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APSP J Case Rep 2010; Vol. 1 (2)
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An Interesting Case of Bishop-Koop Stoma Prolapse
Bilal Mirza
Department of Paediatric Surgery, The Children's Hospital & The Institute of Child Health Lahore, Pakistan
*Corresponding Author's E-mail address: blmirza@yahoo.com
APSP J Case Rep 2010; 1: 24
How to cite
Mirza B. An interesting case of Bishop-Koop stoma prolapse. APSP J Case Rep 2010; 1: 24
A 4-month-old male baby presented with enterostomy prolapse. Past medical history revealed two operations elsewhere during third week of life. The first operation was performed for pneumoperitoneum due to necrotizing enterocolitis (NEC) of distal jejunum. The involved portion of small intestine was resected and a primary end-to-end jejuno-ileal anastomosis performed. The patient had to be re-explored due to anastomotic disruption and then an end-to-side jejuno-ileal anastomosis with Bishop-Koop ileostomy fashioned [Image 1]. The patient remained well for three months and passed stool per rectally and occasionally from stoma.
The patient on arrival was vitally stable with normal labs. The general physical and systemic examinations were unremarkable besides a prolapsed enterostomy. Patient was anesthetized. The prolapse was inverted Y shaped, with the first limb the original Bishop Koop prolapse of ileal mucosa; whereas the second limb was the prolapsed mucosa of jejunum through end-to-side jejuno-ileal anastomosis. The mucosal anastomotic line was visible at the proximal part of that limb [Image 2]. Initially the jejunal mucosa was returned back to the main stump followed by reduction of ileal mucosa. U-stitches were applied to hold the mucosa in place [Image 3]. Patient was discharged after 2 days and appointment given for reversal of stoma.
An Interesting Case of Bishop-Koop Stoma Prolapse
Bilal Mirza
Department of Paediatric Surgery, The Children's Hospital & The Institute of Child Health Lahore, Pakistan
*Corresponding Author's E-mail address: blmirza@yahoo.com
APSP J Case Rep 2010; 1: 24
How to cite
Mirza B. An interesting case of Bishop-Koop stoma prolapse. APSP J Case Rep 2010; 1: 24
A 4-month-old male baby presented with enterostomy prolapse. Past medical history revealed two operations elsewhere during third week of life. The first operation was performed for pneumoperitoneum due to necrotizing enterocolitis (NEC) of distal jejunum. The involved portion of small intestine was resected and a primary end-to-end jejuno-ileal anastomosis performed. The patient had to be re-explored due to anastomotic disruption and then an end-to-side jejuno-ileal anastomosis with Bishop-Koop ileostomy fashioned [Image 1]. The patient remained well for three months and passed stool per rectally and occasionally from stoma.
The patient on arrival was vitally stable with normal labs. The general physical and systemic examinations were unremarkable besides a prolapsed enterostomy. Patient was anesthetized. The prolapse was inverted Y shaped, with the first limb the original Bishop Koop prolapse of ileal mucosa; whereas the second limb was the prolapsed mucosa of jejunum through end-to-side jejuno-ileal anastomosis. The mucosal anastomotic line was visible at the proximal part of that limb [Image 2]. Initially the jejunal mucosa was returned back to the main stump followed by reduction of ileal mucosa. U-stitches were applied to hold the mucosa in place [Image 3]. Patient was discharged after 2 days and appointment given for reversal of stoma.
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DISCUSSION
Enterostomies are commonly made for various pediatric surgical conditions. Different types of enterostomies include loop, divided/double barrel, Hartmann, santulli, Bishop-Koop etc. These may be classified as temporary or permanent depending upon the underlying condition for which they have been formed [1,2].
Bishop-Koop enterostomy was originally devised for the patients with meconium ileus, but, it has also been used for other pediatric surgical conditions such as intestinal atresia and NEC. Forming a Bishop Koop stoma involves anastomosis of end of proximal bowel to the side of distal bowel and exteriorizing the end of distal bowel as chimney -enterostomy [Image 1] [2,3].
The basic purpose of a Bishop-Koop enterostomy, in patients of meconium ileus, is to provide a vent for and irrigation of the distal bowel having thick inspissated meconium. In other pediatric surgical conditions, it is being used as a safety guard for intestinal anastomosis where a diversion enterostomy is not desirable like stoma in very proximal part of intestine and in conditions where intestinal length is short [3].
Enterostomies are associated with many problems such as; stoma retraction, prolapse, narrowing, peri-stomal hernia/evisceration of intestine, bleeding, skin excoriations, wound dehiscence, and so on. In one study enterostomy related complications were about 68% in children of different age groups. The incidence of prolapse in pediatric patients ranges between 3% and 25%. The incidence of stoma prolapse is higher with loop enterostomy and minimum with divided enterostomy. The highest prolapse (25%) is observed in the distal stoma of transverse loop colostomy [4].
In temporary ostomies, the stoma prolapse is usually managed conservatively, however in cases where the stoma is desired for a longer period or in case of permanent enterostomy, a revision of the stoma has been advocated [5,6].
