ABSTRACT

Stoma formation, be it ileostomy or colostomy, is a well-known surgical procedure done in

various elective and emergency surgeries. These routinely placed diversions stomas require
elective closure once the primary pathology has been dealt with. CASE: A 33 year old
woman who presented with perforation peritonitis following a previous LSCS (lower
segment caesarean section) underwent limited right hemicolectomy with end ileostomy and
transverse colon as DMF (distal mucus fistula). The ileostomy retracted slowly over a period
of time followed by complete internalization and closure without any surgical intervention.
This phenomenon is very rare and without any known etiology.

Keywords: ileostomy, stoma closure

INRODUCTION

Whether following elective or emergency gastrointestinal surgery, diversion is generally

recommended away from fresh anastomoses or primary repair of perforation which yields
better patient recovery. Ileostomies are preferred over colostomies in such cases, when
possible, due to better rates of reversal1, and are common means of anastomotic protection
after excision of distal colon. Other indications include relief of intestinal obstruction and
control of bacterial contamination in cases of peritonitis or non-healing sacral wounds in the
incontinent patient.2 Early stoma reversal, within 10 days of primary surgery, have shown
good results pertaining to some intestinal pathologies.3 Contrary to pathologic
enterocutaneous fistulae (ECF), which often close spontaneously following conservative
management,5 diverting stoma always require additional surgery to close, with only 4
exceptions reported in the literature to date.6,7 The etiology behind this phenomenon is still
unknown and not understood, as well as no common patient factors have been found. Our
experience with one such patient further demonstrates the potential for the human body to
heal itself irrespective of primary pathology or patient factor. Our objective behind this case
report is to put light on the clinical progress of spontaneous closure of stoma.

CASE REPORT

A 33 year old female, gravid at 39+3 weeks presented in emergency labour room with per
vaginal leak and uncontrolled hyperthyroidism. The patient was taken up for LSCS in view of
above said indications. LSCS with bilateral tubal ligation was done with a live baby delivery.
Post operatively, patient complained of abdominal distension for which general surgery
consultation was taken. On abdominal examination, it was distended and bowel sounds
were absent. Per rectal examination of the patient showed ballooning with fecal staining.

Patient was planned for CECT Abdomen which suggested of small and large bowel dilatation
with no specific transition point. Based on clinical findings and CECT correlation plan for
surgery was made. Patient underwent exploratory laparotomy.
Intra operatively there was a perforation in ascending colon with gangrenous and pre
gangrenous patches in ascending colon and caecum.

EL with limited right hemicolectomy with end ileostomy and DMF of transverse colon with
PL and PD was done.

Patient stoma was functional on POD (post-op day) 2 and she had an uneventful stay in the
hospital under General surgery department. She was discharged on POD 10 with functional
stoma and stable vitals. She was advised follow up in OPD. During the course of follow up,
her stoma started retracting progressively. Stoma retracted completely after 3 months of
surgery though it was functional without any signs of peritonitis. She was planned for
conservative management and kept on follow up. Gradually, the stoma output started
decreasing and she started passing stool and flatus via anus. She was continuously
monitored over teleconsultation during COVID-19 time after OPDs were closed. Over the
course of next 8 months her stoma closed spontaneously with complete epithelisation of
the skin over it. On recent visit, midline was healthy, healthy scar was present at the stoma
and drain site. She was taking a normal diet and passing stool and flatus via anus.

Repeat CECT was done to check for any anomaly and patency of the bowel. The CECT
revealed anastomosed distal ileum to colon with no active leakage of the oral contrast from
previous stoma site.

Figure 1: CECT slice of the patient showing scar site and bowel loops in the subcutaneous
plane.
Figure 2: Healed RBC site post spontaneous reversal.

Discussion

Spontaneous resolution of ileostomy is a very rare occurrence. The fact that the etiology is
unknown has gathered interest of surgeons in this phenomenon. Throughout the history of
surgical text, ileostomies have been compared to iatrogenic enterocutaneus fistulas. The
initial step of resolution is the retraction of stoma as evident by Salvadena8 in his literature.
The study has shown the incidence of retraction decreases with time, which was 8% by day
10, 7% by 3 month and 1% by 1 year. Among the stoma complications, retraction occurs in 0
to 40% of cases.8 The factor behind the retraction of stoma can be excessive tension over to
gut or its mesentery. This tension may be due to tethering of the mesentery or insufficient
mobilization of bowel or sites and the types of stomas. Other factors such as high Body
Mass Index (BMI), steroid use, malnutrition, diabetes and smoking have also been
implicated for the retraction of stomas. The spontaneous closure of a stoma can be
considered as the final outcome of a gradually progressive stoma retraction. 9 In our case,
the retraction started around 1 month and was not associated with peritonitis. The patient
was passing stools and flatus per anus. Therefore, an approach of watchful waiting was
adopted and revision surgery was postponed. However, factors pertaining to this particular
case which led to spontaneous closure of stoma remain undiscovered. The possibility of
entero-enteric or entero-colic fistula bypassing ileostomy leading to spontaneous closure
was made in some reported cases but needs additional investigations like CECT abdomen or
other contrast studies to support this.4

Approximately 30% of patients develop incisional hernia requiring repair after surgical
stoma closure. Owing to this fact, this incidence may even increase in case of spontaneous
closure of stoma, where the defect of the abdominal fascia is open and thus may need
regular follow up.10

Conclusion

Owing to its rare occurrence, exact pathophysiology of spontaneous closure of ileostomy is

still inconclusive and debatable. This needs a considerable number of cases and work before
coming to any conclusion. Whether we may want to call it a rare ‘complication’ or a ‘boon’,
ultimately patient is the real beneficiary.

Conflicts of interest
There are no conflicts of interest.

Consent
Written informed consent was obtained from the patient for publication of this case report
and accompanying images. A copy of the written consent is available for review by the
Editor-in-Chief of this journal.

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