Colostomy Site Research Articles

Incisionless Hartmann’s procedure: an innovative minimal access technique for surgical treatment of sigmoid volvulus in debilitated patients with faecal incontinence

Sigmoid volvulus requires decompression and subsequent surgical correction, and is often seen in debilitated patients. In an effort to decrease the physiological burden of surgery in these high-risk patients, we report an innovative minimal access technique for the definitive treatment of decompressed sigmoid volvulus in patients with concomitant faecal incontinence. A retrospective chart review of a series of two consecutive patients who had undergone a minimal access Hartmann's procedure (HP) between November 2005 and October 2006 was performed. A single skin incision of < or = 4 cm at the proposed colostomy site was used to identify, exteriorize, divide, and resect the redundant mesosigmoid and sigmoid colon. The same incision was used to mature the end-colostomy. No other incisions were created, and no laparoscopy or laparoscopic instruments were used. Perioperative clinical parameters and outcomes are reported. Patient 1 was a 94-year-old male, American Society of Anesthesiologists (ASA) class 4, who underwent a HP via a 4-cm skin incision under general anaesthesia in 150 min with a length of inpatient stay of 5 days. Patient 2 was an 83-year-old female, ASA class 3, who underwent a HP via a 3-cm skin incision under conscious sedation in 83 min, with a length of inpatient stay of 4 days. Estimated blood loss was <50 cm(3) for both patients, both patients had bowel function and were tolerating oral feeds upon discharge, and there was no perioperative morbidity or mortality in either patient at 30 days. Incisionless HP appears feasible in treating sigmoid volvulus and faecal incontinence in debilitated patients.

Endovascular Aortic Occlusion for a Secondary Aorto-Enterocutaneous Fistula:44-Month Follow-up

To describe the durability of endovascular aortic occlusion as an alternative treatment of an aortoenteric fistula in a severely unstable patient. A 47-year-old patient with a history of numerous previous vascular reconstructions underwent surgical exclusion of a persistent aorto-enterocutaneous fistula originating from a former colostomy site in proximity with the occluded left leg of an aortobifemoral bypass. Nine weeks later, he presented in profound hypovolemic shock from bleeding via the cutaneous remnant of the fistula and gastrointestinal tract. Because of the severe shock, recent surgery, and lack of a suitable endograft for the small-caliber aorta (19 mm), endovascular exclusion of the fistula was undertaken by occluding the infrarenal aorta. Talent occluders were also placed in the right femoral bypass limb and the right common iliac artery. An extra-anatomical bypass was created to revascularize the lower extremities. The patient was discharged in good condition on day 20. The fistula spontaneously regressed after 12 months. Since the patient refused further surgery, 44-month follow-up is now available. There are no signs of reinfection or recurrent aortoenteric fistula. Endovascular occlusion of a small caliber aorta with extra-anatomical revascularization of the lower extremities may be considered a useful treatment alternative for an aortoenteric fistula in severely unstable or compromised patients, either as a bridge to open surgery or as a definitive treatment if signs of reinfection do not occur.

Adenocarcinoma at the Colostomy Site in a Patient Presenting for Ulcerative Colitis Dysplasia Surveillance

Adenocarcinoma at the Colostomy Site in a Patient Presenting for Ulcerative Colitis Dysplasia Surveillance

Isolated colostomy site recurrence in rectal cancer-two cases with review of literature