In a perusal of English literature through “Pubmed website” using keywords “Bishop Koop” and “prolapse” no relevant paper was found. The prolapse of Bishop-Koop stoma is therefore a rare event. This may be due to a very small caliber stoma in cases with meconium ileus where it was primarily recommended; however, in our case, NEC was the primary diagnosis thus caliber of Bishop-Koop stoma was not small. This contributed to the prolapse of not only intestine but also adjacent anastomosis.
REFERENCES
1. DelPino A, Citron JR, Orsay CP. Enterostomal complications: are emergently created enterostomas at greater risk? Am Surg 1997; 63:653-6.
2. Gauderer MWL. Stomas of the small and large intestine. In: Grosfeld JL O’Neill JA Jr, Coran AG, Fonkalsrud EW, Caldamone AA. editors. Pediatric surgery. 6th ed. Chicago: Mosby Elsevier; 2006. p. 1479-91.
3. Ziegler MM. Meconium Ileus. In: Grosfeld JL O’Neill JA Jr, Coran AG, Fonkalsrud EW, Caldamone AA. editors. Pediatric surgery. 6th ed. Chicago: Mosby Elsevier; 2006. p. 1289-303.
4. Sheikh MA, Akhtar J, Ahmed S. Complications/problems of colostomy in infants and children. J Coll Physicians Surg Pak 2006; 16: 509-13.
5. Duchesne JC, Wang YZ, Weintraub SL. Stoma complications: a multivariate analysis. Am Surg 2002;68: 961-86.
6. Shellito PC. Complications of abdominal stoma surgery. Dis Colon Rectum 1998;41:1562-72.
Enterostomies are commonly made for various pediatric surgical conditions. Different types of enterostomies include loop, divided/double barrel, Hartmann, santulli, Bishop-Koop etc. These may be classified as temporary or permanent depending upon the underlying condition for which they have been formed [1,2].
Bishop-Koop enterostomy was originally devised for the patients with meconium ileus, but, it has also been used for other pediatric surgical conditions such as intestinal atresia and NEC. Forming a Bishop Koop stoma involves anastomosis of end of proximal bowel to the side of distal bowel and exteriorizing the end of distal bowel as chimney -enterostomy [Image 1] [2,3].
The basic purpose of a Bishop-Koop enterostomy, in patients of meconium ileus, is to provide a vent for and irrigation of the distal bowel having thick inspissated meconium. In other pediatric surgical conditions, it is being used as a safety guard for intestinal anastomosis where a diversion enterostomy is not desirable like stoma in very proximal part of intestine and in conditions where intestinal length is short [3].
Enterostomies are associated with many problems such as; stoma retraction, prolapse, narrowing, peri-stomal hernia/evisceration of intestine, bleeding, skin excoriations, wound dehiscence, and so on. In one study enterostomy related complications were about 68% in children of different age groups. The incidence of prolapse in pediatric patients ranges between 3% and 25%. The incidence of stoma prolapse is higher with loop enterostomy and minimum with divided enterostomy. The highest prolapse (25%) is observed in the distal stoma of transverse loop colostomy [4].
In temporary ostomies, the stoma prolapse is usually managed conservatively, however in cases where the stoma is desired for a longer period or in case of permanent enterostomy, a revision of the stoma has been advocated [5,6].
In a perusal of English literature through “Pubmed website” using keywords “Bishop Koop” and “prolapse” no relevant paper was found. The prolapse of Bishop-Koop stoma is therefore a rare event. This may be due to a very small caliber stoma in cases with meconium ileus where it was primarily recommended; however, in our case, NEC was the primary diagnosis thus caliber of Bishop-Koop stoma was not small. This contributed to the prolapse of not only intestine but also adjacent anastomosis.
REFERENCES
1. DelPino A, Citron JR, Orsay CP. Enterostomal complications: are emergently created enterostomas at greater risk? Am Surg 1997; 63:653-6.
2. Gauderer MWL. Stomas of the small and large intestine. In: Grosfeld JL O’Neill JA Jr, Coran AG, Fonkalsrud EW, Caldamone AA. editors. Pediatric surgery. 6th ed. Chicago: Mosby Elsevier; 2006. p. 1479-91.
3. Ziegler MM. Meconium Ileus. In: Grosfeld JL O’Neill JA Jr, Coran AG, Fonkalsrud EW, Caldamone AA. editors. Pediatric surgery. 6th ed. Chicago: Mosby Elsevier; 2006. p. 1289-303.
4. Sheikh MA, Akhtar J, Ahmed S. Complications/problems of colostomy in infants and children. J Coll Physicians Surg Pak 2006; 16: 509-13.
5. Duchesne JC, Wang YZ, Weintraub SL. Stoma complications: a multivariate analysis. Am Surg 2002;68: 961-86.
6. Shellito PC. Complications of abdominal stoma surgery. Dis Colon Rectum 1998;41:1562-72.
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