Parastomal Hernia with Intestinal Parastomal Hernia with Intestinal Evisceration: A Common Problem with a Evisceration: A Common Problem with a Rare Complication Rare Complication Jorge Almodovar MD, Jeffrey Chiu MD, Bernadette Profeta MD, Jorge Almodovar MD, Jeffrey Chiu MD, Bernadette Profeta MD, Franc Francisco Couto MD, Alexandros Cout sco Couto MD, Alexandros Coutsoumpos MD, Rachael Gentry PA-C, soumpos MD, Rachael Gentry PA-C, Scott Bloom MD, Steve Scott Bloom MD, Steve Eubank Eubanks MD s MD
Disclosures Disclosures • No conflicts to disclose No conflicts to disclose
Case Case 48 year old female presented w 48 year old female presented with sudden onset, right sided ith sudden onset, right sided abdominal pain for 1 abdominal pain for 1 day day She noticed blood She noticed blood in her ostomy bag followed by the sudden in her ostomy bag followed by the sudden protrusion of a protrusion of a loop of bowel through her ileostomy site loop of bowel through her ileostomy site Surgical History Surgical History • Sigmoid colectomy Sigmoid colectomy • Subtotal colectomy with ileorectal anastomosis Subtotal colectomy with ileorectal anastomosis • End ileostomy End ileostomy
end ileostomy end ileostomy eviscerated eviscerated small bowel small bowel
Operative Course Operative Course Emergent laparotomy with extensive adhesiolysis Emergent laparotomy with extensive adhesiolysis Eviscerated small bowel reduced into abdomen Eviscerated small bowel reduced into abdomen Eviscerated loop was grossly hemorrhagic and ischemic and Eviscerated loop was grossly hemorrhagic and ischemic and located 10 cm proximal to ileostomy located 10 cm proximal to ileostomy Ischemic bowel and ileostomy resection with creation of end Ischemic bowel and ileostomy resection with creation of end ileostomy through existing abdominal wall defect ileostomy through existing abdominal wall defect Parastomal defect partially prim Parastomal defect partially primarily closed to circumference arily closed to circumference of the new end-ileostomy of the new end-ileostomy
Post-Operative Course Post-Operative Course Post-operative ileus managed nonoperatively Post-operative ileus managed nonoperatively Discharged to home POD 11 Discharged to home POD 11 No acute complications at 2 No acute complications at 2 week post-discharge follow-up week post-discharge follow-up and 6 and 6 month follow-up month follow-up Will follow patient yearly for Will follow patient yearly for continued evaluation and plan continued evaluation and plan for elective definitive repair if parastomal hernia recurs and for elective definitive repair if parastomal hernia recurs and becomes symptomatic becomes symptomatic
Revised end Revised end ileostomy ileostomy
Discussion Discussion Parastomal hernias are incisional hernias with protrusion of Parastomal hernias are incisional hernias with protrusion of intraabd intraabdominal contents through the created abdominal wall ominal contents through the created abdominal wall defect defect Parastomal hernias occur in up to 50% of ileostomies and Parastomal hernias occur in up to 50% of ileostomies and rarely require emergent surgical intervention rarely require emergent surgical intervention
Devlin Classification Devlin Classification Dev Devlin HB lin HB. P . Peristomal her ristomal hernia. I ia. In: : Operative Surgery Vo Operative Surgery Volume 1: lume 1: Alim Alimentary Tract and entary Tract and Abdom Abdominal Wall, 4th ed nal Wall, 4th ed
Discussion (con’t) Discussion (con’t) Emergent surgery is indicated for patients with acute Emergent surgery is indicated for patients with acute obstruction concerning for strangulation and bowel ischemia obstruction concerning for strangulation and bowel ischemia Surgical management of elective parastomal hernia repair Surgical management of elective parastomal hernia repair includes repair with mesh or relocation of the stoma via an includes repair with mesh or relocation of the stoma via an open or laparoscopic approach open or laparoscopic approach
Parastomal Hernia Repair Parastomal Hernia Repair open “keyhole” open “keyhole” open Sugarbaker overlay open Sugarbaker overlay laparoscopic Surgarbaker laparoscopic Surgarbaker laparoscopic “keyhole” laparoscopic “keyhole” rd ed ASCRS Textbook of Colon ASCRS Textbook of Colon and Rectal and Rectal Surgery, 3 Surgery, 3 rd ed
