Short-term outcomes of local correction of stoma prolapse with a stapler device

Mid-term Efficacy of Local Repair Using Modified Altemeier Technique for Stomal Prolapse: A Case Series

Introduction: Stomal prolapse (SP) is characterized by full-thickness protrusion of the bowel through the stoma site. The surgical procedures for SP include local repair, abdominal wall fixation, and stoma relocation. However, previous reports were mostly case reports or case series with a small number of patients and lacked long-term results. A modified Altemeier technique (MAT) has been used for the local repair of SP in our institution, and this study aimed to evaluate its mid-term efficacy.

Methods: We reviewed patients who underwent MAT for SP between August 2013 and December 2020. The variables included patient characteristics, type of stoma, indications of stoma creation, the time interval from stoma creation to prolapse, site of prolapse, reasons for SP surgery, perioperative variables, complications during SP surgery, and length of follow-up. Recurrence of SP was defined as the need for change in stoma care or re-protrusion of the stoma by more than 5 cm in length.

Results: Ten patients were included in this study. The median age at the time of SP surgery was 71.5 years. The indications of stoma creation included unresectable or recurrent intra-abdominal malignancies in four patients, diverting ileostomy with rectal cancer surgery in two, transverse colon cancer in one, gastric and rectal cancer in one, rectovaginal fistula in one, and non-occlusive mesenteric ischemia in one. The median interval from stoma creation to prolapse was 2.5 months. Six patients underwent elective SP surgery, and four patients underwent emergency surgery for incarcerated prolapse. The median operative time was 75.5 min. Postoperative complications that included transient mucosal ischemia and subcutaneous abscess occurred in one patient. There were four recurrences (40%), and the median time interval from surgery to recurrence was 4.5 months. Two patients underwent repeated MAT, one of whom underwent stomal reversal with laparotomy for re-recurrence. The median follow-up duration was 19 months.

Conclusion: MAT for SP is associated with a high recurrence rate in mid-term follow-up.

Evaluation of the Outcome of Local Surgery for Stomal Prolapse

We reviewed the results of local surgical treatment of stoma prolapse, a long-term complication of stoma construction. Fifteen patients treated for stomal prolapse between 2009 and 2020 at the authors' and affiliated hospitals were included in this study. The treatment comprised local laparotomic stomal reconstruction (LLSR) in nine patients and stapling repair (SR) in six. We compared and evaluated the clinical and surgical information and postoperative complications. Operation time was significantly shorter in the SR group than in the LLSR group: 20 and 53 min, respectively (p = 0.036). The duration of postoperative hospitalization was shorter in the SR group than in the LLSR group: 5.5 and 8 days, respectively; the difference was not significant (p = 0.088). No short-term complications were found in either group. Regarding long-term, postoperative complications, parastomal hernias developed after 2.5 years in one patient in the LLSR group and after 6 months in one patient in the SR group; both patients had histories of parastomal hernia surgery and had relatively high body mass indices. Local surgery for stomal prolapse was minimally invasive and performed safely. In patients with a history of surgery for parastomal hernia, attention must be paid to the potential of parastomal hernia developing as a postoperative complication.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

Outcomes of stapler repair with anastomosis for stoma prolapse

PURPOSE

The published data on the outcomes of an operative repair for stoma prolapse are limited. This study aimed to clarify the long-term outcomes of stapler repair with anastomosis for stoma prolapse.

METHODS

Twenty-four patients (15 men, median age 64 years, range 33-88 years) undergoing 25 stapler repairs with anastomosis were prospectively registered, and their medical records were retrospectively reviewed.

RESULTS

The median length of prolapse was 10 cm (range 5-22). Stoma prolapse repair was performed by means of 16 loop colostomies, four end colostomies, three loop ileostomies, and one end ileostomy. A stapler was used 4.6 times on average (range 4-8). The average operative time and bleeding were 40.8 (range 15-75) min and 40 (range 0-214) mL, respectively. No mortality and morbidity were observed after surgery. A recurrence of stoma prolapse was reported in only one of 25 repairs (4%) at the proximal limb of loop ileostomy during a median follow-up period of 1 year (range 1-120 months). However, a new stoma prolapsed in one untreated limb of loop stoma.

