Figure 6.30. Parastomal hernias. (A-C) Contrast studies on three different patient demonstrating bowel extending out from the abdominal cavity into parastomal hernias. (D) CT scan through the upper pelvis demonstrating herniated small-bowel adjacent to the patient's colostomy.
Figure 6.31. Surgical error: opening the wrong (distal) end of a divided colostomy. Large-bowel obstruction resulted when the distal end of the colostomy rather than the proximal limb was opened.

revision if they are associated with a permanent colostomy. The long-term incidence of parasternal hernia after colostomy is 37% [47]. Most hernias develop by 2 years after surgery, although some may not appear until 20 to 30 years later. The incidence increases in the elderly and in those with other abdominal wall hernias, obesity, malnourish-ment, steroid use, chronic cough, and wound sepsis.

Diversion colitis is a nonspecific colitis that has been shown to be present on biopsy in the majority of postcolostomy patients, although it is generally an asymptomatic condition [48]. Symptomatic patients may develop crampy abdominal pain, mucous discharge, and rectal bleeding, which may occur at any time after surgery. The etiology of diversion colitis is unclear; it is hypothesized to be due either to bacterial overgrowth of normal flora or pathogenic organisms or to a nutritional deficiency of short-chain fatty acids in the bowel lumen [49]. A spectrum of radiographic findings has been reported, including ulceration, a nodular mucosal pattern, pseudopolyposis, and nondisten-sibility [50]. Nondistensibility, also termed disuse microcolon, is probably due to chronic lack of distention (Fig. 6.32). All findings resolve with closure of the colostomy and reconstitution of the fecal stream.

Figure 6.32. Disuse microcolon. (A, B) Colostomy studies on two different patients showing distal limbs of the colon markedly narrowed as a result of disuse microcolon.

Complications of colostomy closure include anastomotic stricture and leakage at the anastomotic site, in addition to enterocutaneous fistula, obstruction, and infection [51]. Dehiscence of the anastomosis may be more likely if an unrecognized distal stricture is present. In some cases after colostomy closure, a deformity may be identified in the colon at the site of the previous colostomy. This may appear as an annular or asymmetric short segment area of narrowing with intact mucosa.

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