EP680 - A Patient with Uncorrected Anorectal Malformation Reaching Adulthood with a Large Stomal Prolapse

Purpose/Background: Anorectal malformation (ARM) refers to a variety of birth defects in which the anus and rectum do not develop properly. These are commonly corrected in infancy, or childhood. It is not unheard of, especially in resource-limited settings, to encounter patients with uncorrected ARM reaching adulthood. A diverting stoma may be created as part of the initial management, particularly those for staged repair. As the ARM remains uncorrected, the stoma remains necessary-with it comes complications associated with a long-standing stoma, such as prolapse. Stomal prolapse may range in severity from a localized abdominal deformity to complete bowel evisceration. We presented an adult ARM patient with stomal prolapse, and highlighted the surgical management of this condition.

Methods/Interventions: A 23/M, diagnosed with Down syndrome and ARM without fistula, underwent transverse colostomy in 2001. He presented at our outpatient clinic for a 12-year history of a prolapsed stoma. Based on previous records, anoplasty was not feasible on this patient given the findings of underdeveloped sphincter muscles seen on pelvic MRI. Physical examination showed a long segment of viable bowel (involving both limbs) protruding through the stoma at the right upper quadrant (RUQ).

Abdominal CT scan done showed a stoma site defect measuring 6.4 x 5.6 cm (CC x W) in the RUQ through which segments of colon were eviscerated. Additionally, non-dilated jejunal segments and their associated mesentery and vasculature, were seen herniating through the parastomal region.

Results/Outcomes: The patient underwent takedown of colostomy, segmental colonic resection (ascending to descending colon), stoma re-siting (to the left lower quadrant) and intraperitoneal only mesh (IPOM) plus technique using a composite mesh. The patient had an unremarkable postoperative course and was discharged 3 days after surgery.

Conclusion/Discussion: Prolapse is a significant long-term complication of having a stoma. We highlighted the surgical management done that focused on providing acceptable function and quality of life, and decreasing the likelihood of a recurrence, on what is expected to be a permanent stoma.

Figure 1. Preoperative, intraoperative, and postoperative images of a 23/M with a long-standing stomal prolapse from an uncorrected ARM reaching adulthood.
(A) A representative CT scan cut showing the herniated bowel segments and abdominal wall defect. (B) The patient presented at the outpatient clinic with a long-standing stomal prolapse. (C) Intraoperatively, segments of small bowel, cecum, ascending, transverse, and descending colon were released through a combined midline and parastomal approach. A resection from the ascending colon to the descending colon was done. (D) The previous trephine was seen to have a 7 x 6 cm defect.The anterior fascia of the previous trephine was primarily sutured. (E) A composite mesh was laid down and secured to the abdominal wall, providing support to both the midline and stoma defects. (F) Postoperative photograph showing the resited stoma. PGH, 2024.