Parastomal Hernia with Intestinal Parastomal Hernia with Intestinal - - PowerPoint PPT Presentation

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

• f the new end-ileostomy
• f 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

• minal 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

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

Devlin Classification Devlin Classification

Discussion (con’t) Discussion (con’t)

Emergent surgery is indicated for patients with acute Emergent surgery is indicated for patients with acute

• bstruction concerning for strangulation and bowel ischemia
• bstruction 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

• pen or laparoscopic approach
• pen or laparoscopic approach

Parastomal Hernia Repair Parastomal Hernia Repair

ASCRS Textbook of ASCRS Textbook of Colon Colon and Rectal and Rectal Surgery, 3 Surgery, 3rd

rd ed

ed

• pen “keyhole”
• pen “keyhole”
• pen Sugarbaker
• pen Sugarbaker overlay
• verlay

laparoscopic “keyhole” laparoscopic “keyhole” laparoscopic Surgarbaker laparoscopic Surgarbaker

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

• mal 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

• n 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
• mal 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

• f

paras parastom

• mal hernia
• hernia. Hernia

. Hernia 2016;20:327-330. 2016;20:327-330. 6.

• 6. Moffett

Moffett PM, Younggren BN. PM, Younggren BN. Paras Parastom

• mal intes

intestin inal evis al eviscera cerati tion

• n. 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

• mal evis

eviscera cerati tion: rare compli : rare complica catio tion after tota after total abdomi l abdomina nal colect l colectom

• my. 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

• u 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

• f
• f a

a comm common procedure. Ann R

• n procedure. Ann R Co

Coll ll Surg Engl. 2015; Surg Engl. 2015; 97(7): e103–e104 97(7): e103–e104 9.

• 9. St

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, 3rd

rd Ed

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)

BEFORE AFTER

CXR CT removal

CT post IR – CT Re insertion

 Right upper lobe

wedge resection with large bulla. Right upper lobe wedge resection with small

• blebs. Mechanical

pleurodesis.  32 Fr Blake Chest

tube

Surgery

HOSPITAL COURSE

 POD 1: comfortable. Vitals stable. Chest tube w/o

air leak. CXR stable. Continued suction of 24 hrs.

 POD 2: Clinical stable. CXR stable. Chest tube to

waterseal.

 POD 3: No changes. Chest tube w/o air leak. CXR

• stable. Chest tube discontinued. Patient was

discharged.



Vaping increase in prevalence since 2009 to 2014 

1.5% to 14% among the young population in US



Gene mutation associated with primary PTX – FLCN 

Act as tumor suppressor gene; Role in uptake of foreign body, and strutural framework



Alteration – increase inflammation  tissue damage  Bleb



High levels of aldehyde in exhaled breath during E- Cigarette vaping



Aldehyde causing DNA damage by increase free oxygen radical, an indirect malfunction of FLCN protein and inhibiting DNA repair 

Pro-inflammatory effect + lipid peroxidation  lung parenchymal injury

DISCUSSION

CONCLUSION

 Smoking is well known risk factor for primary SPX  Cessation is advisable to those at risk  No documentation of vaping as a risk factor  In spite of the unknown correlation, vaping should be

ceased

 Both cigarette and e-cigarette smoke contain high level of

aldehyde, which may be the potential cause for the incidence

• f primary spontaneous pneumothoraces

Thank you!