CASE REPORTS
STRANGULATED PARA-ILEOSTOMY HERNIA A. M. CUTHBERTSON and J O H N P. COLLINS Royal Melbourne Hospital Para-ileostomy hernia is an uncommon cause of bowel obstruction following ileostomy.
Two cases are reported that demonstrate the difficulty in diagnosis and the high morbidity
associated with this condition. Early recognition and repair uncomplicated and strangulated hernia are recommended.
IT is now 25 years since the modern technique of ileostomy construction, combining proper siting of the stoma, internal fixation of the mesentery, terminal ileal eversion, and immediate mucocutaneous suture, was described by Brooke (1952), Turnbull and Crile (1955), Goligher ( 1958), and others. By the use of these techniques and modern stoma1 appliances, the problems of ileostomy dysfunction, skin irritation, internal and external herniation, which prior to 1950 (Bargen, 1956) made ileostomy such an undesirable procedure, have been largely overcome. This report describes two cases of paraileostomy herniation complicated by strangulation of the terminal ileum, and emphasizes the severity of this condition, the associated morbidity, and the need for early diagnosis and treatment. CLINICALRECORDS CASE I.-A 65-year-old woman presented with a history of having undergone proctocolectomy and end ileostomy for mucosal ulcerative colitis in 1956. In 1974 she noticed a lump below and lateral to her stoma, and subsequently had two episodes of subacute small bowel obstruction which settled spontaneously. She next presented with a three-day history of abdominal pain, distension, vomiting, and decreased ileostomy output. Examination revealed a distended tympanitic abdomen with a tender mass below her stoma. Laparotomy was performed, and a segment of four feet of gangrenous small bowel was removed Reprints: A. M. Cuthbertson, 5 Coonil Crescent, Malvern, Vic. 3144.
86
of
the
from the hernial sac and resected, A new stoma was constructed on the opposite side of the abdomen, and the hernial sac was obliterated. After operation her course was complicated by Gram-negative septiczmia, renal failure, and extensive necrosis of the anterior abdominal wall between the old stoma and the scar, which eventually required skin grafting. She had not taken steroids for rg years. CASE 2.-A 69-year-old man, with a past history of mucosal ulcerative colitis treated by subtotal colectomy and end ileostomy in 1962 and proctectomy in 1969, presented with a two-day history of abdominal pain, vomiting, and decreased ileostomy output. Examination revealed a mildly distended abdomen and a non-tender mass lateral to the ileostomy. Conservative treatment, with intravenous fluids, nasogastric suction, and ileostomy irrigation, failed to relieve the obstruction, and laparotomy was performed. T h e proximal small bowel was distended, and two feet of gangrenous small bowel were removed from the hernial sac and excised. A new ileostomy was constructed and the hernial defect repaired. After operation he developed a Gram-negative septiczmia, hepatic failure, and gross wound sepsis, with necrosis of the wound edges. After prolonged hospitalization he recovered and was discharged. He had not taken steroids for 12 years.
DISCUSSION Small-bowel obstruction following ileostomy is a well-recognized complication, occurring in up to 29% of all ileostomy patients (Graham et dii, 1965). The usual causes are adhesive bands and volvulus of the terminal ileum. Para-ileostomy hernia is usually included as a less common cause, although few cases have been reported since 1950. Obstruction is a serious complication, a mortality of between 10% and 20% being AUST. N.Z. J.
SURG.,
VOL. 47-”o.
I,
FEBRUARY, 1977
ADOLESCENT PANCREATITIS WITH GALLSTONES
reported (Turnbull and Crile, 1955; Graham et alii, 1965). This high mortality is due to difficulty in early diagnosis, as cramping pain and mild distension are usually attributed to bowel hyperactivity, and early radiographic findings are often misleading. Considerable significance should be given to decreased ileostomy output as an ominous sign. T h e atiology of para-ileostomy hernia is related to the technique of construction of the stoma. If it is placed lateral to the rectus sheath, herniation with ramification through the flat muscles of the abdominal wall will often OCCIII-. If the opening in the rectus sheath is made too large, herniation will occur alongside it. Tn both cases the neck of the sac will be narrow, and its contents therefore likely to undergo obstruction and strangulation. The uncomplicated hernia produces symptoms of a lump around the stoma, difficulty in fitting an appliance, or subacute small-bowel obstruction which spontaneously resolves. If recognized at this stage the hernia should be repaired, preferably by relocation of the stoma at a new site and complete obliteration of the hernial defect. Any attempt to repair the hernia locally and leave the stoma in situ should he
PEASE
avoided, as recurrence of the hernia or stoma1 difficulties commonly follow this procedure. Once the features of obstruction are present, early surgical intervention after failure of intestinal decompression is imperative. Laparotomy should be performed, as a local approach to the stoma is inadequate. The hernia should be reduced, the bowel resected or retained according to established practice, and the stoma relocated at a new, previously marked, site. When deciding the extent of bowel resection, the problem of “short-bowel syndrome” should be remembered and a conservative approach adopted. If massive resection is required, careful attention must be given after operation to fluid and electrolyte balance and 1ong-term nutritional deficiencies.
