V69 - Robotic Partial Colectomy and Closure of Enterocutaneous Fistula in the Setting of Crohn’s Disease

CME Eligible

Purpose/Background: A video presentation was created to demonstrate an unusual case of fistulizing Crohn's disease. The patient is a 74-year-old female smoker with a long-standing history of Crohn's disease on medical management consisting of infliximab and azathioprine who presented with enterocutaneous, colo-colonic, and rectovaginal fistulas. The patient initially presented to the ER in September 2024 with sepsis and left hip pain. She was found to have a left lateral gluteal abscess and underwent incision and drainage; feculent fluid was encountered, suggestive of an enterocutaneous fistula, which was confirmed on imaging. The patient clinically improved but continued to have feculent drainage from the gluteal wound. She underwent a colonoscopy in March of 2025 and was found to have stenosis within the transverse colon with an adjacent fistula opening. She was additionally found to have a distal rectovaginal fistula during an exam under anesthesia. She was evaluated by the Colorectal Surgery team at the University of Florida - Jacksonville and was deemed an appropriate candidate for robotic partial colectomy with closure of enterocutaneous fistula.

Methods/Interventions: The patient underwent a robotic partial colectomy with low pelvic anastomosis, closure of enterocutaneous fistula, and diverting loop ileostomy. The enterocutaneous fistula was encountered between the mid-descending colon and the lateral abdominal wall. The fistula tract was transected from the abdominal wall. A colo-colonic fistula was identified between the proximal descending and distal transverse colon. Dense adhesions were noted in the pelvis between the uterus and appendiceal tip, which was also concerning for a fistulous connection and an appendectomy was performed. A partial colectomy was performed from the mid-transverse colon to the upper rectum, including the two areas of colonic fistulization. The specimen was extracted through a Pfannenstiel incision and a circular stapler was used to create an end-to-end colorectal anastomosis with 2 complete anastomotic donuts. Flexible sigmoidoscopy was utilized to perform a leak test, which was negative. Finally, a diverting loop ileostomy was matured in the RUQ.

Results/Outcomes: The patient did well in the immediate postoperative course. She has had complete resolution of the left gluteal wound and remains asymptomatic from the distal rectovaginal fistula. She completed a barium enema study in August 2025, which was negative for leakage of contrast at the colorectal anastomosis. She is currently scheduled for closure of the rectovaginal fistula via a transperineal approach in November 2025, followed by eventual reversal of the ileostomy.

Conclusion/Discussion: Crohn's disease is primarily managed with medical therapy; however, the role of surgery becomes more significant with the involvement of fistulas or stenosis. This patient, despite being compliant with medical therapy, was found to have a colo-colonic, enterocutaneous, and rectovaginal fistula, as well as two areas of significant colonic stenosis. Given the severity of her disease, a multi-stage approach was taken beginning with robotic enterocutaneous and colo-cutaneous fistula takedown and partial colectomy, followed by transperineal rectovaginal fistula takedown at a later date. This video demonstrates an interesting case of fistulizing Crohn's disease and provides an insight into surgical management utilizing minimally invasive techniques.