Diverting Stoma-Related Evisceration: A Comprehensive Review of 28 Case Reports Published in the Medical Literature in English

Evisceration is an exceptional complication of diverting a stoma (a common procedure, often considered a minor surgery) with peculiar, specific, features (distinct-to-usual incisional evisceration), due to the presence of a stoma. Available data are limited to a few case reports; some aspects are not fully documented. The results of 28 case reports (full-text articles published in the English literature) were analyzed using 14 variables: age and gender; pathology; surgical setting; index surgery and type of stoma; intended stoma creation; time from surgery to evisceration; type of evisceration; visceral content; cause of evisceration; specific predisposing/risk factors; surgical approach; resection of nonviable content; surgical stoma treatment; and short-term outcome. Urgent surgery resulted in 46.42% resection of nonviable eviscerated content and 7.14% mortality. All issues (some not discussed in previous reviews) were analyzed, to highlight their clinical relevance for surgical practice. The mechanisms (types of evisceration) are different in parastomal and transstomal/intrastomal evisceration; they should be considered as distinct entities. The real (underlying) etiology was identified in 26/28 case reports (92.85%): surgical failure, such as inadequate technique/tactics/strategy (12/26 case reports, 46.15%); trauma (7/26 case reports, 26.92%); and spontaneous necrosis (6/26 case reports, 21.42%). Parastomal hernia and/or prolapse (10/28 case reports, 35.71%) were specific predisposing factors; in such cases, early surgical treatment is recommended. Temporary stoma was a potential risk factor, both for early as well as for late evisceration (e.g., long-standing temporary stoma); in such cases, early take-down or conversion to definitive stoma is beneficial. A local surgical approach (avoiding median laparotomy) was used in 13/28 (46.42%) of case reports. Seven different surgical options were used for surgical stoma treatment, demonstrating versatility; the initial stoma site was preserved in 22/28 (78.57%) of case reports.


Introduction And Background
Temporary/permanent diverting stoma (ileostomy/colostomy) is a common surgical procedure (often considered a minor surgery) but is associated with its own morbidity/mortality; complications are described as early (within 30 days after surgery) or late.Usual complications can be avoided through adherence to meticulous techniques and sound surgical principles [1]; elective take-down of temporary stoma can also be associated with morbidity/mortality [2].The incidence of usual complications is a variable reported in a retrospective analysis [3], a multivariate analysis [4], a literature overview [5], a systematic review of selected randomized controlled trials (RCTs) [6], consensus guidelines [7], and a retrospective study [8].
Evisceration related to stoma formation is unusual (exceptional) and neglected in these studies; it is associated with a high rate of morbidity and even mortality (a potentially life-threatening condition; immediate surgery is mandatory) and is relatively undocumented in previous reviews.The objective of this review is to realize a synthesis of published case reports providing a comprehensive analysis of issues related to the topic (some not discussed in previous reviews) to highlight their clinical relevance for surgical practice and to offer information to the medical community.
Results of each case report were briefly described (with minimal additional comments), to facilitate comparison of their key characteristics, in a tabular structure; 14 variables were studied (age and gender, pathology, surgical setting, index surgery, type of stoma, intended stoma creation, time from surgery to evisceration, type of evisceration and visceral content, cause of evisceration, specific predisposing/risk factors, surgical approach, resection of nonviable content, surgical ostomy treatment, and short-term outcomes).There were no twin case reports; each demonstrated individual characteristics.Specific statistical synthesis was virtually impossible for the following reasons: the absence of series, the limited number of patients (28 case reports); and underlying heterogeneity (14 variables), so a systematic review was not feasible.

