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B. Abboud, G. Tabet, J. Jaoudé, G. Sleilaty (2007)
Gastric incarceration and perforation following posttraumatic diaphragmatic hernia: case report and review of the literature.Le Journal medical libanais. The Lebanese medical journal, 55 2
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Parastomal hernias.The Surgical clinics of North America, 88 1
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JSCR 2013; 4 (2 pages) doi:10.1093/jscr/rjt029 Case Report Incarcerated and perforated stomach found in parastomal hernia: a case of a stomach in a parastomal hernia and subsequent strangulation-induced necrosis and perforation Anne K. Marsh and Martin Hoejgaard Department of Urology, Herlev Hospital, Herlev, Denmark *Correspondence address. Department of Urology, Herlev Hospital, HA54F1, Herlev Ringvej 75, 2730 Herlev, Denmark. Tel: þ45-20-85-77-89; E-mail: martin@hojgaard.com Received 1 March 2013; revised 24 March 2013; accepted 1 April 2013 Parastomal hernias (PSHs) are a common type of incisional hernia and the most frequent com- plication to colostomies. Usually only mobile structures of the abdomen herniate in the hernial sac of the non-traumatic hernia. This case describes a large PSH adjacent to a lower left quad- rant colostomy containing the mobile small intestine, part of the colon and a perforated stomach. The PSH presented with acute abdomen requiring explorative laparatomy and de- bridement. Large hernias may over time predispose to stretching of ligaments and mobilization of otherwise immobile structures with damage to these structures. The case report includes a short overview of hernia types associated with dislocation of the fixed organs of the abdominal space. INTRODUCTION This case illustrates that other contents of the abdomen may herniate as well. A parastomal hernia (PSH) is a type of incisional hernia oc- curring at the site of the stoma or immediately adjacent to the stoma. It forms when the abdominal wall is continually CASE REPORT stretched by the tangential forces applied to the circumference of the abdominal wall opening [1]. An 81-year-old male patient was admitted to a surgical PSH is the most frequent complication following the con- ward with acute onset of severe abdominal pain, vomiting struction of a colostomy. A literature review found that PSHs and abdominal distension. Clinical examination found circu- occur in 4.0–48.1% of patients with end colostomies [2]. latory instability, a peritoneal abdomen and increased leuco- Patient characteristics associated with increased risk of PSH cyte count and C-reactive protein on laboratory reports, include obesity, weight gain after ostomy construction, poor with several litres of fluid aspirated after insertion of a nutritional status, immunosuppressive drugs, emergency con- nasogastric tube. struction of the stoma, chronic coughing, infection and under- His past medical record included rectal cancer 19 years ago lying diseases such as malignancy. managed with rectal resection and subsequently fitted left Most patients with PSH are asymptomatic and do not lower quadrant colostomy. He had developed a large PSH require surgical repair. They typically present with a bulge at over a period of several years. Due to the patients’ reluctance the site of, or adjacent to, the intestinal stoma with or without to seek medical attention for the hernia, its diameter had pain. Symptoms range from mild abdominal discomfort, dis- increased to 20 cm at the time of diagnosis. Surgical correc- tension, nausea, constipation to severe abdominal pain, fever tion had been deemed infeasible and a truss was fitted instead and an irreducible hernia [3]. to the patient’s satisfaction. The hernia contents are almost exclusively limited to the Plain film abdominal x-ray showed not only a large part of mobile structures of the abdomen, i.e. intestines and their sup- the small intestine, but also the stomach located in the PSH portive tissue. with signs of pneumoperitoneum (Fig. 1). Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved.# The Author 2013. