Reversal of a Diversion Loop Ileostomy in a Patient with a Prior Gracilis Transposition Flap for Rectovaginal Fistula Due to Crohn’s Disease
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This case takes an in-depth look at the reversal of a diverting loop ileostomy performed for a patient who had received a prior gracilis transposition flap for a rectovaginal fistula due to Crohn’s disease. This video provides a detailed step-by-step demonstration of the reversal of this diverting loop ileostomy. It serves as an excellent educational resource for surgeons learning how to close loop ileostomies.
Ileostomies are artificial bowel openings of the ileum to the abdominal wall that can be either temporary or permanent.1 Temporary ileostomies are usually constructed to divert stool away from a healing anastomosis or from a fistula repair, as in our patient in this video who suffered from a rectovaginal fistula. The treatment chosen for this patient was a gracilis flap. This technique utilizes the gracilis muscle’s reliable blood supply and minimal donor site morbidity to provide healthy tissue for fistula repair. Gracilis flap repair for Crohn’s disease-related rectovaginal fistulas has shown promising results, making it a valuable surgical option.2
Gracilis transposition is usually performed as a two- or three-stage procedure. Before flap transposition, a diverting loop ileostomy is created to allow the flap to heal without stool passing through the diseased area. Crohn’s disease did not influence the decision for creating and later reversing the ileostomy as the patient had isolated perianal Crohn’s disease with no small bowel involvement.
Loop ileostomies, although reducing the catastrophic effects of a potential anastomotic leak, are not without complications: risk of dehydration from high stoma output, parastomal hernia, stoma prolapse, failure to thrive, acute kidney injury, outlet obstruction, diversion colitis, and impact on quality of life.2-6
Therefore, whenever feasible, physiologic continuation of the alimentary tract should be restored.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
Citations
- Keane C, Sharma P, Yuan L, Bissett I, O'Grady G. Impact of temporary ileostomy on long-term quality of life and bowel function: a systematic review and meta-analysis. ANZ J Surg. 2020 May;90(5):687-692. doi:10.1111/ans.15552.
- Garoufalia Z, Gefen R, Emile SH, et al. Gracilis muscle interposition for complex perineal fistulas: a systematic review and meta-analysis of the literature. Colorectal Dis. 2023 Apr;25(4):549-561. doi:10.1111/codi.16427.
- Mathew AP, M S, K C, Muralee M, Wagh M. Morbidity of temporary loop ileostomy in patients with colorectal cancer. Indian J Surg Oncol. 2022 Sep;13(3):468-473. doi:10.1007/s13193-022-01501-1.
- Gessler B, Haglind E, Angenete E. A temporary loop ileostomy affects renal function. Int J Colorectal Dis. 2014 Sep;29(9):1131-5. doi:10.1007/s00384-014-1949-0.
- Chow A, Tilney HS, Paraskeva P, Jeyarajah S, Zacharakis E, Purkayastha S. The morbidity surrounding reversal of defunctioning ileostomies: a systematic review of 48 studies including 6,107 cases. Int J Colorectal Dis. 2009 Jun;24(6):711-23. doi:10.1007/s00384-009-0660-z.
- Matsumoto Y, Aisu N, Kajitani R, Nagano H, Yoshimatsu G, Hasegawa S. Complications associated with loop ileostomy: analysis of risk factors. Tech Coloproctol. 2024 May 27;28(1):60. doi:10.1007/s10151-024-02926-2.
Cite this article
Garoufalia Z, Wexner SD. Reversal of a diversion loop ileostomy in a patient with a prior gracilis transposition flap for rectovaginal fistula due to Crohn’s disease. J Med Insight. 2025;2025(471). doi:10.24296/jomi/471.