Conclusion Conclusion The The emergent presentation of an obstructed parastomal hernia emergent presentation of an obstructed parastomal hernia with with ischemia and intestinal evisceration is unique ischemia and intestinal evisceration is unique Parastomal hernia with Parastomal hernia with intestinal evisceration is intestinal evisceration is a rare a rare complication with complication with less than 10 less than 10 documented cases documented cases Intestinal evisceration most commonly occurred through Intestinal evisceration most commonly occurred through ileostomies but three cases of evisceration through colostomies ileostomies but three cases of evisceration through colostomies have been described have been described Any parastomal hernia presenting with Any parastomal hernia presenting with evisceration is a surgical evisceration is a surgical emergency and requires consideration of possible bowel emergency and requires consideration of possible bowel ischemia to guide surgical decision making ischemia to guide surgical decision making
References References 1. 1. Tam KW, Wei PL, Kuo LJ, Wu Tam KW, Wei PL, Kuo LJ, Wu CH. Sys CH. Systema ematic review of the use of review of the use of mes mesh to pr to prevent event parasto parastomal herni al hernia. World J . World J Surg Surg 2010;34(11):2723-2729. 2010;34(11):2723-2729. 2. 2. Carne PW, Roberts Carne PW, Robertson GM, Frizel n GM, Frizelle FA. Pa le FA. Paras rastom omal hernia;Br J hernia;Br J Surg 2003;90(7):784-793. Surg 2003;90(7):784-793. 3. 3. Yucel AF, Pergel A, Yucel AF, Pergel A, Aydin I, Sahin DA. Aydin I, Sahin DA. A A rare stoma rare stoma-rela related compli ted complica cati tion: paras : parastomal evis eviscera cerati tion on Indian J Indian J Surg 2014; Surg 2014; 76(2): 154–155. 76(2): 154–155. 4. 4. Dev Devlin lin HB. Peris HB. Peristom omal hernia hernia. In: Oper . In: Operative S ative Surgery Volume 1: rgery Volume 1: Alimentary Trac Alimentary Tract and Abdominal Wall, 4th ed, t and Abdominal Wall, 4th ed, Dudley H Dudley H (Ed), Butterw (Ed), Butterworths rths, London 1983. , London 1983. p.441. p.441. 5. Ramly E EP, C Crosslin T T, Orkin B B, Popowich D D. S Strangulated i ileostomy e evisceration f following l lateralizing m mesh r repair o of paras parastom omal hernia hernia. Hernia . Hernia 2016;20:327-330. 2016;20:327-330. 6. 6. Moffett Moffett PM, Younggren BN. PM, Younggren BN. Paras Parastom omal intes intestin inal evis al eviscera cerati tion on. Wes . West J J Emerg Med 2010; Emerg Med 2010; 11(2): 214. 11(2): 214. 7. 7. Abra CA, Fann SA. Paras Abra CA, Fann SA. Parastom omal evis eviscera cerati tion: rare compli : rare complica catio tion after tota after total abdomi l abdomina nal colect l colectom omy. Am Surg 2017;83:E379- y. Am Surg 2017;83:E379- 380. 380. 8. 8. Loli Lolis ED, Savvi s ED, Savvidou P, Vardas K, Loutse ou P, Vardas K, Loutset D t D, Ko Koutsoump utsoumpas V. s V. Parastomal e stomal evisce cera rati tion as as an extremel an extremely rare complication y rare complication of a of a comm common procedure. Ann R on procedure. Ann R Co Coll ll Surg Engl. 2015; Surg Engl. 2015; 97(7): e103–e104 97(7): e103–e104 rd Ed 9. St 9. Steel eele SR, et al. SR, et al. The The ASCRS Textbook of Colon and Rect ASCRS Textbook of Colon and Rectal Surger Surgery, 3 y, 3 rd Ed
Primary Spontaneous Pneumothorax Secondary to Vaping S. Hung Fong, MD; J. Prince, MD; S. Misra, MD, MS, FACS; M. Siegman, MD
Background Spontaneous pneumothorax (SPX) – Primary or secondary Primary – most common in young adults Male > female (7.4 to 18 and 1.2 to 6 per 100,000/yr, respectively) Smoking – known to increase risk for primary SPX Vaping – not documented as a risk factor One case report primary SPX associated with vaping
Case Presentation HPI : 30 year-old male presenting with sudden onset of mid- sternal chest pain after a severe coughing fit following “a big hit on his vape” PMH : asthma, kidney stones, chronic back pain PSH : none FH : Hypertension (mother and maternal grandmother) Social Hx : former smoker, current vaping (e-Cig); cook
30 M ED vitals: T 36.8 BP 162/97 HR 72 Pulse Ox 92 PE: CV: Normal HR, regular, no murmurs Chest : No breath sound on the right lung CBC and CMP: within normal limits CXR : Large right pneumothorax with left shift of mediastinum
ED-CXR
CT scan post chest tube (CT)
CXR CT removal BEFORE AFTER
CT post IR – CT Re insertion
Surgery Right upper lobe wedge resection with large bulla. Right upper lobe wedge resection with small blebs. Mechanical pleurodesis. 32 Fr Blake Chest tube
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