BackgroundColostomy site carcinomas are rare with only eight cases reported in the world literature. Various etiological factors like adenoma-cancer sequence, bile acids, recurrent and persistent physical damage at the colostomy site by faecal matter due to associated stomal stenosis have been considered responsible. Two such cases are being reported and in both cases there was no evidence of any local recurrence in the pelvis or liver and distant metastasis. Both patients had received adjuvant chemotherapy following surgery.Case presentationFirst case was a 30-year-old male that had reported with large bowel obstruction due to an obstructing ulcero-proliferative growth (poorly differentiated adenocarcinoma) at the colostomy site after abdomino-perineal resection, performed for low rectal cancer six years previously. Wide local excision with microscopically free margins was performed with a satisfactory outcome. Four years later he presented with massive malignant ascites, cachexia and multiple liver metastasis and succumbed to his disease.Second case was a 47-year-old male that presented with acute large bowel obstruction due to an annular growth (well differentiated adenocarcinoma) in the upper rectum. He was managed by Hartmann's operation and the sigmoid colostomy was closed six months later. Five years following closure of colostomy, he presented with two parietal masses at the previous colostomy site scar, which, on fine needle aspiration cytology were found to be well-differentiated adenocarcinomas of colorectal type. Surgery in the form of wide local resection with free margins was performed. He presented again after five years with recurrence along the previous surgery scar and an incisional hernia and was managed by wide local excision along with hernioplasty. Follow-up of nine years following first surgery is satisfactory.ConclusionColostomy site/scar recurrence of rectal carcinoma is rare and could be due to various etiological factors, although the exact causative mechanism is not known. Surgery with microscopically free margins is recommended in the absence of metastatic disease. Stenosis of the stoma is considered as one of the most important contributory factors and should be followed carefully.

Self Expanding Metal Stents for Malignant Colorectal Obstruction Experience At a Private Hospital in Turkey

Background: The treatment of malignant obstruction of the colon or rectum usually requires emergency surgery on poor risk patients and the creation of a stoma is usually inevitable. SEMS have made prompt relief of obstruction without surgery possible. Aims: The purpose of our study was to evaluate the feasibility, effectiveness, safety and outcome in using SEMS to relieve acute colorectal obstruction for two different treatment in tentions, group I; preoperative decompression before surgical resection with primary anastomosis, group II; palliation for patients with inoperable malignant colorectal obstruction. Methods; From July 2003 to July 2006 10 SEMS (enteral wallstents) were placed in 10 patients under fluoroscopic and endoscopic control by a single experienced endoscopist. The data on the nature of pathology, success of the procedure, the complications and the outcomes of the patients were collected prospectively. Results: Nine patients had colorectal cancer, one patient had recurrent inoperable ovarian cancer. The procedure was for palliative intend in 5 patients (50%). Successfull insertion of the stent was achieved in 9 patients (90%). The clinical success rate was 90% . In one patient two stents were placed coaxially and overlapping for a long stricture. Location of the stricture were left colon (6 patients), transvers colon (3), cecum (1), colostomy site (1). In the patient with the obstruction at the level of cecum the stent could not be carried over the guidewire to the stricture site due to a long redundant sigmoid colon. The patient with two overlapping stents had a perforation 5 days after the procedure which was managed surgically. In group one all patients underwent subsequent definitive surgery, one had an ileostomy, mean ICU stay was 1.2 days, mean hospital stay was 7.6 days, no major perioperative complications occured. In group II, the mean survival was 8 months, all the patients died from reasons unrelated to stent obstruction. Conclusions: The use of SEMS for malignant colorectal obstruction is safe and effective. It provides good palliation for unresectable advanced tumors. It may also have a role in the temporary relief of obstruction so that subsequent definitive surgery can be performed under elective conditions. Through the scope technique with a large channel colonoscope rather than carrying the stent over a guidewire under floroscopic control might be preferable for right sided colonic strictures.

Laparoscopically assisted reversal of Hartmann’s procedure

Restoration of bowel continuity after Hartmann's procedure is a major surgical procedure associated with substantial morbidity and occasional mortality. The authors review their experience with laparoscopically assisted reversal of Hartmann's procedure (LARH) to assess difficulties and potential advantages associated with this procedure. A retrospective chart review of a prospectively entered database was performed to identify patients who underwent LARH over a period of 7 years. Data regarding demographic and clinical characteristics, surgical details, and postoperative course were reviewed. Specifically, age, gender, diagnosis at initial operation, American Society of Anesthesiology (ASA) score, comorbidities, operative time, conversion, surgical team, complications, postoperative bowel movements, and hospital stay were assessed. All surgeries were performed by six experienced laparoscopic surgeons. A total of 27 patients, 17 men and 10 women, with mean ages of 58.1 and 62.9 years, respectively, underwent LARH. The procedure was laparoscopically completed for 23 patients. Conversion to laparotomy was required for four patients (14.8%) because of dense adhesions after the initial Hartmann's procedure in three patients and rectal perforation in one patient. The median operative time was 226 min, and the median hospital stay was 6 days. The overall morbidity rate was 33% (9 patients), attributable to colostomy site infection in 5 of the 9 patients. One patient required reoperation because of intraabdominal bleeding. No anastomotic leaks or intraabdominal abscesses were recorded. There was no operative mortality. Laparoscopically assisted reversal of Hartmann's procedure is technically challenging and time consuming. However, in the hands of experienced laparoscopic surgeons, it is safe and associated with a reasonably low conversion rate. Furthermore, the relatively low morbidity rate, short hospital stay, and earlier return of bowel function may be beneficial to patients.

