomy site without complication . 
 this is an unusual case and no similar episodes of asymptomatic pec migration have been reported . 
 we demonstrate that such cases may be offered an appropriate trial of conservative management . here 
 , we describe our experience and critically appraise the literature .