REFERENCES BARGEN,J. A. (1956), Gastroenterologia (Basel), 86: 674. BROOKE,B. N. ( I ~ s z ) , Lancet, 2 : 102. BROOKE, B. N. (1957), Amer. J . dig. Dis., 2 : 405. GOLIGHER,J, D. (1958), Brit. J. Surg., 46: 97. GRAHAM,W. P., GALANTE, M., GOLDMAN,L., MCCORKLE.H. T. and WANEBO. H. T. (106q). .~ - . Amer. J. Surg. I 110. TURNRULL, R. B., JR and CRILE,G., JR (1955), J. Amer. wed. Ass., 158: 32. ~
ACUTE PANCREATITIS ASSOCIATED WITH GALLSTONES IN A TWELVE-YEAR-OLD GIRL RICHARD PEASE Department of Surgery, St James’s Hospita2, L eeds, England Pancreatitis is a rare dlsease under the age of 15 years, and especially s‘o when associated w lt h gallstones. A case is reported here of a young girl who had acute pancreatitis and was subsequently found to have gallstones. She made an uneventful recovery and remains symptom-free after cholecystectomy.
CLINICAL RECORD A IZ-YEAR-OLD
was admitted to hospital with a three-day history of epigastric pain of increasing intensity, associated with vomiting. She had been treated at home by her family doctor, who preGIRL
Reprints : M r Richard Pease, F.R.C.S., F.R.C.S.E., Medical consulting centre, Church St., Traralgon, Victoria, 3844.
AUST. N.Z. J. SURG., VOL.47-No.
I,
FEBRUARY, 1977
scribed bed rest and diazepam, but with no effect. She had had six previous attacks of similar pain in the past year, all associated with vomiting and lasting one day. The past history was otherwise unremarkable except for an episode of jaundice a few days after birth (her mother was Rh negative). She had suffered all the usual childhood complaints, including mumps, before the age of five years. There had been no recent contact with mumps.
87
STRANGULATED PARA-ILEOSTOMY HERNIA A. M. CUTHBERTSON and J O H N P. COLLINS Royal Melbourne Hospital Para-ileostomy hernia is an uncommon cause of bowel obstruction following ileostomy.
Two cases are reported that demonstrate the difficulty in diagnosis and the high morbidity
associated with this condition. Early recognition and repair uncomplicated and strangulated hernia are recommended.
IT is now 25 years since the modern technique of ileostomy construction, combining proper siting of the stoma, internal fixation of the mesentery, terminal ileal eversion, and immediate mucocutaneous suture, was described by Brooke (1952), Turnbull and Crile (1955), Goligher ( 1958), and others. By the use of these techniques and modern stoma1 appliances, the problems of ileostomy dysfunction, skin irritation, internal and external herniation, which prior to 1950 (Bargen, 1956) made ileostomy such an undesirable procedure, have been largely overcome. This report describes two cases of paraileostomy herniation complicated by strangulation of the terminal ileum, and emphasizes the severity of this condition, the associated morbidity, and the need for early diagnosis and treatment. CLINICALRECORDS CASE I.-A 65-year-old woman presented with a history of having undergone proctocolectomy and end ileostomy for mucosal ulcerative colitis in 1956. In 1974 she noticed a lump below and lateral to her stoma, and subsequently had two episodes of subacute small bowel obstruction which settled spontaneously. She next presented with a three-day history of abdominal pain, distension, vomiting, and decreased ileostomy output. Examination revealed a distended tympanitic abdomen with a tender mass below her stoma. Laparotomy was performed, and a segment of four feet of gangrenous small bowel was removed Reprints: A. M. Cuthbertson, 5 Coonil Crescent, Malvern, Vic. 3144.
