Laparoscopic Ileostomy in Severe, Obscure Gastrointestinal Hemorrhage

Abstract

Laparoscopic diverting ileostomy should help define whether a severe, obscure gastrointestinal hemorrhage is in the upper or lower gastrointestinal tract in preparation for subtotal resection without increasing risk of patient morbidity and mortality. Case reports. University hospital. Patient 1 is an 83-year-old woman. Patient 2 is a 75-year-old woman. Both were admitted to the hospital for massive gastrointestinal hemorrhage, which required multiple blood transfusions. Extensive workup revealed multiple diverticula in the small and large intestines without identification of any source of active bleeding in either patient. Laparoscopic exploration of the abdominal cavity was performed. The terminal ileum at the ileocecal valve was identified and, 5 cm proximal to the ileocecal valve, the small bowel was transected. The distal end staple line was secured in end-to-side fashion to the proximal end, and the proximal end was brought out as an end ileostomy. Patients were then observed for bleeding into the ostomy bag or in the rectum. Localization of the source of bleeding as upper or lower, occurrence of surgical complications, and clinical outcome. No intraoperative complications occurred in either patient. Patient 1 had significant bleeding into her ileostomy bag on postoperative day 1. She was taken back to the operating room for empirical small bowel resection. She was discharged, had no further bleeding, and underwent closure of the ileostomy 2 months later. The postoperative course of patient 2 was complicated by a small parastomal abscess that resolved with percutaneous drainage and antibiotics. Patient 2 returned on postoperative day 22 with bleeding in the rectum. She was taken to the operating room for laparoscopic total colectomy with ileosigmoid anastomosis and ileostomy closure. Both patients recovered uneventfully and had no recurrent bleeding. Our experience with these 2 patients suggests that in cases in which the risk of blind resection appears ill-advised, laparoscopic compartmentalization of the small bowel from the colon via end ileostomy may be safely performed.