Mateş Ioan Nicolae, Gheorghe Mircea, Tomşa Roxana, Sumedrea Elena Liliana
Chirurgia (Bucur). 2020 Jan-Feb;115(1):95-101. doi: 10.21614/chirurgia.115.1.95.
Diverting ostomy is a commonly perfomed procedure but may be associated to its own morbidity (early or late complications). Colostomy-related evisceration is a rare but potentially life threatening condition (requiring emergency surgery), relatively undocumented for its mechanisms. Case report: A male aged 84 was admited for chronic low digestive occlusion due to a locally advanced, stenosing, rectal adenocarcinoma. Prior to neoadjuvant therapy, a loop sigmoidostomy was indicated using a left iliac open aproach, with no preparation of the colic content. The sigmoid was loaded with hard stools. The parietal breach was reaproximated by 2 monofilament nylon sutures, fascial and colocutaneus fixation. Colostomy was opened two days later, but was not functional (postoperative paralytic ileus). Parastomal evisceration of ileum in day 3, dehiscence of parietal suture. Emergency operation, using the same aproach. Favourable outcome. Thoraco-abdominal CT scan: N0,M0. Pelvic MRI: proliferative mass of inferior and middle rectum, involving mesorectum fascia, levator ani and a few regional lymphatic nodes. Radio-chemotherapy and abdomino-perineal resection. Pathologic result: colorectal adenocarcinoma, G2, ypT1ypN0, ICD-O: 8140/3. We rewiewed 8 case reports published since 2011, equally distributed as late or early complications. There was no connection with the princeps indication (colorectal cancer in half of cases); neither related to topography (transverse or sigmoid) or type of colostomy (loop or end). Occurence of the complication is not time-dependent (5 to18 months in late, 3 to 12 days for early eviscerations). The main premise is colostomy itself (a place of reduced parieto-abdominal resistence), stressed by increassed intra-abdominal pressure (eg. bronchopulmonary disease, digestive obstruction). Predisposing factors for late evisceration seems to be related to spontaneous rupture of parastomal hernia/colostomy prolapse. As for early evisceration, both technical details and surgical strategy must be considered (indequate fixation; creation of a larger than necessary colostomy aperture).
转流性造口术是一种常用的手术，但可能伴有其自身的并发症（早期或晚期）。结肠造口相关的脏器脱出是一种罕见但可能危及生命的情况（需要急诊手术），其机制相对缺乏文献记载。病例报告：一名84岁男性因局部晚期、狭窄性直肠腺癌导致慢性低位消化道梗阻入院。在新辅助治疗前，采用左髂部开放入路行乙状结肠袢式造口术，未对结肠内容物进行准备。乙状结肠内充满硬便。用2根单丝尼龙缝线、筋膜和结肠皮肤固定术将腹壁创口重新缝合。两天后打开结肠造口，但未发挥功能（术后麻痹性肠梗阻）。术后第3天回肠造口旁脏器脱出，腹壁缝线裂开。采用相同入路进行急诊手术。预后良好。胸腹部CT扫描：N0，M0。盆腔MRI：直肠中下段增殖性肿块，累及直肠系膜筋膜、肛提肌和一些区域淋巴结。进行放化疗和腹会阴联合切除术。病理结果：结直肠腺癌，G2，ypT1ypN0，ICD-O：8140/3。我们回顾了自2011年以来发表的8例病例报告，晚期或早期并发症分布均匀。与主要适应证（半数病例为结直肠癌）无关；也与部位（横结肠或乙状结肠）或结肠造口类型（袢式或端式）无关。并发症的发生与时间无关（晚期为5至18个月，早期脏器脱出为3至12天）。主要前提是结肠造口本身（腹壁抗阻力降低的部位），腹内压升高（如支气管肺部疾病、消化道梗阻）会加重这种情况。晚期脏器脱出的易感因素似乎与造口旁疝/结肠造口脱垂的自发破裂有关。至于早期脏器脱出，必须考虑技术细节和手术策略（固定不当；造口孔径过大）。