Results
Studies were chronologically ordered and details of each case report are mentioned below.
Fitzgerald et al. [12], 2008, reported an early (after 10 days of surgery) parastomal small bowel (SB) evisceration in a 65-year-old male (M) after an anterior rectal resection (for rectosigmoid villous adenoma) with a defunctioning loop ileostomy.A high ileostomy output (on day six after index surgery, due to Clostridium difficile colitis) was followed by early ileostomy prolapse (that was manually reduced), and later on, by spontaneous mucocutaneous separation of ileostomy.A transverse parastomal incision was practiced, the content was reduced in the abdominal cavity, and the loop ileostomy was converted to end ileostomy.Although the abdominal wall opening appeared appropriately sized, the surgical failure was (probably) related to an inadequate fascia and mucocutaneous fixation; evisceration could have been prevented by surgical reduction of early prolapse.
Park et al. [13], 2010, reported the case of a 58-year-old male, with late (four months after surgery) parastomal SB evisceration after anterior rectal resection for rectal adenocarcinoma (ADK) with defunctioning loop ileostomy (complicated by a parastomal hernia and prolapse).Evisceration was iatrogenic: traumatic rupture (secondary to forceful manipulation to reduce prolapse).A resection of strangulated SB was realized, followed by ileostomy closure.
Carmen Nofuentes et al. [14], 2011, reported the case of an 83-year-old male (with a history of senile dementia) who was operated on for rectal ADK (abdominoperineal amputation).Three months after index surgery a late transstomal evisceration of large omentum (LO) was reported.Evisceration occurred through a defect in the colostomy wall and it was secondary to self-induced trauma: the patient had the habit of introducing his index in the stoma.A local surgery approach was used to perform resection of LO and suture of the colonic parietal defect.[15], 2011, published the case of a 23-year-old male with a history of Crohn's disease and prior ileostomy; the initial procedure is not mentioned in the case report.The end ileostomy was complicated by a late SB parastomal evisceration, caused by blunt abdominal trauma, requiring laparotomy, reduction, and recreation (repositioning) of ileostomy to his left side.

