INTRODUCTION
Colostomies are one of the most commonly performed operations in colorectal surgery. Like other surgeries, it has its own complications.[1] Colostomy prolapse is a delayed but annoying complication. This can lead to local skin problems, difficulty in stoma evacuation, intestinal obstruction, strangulation, etc.[1] Small prolapse without any complication can be treated conservatively, but larger prolapse or complicated prolapse needs surgical management.[2] Conventionally, stoma refashioning is the most commonly performed procedure used to treat this condition. Here, we present a simpler way to treat stoma prolapse, which can even be done under local or regional anesthesia.
CASE REPORT
A 56-year-old woman with a known history of diabetes, hypertension, and hepatitis B positivity presented with bleeding per rectum, recurrent vomiting, abdominal distension, tenesmus, and weight loss. After evaluation, colonoscopy and magnetic resonance imaging (MRI) pelvis showed a proliferative locally advanced growth at 4 cm from the anal verge with intestinal obstruction. Colonoscopicy biopsy confirmed adenocarcinoma rectum. MRI showed T3N1 disease. Then, she was planned for Chemoradiotherapy (CT/RT) after diversion colostomy. After preoperative optimization, transverse loop colostomy was done.
She recovered well in the postoperative period. She reported to the outpatient department with a stomal prolapse 2 months after the surgery. It was a 6-cm full-thickness symptomatic prolapse through the proximal opening [Figure 1]. She was planned for stoma revision with “transstomal colectomy” under local anesthesia to correct the prolapse. This operation can be under local, spinal, or general anesthesia.
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Figure 1: Prolapsed transverse colon
Surgical technique
This procedure can be done under regional or local anesthesia, depending on the site of the stoma and patient profile. In the case of local anesthesia, pericolostomy infiltration of 2% lignocaine is done in a ring block manner.
A circumferential incision is made 2 cm inner to the mucocutaneous junction of the colostomy. This incision is deepened through the wall of the ostomy colon up to the plane between two layers of the prolapsed colon [Figure 2].
Figure 2: Dissection between outer and inner colon
Considering prolapse as intussusception, there are two layers of the colon at the site of prolapse. Once through-and-through resection of the outer colon is done, the mesentery of the colon inside is exposed (mesentery of the intussusceptum, considering stoma prolapse – an everted intussusception). The redundant part of colon is brought out through ostomy wound. This redundant part, along with its mesentery is resected out. Then, the inner colon cut edge is anastomosed with the outer colon cut edge [Figure 3].
Figure 3: After resection
DISCUSSION
Colostomies are the commonly performed procedure in colorectal surgery. Permanent colostomy is done after abdominopelvic resection. Temporary diversion colostomy is done in f locally advanced obstructing rectal cancer cases to protect against colo-anal anastomosis following low anterior resection. Early complications of colostomy are improper site selection, vascular compromise, stoma retraction, peristomal skin irritation, acute parastomal hernia, bowel obstruction, etc.[3] The delayed complications are parastomal hernia, stoma prolapse, etc. Stoma prolapse can lead to malfunction of stoma, morbidity, skin excoriation and intestinal obstruction, gangrene, etc.
Treatment of stoma prolapse varies. This ranges from local treatment to stoma refashioning or stoma reversal. Local treatment with compression, manual reduction, application of appliances, etc., can give temporary benefits. Local surgical treatment with a stapler or local resection can provide good results.[4,5]
Transcolostomy colectomy (TCC) with end-to-end anastomosis is a simple but effective method of stoma prolapse correction. The advantages are as follows: this can be done under local anesthesia, day-care surgery is possible, less pain, and it does not require skin incision laparotomy. However, this requires larger long-term studies to prove its sustainable benefit.
CONCLUSION
TCC with end-to-end anastomosis is an easy, reproducible method of stoma prolapse correction. However, larger studies are required to establish it as a standard of care.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
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