#loop ileostomy

[surgicalcases]

Fecal Peritonitis As A Result Of Multiple Diverticular Ruptures

The Case

A man of 50 years of age visits our clinic with acute pain in the anal region due to hemorrhoidal disease, at about noon. He mentioned that two (2) weeks before his visit to our clinic, he visited his gastroenterologist who told him to seek surgical consult immediately, but instead he took antibiotics to manage his condition. Upon physical examination, there was a man in pain, with fever, who could not sit due to the pain. Digital examination was impossible since he did not allow it, but the examination revealed an acute inflammation of the hemorrhoid in the 3rd hour, and pus coming out of the anal canal. The patient said he had a mild pain on his left lower quadrant, but nothing special, and he mentioned that the pain was relieved once he defecated.

We admitted the patient, and started hydration, and antibiotic therapy, while painkillers were administered to manage his pain. After almost twelve (12) hours, the clinical picture of the patient changed, with rapid deterioration of his pain. The pain became severe, including in his abdomen, with tenderness, guarding, and rebound tenderness. No bowel movement could be heard, and the fever was present despite the administration of antipyretics and painkillers. An important sign of the deterioration of his clinical condition was the fact that the patient did not wish to proceed to the operation, he now stood quietly on his bed and with a face of agony, asking us to operate on him to “take away his pain”.

Immediately and abdominal CT was ordered, since peritonitis due to ruptured diverticula was our first diagnosis. The CT scan (pic.1 – 3) confirmed our diagnosis, and the patient was prepared for emergency operation.

Pic. 1: edema of the bowel, abscess, and free air in the peritoneal cavity

Pic. 2: CT scanning findings of the patient with peritonitis from diverticular disease.

Pic. 3: free air in the peritoneal cavity, fluid (pus) collection

The findings were impressive, since acute fecal peritonitis was confirmed, with large amounts of pus and feces throughout the peritoneal cavity. After adequate irrigation with many liters of warm natural saline solution of the peritoneal cavity to reduce the microbial and fecal load, symphysiolysis took place, along with the removal of pseudomembranes from the peritoneal reaction.

After mobilization of the sigmoid, the lesions were localized and identified. Multiple ruptures of diverticula in the sigmoid (pic.4). A large amount of the sigmoid was transformed into an abscess (pic. 5), and the disease extended from the sigmoid to descending colon passing the splenic flexure reaching a small portion of the transverse colon. Another impressive finding was the diameter of the ruptured diverticulum at the descending colon (pic. 6). Mobilization of the whole diseased sigmoid and colon was performed, the splenic flexure was mobilized and the colon freed from the spleen and the local symphyses. The part of the transverse colon which was affected was also mobilized and prepared for removal. Indeed, a non oncologic left extended hemicolectomy was performed (pic. 7).

Pic. 4: Rupture lesions from the diverticula

Pic. 5: Sigmoid abscess

Pic. 6: Diameter of the lesion is 3.4cm on the descending colon

Pic. 7: The whole specimen of our non oncologic left extended hemicolectomy, due to diverticular rupture throughout the diseased colon and sigmoid.

After the diseased colon and sigmoid were removed, the operation continued with the anastomosis between the rectum and the transverse colon. An end to end anastomosis was performed with the help of a circular colonic stapler.

Thorough investigation for hemostasis took place. The anastomosis was tested twice for possible leakage. Irrigation of the peritoneal cavity was performed once again.

A loop eileostomy was performed approximately 40 cm from the ileo-cecal valve.

Closure of the abdominal wall was performed with two nylon loop sutures (No.0), and the skin was closed with clips.

The patient recovered from anesthesia in the operating room.

The postoperative course of the patients involved a remarkable recovery from the septic state. On the 2nd postoperative day, the loop ileostomy was functioning, a fact that allowed the patient to start drinking water and tea. Bowel movement was restored on the same day.

The drainage tubes were removed on the 7th day, and on the 8th postoperative day the patient was discharged from the clinic in an excellent condition.

Discussion about this case will follow in the next days.

[ourbowelcancer]

First Visit to Fremantle Hospital

Our first appointment at the Fremantle Hospital Colo-rectal Unit was in mid February. My father, hubby, myself and our month old daughter attended. While mom and toddler stayed home. While we were waiting there, a considerate lady staff arranged a nook for me to feed my little one. After a bit of waiting, came our turn. There we met the Registrar doctor and a Colo-rectal nurse. The doctor was a very kind man who patiently explained what was happening as per the biopsy report. We froze when the colo-rectal team recommended a major surgery. To be precise, they suggested a Laproscopic Ultra Low Anterior Resection + Loop Ileostomy. Considering how young hubby was, the doctor emphasized the importance of this operation. The procedure was explained, the surgeon would identify the spot where the polyp was removed from, then resect that part. They would then perform an anastomosis, which is to reconnect the other two ends. This would prevent a future polyp growing out of the same spot. Alhamdulilah that seemed fair. The second part of the operation is the Temporary Loop Ileostomy. This procedure would temporarily link the end of the small intestine directly to the skin surface, thus avoiding the digesting materials from entering the large intestine(colon). This helps from straining the anastomosis and encourage better healing conditions. The doctor mentioned that hubby may or may not undergo the ileostomy as the decision is based on the nature of the anastomosis. Further, post operatively hubby would need four to six weeks of rest. By the way, ileostomy like mentioned above, connects the small intestine to the skin surface. That means all the faecal matter will come out of this hole(called stoma) somewhere near our tummy. A stoma-nurse(that was her specialty) spent a good hour discussing an ileostomy factbook. A 'stoma bag' with a sticky neck will be attached to the stoma and faecal matters would just come and fill the bag involuntarily. It had to be emptied, replaced, checked for leakage, watched out for culprit foods ... and the list goes on. And finally few month after the surgery, when the anastomosis is healed, another surgery will reverse the ileostomy and everything will be back to normal. Hubby was mortified by the ileostomy and the stoma more than the surgery itself. We were double minded when the doctor asked us for a decision. On one hand, the surgery would prevent a future polyp and that was important. But on the other hand, the surgery obviously would not guarantee against polyps growing at other sites. Adding to this, the list of possible side effects from the surgery. We both struggled to weigh the benefits. In the end, we gave our consent as further delay would push us deeper down the waiting list. Looking back, it seems unbelievable how fast things were progressing towards a major surgery in a half an hour(or so) discussion. Hubby was going through procedures after procedures such as, chest x-rays, blood checks etc. The pre-operative procedures were completed that day itself. We returned home by evening. The date of the surgery would be notified through a phone call. So we were told to expect it soon.