Moffett and Younggren
Vornehm et al. [16], 2011, reported a late (two years after surgery) SB parastomal evisceration in a 66-yearold female with a long history of Crohn's disease after Hartmann's procedure for perforated diverticulitis.Extensive chronic parastomal pyoderma gangrenosum created a large fascial defect.Reduction and repositioning of colostomy in the left upper quadrant was the surgical solution in this case.
Salles et al. [17], 2011, reported the case of a 62-year-old male with rectal ADK; he was taking an oncologic neoadjuvant treatment.The patient was urgently submitted to loop transversostomy for acute bowel obstruction (ABO) decompression.His comorbidity was chronic pulmonary disease (COPD); a bronchospasm crisis with intermittent cough worsened his respiratory condition, requiring mechanical ventilation support four days after surgery.During this event, he presented a parastomal SB and transverse colon (TC) evisceration.The patient was reoperated through the stoma: SB reduction, partial resection of microperforated TC, and conversion to end TC colostomy.The hole diameter of the stoma was larger than required for TC extrusion due to the large distension observed in the episode of ABO.
Villa et al. [18], 2012, reported the case of a 69-year-old male with the previous therapy sequence: transverse loop colostomy (emergency treatment of obstructing rectal ADK); neoadjuvant radiochemotherapy (for five months); and finally, elective low anterior rectal resection, leaving the temporary colostomy in situ.The course of the low anterior rectal resection was uneventful, so the closure of the temporary stoma was scheduled for three months later; unfortunately, it was not realized because evisceration occurred first.A late (eight months after surgery) transstomal SB evisceration was secondary to postoperative ABO (SB obstruction by omentum band and adhesions).Surgery consisted of laparotomy, SB reduction, and suture of colonic wall perforation below the mucocutaneous plane.Evisceration could have been prevented by an earlier take-down of the colostomy.
Guner et al. [19], 2012, published the case of a 76-year-old male with Hartmann's procedure for sigmoid necrosis (ischemic gangrenous colitis) complicated (11 months later) by a late SB transstomal evisceration, occuring through a spontaneous perforation (10 cm proximal to the end colostomy opening).Evisceration was caused by the recurrence of diffuse ischemia (ischemic colitis), requiring laparotomy followed by SB reduction, partial colon resection, and recreation of the end colostomy.
Azouz et al. [20], 2014, reported the case of a 69-year-old male operated on for necrotizing perianal fasciitis (soft tissue debridement and diverting end sigmoidostomy), followed by early (three days after surgery) strangulated SB parastomal evisceration.Reoperation consisted of laparotomy, resection of 100 cm of compromised SB, and repair of the parastomal defect.A stomatal aperture larger than the ideal size was the cause of evisceration.
Yucel et al. [21], 2014, reported a 62-year-old male who underwent Miles's operation for rectal ADK; a parastomal hernia occurred eight months after surgery.One year after index surgery, the following sequence occurred: irreducible parastomal hernia (ABO of SB demonstrated by plain abdominal X-ray), prolapsed colon, rupture of hernia, and SB evisceration during the observation period.Surgery consisted of expansion of the stoma opening, SB reduction, and closure of the fascial defect.The rupture of the parastomal hernia could have been prevented by immediate surgery.
Ramly et al. [22], 2014, reported the case of an 81-year-old male who underwent total completion abdominal colectomy (for refractory Clostridium difficile colitis) and end ileostomy (reinforced with intraperitoneal mesh), complicated by early prolapse and early (nine days after surgery) strangulated parastomal ileostomy evisceration, requiring SB resection and recreation of ileostomy.A lot of associated risk factors were identified, but early prolapse was the real cause of evisceration, so a technical failure cannot be excluded.
Lolis et al. [23], 2015, reported the case of a 48-year-old female with stage IV rectal ADK and end-transverse colostomy for rectovaginal fistula, presenting a late (18 months after surgery) SB and LO transstomal evisceration (exteriorized through the end-transverse colostomy); chronic colostomy prolapse in conjunction with the underlying parastomal hernia caused necrosis of the colostomy wall.The surgical solution was right hemicolectomy and loop sigmoidostomy.Evisceration was labeled as parastomal, but, obviously, it was a transstomal one.
Salles et al. [24], 2016, published a second case of early (10 days after surgery) SB parastomal evisceration following loop transversostomy in an 82-year-old male, similar to a previous report [17].Once again a parastomal approach was used for SB reduction and resizing of the aponeurotic aperture.Similar to the previous case report, it was considered that the diameter of the stoma remained notably superior to the necessity of transverse exteriorization, attributed to its large distension at the time of the ABO.The clinical outcome was unfavorable (acute inflammatory response syndrome, pneumonia, and acute renal failure requiring mechanical respiratory support); the patient's condition worsened and he died seven days later.
Arbra and Fann [25], 2017, reported a 90-year-old male with subtotal colectomy and end-ileostomy (for failed conservative management of Ogilvie syndrome) and early (seven days after surgery) SB parastomal evisceration, preceded by atrial arrhythmia and respiratory failure (with subsequent tracheostomy).Emergency surgery showed an appropriately sized myofascial aperture created during the initial endileostomy.The operation consisted of SB reduction and stoma revision.Basnayake et al. [26], 2019, described a 51-year-old male with temporary loop sigmoidostomy (for extensive hidradenitis suppurativa of the perineum), parastomal hernia, and stoma prolapse (six weeks after surgery).The authors considered that ischemia and weakening of the underlying abdominal wall and the overlying skin caused a late (six months after surgery) SB parastomal evisceration.Surgical treatment consisted of reduction and resiting of the sigmoid colostomy.
Kulkarni et al. [27], 2019, highlighted the importance of meticulous surgical technique and emergency surgical intervention in two case reports of early parastomal eviscerations secondary to loop-diverting sigmoidostomy.Case 1 was a 45-year-old male operated on for repair of an iatrogenic rectal injury (during surgery for sacral chordoma).An early evisceration of TC and LO occurred on day 12 after surgery, preceded by a severe bout of coughing.The creation of a larger aperture to accommodate the dilated sigmoid (distended and loaded with hard stool) was identified as a possible cause of evisceration.Surgery included reduction and resizing of the enlarged stoma opening.Case 2 was a 50-year-old female with locally advanced cervix carcinoma (squamous cell carcinoma (SCC)) and loop-diverting sigmoidostomy for rectovaginal fistula.The evolution of the case was complicated by an early (day nine after surgery) evisceration of SB loops (that were contaminated with feces and edematous because of their proximity to the colostomy site); contamination induced severe sepsis with multiorgan dysfunction.Reoperation consisted of reduction of SB through an extension of the previous incision and stoma reconstruction.The patient died five days later due to sepsis and multiorgan dysfunction syndrome.
