Background
The exteriorization of the large bowel (colostomy) through the anterior abdominal wall is performed to manage malignant or benign gastrointestinal conditions on elective or emergency procedures [1]. The stoma will be closed through surgery if the indications have been resolved and the patient’s complaints have improved. Spontaneous closure of the stoma is very rare [2]. Here is an interesting case of spontaneous stoma closure.
Case Presentation
A 62-year-old male with a malignant rectal tumor was admitted to the emergency ward from another hospital with a history of iatrogenic injury post-colonoscopy. He complained of worsening diarrhea and abdominal pain over the last three months. He also experienced weight loss and decreased appetite. Based on physical examination, the abdomen looks distended with tenderness all over the abdominal area. There was abdominal wall rigidity with musculature and guarding signs. From percussion, we found hyper tympany and no liver dullness with minimal bowel sound. We found pneumoperitoneum and focal ileus in small bowels from the abdominal radiograph. Thus, laparotomy adhesiolysis exteriorization of the sigmoid and transverse colon was performed in December 2022.
There was >50% diameter perforation of the sigmoid and transverse colon. We decided to resect each perforated segment. The white line was freed, and we extruded the perforated part in the lower left and right abdomen. We made a loop colostomy of the transverse colon at the lower right abdomen and sigmoid at the left (Figure 1). Each stoma was fixated in eight corners and maturated. The patient was discharged on day ten and received follow-up every two months with satisfactory results.
After seven months of routine follow-up and stomal care, there were no complaints, and gastrointestinal function was sufficiently restored. Thus, we scheduled the patient for stomal closure. The patient came to the outpatient department for pre-operative preparation one month later and found a retraction on the right-sided stoma (Figure 2). When the patient came for the surgery, we found a spontaneous stomal closure six weeks after the first retraction was identified. Then, a colonoscopy was ordered to ensure any colitis, or any mass developed. We confirmed the stomal closure with a lopography examination that showed no contrast extravasation along the rectum, sigmoid, descending, and transverse colon.
We identified adhesions between the ileostomy and peritoneum during the other stomal closure procedure. Thus, surgical adhesiolysis and ileum resection were carried out, followed by an end-to-end colo-colic anastomosis with continuous interlocking sutures. The patient was discharged after five days postoperative and was in good condition. We routinely checked up on the patient at the one week, one month, six months, and one year after surgery at the outpatient department. The patient had good gastrointestinal functioning, defecated per rectal, and had regular bowel habits (Figure 3).
Discussion
We conducted an advanced search on case reports of spontaneous stoma closure across several online databases (PubMed, Cochrane, EBSCO, ClinicalKey, and Scopus) and found only nine published cases of spontaneous stoma closure (5 ileostomies and 4 colostomies) (Table 1) [2–9]. Each case had its indications for stoma creation, such as colon malignancies, perforations, trauma, and abdominal infections in a varied age group (15-67 years). Although stoma is a standard procedure, understanding spontaneous stoma closure remains scarce, and the factors influencing it are unknown. Spontaneous closure of a stoma could become problematic when the purpose of it has not been achieved [8]. Also, spontaneous closure can lead to obstructions caused by ventral herniation of the old stoma site and colonic mucosa adhesions [7,9]. Stoma procedure has the risk of postoperative complications such as strangulation, obstruction, stenosis, and mucocutaneous fistula. Late complications (>1 month) such as stoma retraction, para-stomal hernia, and skin issues may occur [4]. Based on the known pathophysiology of spontaneous stoma closure, this condition can be categorized as one of the complications of the stoma procedure.
On the other hand, if the function and purpose of stoma placement have been achieved, spontaneous closure can benefit the patient. In this case, we reported spontaneous stoma closure occurred 40 weeks after the patient underwent the procedure due to transverse and sigmoid colon perforation. The stoma function, colon recovery post-resection, and anastomosis were achieved during that period, thus eliminating the need for stoma repair. We conducted endoscopic and lopography examinations to rule out any abnormalities or complications (ventral herniation, obstruction, and mucocutaneous fistula) due to spontaneous stoma closure. All examinations found no abnormalities, and GI function was running well. Therefore, in cases like this, the phenomenon benefits the patient by eliminating the need for surgical stoma closure procedures. Avoiding unnecessary surgical procedures equates to protecting the patient from the risk of postoperative morbidity [10]. Such benefits have also been found in six other cases where spontaneous stoma closure occurred after the purpose of stoma formation was achieved.
