Ostomy Complications and Management
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Benign Disease- A morbidly obese patient is undergoing a total abdominal colectomy for fulminant colitis. He is receiving high-dose steroids and biologic therapy, and he has been preoperatively marked by an enterostomal therapist. The ileal mesentery is foreshortened, and the abdominal wall is thick. You are unable to bring the divided end of the ileum to the skin without tearing the mesentery. What is the best next step in management?
- A 43-year-old morbidly obese man is undergoing a Hartmann procedure for Hinchey IV perforated diverticulitis. Two days postoperatively, the ostomy has retracted below the skin and appears purple. The patient remains afebrile and hemodynamically normal without peritonitis. Intubation of the colostomy with a test tube reveals black mucosa proximal to the fascia. What is the next step in management?
- A 62-year-old man presents to the emergency department with acute-onset left lower quadrant abdominal pain. He is mildly tachycardic but is otherwise hemodynamically stable. On abdominal examination, he has diffuse peritonitis. Laparoscopy reveals sigmoid diverticulitis with purulent fluid throughout the abdomen without fecal contamination. What is the best next step in management?
- You operate on a 23-year-old man who sustained multiple stab wounds to the abdomen. His injuries include a grade II splenic hematoma and a sigmoid colon laceration involving 40% of the colonic wall. The perisigmoid mesentery is intact. He has received 3 units of blood in the operating room. What is your recommendation for repair of his colonic injury?
- Perioperative
- A 56-year-old man undergoes a low anterior resection after neoadjuvant chemoradiation for a T3N0M0 rectal cancer located 9 cm from the anal verge. Eight days later, he presents to the emergency department with mild abdominal pain and a temperature of 102.2°F (39°C). Laboratory results are significant for a white blood cell count of 14,000/µL (14×109/L). Computed tomography of the abdomen and pelvis shows pneumoperitoneum with contrast extravasation into the pelvis. Abdominal examination shows focal peritonitis in the left lower quadrant. Intraoperative findings demonstrate a 3-mm anastomotic disruption anteriorly. In addition to abdominal washout, what is the best surgical option for this patient?
- A 50-year-old woman who has had a hysterectomy undergoes an exploratory laparotomy with extensive lysis of adhesions for a small bowel obstruction. She has an uneventful postoperative course and is discharged. She presents to your clinic 2 weeks later with an apparent midline wound infection and skin separation. Local wound care is initiated to include damp to dry dressings twice daily. One week later, the patient presents with bilious drainage from the wound. Physical examination demonstrates small bowel mucosa extruding from the upper portion of the wound. What is the best next step in management?