Mateș et al. [28], 2020, reported the case of an 84-year-old male admitted for a two-month history of chronic low bowel obstruction (CLBO) due to a locally advanced rectal ADK.Prior to neoadjuvant therapy, a diverting loop sigmoidostomy (with no previous colonic preparation) was practiced; the colon was loaded with hard stool, similar to Kurkarni et al. (case 1) [27].Colostomy was maturated on day two but it was not functional on day three, resulting in early SB parastomal evisceration (immediate surgery using a parastomal approach: SB reduction and suture of fascial disruption).In the pathological context, paralytic ileus was blamed as the cause of evisceration, but in retrospect, maybe, evisceration could have been prevented by instant stoma maturation; a surgical failure.
Lapena-Rodriguez et al. [29], 2020, presented the case report of a 44-year-old male, with a consecutive surgical history of sigmoidectomy (for relapsing volvulus), anastomosis leak, emergency end colostomy, parastomal hernia, and stoma prolapse five months later.Laparotomy was used as a surgical approach for a late (13 months after surgery) SB transstomal evisceration.Intraoperatively, necrosis and perforation in the lateral wall of the prolapsed end colostomy were demonstrated as the point for SB evisceration.Surgical treatment consisted of reduction of SB and partial resection of perforated end colostomy followed by recreation of end colostomy.Etiology was similar to [23], misinterpreted in both studies as parastomal evisceration, but was in fact transstomal.
Basnayake et al. [30], 2021, reported a 53-year-old male (with a history of bronchial asthma) diagnosed with stage IV ADK of hepatic flexure, without previous intestinal obstruction (according to contrast-enhanced CT).He developed ACO during bowel preparation for colonoscopy, so an emergency trephine loop ileostomy was created.Early (day seven after surgery) SB parastomal evisceration was followed by laparotomy, SB resection, and ileostomy refashioning.On day five, he died due to subsequent pneumonia and worsening acute respiratory distress syndrome (ARDS).A technical failure was identified as the cause of evisceration: a larger stoma opening to accommodate the dilated SB (secondary to ABO) so that the resolution of intestinal edema may have created enough space for intestinal evisceration.
Cecire et al. [31], 2021, reported a 77-year-old male with multiple previous surgeries for Crohn's disease: right hemicolectomy (for terminal ileal disease) and subsequent loop colostomy (for rectal stricture) that was converted to an end colostomy (due to stomal prolapse).During a recent admission, the patient presented an episode of SB obstruction (secondary to adhesions) that was managed nonoperatively; he was noted to have a reducible stoma prolapse of 10 cm and a parastomal hernia containing SB.A blunt force (trauma) was responsible for late SB transstomal evisceration: a large colonic perforation proximal to the stoma, through which the SB protruded into the colonic lumen and then through the colostomy, a perforation in the colon that was known to prolapse at times.Laparotomy was followed by reduction of SB, partial colonic resection, and refashioning of stoma.
Rockson et al. [32], 2021, published the case of a 56-year-old male who underwent surgery for a locally advanced rectal ADK after receiving total neoadjuvant therapy.Loop sigmoidostomy was practiced for CLBO decompression; ~5 liters of the ascitic liquid were suctioned during index surgery without placing intraabdominal drains.An early (day 10 after surgery) parastomal evisceration (with strangulated LO) was treated using a peristomal incision.Both the necrotic LO and the protruding, prolapsed segment of the stoma were resected and a new proximal colostomy was then rematurated; this time, two drains were placed to collect ascites.Ascites (not a lack of technique) was blamed for evisceration, but it could have been prevented by the drainage of ascites during index surgery.Momah et al. [33], 2021, reported a 35-year-old male with a significant history (AIDS, prior infections from several AIDS-defining organisms, Kaposi sarcoma, chemotherapy and steroid use for adrenal insufficiency, diabetes mellitus, and protein malnutrition).Index surgery was a diverting end colostomy for invasive anal SCC.Blunt abdominal trauma was the cause of a late (seven weeks after surgery) SC and LO parastomal evisceration, which was treated using a parastomal approach (partial resection and recreation of the stoma).
Gómez Contreras et al. [34], 2022, reported a 77-year-old male with sigmoidectomy and end colostomy (for occlusive colon ADK) and late (four years after surgery) SB transstomal evisceration (caused by blunt abdominal trauma).Surgery consisted of laparotomy, SB reduction, and suture of the defect.Karadaghi et al. [35], 2022, reported the case of a 62-year-old male who previously underwent a sigmoidectomy and end colostomy for rectal ADK.The patient presented a long-standing parastomal hernia that was ruptured (seven years after surgery) due to a blunt abdominal trauma, with a secondary occurence of a late SB transstomal evisceration.Urgent surgery consisted of laparotomy, reduction of SB, and repair of the colostomy defect with interrupted sutures.insufficient to identify the etiology of evisceration in this case.
Iswan et al. [37], 2023, reported a 50-year-old male with loop ileostomy (for obstructing rectal ADK), complicated three months later by parastomal hernia containing SB (managed non-operatively in the context of neoadjuvant therapy).Rupture of the neglected parastomal hernia was, probably, the cause of the late (seven months after surgery) parastomal evisceration.The patient was reoperated using a parastomal approach, SB reduction, and stoma revision.
Hasnaoui et al. [38], 2023, reported the case of a 58-year-old female, operated on for perforated cecal ADK (generalized purulent peritonitis): right colectomy and end-loop ileocolostomy (double-barrel stoma), followed by six sessions of adjuvant chemotherapy.A suspicion of peritoneal carcinomatosis (based on CT scans and abdominal MRI) was confirmed (frozen section report) during an elective reoperation (laparotomy) one month later; stoma mobilization was unable to offer a comprehensive peritoneal cavity exploration, thus a midline incision was executed and the decision was made to retain the double-barrel stoma.Early (two days after surgery) parastomal evisceration (1 m of viable SB), in the context of ongoing paralytic ileus, was determined by a surgical faiure: a large defect in the musculoaponeurotic sheath and consequent mucocutaneous dehiscence at the inferior angle of the stoma site.Immediate emergency surgery was practiced using a parastomal approach: SB reduction and stoma revision.