| AUTHOR, COUNTRY (YEAR) | AGE, GENDER | TYPE OF STOMA | RISK FACTORS | OBSTRUCTING DISTAL LESION (INTERVENTION*) | TIME FOR STOMA CLOSURE | FOLLOW-UP (PERIOD) |
| Albandar, SAU. (2024) [6] | 67, F | Loop Ileostomy | Chemoradiotherapy Self-manipulation (pushing stoma inside) after 12 weeks Retracted stoma (gradual decreased of stoma output, weeks 20) | No Diagnostic laparoscopy: a complete closed stoma | 24 weeks complete closure of the stoma and epithelialization | N/A |
| Aghahowa, Nigeria (2023) [5] | 22, M | Transverse loop colostomy | Surgical site infection Retracted stoma, day 6 (Well function) | No | 6 weeks complete closure of the stoma and epithelialization | No complaint (6 months) |
| Saxena, India (2022) [3] | 18, M | Loop ileostomy | Wound dehiscence due to SSI History of the stoma suture falling out on the 12th postoperative day stoma retraction (gradual decreased of stoma output, 1st month) | No | 16 weeks complete closure of the stoma | N/A |
| Thota et al., India (2022) [7] | 15, M | Sigmoid loop colostomy | None | Yes*, after 27 years Strangulated ventral hernia (at the level of the skin) laparoscopic segmental sigmoid colectomy with a mesh hernioplasty | 8 weeks post surgery | No complaint (6 months) |
| Jin-Jiun, Malaysia (2021) [9] | 66, F | Sigmoid loop colostomy | None | Yes*, Performed transverse loop colostomy | 35 weeks complete closure of the stoma and epithelialization | N/A |
| Alyami et al., France (2016) [8] | 65, F | Loop Ileostomy | Adjuvant chemotherapy | Yes*, Performed refistulization | 10 weeks complete epithelialized (1st) 8 weeks complete closure of the stoma (2nd) | N/A |
| Pandit, India (2016) [2] | 64, M | Sigmoid Loop Colostomy | Retracted stoma (Well function) | No | 11 weeks complete closure of the stoma and complete epithelialization | No complaint (12 months) |
| Pandit, India (2016) [2] | 45, M | Loop Ileostomy | Adjuvant chemoradiotherapy | No | 6 weeks complete retraction 13 weeks complete epithelialization | No complaint (6 months) |
| Saxena, India (2015) [4] | 26, F | Loop Ileostomy | Anti-TB therapy Surgical site invection Retracted stomal (Well function) | No | 24 weeks complete closudre of the stoma 32 weeks complete epithelialization | N/A |
Principally, a stoma is an intentionally created mucocutaneous fistula to achieve the expected function through a surgical procedure. When the goal of healing the anastomosis or reconstruction post-perforation of the intestine has been achieved, the stoma will be reversed through surgery. However, in that period, the stoma’s patency must be maintained to prevent retraction or necrosis of the stoma that will disrupt its function. Most (up to 92%) pathological enterocutaneous fistula management can be handled conservatively, where the tunnel can close spontaneously [11]. The concept of mucocutaneous fistula spontaneous healing can apply to spontaneous stoma closure. Several factors hinder the spontaneous healing of a mucocutaneous fistula, namely FRIEND (foreign body, radiation, infection, epithelialization, neoplasm, and distal obstruction), high output fistula (>500 ml/24 hours), involvement >50% of the mucosa, and a fistula tract length of less than 2.5 cm [12]. As an iatrogenic mucocutaneous fistula, spontaneous healing of the fistula will occur when none of the above factors are found in a stoma.
Based on the stoma creation procedure, there is a stomal maturation step to prevent retraction that initiates spontaneous mucocutaneous healing. However, 1.4%-9% of stomas are reported to retract for several reasons [13]. In patients with nutritional disorders (malnourished, obese, and immunocompromised), there will be impaired wound healing processes that cause unachieved stomal maturation function. Meanwhile, in some cases where the mobilization of the intestine made into a stoma is inadequate or there is tension from the mesentery, stomal retraction can also occur due to the separation of the stoma with mucocutaneous fascial planes. This mechanism is the initial phase of spontaneous stoma closure [13].
Conclusion
Spontaneous stoma closure can be considered the outcome of progressive stoma retraction followed by healing of the mucocutaneous fistula. In this case, we report the benefit of spontaneous stomal closure, no complications were found from stoma closure, and the primary goal of stoma placement was achieved. Apart from that, up to a follow-up period of 18 months, the patient was able to defecate generally through the anus and had no complaints. Management of spontaneous stoma closure can be done conservatively after carrying out a comprehensive examination to rule out possible complications. We report the usefulness of endoscopy and lopography in achieving these goals.