Mirza, Bishop-koop stoma prolapse I M A G E S OPEN ACCESS An Interesting Case of Bishop-Koop Stoma Prolapse Bilal Mirza A 4-month-old male baby presented with enterostomy prolapse. Past medical history revealed two operations elsewhere during third week of life. The first operation was performed for pneumoperitoneum due to necrotizing enterocolitis (NEC) of distal jejunum. The involved portion of small intestine was resected and a primary end-to-end jejuno-ileal anastomosis performed. The patient had to be re-explored due to anastomotic disruption and then an end-to-side jejuno-ileal anastomosis with Bishop-Koop ileostomy fashioned [Image 1]. The patient remained well for three months and passed stool per rectally and occasionally from stoma. The patient on arrival was vitally stable with normal labs. The general physical and systemic examinations were unremarkable besides a prolapsed enterostomy. Patient was anesthetized. The prolapse was inverted Y shaped, Image 1: A line diagram illustrating end-to-side jejuno-ileal anastomosis with Bishop-Koop ileostomy. with the first limb the original Bishop Koop prolapse of ileal mucosa; whereas the second limb was the prolapsed The basic purpose of a Bishop-Koop enterostomy, in mucosa of jejunum through end-to-side jejuno-ileal patients of meconium ileus, is to provide a vent for and anastomosis. The mucosal anastomotic line was visible irrigation of the distal bowel having thick inspissated at the proximal part of that limb [Image 2]. Initially the meconium. In other pediatric surgical conditions, it is jejunal mucosa was returned back to the main stump being used as a safety guard for intestinal anastomosis followed by reduction of ileal mucosa. U-stitches were where a diversion enterostomy is not desirable like stoma applied to hold the mucosa in place [Image 3]. Patient in very proximal part of intestine and in conditions where was discharged after 2 days and appointment given for intestinal length is short [3]. reversal of stoma. Enterostomies are associated with many problems such DISCUSSION as; stoma retraction, prolapse, narrowing, peri-stomal hernia/evisceration of intestine, bleeding, skin Enterostomies are commonly made for various pediatric excoriations, wound dehiscence, and so on. In one study surgical conditions. Different types of enterostomies enterostomy related complications were about 68% in include loop, divided/double barrel, Hartmann, santulli, children of different age groups. The incidence of Bishop-Koop etc. These may be classified as temporary prolapse in pediatric patients ranges between 3% and or permanent depending upon the underlying condition 25%. The incidence of stoma prolapse is higher with loop for which they have been formed [1,2]. enterostomy and minimum with divided enterostomy. The Bishop-Koop enterostomy was originally devised for the highest prolapse (25%) is observed in the distal stoma of patients with meconium ileus, but, it has also been used transverse loop colostomy [4]. for other pediatric surgical conditions such as intestinal In temporary ostomies, the stoma prolapse is usually atresia and NEC. Forming a Bishop Koop stoma involves managed conservatively, however in cases where the anastomosis of end of proximal bowel to the side of distal stoma is desired for a longer period or in case of bowel and exteriorizing the end of distal bowel as permanent enterostomy, a revision of the stoma has been chimney -enterostomy [Image 1] [2,3]. advocated [5,6]. APSP J Case Rep 2010; 1: 24 1 Mirza, Bishop-koop stoma prolapse prolapse of not only intestine but also adjacent anastomosis. REFERENCES 1. DelPino A, Citron JR, Orsay CP. Enterostomal complications: are emergently created enterostomas at greater risk? Am Surg 1997; 63:653-6. 2. Gauderer MWL. Stomas of the small and large intestine. In: Grosfeld JL O’Neill JA Jr, Coran AG, Fonkalsrud EW, Caldamone AA. editors. Pediatric surgery. 6 th ed. Chicago: Mosby Elsevier; 2006. p. 1479-91. 3. Ziegler MM. Meconium Ileus. In: Grosfeld JL O’Neill JA Jr, Coran AG, Fonkalsrud EW, Caldamone AA. editors. Image 2: The Prolapse of ileal and jejunal mucosa along with Pediatric surgery. 6 th ed. Chicago: Mosby Elsevier; 2006. anastomotic line of end-to-side jejuno-ileal anastomosis is evident. p. 1289-303. 4. Sheikh MA, Akhtar J, Ahmed S. Complications/problems of colostomy in infants and children. J Coll Physicians Surg Pak 2006; 16: 509-13. 5. Duchesne JC, Wang YZ, Weintraub SL. Stoma complications: a multivariate analysis. Am Surg 2002;68: 961-86. 6. Shellito PC. Complications of abdominal stoma surgery. Dis Colon Rectum 1998;41:1562-72. Bilal Mirza Image 3: After reduction of prolapsed enterostomy. Address: Department of Paediatric Surgery, The Children’s Hospital & The Institute of Child Health Lahore, In a perusal of English literature through “Pubmed Pakistan. website” using keywords “Bishop Koop” and “prolapse” Email: [email protected] no relevant paper was found. The prolapse of Bishop- Received on: 05-08-2010 Accepted on: 25-08-2010 Koop stoma is therefore a rare event. This may be due to a very small caliber stoma in cases with meconium ileus http://www.apspjcaserep.com © 2010 Mirza where it was primarily recommended; however, in our This work is licensed under a Creative Commons case, NEC was the primary diagnosis thus caliber of Attribution 3.0 Unported License Bishop-Koop stoma was not small. This contributed to the How to cite Mirza B. An interesting case of Bishop-Koop stoma prolapse. APSP J Case Rep 2010; 1: 24 APSP J Case Rep 2010; 1: 24 2 .