Successful Management of Peristomal Variceal Bleeding with Coil Embolization in a Patient with Decompensated Cirrhosis

Peristomal varices occasionally form in cirrhotic patients who have surgically created anastomoses and stomas. Variceal hemorrhage in this group carries an estimated mortality of 3%- 4% per episode, compared to the 30%- 40% mortality with esophageal variceal bleeding. We present a 59 year old African American male with Hepatitis C and Child's B cirrhosis, 5 years s/p colostomy for colon cancer, diabetes, end stage renal disease, peripheral vascular disease with bilateral amputations who presented with recurrent episodes of active bleeding in his colostomy bag over the past year. The patient was hemodynamically stable on presentation but had to be transfused one unit of packed RBC's. He had a Hb of 8.1 gm/dl with an INR of 1.4. His liver function tests were significant for an albumin of 1.1 gm/dl. An endoscopy done one month ago showed hemorrhagic esophagitis with duodenal polyps and no evidence of esophageal or gastric varices. A Colonoscopy through the colostomy site showed diverticulosis. An abdominal CT revealed a cirrhotic liver, splenomegaly, and moderate ascites with confluent veins around stoma site. The etiology of his bleeding was thought to be due to peristomal varices secondary to portal hypertension. Surgical intervention or Transjugular intrahepatic portosystemic shunt (TIPS) placement were not suitable options in him secondary to multiple co morbidities and the risk of encephalopathy and liver failure. Interventional radiology attempted coil embolization of these peristomal varices. Access into the portal system was obtained using a percutaneous portal transhepatic puncture. Inferior mesenteric venogram demonstrated enlarged IMV with hepatofugal flow into varices around the colostomy site. The main varix was coil embolized with four 8 mm nester coils. The post coil embolization venogram revealed a collateral vessel supplying the varix to the stomal site. Two coils were then placed at the origin of this vessel. The catheter was removed with no post procedure complications. The patient had no further episodes of bleeding after the embolization and continues to do well at the 3 month follow up. Stomal variceal hemorrhage has a lower mortality compared to esophageal variceal bleeding. TIPS is another modality to control bleeding from ectopic/stomal varices. Coil embolization with or without TIPS should be considered as a therapeutic option in stomal variceal bleeding especially in high-risk surgical patients.

Desmoid Tumor Arising at the Colostomy Site After Abdominoperineal Resection for Rectal Carcinoma: Report of a Case

A 69-year-old male who developed a desmoid tumor at the site of his end colostomy after abdominoperineal resection for rectal carcinoma is reported. The tumor was resected with wide margins. Histopathology revealed desmoid tumor of the anterior abdominal wall with no malignant features. The patient had an uneventful postoperative course. To our knowledge, this is the first case of solitary desmoid tumor of anterior abdominal wall at the colostomy site reported in the literature.

Gossypiboma as an Incidentaloma

A 72-year-old woman with known rectal carcinoma had an abdominal perineal resection. Within 11 months, the serum CEA was rising. PET revealed a lesion in the left mid pelvis and an unusual rim of enhanced activity within the left mid abdomen. Magnetic resonant imaging (MRI) localized an enlarged left internal iliac lymph node and ovoid abdominal mass. Computed tomography (CT) identified a serpiginous area compatible with an opaque sponge marker near the colostomy site. The left internal iliac lymph node was moderately differentiated necrotizing adenocarcinoma consistent with metastatic colon primary.

