Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1143_Библиотеки_им_академика_М_И_Перельмана
.pdf
91 Case on Leakage of Distal Anastomosis After Low Anterior Resection (LAR)
https://t.me/med1917
Fig. 91.1 ( a )
Pneumoperitoneum on the
abdominal X-ray. ( b ) CT
scan, leakage of the
colorectal anastomosis. ( c )
CT scan fl uid collection in
the upper abdomen. Gastric
dilatation
a
b
499
c
500
https://t.me/med1917
Fig. 91.2 CT scan-guided
percutaneous drainage
paracolic abscess left . Two
stomas, ileostomy and
colostomy
M.G. Moreno et al.
References
1. Matthiessen P, Hallbook O, Rutegard J, et al. Defunctioning stoma reduces symptomatic anas-
tomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter
trial. Ann Surg. 2007;246:207–14.
2. Giannakopoulos GF, Veenhof AAFA, van der Peet DL, et al. Morbidity and complications of a
protective loop ileostomy. Colorectal Dis. 2009;11:609–12.
3. Gooszen AW, Geelkerken RH, Hermans J, et al. Quality of life with a temporary stoma: ileos-
tomy vs colostomy. Dis Colon Rectum. 2000;43:650–5.
Chapter 92
https://t.me/med1917
Case on Complications of Ileostomy
Miguel A. Cuesta
Keywords Ileostomy • Stenosis • Prolapse • Torsion • High production
Stenosis
Diagnosis and Indication for Surgery
A 50-year-old technician suffered from having disturbing perineal fi stulas and corresponding recurrences for the last 10 years. After the tenth operation, he still experienced soiling by pus as well as anal pain, and so he was referred to our Colorectal
Unit. After local exploration at an outpatient clinic, we noticed that the patient had
two large external perianal openings with pus pouring spontaneously out of these
along the posterior aspect of thigh. We decided before redoing a fi stula operation to
create a period of rest by constructing a loop ileostomy.
Operation
Loop ileostomy was then created laparoscopically, and during the same operation,
two setons were put in the two located fi stula tracks.
M. A. Cuesta , M.D.
Department of Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: ma.cuesta@vumc.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_92,
© Springer International Publishing Switzerland 2014
501
502
https://t.me/med1917
M.A. Cuesta
Postoperative Course: Identifi cation and Treatment
the Complication
The patient developed postoperatively a small bowel ileus with no ileostomy production. The ileostomy was vital and edematous, but diffi cultly assessed by digital
examination. A CT scan showed that a stenosis at the level of fascia caused the
intestinal obstruction (Fig. 92.1a, b ); its being subsequently locally repaired under
anesthesia by enlarging the fascia (Illustration 92.1 ). After a period of 6 weeks, the
ab
Fig. 92.1 ( a ) Intestinal obstruction. ( b ) CT scan, intestinal obstruction by a stenosis of the
ileostomy
Stenosis Torsion
Illustration 92.1 Loop ileostomy was found to be associated with relatively high morbidity, e.g.,
stenosis and torsions
92 Case on Complications of Ileostomy
https://t.me/med1917
fi stula was treated by mucosa advancement plasty, which healed. After a period of
three months, the ileostomy became closed with subsequently still some soiling happening. After 6 years, we again saw the patient with a late recurrence of the fi stula,
yet without much complaint. Currently, his fi stula is being conservatively treated.
503
Prolapse
Diagnosis and Indication for Surgery
A 58-year-old female high school teacher was seen at the outpatient clinic because
of constipation complaints. For the last 10 years she had no spontaneous defecation
and so had become completely dependent on taking enemas. She considered herself
totally incapacitated, and after a marker study showing location of markers along
the whole colon, it was decided to start with a loop ileostomy to treat the constipation and investigate the small bowel function. Proposal was to undertake other treatments in the future, e.g., total colectomy and ileorectal anastomosis.
Patient became so pleased with the optimally functioning ileostomy that she then
refused more studies and surgical interventions.
