International Journal of Surgery Case Reports · 3 authors, 2 centres
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This case report describes a 50-year-old man with obstructing rectal cancer who developed a rare late parastomal evisceration seven months after loop ileostomy creation, triggered by a coughing fit. The eviscerated small bowel was successfully reduced and the stoma revised without bowel resection. Parastomal evisceration is a life-threatening emergency requiring prompt recognition, resuscitation, and surgical intervention.
**Background:** Stoma formation is a common colorectal surgery procedure with a complication rate of 20–70%. Parastomal evisceration—the herniation of abdominal contents through a dehiscence adjacent to a stoma—is an extremely rare complication, with only 16 cases reported in the literature. Most cases occur in the early postoperative period, though late presentations up to 18 months after index surgery have been documented. This report describes a case of late parastomal evisceration in a patient undergoing neoadjuvant therapy for rectal cancer.
**Methods:** The authors present a case report prepared in accordance with the SCARE criteria. A 50-year-old male with a T4aN2 obstructing mid-rectal cancer underwent elective laparoscopic loop ileostomy formation seven months prior to presentation. He had completed 50 Gy in 25 fractions of radiation therapy five months prior and was three days post his sixth cycle of neoadjuvant chemotherapy with capecitabine and oxaliplatin. His medical history included a 20 pack-year smoking history, obesity, hypertension, dyslipidaemia, and alcohol excess. Three months post-ileostomy, he developed a small non-obstructing, bowel-containing parastomal hernia that was managed non-operatively. Seven months post-ileostomy, following a severe coughing fit at home, he presented to the emergency department with severe pain, distension of his ileostomy bag, and eviscerated dilated loops of small intestine at the superior aspect of the ileostomy. Laboratory findings showed mild anaemia (haemoglobin 122 g/L, reference range 135–180 g/L), normal white cell count (5.4 × 10⁹/L, reference 4–11 × 10⁹/L), and rising serial lactate from 5.4 to 7.5 mmol/L (reference 0.5–2.2 mmol/L). He was resuscitated with intravenous fluids and intravenous Ceftriaxone and Metronidazole, and taken for urgent surgical exploration.
**Key Results:** Intraoperative findings revealed parastomal evisceration of approximately 40 cm of small bowel at the 12 o'clock aspect of the loop ileostomy. The proximal limb was at 3 o'clock and the distal limb at 9 o'clock. The eviscerated bowel was distended, indurated, and mildly haemorrhagic but not necrotic or perforated. The stomal orifice was sharply extended superiorly to facilitate reduction. After reduction and a 10-minute observation period, the reduced small intestine was confirmed viable. The posterior and anterior rectus sheaths were approximated with figure-of-8 1-PDS sutures to narrow the stomal orifice, and the superior aspect of the mucocutaneous junction was approximated with interrupted 3-0 Monocryl sutures. The patient had an uneventful recovery with return of stomal function on postoperative day one and was discharged on postoperative day five. At 30-day follow-up, he reported normal stomal function and adherence to smoking reduction and alcohol cessation.
**Clinical Implications:** Parastomal evisceration is a life-threatening surgical emergency. Identified risk factors include coughing, increased intra-abdominal pressure, emergency surgery, corticosteroid use, stomal prolapse, parastomal hernia, malignant colorectal disease, smoking, and alcohol excess. This case highlights that even patients with known parastomal hernia managed non-operatively remain at risk. Successful management requires early recognition, fluid and electrolyte resuscitation, antibiotic administration, protection of exposed bowel, and prompt surgical exploration. Viable bowel should be reduced (potentially requiring enlargement of the stomal orifice), while gangrenous or perforated bowel requires resection. Decisions regarding stoma revision, resiting, or reversal depend on patient factors, disease factors, surgeon expertise, and local resources. In this case, simple revision was chosen as the patient was planned for completion of neoadjuvant therapy followed by curative low anterior resection. The authors suggest that elective repair of parastomal hernia in high-risk patients may reduce the risk of this rare but serious complication.