86
of
the
from the hernial sac and resected, A new stoma was constructed on the opposite side of the abdomen, and the hernial sac was obliterated. After operation her course was complicated by Gram-negative septiczmia, renal failure, and extensive necrosis of the anterior abdominal wall between the old stoma and the scar, which eventually required skin grafting. She had not taken steroids for rg years. CASE 2.-A 69-year-old man, with a past history of mucosal ulcerative colitis treated by subtotal colectomy and end ileostomy in 1962 and proctectomy in 1969, presented with a two-day history of abdominal pain, vomiting, and decreased ileostomy output. Examination revealed a mildly distended abdomen and a non-tender mass lateral to the ileostomy. Conservative treatment, with intravenous fluids, nasogastric suction, and ileostomy irrigation, failed to relieve the obstruction, and laparotomy was performed. T h e proximal small bowel was distended, and two feet of gangrenous small bowel were removed from the hernial sac and excised. A new ileostomy was constructed and the hernial defect repaired. After operation he developed a Gram-negative septiczmia, hepatic failure, and gross wound sepsis, with necrosis of the wound edges. After prolonged hospitalization he recovered and was discharged. He had not taken steroids for 12 years.
DISCUSSION Small-bowel obstruction following ileostomy is a well-recognized complication, occurring in up to 29% of all ileostomy patients (Graham et dii, 1965). The usual causes are adhesive bands and volvulus of the terminal ileum. Para-ileostomy hernia is usually included as a less common cause, although few cases have been reported since 1950. Obstruction is a serious complication, a mortality of between 10% and 20% being AUST. N.Z. J.
SURG.,
VOL. 47-”o.
I,
FEBRUARY, 1977
ADOLESCENT PANCREATITIS WITH GALLSTONES
reported (Turnbull and Crile, 1955; Graham et alii, 1965). This high mortality is due to difficulty in early diagnosis, as cramping pain and mild distension are usually attributed to bowel hyperactivity, and early radiographic findings are often misleading. Considerable significance should be given to decreased ileostomy output as an ominous sign. T h e atiology of para-ileostomy hernia is related to the technique of construction of the stoma. If it is placed lateral to the rectus sheath, herniation with ramification through the flat muscles of the abdominal wall will often OCCIII-. If the opening in the rectus sheath is made too large, herniation will occur alongside it. Tn both cases the neck of the sac will be narrow, and its contents therefore likely to undergo obstruction and strangulation. The uncomplicated hernia produces symptoms of a lump around the stoma, difficulty in fitting an appliance, or subacute small-bowel obstruction which spontaneously resolves. If recognized at this stage the hernia should be repaired, preferably by relocation of the stoma at a new site and complete obliteration of the hernial defect. Any attempt to repair the hernia locally and leave the stoma in situ should he
PEASE
avoided, as recurrence of the hernia or stoma1 difficulties commonly follow this procedure. Once the features of obstruction are present, early surgical intervention after failure of intestinal decompression is imperative. Laparotomy should be performed, as a local approach to the stoma is inadequate. The hernia should be reduced, the bowel resected or retained according to established practice, and the stoma relocated at a new, previously marked, site. When deciding the extent of bowel resection, the problem of “short-bowel syndrome” should be remembered and a conservative approach adopted. If massive resection is required, careful attention must be given after operation to fluid and electrolyte balance and 1ong-term nutritional deficiencies.
REFERENCES BARGEN,J. A. (1956), Gastroenterologia (Basel), 86: 674. BROOKE,B. N. ( I ~ s z ) , Lancet, 2 : 102. BROOKE, B. N. (1957), Amer. J . dig. Dis., 2 : 405. GOLIGHER,J, D. (1958), Brit. J. Surg., 46: 97. GRAHAM,W. P., GALANTE, M., GOLDMAN,L., MCCORKLE.H. T. and WANEBO. H. T. (106q). .~ - . Amer. J. Surg. I 110. TURNRULL, R. B., JR and CRILE,G., JR (1955), J. Amer. wed. Ass., 158: 32. ~
ACUTE PANCREATITIS ASSOCIATED WITH GALLSTONES IN A TWELVE-YEAR-OLD GIRL RICHARD PEASE Department of Surgery, St James’s Hospita2, L eeds, England Pancreatitis is a rare dlsease under the age of 15 years, and especially s‘o when associated w lt h gallstones. A case is reported here of a young girl who had acute pancreatitis and was subsequently found to have gallstones. She made an uneventful recovery and remains symptom-free after cholecystectomy.
CLINICAL RECORD A IZ-YEAR-OLD
was admitted to hospital with a three-day history of epigastric pain of increasing intensity, associated with vomiting. She had been treated at home by her family doctor, who preGIRL
Reprints : M r Richard Pease, F.R.C.S., F.R.C.S.E., Medical consulting centre, Church St., Traralgon, Victoria, 3844.
AUST. N.Z. J. SURG., VOL.47-No.
I,
FEBRUARY, 1977
scribed bed rest and diazepam, but with no effect. She had had six previous attacks of similar pain in the past year, all associated with vomiting and lasting one day. The past history was otherwise unremarkable except for an episode of jaundice a few days after birth (her mother was Rh negative). She had suffered all the usual childhood complaints, including mumps, before the age of five years. There had been no recent contact with mumps.
87
