Stoma prolapse is an increase in the size of the stoma secondary to intussusception of the proximal bowel segment. Strangulation and ischemia of the prolapsed segment have been reported as complications.
This is the case of a 58-year-old man with multiple comorbidities who was diagnosed with an adenocarcinoma of the ascending colon with hepatic metastasis. He was considered unable to start conversion chemotherapy because of his cardiovascular comorbidities and was therefore under paliative chemotherapy.
Patient came into emergency room with an acute bowel obstruction and underwent a loop ileostomy as a diversion procedure. Following up the procedure, the patient developed an acute on chronic kidney failure because of dehydration from high output ileostomy. In the postoperative day 17, patient presented with an acutely incarcerated prolapsed afferent limb of the loop ileostomy. Attempts at reduction were unsuccessful.
Herein we present a simple, safe, and fast approach for correcting a prolapsed loop or terminal stoma using a step-wise application of linear staplers.
When laparotomy and/or stoma reversal is not appropriate, local revision of stoma prolapse provides a low-risk and high-benefit alternative solution.
By using this local repair technique, we were able to avoid the consequences of a major laparotomy with a low-risk and high-benefit alternative solution.
This technique can be performed without spinal or general anesthesia and seems to be a very useful procedure for patients with prolapse of a stoma.
Local repair of stoma prolapse avoids the consequences of a major laparotomy.
Ostomy complications are known to negatively affect the quality of life of ostomates. Therefore, correcting an ostomy prolapse aims at improving the quality of life. The short duration of surgery of just over 15 min can be seen as a reason to employ this technique in patients with relevant morbidities.
When there is doubts how the initial loop ileostomy was done an which is the afferent or efferent loop, one should avoid doing this procedure as there is the risk of hemorrhage and ischemia from divided mesenteric vessels resulting in necrosis, stenosis, or retraction and bowel obstruction.
In that case, the surgeon should go for a emergency laparotomy.
The patient underwent general anaesthesia and was placed in the supine position.
The surgeon was positioned at the left side of the patient and the first assistant on the right side of the patient.
A total of six staple loads, four for the bisection and two for the base of each half, were thus used in the entire procedure.
After administration of preoperative antibiotics, the prolapse segment was examined and confirmed to be the afferent limb of the loop ileostomy. The segment was incarcerated and could not be reduced even under general anaesthesia.
The diagnosis of stoma prolapse with incarceration is a clinical one, thus no other investigations were done.
Patient had the diverting loop ileostomy on the left flank.
Start transecting the prolapsed stoma in a longitudinal fashion starting at the superior border, nine o'clock position. Followed by transection of the prolapsed stoma at three o'clock position.
Use linear staplers as neded at the same previously mentioned positions to complete the bisection of the prolapsed segment into two halves.
The base of each half is then transected at approximately 1 cm above the skin level in a perpendicular fashion with two 75 cm gastrointestinal linear staplers, green cartridges.
No intraoperative or postoperative complications occurred. Entry into the abdomen was completely avoided. In the recovery phase, no narcotic medications were required as the patient had minimal pain requirements and oral intake was resumed the day of surgery. Stoma function returned and he was dismissed on post-operative day one. On four-week post-operative follow-up, he had no evidence for recurrent prolapse, obstruction or other complications. The patient was satisfied with his care and is currently receiving palliative chemotherapy for progression of disease with new liver metastasis.
One of the most common late complications following stoma construction is prolapse. Although the majority of prolapse can be managed conservatively, surgical revision is required with incarceration/strangulation and in certain cases laparotomy and/or stoma reversal are not appropriate.
A possible pitfall with such stapler-assisted techniques is the risk of hemorrhage and ischemia from divided mesenteric vessels resulting in necrosis, stenosis, or retraction. After correction might be helpful in examining the perfusion status before and after prolapse repair, thus reducing the risk of ischemia.
Over-sewing the stapler lines, in turn, aims to reduce the risk of hemorrhage
No disclosure of conflicts.