Effect of defunction on cytokinetics and cancer at colonic suture lines

An intestinal suture line potentiates experimental carcinogenesis in its vicinity, probably due to adaptive hyperplasia. By contrast, a defunctioning colostomy causes distal hypoplasia, and fewer tumours develop. Male Sprague-Dawley rats (n = 160) were used to study adaptation (assessed by a stathmokinetic technique) and carcinogenesis (induced by azoxymethane) at an end-to-end anastomosis that was raised in either functioning or defunctioned left colon. Controls had no procedure and other rats had proximal colostomy alone. Defunction had a profound antitropic effect on the colon, reducing bowel length and weight and crypt cell production rate (CCPR) by 22-56 per cent. Anastomotic CCPR was increased by a factor of 2.6 over controls: mean(s.e.m.) values of 12.71(2.85) versus 4.87(0.41) cells/crypt/h (P less than 0.01), but defunction reduced this by 76 per cent to a mean(s.e.m.) value of 3.00(0.52) cells/crypt/h below that in the intact colon. In the left colon, 39-50 per cent of tumours were sited at the anastomosis. Compared with controls there were 77 per cent fewer tumours in defunctioned colon, but they still favoured the site of anastomosis. Neoplasms at the colostomy site accounted for 74-77 per cent of all right-sided tumours. Anastomosis and defunction have powerful but contrasting effects on colonic adaptation and carcinogenesis; when combined they tend to cancel each other out.

Metachronous stomal adenocarcinoma following abdominoperineal resection for rectal cancer

Although metachronous colorectal tumours are relatively common, they seldom occur at stomasites. We present the case of a 57-year-old woman who developed a colostomy site malignancy. Possible associations and risk factors are discussed.

Laparoscopic restoration of intestinal continuity after Hartmann’s procedure

Background Colostomy closure after a Hartmann’s procedure typically requires a laparotomy. It also carries the risk of significant morbidity including anastomotic leak, wound infection, and incisional hernia. The aim of this study was to review our experience with laparoscopic restoration of intestinal continuity after Hartmann’s procedure. Methods After institutional review board approval, we retrospectively reviewed the medical records of patients undergoing laparoscopic colostomy reversal between July 1997 and July 2004. Results Twenty-two patients were identified; all patients had left colon colostomies. A laparoscopic technique was used in 21 patients, and 1 patient underwent hand-assisted colostomy reversal concurrently with right radical nephrectomy. The laparoscopic approach was successful in 20 cases, and there were 2 conversions to open (9%) secondary to dense adhesions around the rectal stump. The mean time to closure of the colostomy was 168 days (range 69–385 days). The mean operative time was 158 minutes (range 84–356 minutes). The estimated blood loss averaged 114 mL (range 30–250 mL). The average length of hospitalization was 4.2 days (range 2–6 days). Bowel function returned on an average of 3.5 days (range 2–5 days). Three patients (14%) developed postoperative wound infections. There were no anastomotic leaks and no mortality. At a mean follow-up of 14.7 months, the only long-term complication has been a small hernia at a colostomy site. Conclusions Laparoscopic colostomy reversal after Hartmann’s procedure can be performed with low morbidity and a short hospital stay. The need for conversion to open surgery is uncommon despite patients’ previous surgeries. A laparoscopic approach to colostomy takedown is safe and feasible and may result in a reduction in complications and length of stay as has been seen with other minimally invasive procedures.

