An unusual cause for small bowel obstruction as a complication of an ileostomy formation

An unusual cause for small bowel obstruction as a complication of an ileostomy formation Ileostomy formation is a fundamental component in the surgical management of many gastrointestinal diseases and like all intra-abdominal surgeries, small bowel obstruction is a recognized complication. In this paper we discuss a case of a 44- year-old female who previously had a loop ileostomy for slow bowel transit in the presence of spinal bifida. She presented for subsequent total colectomy because of ongoing pain due to chronic colonic dilation. At surgery, the stoma was not revised and the efferent loop was divided at the peritoneal level of the anterior abdominal wall. Six days postoperatively, the patient developed a small bowel obstruction as a result of the remnant efferent loop within the anterior abdominal wall, forming a cystic mass compressing the ileostomy, requiring surgical intervention. As far as we are aware, this is the first case of small bowel obstruction described due to this unusual etiology. INTRODUCTION decided to divide the efferent ileal limb at the peritoneal level of the anterior abdominal wall, leaving the afferent ileal limb to Ileostomy formation is an integral component in the surgical man- function as an end ileostomy. agement of many gastrointestinal diseases mainly colorectal sur- The patient recovered well with the stoma functioning well gery and may be permanent or temporary. Specific complications until Day 6, when she developed a small bowel obstruction. CT of an ileostomy may be classified according to the time of onset scan demonstrated cystic structure compressing the ileum loop (early or late) and in relation to the procedure (after construction or within the anterior abdominal loop just before the stoma open- takedown) [1]. This case report presents an unusual cause for a ing (Figs 1 and 2). Digital stomal examination and Foley’s cath- small bowel obstruction as a complication of an ileostomy. eter failed to pass through the stoma opening confirming the obstruction being at the abdominal wall. Failure of supportive CASE REPORT measures, the patient was taken to theatre for revision of the stoma. Per stoma endoscopy was attempted with a gastroscope A 44-year-old female who has already had loop ileostomy for and which also failed to traverse the compression. At surgery, a slow bowel transit in the setting of spinal bifida presented 12 semicircular skin incision was made adjacent to the stoma years later for a total colectomy because of ongoing pain as a revealing what remained of the efferent ileal loop transformed consequence of chronic colonic dilatation. A laparotomy was into cystic mass abutting the stoma causing tight compression performed for total colectomy but the stoma, being well situ- and was tightly adherent to the afferent ileal loop (Fig. 3). This ated and with good function, was not revised and the surgeon Received: January 24, 2018. Accepted: April 19, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy086/4993409 by Ed 'DeepDyve' Gillespie user on 21 June 2018 2 N. Ramdwar et al. Figure 1: Cross sectional CT Image showing compression of ileostomy opening. Figure 3: Cystic mass opened confirming remnant of efferent loop. bowel adhesions in the area around the ileostomy, intraperito- neal adhesions or an acute parastomal hernia [1]. The incidence of early parastomal herniation and bowel obstruction ranges from 4.6% to 13% [2–5] and usually requires urgent reoperation. In this unusual cause, the small bowel obstruction, the rem- nant efferent ileal loop developed into closed loop, because its opening was fibrosed and transformed into a cystic mass, obstructing the afferent loop within the abdominal wall. This option is quite a feasible one to convert a loop ileostomy into a functional end ileostomy, however, one must ensure the effer- ent loop is patent at its opening. As far as we are aware, this is the first case of small bowel obstruction described due to this unusual etiology. CONFLICT OF INTEREST STATEMENT None declared. Figure 2: Coronal section showing compression of ileostomy. REFERENCES was drained and partially excised with limited mobilization of the stoma. The remnant mucosa adherent to the afferent ileal 1. Kann B. Early stomal complications. Clin Colon Rectal Surg loop was cauterized. Her recovery was unremarkable and was 2008;21:23–30. discharged Day 4 postsurgery. Histopathology of the partially 2. Pearl RK, Prasad LM, Orsay CP, Abcarian H, Tan AB, Melzl excised cyst wall confirmed small bowel with viable mucosa MT. Early local complications from intestinal stomas. Arch showing mucosal flattening and complete loss of the villi. Surg 1985;120:1145–7. 3. Feinberg SM, McLeod RS, Cohen Z. Complications of loop ile- DISCUSSION ostomy. Am J Surg 1987;153:102–7. 4. Grobler SP, Hoise KB, Keighley MRB. Randomized trial of loop Small bowel obstruction is a recognized complication of ileostomy in restorative proctocolectomy. Br J Surg 1992;79: ileostomy 903–90. Small bowel obstruction may occur because of too small tre- 5. Shellito PC. Complications of abdominal stoma surgery. Dis phine in the anterior abdominal wall, a twisted loop, small Colon Rectum 1998;41:1562–72. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy086/4993409 by Ed 'DeepDyve' Gillespie user on 21 June 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