Discussion
Previous reviews [27,28,30,31,[36][37][38] included fewer case reports and variables.Issues related to the topic (some not discussed before) are described and analyzed to highlight their clinical relevance for surgical practice.Results are summarized in Tables 1, 2

Age and Gender
The mean age (all patients) was 61.78 years: higher in males (62.83 years; range 23 to 90 years) compared to females (55.5 years).Advanced age and male dominance (85.71%) were not considered risk factors; their significance is related to pathology.

Surgical Setting
Emergency surgery was not a predisposing factor; 64.28% of eviscerations occurred after elective surgery.

Index Surgery and Type of Stoma
Both ileostomy and colostomy eviscerations were studied.Data regarding ileostomy (32.14%) was limited; this review did not include a comparison of ileostomy vs. colostomy evisceration.The occurrence after loop ileostomy/colostomy (53.57%) was similar to end-ostomy; the type of stoma was irrelevant.

Intended Stoma Creation
Incidences after permanent and temporary stomas were identical (50%); they must be discussed according to the time after the creation of the stoma.

Visceral Content
The eviscerated content varied according to each case report and it was not connected to the type of stoma or mechanism of evisceration: SB (24/28; 85.71%), TC [17,27], SC [33], LO alongside a hollow viscus or only LO [14,32].

Specific (Associated) Risk Factors
A specific risk factor was considered only if directly related to the cause of stoma evisceration.Parastomal hernia and/or prolapse (10/28, 35.71%) were specific predisposing factors both for early [12,22] and late [13,21,23,26,29,31,35,37] stoma evisceration; their presence was a determining factor (evisceration could not happen in their absence); early surgical treatment is recommended to prevent stoma evisceration.

Short-Term Outcomes
A favorable outcome (up to 30 days after urgent surgery for stoma evisceration) was reported in 26/28 case reports (92.85%), with only two fatalities [24,27].

Conclusions
Diverting stoma-related evisceration is an exceptional complication of a common surgical procedure, relatively undocumented but associated with high morbidity and mortality in spite of immediate surgery.A number of issues related to the topic (including those not discussed in previous reviews) were analyzed to highlight their clinical relevance for surgical practice.Some (e.g., age and gender, malignancy, emergency surgery, type of stoma, intended stoma creation, and time from surgery to evisceration and visceral content) were irrelevant in this review.
Parastomal and transstomal eviscerations are distinct entities.Etiology includes surgical failure, trauma, and spontaneous necrosis.A temporary stoma is a potential risk factor for early evisceration and also for late evisceration (e.g., long-standing temporary ostomy), suggesting the utility of early takedown or conversion to a permanent stoma.Parastomal hernia and/or prolapse were specific predisposing factors; early surgical treatment is recommended.Unlike common incisional evisceration, stoma evisceration is characterized by variability in selecting the proper surgical options.Three different types of surgical approach were practiced; a local access (avoiding laparotomy) was used in 13/28 cases (46.42%).There were seven options for surgical stoma treatment; the initial site of the stoma was preserved in 22/28 case reports (78.57). .