|Year : 2018 | Volume
| Issue : 1 | Page : 26-29
Perineal colostomy following abdomino-perineal resection for rectal cancer-A case report
Vasudeva Pai Hosdurg, MV Sreeharsha
Department of General Surgery, Columbia Asia Hospital, Mysore, Karnataka, India
|Date of Web Publication||17-Sep-2018|
Vasudeva Pai Hosdurg
539/K, “Mahalasa”, 4th Stage 1st Phase, Vijaya Nagar, Mysore - 570 017, Karnataka
Source of Support: None, Conflict of Interest: None
The management of ultralow rectal cancers within 2 cm from the dentate line is still challenging. Abdominoperineal resection (APR) is the gold standard in the treatment of ultralow rectal cancers. Conventional APR involves the construction of a left iliac fossa (LIF) end colostomy. The taboo associated with a permanent abdominal colostomy results in a poor self-esteem and a poor quality of life. Pseudocontinent perineal colostomy (PCPC) is an alternative reconstruction technique following APR in which the colostomy is placed in the perineum and a graft of smooth colonic muscle tightly surrounds the lowered colon. We present the case of a young unmarried gentleman who underwent an APR and living with a left iliac fossa colostomy who underwent this procedure. The case is of interest since a similar case report could not be found from India and also since the PCPC in our case is done as a secondary procedure.
Keywords: Abdominoperineal resection, colostomy, continence, perineal, rectal cancer
|How to cite this article:|
Hosdurg VP, Sreeharsha M V. Perineal colostomy following abdomino-perineal resection for rectal cancer-A case report. Indian J Colo-Rectal Surg 2018;1:26-9
|How to cite this URL:|
Hosdurg VP, Sreeharsha M V. Perineal colostomy following abdomino-perineal resection for rectal cancer-A case report. Indian J Colo-Rectal Surg [serial online] 2018 [cited 2019 Mar 25];1:26-9. Available from: http://www.ijcrsonweb.org/text.asp?2018/1/1/26/241293
| Introduction|| |
Abdominoperineal resection (APR) is a curative surgery for ultralow rectal cancers. However it leads to a permanent stoma which is not acceptable to many. Perineal colostomy is an alternative to permanent stoma, following APR in which the colostomy is placed in the perineum. We report a case where we constructed a Perineal Colostomy.
| Case Report|| |
A 30-year-old unmarried man presented to our outpatient clinic. He expressed his desire to get rid of the permanent left iliac fossa end colostomy. He gave a history of abdominoperineal resection (APR) for low rectal cancer at his hometown about 18 months back by an oncosurgeon at a secondary care center. He had completed postoperative chemotherapy about 9 months back. He did not have a history of any comorbid medical illness. Histopathology report of the APR specimen showed moderately differentiated adenocarcinoma with clear margins. Examination of the patient revealed stable vitals. Abdominal examination revealed a long midline scar, a well-located, well-constructed, normally functioning left iliac fossa end colostomy. Perineal wound healed well with an unremarkable scar. Patients concerns were genuine about a permanent abdominal wall colostomy which may be an obstacle for him to find a life partner. He was counselled about the options of using better stoma appliances or stoma irrigation system to manage the colostomy. He was explained that conventionally left iliac fossa end colostomy is permanent, but in view of his concerns promised to go through the medical literature and find out an alternative to the LIF colostomy. He was sent back with an advice to use colostomy irrigation system/better stoma appliance.
On reviewing the literature, we found a series of 148 pseudocontinent perineal colostomies (PCPCs) done in Morocco for low rectal cancer with good functional result. A review of the surgical technique was also done and found that the same was technically feasible in our patient. The patient visited me after a month along with family for further counseling. The patient and family were counseled under audiovisual cover highlighting that no such procedures were reported from India, that the author has not performed the procedure before, the need for lifelong stoma irrigation in the perineum, the possibility of failure which may need a reversal back to abdominal wall colostomy, and also the chances of temporary or permanent sexual dysfunction. The patient was fully motivated for the procedure and so was the family.
The patient came back a month later after arranging the finances for the procedure. Counseled again, informed risk consent obtained and admitted for surgery. Routine investigations done such as a hemogram, kidney function test, liver function test, prothrombin time, HIV 1 and 2, HBsAg, HCV, blood group, Chest X-ray, and electrocardiography all were unremarkable. As a recently performed contrast computed tomography abdomen and pelvis did not show any evidence of local recurrence or liver metastasis, only a screening ultrasonography abdomen was ordered at this admission to look for any liver metastasis. After an anesthesiology consultation, the case was planned for the next day.
