Diverting ileostomy for hemorrhagic proctitis after cardiovascular surgery in a patient with prior radiotherapy: a case report
Kenichiro Yambe, Shingo Tsujinaka, Tomoya Miura, Shunsuke Kawamoto, Chikashi Shibata, Yu KatayoseIntroduction and importance:
Hemorrhagic proctitis after cardiovascular surgery is rare, and no established strategy exists when bleeding is refractory but the rectal injury appears reversible.
Presentation of case:
A 74-year-old man with prior pelvic radiotherapy for prostate cancer underwent distal pancreatectomy for an intraductal papillary mucinous neoplasm. On postoperative day (POD) 2, he developed Stanford type A acute aortic dissection with cardiac tamponade and underwent emergency total arch replacement with open stent-graft insertion. Abdominal pain developed on POD 7, followed by massive hematochezia on POD 12. Colonoscopy revealed a circumferential rectal ulcer with diffuse mucosal oozing, and biopsy demonstrated mucosal necrosis without malignancy or viral inclusions. Endoscopy and computed tomography, a normal lactate level (1.2 mmol/L), and the absence of peritoneal signs suggested nontransmural, potentially reversible injury. Bleeding persisted despite bowel rest, transfusion, packing, topical thrombin, and endoscopic therapy. Laparoscopic diverting loop ileostomy was performed on POD 17 to control bleeding while preserving the rectum. The ulcer improved, and he was transferred for rehabilitation on POD 47. Complete ulcer healing was confirmed, and the ileostomy was closed 2 years later. At the latest follow-up, he remained ambulatory without recurrent proctitis, tumor recurrence, or cardiovascular events.
Clinical discussion:
This case combines acute aortic dissection immediately after abdominal surgery, a hemorrhagic rectal ulcer possibly reflecting perioperative hypoperfusion superimposed on radiation-related vulnerability rather than watershed ischemia, and rectal preservation by diversion rather than embolization, colostomy, or resection.
Conclusion:
A diverting ileostomy may be a bowel-preserving salvage option for refractory hemorrhagic proctitis when the rectal injury appears reversible.