Reactive Syringofibroadenomatous Hyperplasia in Peristomal Skin with Formation of Hybrid Epidermal-Colonic Mucosa Glandular Structures, Intraepidermal Areas of Sebaceous Differentiation, Induction of Hair Follicles, and Features of Human Papillomavirus Infection

We report a case of reactive syringofibroadenomatous hyperplasia in peristomal skin. The patient was a 62-year-old woman who had undergone abdominoperineal resection of the rectum for rectal adenocarcinoma with subsequent colostomy 2 years earlier. Clinically, a nodule and small, whitish, warty lesions developed at the outer margin of the stoma extending onto the adjacent skin. Following a clinical suspicion of adenocarcinoma, recurrent at the colostomy site, a 5 x 4 x 3-cm excision of the peristomal skin and the affected portion of the stoma was performed and submitted for histologic examination. The biopsy revealed a peculiar composite lesion of reactive syringofibroadenomatous hyperplasia and the excised part of the stoma. Several unusual histopathological features were detected in the syringofibroadenomatous part of the lesion such as the formation of plentiful hybrid epidermal-colonic mucosa glandular structures, intraepidermal areas of sebaceous differentiation, koilocytic changes, induction of rudimentary hair follicles, and intradermal mucinous lakes. The cellular composition of the glandular structures was mainly similar to that seen in a normal colonic mucosa epithelium. They also contained occasional Paneth cells. Being located at a distance from the stoma, these accentuated colonic mucosa epithelial glands reaching the epidermis may be a diagnostic pitfall prompting the consideration of adenocarcinoma involving the stoma. The rudimentary follicles and sebaceous differentiation were probably induced by an altered stroma and/or human papillomavirus (HPV): HPV, type 36 was identified by PCR using consensus primers followed by sequencing of the PCR products.

直腸癌術後のストーマ周囲に再発をきたした１例

症例は84歳男性.直腸癌のためハルトマン式直腸切除術を行い外来にて経過観察中,ストーマ周囲の痛みを訴え外来を受診した.本人が痛みの原因が装具のためと考えており,そのためストーマ装具の長期装着が困難となっていた.ストーマの指診にて腹壁部に狭窄と硬結を認め,CTにて腹壁の再発と診断された.他に再発巣を認めなかったため,ストーマを含めた再発巣を切除し,上腹部に術前マーキングをした上でストーマを再造設した.現在再発無く,良好なQOLが得られ外来通院中である.ストーマの痛みを訴える場合,再発を疑って検索すべきである.ストーマ部位の再発癌に対しては,可能な限り再切除を試みることでQOLが改善できる。またストーマ外来における定期的なケアが重要と思われた.

直腸癌手術後にストーマ造設部位に再発をきたした１例

直腸癌手術後にストーマ造設部位に再発をきたした１例

人工肛門部癌を含む異時性多発性大腸癌の1例

人工肛門部癌を含む異時性多発性大腸癌の1例

直腸癌術後35年目に人工肛門に発生した大腸癌の1例

直腸癌術後35年目に人工肛門に発生した大腸癌の1例

The use of a subfascial vicryl mesh buttress to aid in the closure of massive ventral hernias following damage-control laparotomy.

Damage control laparotomy for life-threatening abdominal conditions has gained wide acceptance in the management of exsanguinating trauma patients as well as septic patients with acute abdomen. Survivors considered too ill to undergo definitive abdominal wall closure are temporized, often with skin grafting on granulated viscera. These maneuvers compromise the integrity of the anterior abdominal wall and result in a subset of patients with loss of abdominal domain and massive, debilitating ventral hernias. A retrospective review was conducted of 21 such patients (16 men, five women) who underwent elective abdominal wall reconstruction at the Hospital of the University of Pennsylvania between November of 1998 and October of 2000. The purpose of this study was to report the authors' experience with these complex abdominal wall reconstructions. A double-layer, subfascial Vicryl mesh buttress was used in all repairs to aid in reestablishing abdominal wall integrity. The mean hernia size was 813 cm2 (range, 75 to 1836 cm2), and the average interval to definitive repair was 24.4 months (range, 3 weeks to 11 years). Mean follow-up was 13.5 months (range, 1 month to 40 months). Twenty patients (95 percent) had successful ventral hernia repair. Four patients with massive hernias (924 to 1836 cm2) required submuscular Marlex mesh implantation. Two patients (10 percent) developed abdominal compartment syndrome that required surgical decompression. One patient (5 percent) developed an incisional hernia at a prior colostomy site. Four patients (19 percent) had superficial skin dehiscence that healed secondarily with daily wound care. There were no mesh infections. In most cases, successful single-stage repair of large ventral hernias following damage control laparotomy can be achieved using a subfascial Vicryl mesh buttress in combination with other established reconstructive techniques. Massive defects exceeding 900 cm2 typically require permanent mesh implantation to achieve fascial closure and to minimize the risk of postoperative abdominal compartment syndrome and recurrent herniation. This technique represents an improved solution to a complicated problem and optimizes the aesthetic and functional outcome for these debilitated patients.

