Surgery for Complicated Stomal Prolapse: Is the Altemeier Technique an Option? A Report of Three Cases

Abstract

Introduction The incidence of stomal prolapse ranges from 2% to 22%. The risk factors include colostomy, the short length of the stoma, obesity, emergency surgery, and the improper (or even absence of) marking of the preoperative site for the stoma. Complicated stomal prolapse associated with severe mucosal irritation, ischemic changes, or bleeding requires surgical intervention.

Objective To describe the use of the Altemeier technique in the management of cases of complicated prolapsed stoma after failure of the local medical measures and manual reduction.

Methods Case series of three patients with past history of abdominoperineal resection of rectal cancer and permanent end colostomy presented with irreducible prolapse of the stoma. After the failure of the local measures and manual reduction, urgent surgical intervention using the modified Altemeier technique was necessary.

Results The modified Altemeier technique is simple, presents low risk of operative and postoperative complications, besides enabling an early recovery, with a lower risk of recurrence during the first 6 months after the repair.

Conclusion The modified Altemeier technique may be a valid therapeutic modality in the setting of complicated prolapsed stoma.

Resumo

Introdução A incidência de prolapso de estoma varia de 2 a 22%. Os fatores de risco incluem colostomia, comprimento curto do estoma, obesidade, cirurgias de emergência, e marcação não adequada (ou até mesmo ausente) do sítio pré-operatório para o estoma. Prolapso de estoma complicado e associado a irritação grave de mucosa, alterações isquêmicas, ou sangramento requer intervenção cirúrgica.

Objetivo Descrever o uso da técnica de Altemeier para o manejo de prolapso de estoma complicado após fracasso das medidas médicas locais e da redução manual.

Métodos Série de casos de três pacientes com histórico de ressecção abdominoperineal de câncer retal e colostomia terminal permanente apresentaram prolapso irredutível do estoma. Com o fracasso das medidas locais e da redução manual, fez-se necessária intervenção cirúrgica de emergência usando a técnica de Altemeier modificada.

Resultados A técnica de Altemeier modificada é simples e apresenta risco baixo de complicações operatórias e pós-operatórias, além de possibilitar uma recuperação precoce, com menor risco de recorrência durante os 6 primeiros meses após o reparo.

Conclusão A técnica de Altemeier modificada pode ser uma modalidade terapêutica válida em casos de prolapso de estoma complicado.

Keywords

Altemeier technique - stoma - abdominoperineal resection - end colostomy - irreducible prolapse

Palavras-chave

técnica de Altemeier - estoma - ressecção abdominoperineal - colostomia terminal - prolapso irredutível

Publikationsverlauf

Eingereicht: 03. Juli 2020

Angenommen: 18. August 2020

Artikel online veröffentlicht:
19. März 2021

• References

• 1 Harris DA, Egbeare D, Jones S, Benjamin H, Woodward A, Foster ME. Complications and mortality following stoma formation. Ann R Coll Surg Engl 2005; 87 (06) 427-431
• 2 Shellito PC. Complications of abdominal stoma surgery. Dis Colon Rectum 1998; 41 (12) 1562-1572
• 3 Shabbir J, Britton DC. Stoma complications: a literature overview. Colorectal Dis 2010; 12 (10) 958-964
• 4 Formijne Jonkers HA, Draaisma WA, Roskott AM, van Overbeeke AJ, Broeders IA, Consten EC. Early complications after stoma formation: a prospective cohort study in 100 patients with 1-year follow-up. Int J Colorectal Dis 2012; 27 (08) 1095-1099
• 5 Bafford AC, Irani JL. Management and complications of stomas. Surg Clin North Am 2013; 93 (01) 145-166
• 6 Cottam J, Richards K, Hasted A, Blackman A. Results of a nationwide prospective audit of stoma complications within 3 weeks of surgery. Colorectal Dis 2007; 9 (09) 834-838
• 7 Parmar KL, Zammit M, Smith A, Kenyon D, Lees NP. Greater Manchester and Cheshire Colorectal Cancer Network. A prospective audit of early stoma complications in colorectal cancer treatment throughout the Greater Manchester and Cheshire colorectal cancer network. Colorectal Dis 2011; 13 (08) 935-938
• 8 Park JJ, Del Pino A, Orsay CP. et al. Stoma complications: the Cook County Hospital experience. Dis Colon Rectum 1999; 42 (12) 1575-1580
• 9 Arumugam PJ, Bevan L, Macdonald L. et al. A prospective audit of stomas--analysis of risk factors and complications and their management. Colorectal Dis 2003; 5 (01) 49-52
• 10 Maeda K, Maruta M, Utsumi T, Sato H, Masumori K, Aoyama H. Pathophysiology and prevention of loop stomal prolapse in the transverse colon. Tech Coloproctol 2003; 7 (02) 108-111
• 11 Law WL, Chu KW, Choi HK. Randomized clinical trial comparing loop ileostomy and loop transverse colostomy for faecal diversion following total mesorectal excision. Br J Surg 2002; 89 (06) 704-708
• 12 Mäkelä JT, Turku PH, Laitinen ST. Analysis of late stomal complications following ostomy surgery. Ann Chir Gynaecol 1997; 86 (04) 305-310
• 13 Londono-Schimmer EE, Leong AP, Phillips RK. Life table analysis of stomal complications following colostomy. Dis Colon Rectum 1994; 37 (09) 916-920
• 14 Colwell JC, Goldberg M, Carmel J. The state of the standard diversion. J Wound Ostomy Continence Nurs 2001; 28 (01) 6-17
• 15 Shapiro R, Chin EH, Steinhagen RM. Reduction of an incarcerated, prolapsed ileostomy with the assistance of sugar as a desiccant. Tech Coloproctol 2010; 14 (03) 269-271
• 16 Altemeier WA, Culbertson WR, Schowengerdt C, Hunt J. Nineteen years' experience with the one-stage perineal repair of rectal prolapse. Ann Surg 1971; 173 (06) 993-1006
• 17 Apfelbaum JL, Connis RT, Nickinovich DG. et al; Committee on Standards and Practice Parameters, American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology 2012; 116 (03) 522-538
• 18 Lindsey I. Commentary: Best practice in rectal prolapse. Colorectal Dis 2010; 12 (06) 512-514
• 19 Marrosu A, Paliogiannis P, Sassu MA, Attene F, Trignano M. Correction of an end colostomy prolapse with the Delorme technique. A case report. Ann Ital Chir 2012; 83 (06) 567-569
• 20 Watanabe M, Murakami M, Ozawa Y. et al. The modified Altemeier procedure for a loop colostomy prolapse. Surg Today 2015; 45 (11) 1463-1466