CONCLUSIONS

Stapler repair with anastomosis is a safe and minimally invasive treatment option for stoma prolapse with a low recurrence. However, the effectiveness of reparing stoma prolapse on the proximal limb of loop ileostomy might be limited.

Current Management of Intestinal Stomas and Their Complications

Inappropriate stoma site, improper management of stoma, and stoma complications lead to diminished quality of life of ostomates. Healthcare professionals involved in stoma creation and/or care should have the fundamental and updated knowledge of the management of stomas and their complications. This review article consists of the following major sections: principles of perioperative patient management, early complications, and late complications. In the “principles of perioperative patient management” section, the current concepts and trends in preoperative education, stoma site marking, postoperative education, and patient educational resources are discussed. In the “early complications” section, we have focused on the etiology and current management of ischemia/necrosis, fluid and electrolyte imbalances, mucocutaneous separation, and retraction. In the “late complications” section, we have focused on the etiology and current management of parastomal hernia, stoma prolapse, parastomal varices, and pyoderma gangrenosum. Pre- and postoperative patient education facilitates the patient's independence in stoma care and resumption of normal activities. Healthcare providers should have basic skills and updated knowledge on the management of stomas and complications of stomas, to act as the first crisis manager for ostomates.

Successful treatment of recurrent stoma prolapse after Hartmann's procedure through ileorectal anastomosis: A case report

•

The patient with Parkinson’s disease had stoma prolapse after Hartmann’s procedure.

•

Local procedure had failed, and stoma reversal was considered to be favorable.

•

We assumed that stoma reversal alone led to worsening of concomitant constipation.

•

We performed resection of the remnant colon with ileorectal anastomosis.

•

It may be an optimal treatment for patients with concomitant colonic motility disorder.

Introduction

Treatment strategy for recurrent stoma prolapse has not been well-established because of the rarity and complexity of the condition. We report a case of recurrent stoma prolapse that was successfully managed using unique surgical treatments.

Presentation of case

A 72-year-old man with a history of Parkinson's disease presented with transverse (T3N0M0) and sigmoid (T3N0M0) colon cancer. Considering the status of large bowel obstruction, Hartmann's procedure was indicated. Four months after surgery, stoma prolapse occurred, which became irreducible. Six months after surgery, local resection of the prolapsed bowel was performed. The patient continued to receive laxatives for bowel movement control and his abdomen remained distended. Ten months later, stoma prolapse recurred with evident bowel dilatation. Initially, we planned Hartmann’s reversal. However, as the patient had intractable constipation secondary to Parkinson’s disease, resection of the proximal colon and ileorectal anastomosis were considered as the treatment choices. Therefore, we performed right colectomy with ileorectal anastomosis. At 1.5 years after the last surgery, complications such as small bowel obstruction, difficulty in defecation, or fecal incontinence were not detected.

Discussion

The cause of stoma prolapse is generally ascribed to various anatomical factors such as redundant intestine, high intra-abdominal pressure, and intraperitoneal route. Stoma prolapse is also influenced by other factors, including old age, obesity, and the severity of illness that necessitated stoma creation. In this case, the decision regarding surgical management was complicated by colonic motility disorder with concomitant Parkinson’s disease.

Conclusion

We suggest that ileorectal anastomosis may be an optimal surgical treatment for patients with recurrent stoma prolapse and concomitant colonic motility disorder who have undergone Hartmann’s procedure.

The Difficult Stoma: Challenges and Strategies

The problems that a patient experiences after the creation of a temporary or permanent stoma can result from many factors, but a carefully constructed stoma located in an ideal location is typically associated with appropriate function and an acceptable quality of life. The construction of the stoma can be confounded by many concomitant conditions that increase the distance that the bowel must traverse or shorten the bowel's capacity to reach. Stomas can be further troubled by a variety of problems that potentially arise early in the recovery period or months later. Surgeons must be familiar with these obstacles and complications to avoid their occurrence and minimize their impact.