Under general anesthesia and epidural analgesia, the patient was placed in lithotomy position. Prophylactic antibiotic cefuroxime injection 1.5 g along with metronidazole 500 mg intravenous (IV) was administered at induction of general anesthesia. Nipple to midthigh and perineum and genitals were painted with povidone-iodine solution. Through a midline incision excising the previous scar, the peritoneum was entered. A post-APR status with LIF end colostomy was found. Omental adhesions to the pelvis along with few small bowel adhesions were encountered. There was no evidence of local recurrence or liver metastasis.
Adhesions were taken down meticulously. The colostomy mobilized and taken down. The descending colon, splenic flexure, and transverse colon were mobilized. For better tension-free reach of the colon to the perineum, the left colic vessels were ligated and divided after ensuring a good flow through the marginal vessels. The terminal 10 cm of the mobilized colon resected as a free graft. This free colonic graft was freed of all the mesocolon, appendices epiploicae, inverted, and the mucosa was stripped off meticulously [Figure 1]. This graft is treated with metronidazole solution for 15 mts. This prepared seromuscular tube is passed over the end of the colon [Figure 2] and tightly double breasted using 3/0 vicryl [Figure 3]. A suitable location selected in the perineum for placing the neoanus, scar excised in that location, deepened and tunneled into the pelvis. Now the colonic end with the graft pulled down to the perineum and matured [Figure 4]. Mobilized omentum placed into the pelvic cavity as an omentoplasty. Abdomen closed over a 28F tube drain in the pelvis through the left flank. Estimated blood loss was approximately 50 ml and the duration of surgery was 335 min.
Postoperatively, the prophylactic cefuroxime and metronidazole were continued for two more doses as per protocol. The patient was kept nil by mouth, on IV fluids, epidural analgesia, deep vein thrombosis prophylaxis by Flotron application, and enoxaparin injection. On day 1, perineal colostomy was inspected, found healthy with no soiling. Oral clear liquids were allowed. On day 2, the patient had minimal bloating of the abdomen and had passed minimal flatus per perineal colostomy. No soiling of the stoma. On day 4, minimal soiling of the perineal colostomy was found. Irrigation of the stoma started with help from stoma care personnel. The patient improved, had control over the flatus. No soiling of the stoma site. The patient had some seropurulent discharge from the midline wound on 5th day, few sutures were removed and the collection drained and a sample sent for culture. The patient was discharged on the 6th postoperative day in stable condition. Later, the patient was called and prescribed a course of injection amikacin for 7 days following the culture report which showed Gram-negative bacilli sensitive to amikacin. At 3-week postsurgery, the patient had a well-healed abdominal wound and the colostomy site [Figure 5]. The patient is well versed with irrigation and with good continence. At 1-year follow-up, the patient had a near-normal continence with the need for once-daily irrigation of the stoma. The patient's sexual function is normally preserved. The patient has a good quality of life and back to work.
| Discussion|| |
Several techniques of anal sphincter conservation have been described like artificial sphincter, nearby skeletal muscles such as gracilis, adductor longus, or gluteus maximus ,, with or without electrical stimulator transposed around the PCPC  to improve the continence, and more recently, the combination of both rectus abdominis myocutaneous flap and PCPC.
Smooth muscles of the intestinal tract can be autotransplanted and can function as a sphincter after healing. PCPC is a reconstruction technique performed after APR in which a permanent colostomy is placed in the left lower quadrant of the abdomen instead of the iliac fossa. In this procedure, a graft of smooth colonic muscle tightly surrounds the colon. This technique was first described by Schmidt for abdominal colostomies  and then applied by Gamagami to the perineum. The invisible perineal placement of the colostomy offers the advantages of preserved body image with the improved quality of life  and a reasonable continence with acceptable functional results.,, In our case, this was particularly important in view of the age of the patient and unmarried status and has allowed him to go back to work. There was no report of such a technique being followed in India. An Indian report of 42 cases used an “S” trap arrangement of the colon and continent perineal colostomy controlled by a dynamic bilateral graciloplasty. The Schmidt technique used by us is simpler and easily reproducible. Since it is only a reconstruction technique following an APR on oncologic principles, it has shown comparable results with APR with iliac colostomy. PCPC also offers the theoretical advantage to allow an early diagnosis of pelvic recurrences by rectal examination or by echoendoscopy., The technical challenges of performing the PCPC as a secondary procedure as in our case can be a shorter colonic length which needs more mobilization of the colon for a tension-free reach to the perineum and the chances of encountering intraperitoneal adhesions and pelvic adhesions with more risk of causing sexual dysfunction. Most of the reports of PCPC in literature are as a primary procedure.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]