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by-nc/3.0/), which permits non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com. Page 2 of 2 A.K. Marsh and M. Hoejgaard rare with only a few other published cases in international lit- erature [4–6] and one case of incarceration into an umbilical hernia [7]. Previously the stomach has been reported to herniate into the thoracic space secondary to trauma or surgery on the stomach or near the diaphragm with a few cases presenting with incarceration [8]. Some cases also report complicated paraesophageal or hiatal hernias [9]. Finally, a more common type of hernias are the congenital diaphragmatic defects (Bochdalek’s and Morgagni’s hernia) usually identified upon neonatal ultrasound with just one case of delayed presentation, resulting in stomach incarceration, has been reported [10]. This case report illustrates that not only naturally mobile structures may herniate. The mechanisms for this displace- ment are unknown but increased mechanical stress over time could lead to stretching and elongation of the supporting liga- ments and the oesophagus. Alternatively, the stomach itself may elongate over time as the muscular structure allows for shape and size variation. Although large hernias may remain asymptomatic, they Figure 1: Plain film abdominal X-ray showing the trapped stomach in the should be evaluated on a regular basis as not only intestines large parastomal hernia on the patient’s lower left side. Notice the fundus-like may be at risk of strangulation but also other structures may air on the outer left-hand side of the trapped part. Also visible is free air inside herniate into large, untreated abdominal wall defects. the parastomal hernia. Presumably, a number of large, asymptomatic PSHs may contain stomach or other immobile structures and the thresh- Acute, explorative laparotomy confirmed the finding of dis- old for evaluating these PSHs in case of symptom progression placement of the stomach to the PSH with a 7 cm perforation should be very low. Investigation can be made with plain film of the minor curvature secondary to necrosis. Apart from the contrast investigation or abdominal CT. Such PSHs should be stomach, the hernia contained most of the small intestine in- monitored closely with attempted repair or enlargement to cluding the omentum as well as part of the colon, all these prevent incarceration. intestines were found intact. The necrotic stomach tissue was surgically debrided, the defect closed in two layers and a feeding tube placed in the duodenum. The colostomy was moved to the right lower quad- REFERENCES rant. The original defect in the lower left quadrant was found 1. Pearl RK. Parastomal hernias. World J Surg 1989;13:569–72. beyond repair and was instead enlarged to avoid incarceration 2. Carne PW, Robertson GM, Frizelle FA. Parastomal hernia. Br J Surg in the future. Due to the patient’s severe septic state, further 2003;90:784–93. surgery on the abdominal wall or stomach was not attempted. 3. de RP, Bijnen AB. Successful local repair of paracolostomy hernia with a newly developed prosthetic device. Int J Colorectal Dis 1992;7:132–4. The patient developed a secondary wound infection requir- 4. Bota E, Shaikh I, Fernandes R, Doughan S. Stomach in a parastomal ing vacuum-assisted closure, but otherwise had an uneventful hernia: uncommon presentation. BMJ Case Rep 2012. 6-week admittance period with full recovery and subsequent 5. McAllister JD, D’Altorio RA. A rare cause of parastomal hernia: stomach herniation. South Med J 1991;84:911–2. discharge. 6. Ellingson TL, Maki JH, Kozarek RA, Patterson DJ. An incarcerated peristomal gastric hernia causing gastric outlet obstruction. J Clin Gastroenterol 1993;17:314–6. 7. ORR TG. Incarceration of the stomach in an umbilical hernia. Am J Surg DISCUSSION 1947;74:96. The stomach is supported by the oesophagal fixation to the 8. Abboud B, Tabet G, Bou JJ, Sleilaty G. Gastric incarceration and perforation following posttraumatic diaphragmatic hernia: case report and diaphragm and by the hepatogastric, gastrophrenic and gastro- review of the literature. J Med Liban 2007;55:104–7. splenic ligaments and its mobility restricted by these as well 9. Pearson FG, Cooper JD, Ilves R, Todd TR, Jamieson WR. Massive hiatal as the surrounding structures (liver, diaphragm, left kidney, hernia with incarceration: a report of 53 cases. Ann Thorac Surg 1983;35:45–51. pancreas, spleen and colon tranversum). 10. Lores ME, Delgado R, Marquez E. Delayed presentation of a congenital Usually, the small bowel or omentum is found in a hernial diaphragmatic hernia resulting in stomach incarceration. Bol Asoc Med P sac of the abdomen. A stomach inside a PSH is exceptionally R 1982;74:136–7.
Journal of Surgical Case Reports – Oxford University Press
Published: Apr 18, 2013
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