Postoperative Course: Identifi cation and Treatment
of Complication
After 10 years, she was seen again at the outpatient clinic and readmitted because of
an important prolapsed ileostomy and abdominal distension (Fig. 92.2 ). The pro-
lapse could be manually reduced and followed by optimal ileostomy production.
Shortening repair of the ileostomy was done 3 weeks later. Patient continues to
refuse a defi nitive operation.
Ileostomy Torsion
Diagnosis and Indication for Surgery
A 39-year-old female secretary following a diffi cult vaginal delivery developed a
total perineal rupture, summarily being sutured. Consequentially, she developed a
productive low recto-vaginal fi stula. Incapacitating as it was, she was proposed to
undergo a loop ileostomy to bypass the diffi cult period leading up to reconstruction
of the fi stula by means of Martius plasty. Laparoscopically a loop ileostomy was
created and the fi stula assessed.
504
https://t.me/med1917
Fig. 92.2 Prolapse of the
loop-ileostomy
Fig. 92.3 CT scan showing a
suspicion for torsion of the
ileostomy with intestinal
obstruction
M.A. Cuesta
Postoperative Course: Identifi cation and Treatment
of Complication
Postoperatively for a period of 7 days she passed no stools through a corrected,
vital, and patent loop ileostomy. A CT scan showed an intestinal obstruction and the
possibility of stenosis or torsion by the abdominal wall (Fig. 92.3 ), this being cor-
rected by local exploration and laparoscopic control. Ileostomy was found twisted
180 degrees and this torsion was corrected (Illustration 92.1 ). Ileostomy functioned
correctly, the fi stula being corrected three months later by means of a Martius plasty
with bulbocavernous muscle interposition. After vaginal inspection to control that
92 Case on Complications of Ileostomy
https://t.me/med1917
the fi stula was closed could the ileostomy be closed. Patient continued doing well,
so that 2 years later a second child was delivered by cesarean section.
505
High-Output Ileostomy
Diagnosis and Identifi cation of the Complication
A 40-year-old male patient was operated on because of intractable ulcerative colitis
by means of total laparoscopic panproctocoletomy, ileoanal pouch anastomosis
(IAPA), and protective loop ileostomy. First he developed a paralytic ileus over a
period of 10 days, necessitating nasogastric tube drainage and total parenteral nutrition (TPN). Ileostomy was patent by digital examination. On the CT-scan, intestinal
loop dilatation was seen and other diagnoses such as torsions or presence of
abscesses excluded. After this period, ileostomy production started with a high output between 4 and 6 L per day (Fig. 92.4 ). This situation continued for a period of
3 weeks in spite of nasogastric tube and somatostatin. An important challenge was
the treatment and correction of this metabolic dysfunction by means of oral feeding
and TPN, extra liquids supply, and electrolyte correction. The role of Loperamide ®
was important in order to reduce the ileostomy production. Finally, ileostomy production became normal and he could be discharged. After control of the anastomosis and pouch, the ileostomy was closed 3 months later.
Fig. 92.4 Daily patient’s graphic showing high-output production of the ileostomy (under stoma
in cc/per day) Rest graphic in Dutch
506
https://t.me/med1917
M.A. Cuesta
Discussion
The fi rst point concerns which kind of derivative stoma is better, the loop ileostomy
or the loop colostomy. Rondelli et al., did a meta-analysis comparing the loop ileostomy (LI) with loop colostomy as derivative stoma [ 1 ]. Twelve comparative studies
were included in this analysis, fi ve randomized controlled trials and seven observational studies. They reported on 1,529 patients, 894 (58.5 %) undergoing defunctioning LI. LI reduced the risk of construction of the stoma. Specifi cally, patients
undergoing LI had a lower risk of prolapse and sepsis. Moreover, LI was associated
with an excess risk of occlusion after stoma closure and dehydratation. They concluded that this meta-analysis shows that LI is associated with a lower risk of construction of the stoma outcome measures.