An unusual cause for small bowel obstruction as a complication of an ileostomy formation

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Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018.
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Abstract

Ileostomy formation is a fundamental component in the surgical management of many gastrointestinal diseases and like all intra-abdominal surgeries, small bowel obstruction is a recognized complication. In this paper we discuss a case of a 44- year-old female who previously had a loop ileostomy for slow bowel transit in the presence of spinal bifida. She presented for subsequent total colectomy because of ongoing pain due to chronic colonic dilation. At surgery, the stoma was not revised and the efferent loop was divided at the peritoneal level of the anterior abdominal wall. Six days postoperatively, the patient developed a small bowel obstruction as a result of the remnant efferent loop within the anterior abdominal wall, forming a cystic mass compressing the ileostomy, requiring surgical intervention. As far as we are aware, this is the first case of small bowel obstruction described due to this unusual etiology. INTRODUCTION decided to divide the efferent ileal limb at the peritoneal level of the anterior abdominal wall, leaving the afferent ileal limb to Ileostomy formation is an integral component in the surgical man- function as an end ileostomy. agement of many gastrointestinal diseases mainly colorectal sur- The patient recovered well with the stoma functioning well gery and may be permanent or temporary. Specific complications until Day 6, when she developed a small bowel obstruction. CT of an ileostomy may be classified according to the time of onset scan demonstrated cystic structure compressing the ileum loop (early or late) and in relation to the procedure (after construction or within the anterior abdominal loop just before the stoma open- takedown) [1]. This case report presents an unusual cause for a ing (Figs 1 and 2). Digital stomal examination and Foley’s cath- small bowel obstruction as a complication of an ileostomy. eter failed to pass through the stoma opening confirming the obstruction being at the abdominal wall. Failure of supportive CASE REPORT measures, the patient was taken to theatre for revision of the stoma. Per stoma endoscopy was attempted with a gastroscope A 44-year-old female who has already had loop ileostomy for and which also failed to traverse the compression. At surgery, a slow bowel transit in the setting of spinal bifida presented 12 semicircular skin incision was made adjacent to the stoma years later for a total colectomy because of ongoing pain as a revealing what remained of the efferent ileal loop transformed consequence of chronic colonic dilatation. A laparotomy was into cystic mass abutting the stoma causing tight compression performed for total colectomy but the stoma, being well situ- and was tightly adherent to the afferent ileal loop (Fig. 3). This ated and with good function, was not revised and the surgeon Received: January 24, 2018. Accepted: April 19, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy086/4993409 by Ed 'DeepDyve' Gillespie user on 21 June 2018 2 N. Ramdwar et al. Figure 1: Cross sectional CT Image showing compression of ileostomy opening. Figure 3: Cystic mass opened confirming remnant of efferent loop. bowel adhesions in the area around the ileostomy, intraperito- neal adhesions or an acute parastomal hernia [1]. The incidence of early parastomal herniation and bowel obstruction ranges from 4.6% to 13% [2–5] and usually requires urgent reoperation. In this unusual cause, the small bowel obstruction, the rem- nant efferent ileal loop developed into closed loop, because its opening was fibrosed and transformed into a cystic mass, obstructing the afferent loop within the abdominal wall. This option is quite a feasible one to convert a loop ileostomy into a functional end ileostomy, however, one must ensure the effer- ent loop is patent at its opening. As far as we are aware, this is the first case of small bowel obstruction described due to this unusual etiology. CONFLICT OF INTEREST STATEMENT None declared. Figure 2: Coronal section showing compression of ileostomy. REFERENCES was drained and partially excised with limited mobilization of the stoma. The remnant mucosa adherent to the afferent ileal 1. Kann B. Early stomal complications. Clin Colon Rectal Surg loop was cauterized. Her recovery was unremarkable and was 2008;21:23–30. discharged Day 4 postsurgery. Histopathology of the partially 2. Pearl RK, Prasad LM, Orsay CP, Abcarian H, Tan AB, Melzl excised cyst wall confirmed small bowel with viable mucosa MT. Early local complications from intestinal stomas. Arch showing mucosal flattening and complete loss of the villi. Surg 1985;120:1145–7. 3. Feinberg SM, McLeod RS, Cohen Z. Complications of loop ile- DISCUSSION ostomy. Am J Surg 1987;153:102–7. 4. Grobler SP, Hoise KB, Keighley MRB. Randomized trial of loop Small bowel obstruction is a recognized complication of ileostomy in restorative proctocolectomy. Br J Surg 1992;79: ileostomy 903–90. Small bowel obstruction may occur because of too small tre- 5. Shellito PC. Complications of abdominal stoma surgery. Dis phine in the anterior abdominal wall, a twisted loop, small Colon Rectum 1998;41:1562–72. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy086/4993409 by Ed 'DeepDyve' Gillespie user on 21 June 2018

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Journal of Surgical Case ReportsOxford University Press

Published: May 2, 2018

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