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Stapler-assisted Loop Ileostomy Stoma Prolapse Repair

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
1 - Arumugam PJ, Bevan L, Macdonald L, Watkins AJ, Morgan AR, Beynon J, Carr ND (2003) A prospective audit of stomas—analysis of risk factors and complications and their management. Colorectal Dis 5(1):49–52 2 - Shabbir J, Britton DC (2010) Stoma complications: a literature overview. Colorectal Dis 12(10):958–964 3 - Masumori K., Maeda K., Koide Y., Hanai T., Sato H., Matsuoka H., Katsuno H., Noro T. Simple Excision and closure of a distal limb of loop colostomy prolapse by stapler device. Tech. Coloproctol. 2012;16:143–145. 4 - Ambe PC, Kurz NR, Nitschke C, Odeh SF, Moslein G, Zirngibl H (2018) Intestinal ostomy. Dtsch Arztebl Int 115(11):182–187 5 - Tepetes K., Spyridakis M., Jatzitheofilou C. Local treatment of loop colostomy prolapse with a linear stapler. Tech. Coloproctol. 2005;9:156–158 6 - Geisler D., Glennon E. Intestinal stomas and their complications. Colorectal Surg. 2013;28:440–455.

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