The second point concerns the high % of complications observed as consequence
of its construction, during the period with the stoma and as consequence of the closure. In our department Giannakopoulos et al. analyzed 119 retrospectively patients
with a temporary loop ileostomy [ 2 ]. Fifty-nine stoma-related complications were
seen in 44 patients (37 %) during the period in which the ileostomy was present.
Moreover we found that 34 % of the patients had developed complications after
ileostomy closure and only 40 % of patients suffered neither stoma-related complications nor peri-operative complications following ileostomy closure! Furthermore,
temporary ileostomy were closed after a median period of 106 days.
High stoma output production with dehydration and impaired electrolytes and
renal function was seen in three patients in this series, according with literature [ 3 ] .
References
1. Rondelli F, Reboldi P, Rulli A, et al. Loop ileostomy versus loop colostomy for fecal diversion
after colorectal or coloanal anastomosis: a meta-analysis. Int J Colorectal Dis.
2009;24:479–88.
2. Giannakopoulos GF, Veenhof AAFA, van der Peet DL, et al. Morbidity and complications of a
protective loop ileostomy. Color Dis. 2009;11:609–12.
3. Huber FX, Stern J, Hinz U, et al. Effects of restorative proctocolectomy on renal and adrenal
function. Dis Colon Rectum. 1999;42:1318–24.
Chapter 93
https://t.me/med1917
Case on Necrosis of Colostomy.
Retraction and Stenosis
Ramon Gorter
Keywords Colostomy • Ileostomy • Ischemia • Necrosis • Retraction
First Patient
Diagnosis and Indication for Surgery
A 57-year-old healthy man was admitted to our hospital after ingesting 43 cocaine
packages. At the time of presentation, 23 packages had already passed with stools.
The patient experienced pain in the left lower quadrant of the abdomen, without
nausea or vomiting. On physical examination, his blood pressure was 141/66 mm Hg
and pulse 80 beats/min. There was local tenderness in the left lower quadrant without rigidity. CT scan was performed, revealing one package in the stomach, the rest
in the colon, and also signs of diverticulitis Hinchey 1. The patient was admitted
and oral mechanical bowel preparation was started. A gastroscopy was carried out
to remove the package from the stomach, yet uneventful. On the third day, patient’s
condition worsened. His temperature was 38 °C, pulse 120 beats/min, and blood
pressure 104/62 mm Hg. His abdomen was distended and painful. A new CT scan
revealed intra-abdominal free air and fl uids, showing no clear localization of perforation. A laparotomy showed a perforation of the sigmoid probably caused by diverticulitis with a fecal peritonitis. A left hemicolectomy was performed; all cocaine
packages were removed from the colon and a colostomy was fashioned on the transverse colon. Pathology report confi rmed the diagnosis of perforated diverticulitis.
R. Gorter , M.D.
Pediatric Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: rr.gorter@vumc.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_93,
© Springer International Publishing Switzerland 2014
507
508
https://t.me/med1917
R. Gorter
Postoperative Course: Identifi cation and Treatment
of Complication
Postoperatively, the patient was admitted to the Intensive Care Unit because of a
septic shock for which resuscitation was carried out and broad spectrum antibiotics were started. After surgery, it was noted that the colostomy was ischemic/
necrotic. Endoscopy through the stoma revealed necrosis for a length of 4 cm
(Fig. 93.1a ). It was decided to treat conservatively concerning the ischemic colos-
tomy because the passage of stools was normal and there were no signs of peritonitis. In the following days, retraction of the stoma and stenosis occurred. Patient
recovered with extra local care for the retracted colostomy. During outpatient
follow-up, the colostomy became stenotic, although it stayed productive with
ab
Fig. 93.1 ( a ) Necrosis of a colostomy, 4 cm. ( b ) Necrosis of colostomy, 5 cm
ab
Fig. 93.2 ( a ) Stenosis of colostomy with hyperkeratosis. ( b ) Stenosis of colostomy
Соседние файлы в папке Библиотека им академика М.И. Перельмана