Clinical Quiz

A 9-year-old boy, known to have Crohn disease, presented to the emergency room with a one-week history of increasing, colicky abdominal pain. He was diagnosed at four years of age with severe perianal and rectal disease. His disease was refractory to extensive medical management, and he required a diversion sigmoid colostomy and the establishment of a Hartmann pouch at seven years of age because of persistent anal stenosis and severe dyschezia. In addition to his abdominal pain, he reported the passage of flatus, but no stool, into his colostomy bag. His vital signs were stable; he was apyrexial and had a normal urine analysis. On examination, his abdomen was protuberant with a 15 by 12 cm mass in the hypogastric region extending down into the pelvis. The colostomy site in the left flank appeared healthy. Anal inspection revealed extensive scarring, and no anal orifice was readily identified. Imaging included an abdominal radiograph (Fig. 1), abdominal and pelvic sonography (Fig. 2), and retrograde colon study via his colostomy.FIG. 1. No Caption AvailableFIG. 2. No Caption AvailableWhat is the most likely diagnosis? A. Colostomy stenosis and obstruction B. Pelvic abscess C. Rectal mucocele D. Distended bladder due to outlet obstruction Answer: C. Rectal Mucocele The mucosal lining of a Hartmann's pouch secretes mucus, which must drain or it will accumulate over time. Inflammation, scarring and epithelialization of the anal canal obstructed the drainage in this case, causing a mucocele, which progressively enlarged. The abdominal radiograph indicated a soft-tissue mass arising from the pelvis, displacing bowel superiorly and to the right. Sonography demonstrated a markedly dilated hollow viscus arising from the deep pelvis and extending up to the left hypochondrium. There was no obvious connection to the stoma site. The mass was causing mild, left-sided hydronephrosis. Retrograde enema via the colostomy filled a normal caliber colon. The anus was probed open under general anesthesia and 1100 ml of mucus was evacuated. A Penrose drain was left across the anus to maintain patency. Comment: Mucoceles are commonly associated with the appendix and cranial sinuses. Rectal mucoceles are rare. The first reported pediatric case was an extraluminal pelvic mucocele in a patient with an imperforate anus following an endorectal pull-through operation with incomplete mucosal excision (1). There are case reports of rectal mucoceles following Hartmann's procedure for ulcerative colitis, and secondary to high anal sphincter tone following spinal trauma (2,3). Mucoceles have developed in defunctioned colon after pull-through surgery due to stenosis and retraction of the colonic stump (4,5). Scarring of the mucus fistula, or failure to creat a mucus fistula are other described contributing factors. In our patient, obstruction of the isolated distal colon was caused by severe, long-standing anorectal Crohn disease which caused scarring, stricture and epithelialization of the anal orifice. Treatment requires effective drainage or removal of the mucus-producing epithelium. This case illustrates a rare but interesting complication of Crohn disease.

The use of temporary diverting colostomy to manage elderly individuals with extensive perineal burns

The regimen of burn treatment for five elderly individuals who had sustained burns that had involved the perineum included formation of colostomy to divert fecal passage. The inclusion of diverting colostomy in this group of patients had made the management of burn wound that had included eventual skin grafting technically easy. A total of 168 patients were admitted to the Burn Unit at the Kagoshima City Hospital between 1997 and 2000. There were 36 patients who had perineal involvement. Of these, there were five elderly patients aged 60 years or older. There were two men and three women who were between 60 and 81 years of age. The mean age was 72 years. The total body surface involvement varied between 7 and 55% with an average body surface involvement of 30%. The sigmoid colon was as the colostomy site. Although, two patients died of injury, the morbidities associated with colostomy procedure were nil.