Eva Santos, MD - Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
Márcia Carvalho, MD - Centro Hospitalar do Médio Ave, Famalicão, Portugal
João Louro, MD - Centro Hospitalar do Funchal, Funchal, Portugal
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Authors
Carol Li, MD1*, Apoorva T. Ramaswamy, MD1*, Sallie M. Long, MD 1 , Alexander Chern, MD 1 , Sei Chung, MD 1 , Brendon Stiles, MD 2 , Andrew B. Tassler, MD 1
1Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York, NY 2Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
*Co-First authors
Overview
The COVID-19 pandemic is an unprecedented global healthcare emergency. The need for prolonged invasive ventilation is common amid this outbreak. Despite initial data suggesting high mortality rates among those requiring intubation, United States data suggests better outcomes for those requiring invasive ventilation. Thus, many of these patients requiring prolonged ventilation have become candidates for tracheotomy. Considered aerosol generating procedures (AGP), tracheotomies performed on COVID-19 patients theoretically put health care workers at high risk for contracting the virus. In this video, we present our institution’s multidisciplinary team-based methodology for the safe performance of tracheotomies on COVID-19 patients. During the month of April 2020, 32 tracheotomies were performed in this manner with no documented cases of COVID-19 transmission with nasopharyngeal swab and antibody testing among the surgical and anesthesia team.
Procedure Details
The patient is positioned with a shoulder roll to place the neck in extension. The neck is prepped and draped in a sterile fashion with a clear plastic drape across the jawline extending superiorly to cover the head. An institutional timeout is performed. The patient is pre-oxygenated on 100% FiO2. A 2-cm vertical incision is made extending inferiorly from the lower border of the palpated cricoid cartilage. Subcutaneous tissues and strap muscles are divided in the midline. When the thyroid isthmus is encountered, it is either retracted out of the field or divided using electrocautery. The remaining fascia is then cleared off the anterior face of the trachea.
Prior to airway entry, the anesthesiologist pauses all ventilation and turns off oxygen flow. The endotracheal tube (ETT) is advanced distally past the planned tracheotomy incision, without deflating the cuff, if possible. If necessary, the endotracheal cuff is deflated partially to advance the tube, with immediate reinflation once in position. The surgical team then creates a tracheotomy using cold steel instruments. The cricoid hook is placed in the tracheotomy incision and retracted superiorly for exposure of the lumen. The tube is withdrawn under direct visual guidance, without deflating the endotracheal cuff if possible. The tracheotomy tube is placed, and to minimize aerosolization of respiratory secretions, the cuff is inflated prior to re-initiation of ventilation. The tracheotomy tube is then sewn to the skin using 2-0 prolene suture. A total of five simple stitches are placed around the tube to prevent accidental decannulation.
Indications/Contraindications
Candidacy for tracheotomy was determined on a case by case basis with consideration for progression of ventilator weaning, viral load, and overall prognosis. All patients who underwent tracheotomy were intubated prior to the surgery for a minimum of 14 days, able to tolerate a 90-second period of apnea without significant desaturation or hemodynamic instability, and expected to recover. Optimal ventilator settings included FiO2
As technique and technology have evolved in the modern age, surgical emphasis has shifted steadily towards minimally invasive alternatives. In colon surgery, laparoscopy has been shown to improve multiple outcome metrics, including reductions in post-operative morbidity, pain, and hospital length of stay, while maintaining surgical success rates. Unfortunately, despite the minimally invasive approach, elective laparoscopic sigmoidectomy typically requires an abdominal wall extraction site, leaving a large incision in addition to the laparoscopic port sites. It also utilizes three different types of intestinal staplers, leading to an anastomosis that may have multiple intersecting staple lines, thereby potentially influencing the anastomotic integrity, as well as increasing procedural costs substantially.
We present a case of a totally robotic sigmoidectomy utilizing a single stapler technique and natural orifice specimen extraction in a patient with multiple, severe, recurrent episodes of sigmoid diverticulitis over a 2-year period.
Disclosure/ Conflict of interest: The authors whose names are listed above certify that they have NO affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria; educational grants; participation in speakers ’bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
Review Stapler-assisted Loop Ileostomy Stoma Prolapse Repair.