EP2030 - Ileostomy Volvulus: A Rare Complication

Purpose/Background: Ileostomy creation is a commonly performed operation in colorectal surgery for fecal diversion after ileoanal pouch operations or low colorectal anastomoses, among others. However, ileostomy creation is not without risks. Common complications include stoma prolapse, parastomal herniation, necrosis, high output, or obstruction at the stoma site, known as stoma related obstruction (SRO). SRO occurs in approximately 5.4-27.3% of cases and can usually be managed non-operatively. A rarely reported cause of SRO is volvulus around the ileostomy limbs. In a recent systematic review, ileostomy volvulus was reported in 12 of 159 cases of SRO, most often after loop ileostomy creation. We present two cases of SRO due to ileostomy volvulus. In both cases, patients had an end ileostomy and required operative management, including a novel approach to secure the stoma mesentery.

Methods/Interventions: Case one is a 54-year-old man who presented with synchronous sigmoid and hepatic flexure colon cancer. His hepatic flexure mass was nearly obstructing so he underwent an urgent laparoscopic total abdominal colectomy with end ileostomy creation. His postoperative course was complicated by multiple bowel obstructions, with concern for ileostomy volvulus. He underwent two laparoscopic detorsions of his ileostomy volvulus within one month of his initial operation. Ultimately, he underwent planned reversal of his ostomy 4 months later and has done well since.

Case two is a 29-year-old female with refractory ulcerative colitis (UC) who underwent total abdominal colectomy with end ileostomy due to an obstruction. One year later, she presented with stoma related obstructive symptoms and underwent a diagnostic laparoscopy due to concern for closed loop obstruction. She was found to have volvulized bowel around her ileostomy without adhesions, which was easily reduced. She underwent two more laparoscopic detorsions within the following month. After her third occurrence, we elected a novel approach for surgical management. To prevent future volvulus, the mesentery of the ostomy limb was sutured to the Falciform ligament to close the space superior to the ostomy. She has had no further episodes of SRO.

Results/Outcomes: We present two cases of volvulus around an end ileostomy. This is a rare complication of ileostomy creation. Both instances occurred after laparoscopic total abdominal colectomy, one for synchronous obstructing tumors and the other for refractory UC. Both patients required multiple laparoscopic detorsions of their volvulus. Our first patient underwent reversal of his ostomy which resolved his recurrent volvulus, while our second patient had the mesentery of her ostomy sutured to her Falciform ligament to prevent further twisting of bowel around her ostomy.

Conclusion/Discussion: Stoma related obstruction due to volvulus around the limbs of an ileostomy is an infrequently reported complication of stomas. It can be hard to diagnose, and there are very few described operative techniques to alleviate it, other than ostomy revision or reversal. Our approach of securing the mesentery of the stoma to the Falciform ligament to prevent further volvulus is a unique approach that can be adopted when ileostomy volvulus is identified.

Case One CT Scans
a) Axial imaging depicting transition point at the level of the right upper quadrant ostomy (arrow)

b) Coronal imaging depicting mesenteric swirl at the transition point (arrow)
Case Two CT Scans
a) Axial imaging depicting dilated small bowel in the right mid abdomen concerning for obstruction at the level of the ostomy (arrow)

b) Coronal imaging showing a loop of dilated bowel with decompressed bowel proximally and distally concerning for closed loop obstruction