Surgical management of giant parastomal and incisional hernias in a patient with Crohn’s disease who underwent emergency surgery: a case report

Resumo

Crohn’s disease (CD) is a chronic intestinal disorder of multifactorial etiology that causes segmental, asymmetric, transmural inflammation and may affect the entire gastrointestinal tract. Medical treatment is the first-line approach; however, many patients with CD require surgery at some point, whether urgent, emergent, or elective depending on the case, often involving intestinal resections and fecal diversion. Ostomies account for a large proportion of postoperative complications in these cases, including parastomal and incisional hernias, for which obesity and corticosteroid use are among the risk factors. CASE REPORT: A 37-year-old woman with severe ileocolonic Crohn’s disease experienced treatment failure after multiple biologic agents and corticosteroids. Following an episode of perforated acute abdomen, she underwent Hartmann rectosigmoidectomy and subsequently developed giant parastomal and incisional hernias, persistent rectal symptoms, and stenosis with refractory bleeding. Because inflammation persisted in the rectal stump and could not be clinically controlled, proctectomy with preservation of the anal stump and maintenance of a permanent colostomy was proposed and performed. The hernias were also repaired with onlay mesh. The postoperative course was complicated by infections and localized skin ischemia, followed by favorable clinical recovery. DISCUSSION: This case illustrates the challenges of surgically managing complications in patients with severe refractory CD. Emergency surgery in patients with CD often requires resection of intestinal segments and creation of temporary ostomies, which promotes the development of incisional and parastomal hernias and may leave ongoing inflammatory activity in the preserved bowel. In these cases, rectal amputation with permanent colostomy, although consequential, may be the most definitive alternative. Treatment success depends on patient adherence, careful selection of the surgical technique, and appropriate postoperative management, with the goal of improving quality of life.