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Treatment of intractable enterocutaneous fistula with an island pedicled anterolateral thigh flap in Crohn's disease – case report
Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, 1055e1057
CASE REPORT
Treatment of intractable enterocutaneous fistula with an island pedicled anterolateral thigh flap in Crohn’s disease e case report Shih-Hsin Chang a,c,*, Tze-Chi Hsu b, Huang-Chuan Su a, Kwang-Yi Tung a, Hung-Tao Hsiao a a Department of Plastic and Reconstructive Surgery, Mackay Memorial Hospital, No 92, sec2, ChungSan, North Road, Taipei, Taiwan b Department of Colorectal Surgery, Mackay Memorial Hospital, Taipei, Taiwan c Mackay Medicine, Nursing and Management College, Taipei, Taiwan
Received 9 January 2009; accepted 22 October 2009
KEYWORDS Enterocutaneous Fistula; Crohn’s Disease; Island Pedicled Anterolateral Thigh Flap
Summary Attempts to treat intractable enterocutaneous fistulae secondary to Crohn’s disease are challenging and have been associated with long delays. An island pedicled anterolateral thigh (ALT) flap has been shown to achieve adequate coverage of abdominal wall reconstruction. In this case, with the assistance of a well-vascularised flap and adequate medical supportive managements, the intractable enterocutaneous fistula was closed; it then healed progressively. ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Enterocutaneous fistulae in Crohn’s disease can be severely debilitating, causing metabolic derangements, dehydration and extensive skin damage. The management of these fistulae remains challenging, especially when they lead to full-thickness defects of the abdominal wall, which are notoriously difficult to reconstruct.1e3 Reconstruction has been attempted with a variety of local or distant flaps from
the thigh or back, with or without incorporation of prosthetic materials, according to the size and location of the defects.4 In this report, we present a case of Crohn’s disease with intractable enterocutaneous fistula, which was treated with an island pedicled anterolateral thigh fasciocutaneous flap, to cover a midline abdominal wall defect.
Case report * Corresponding author. Department of Plastic and Reconstructive Surgery, Mackay Memorial Hospital, No 92, sec2, ChungSan, North Road, Taipei, Taiwan. Tel.: þ886 2 25433535. E-mail address: [email protected] (S.-H. Chang).
A 51-year-old woman had been diagnosed with Crohn’s disease 8 years previously. She had relapsing regional enteritis, for which she had undergone partial colectomy
1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2009.10.024
1056
S.-H. Chang et al.
with ileocolic anastomosis, first in July 2005 and again in November 2006. Unfortunately, she developed an intraabdominal abscess complicated by an enterocutaneous fistula. The high output of secretions from the fistula eroded the surrounding tissue, resulting in dehiscence of the abdominal wall. Several attempts at resection of the fistula and closure of the abdominal wall defect had failed. There was extensive scarring of the abdominal wall involving both sides of the defect from the repeated use of retention sutures. Months after the last attempt at direct closure, the patient was referred to our department. At that time, there was a full-thickness abdominal wall defect with exposure of the visceral organs (Figure 1).
Operative technique Colorectal surgeons first closed the enterocutaneous fistula, after which we undertook reconstruction of the abdominal wall defect. Resection of unhealthy or scarred tissue left a full-thickness defect of about 23 7 cm (Figure 2). We designed a left anterolateral thigh fasciocutaneous flap to cover the defect. Three skin perforators were mapped by ultrasound Doppler, and a flap of an appropriate shape and size (23 7 cm) was drawn to include the marked perforators (Figure 2). A medial incision was made and the flap perforators were identified at the fascial level. To gain a longer pedicle, a sizeable perforator 5 cm distal to the midpoint was chosen. The perforator was musculocutaneous and thus required intramuscular dissection. Because the patient had been on long-term corticosteroid treatment, the vessels were fragile, and so, we performed micro-dissection under a loupe. The vascular pedicle was traced to the posterior aspect of the rectus femoris muscle, and then a tunnel was created. The flap was passed through the tunnel beneath the rectus femoris. An extra 2e3 cm of pedicle length was gained by ligating the rectus femoris pedicle.13 The pedicle was then dissected to the origin of the lateral circumflex femoral artery. A wide subcutaneous tunnel was then made to reach the abdominal wall defect. We used an aseptic plastic bag (used in laparoscopy) to protect the flap during transfer and
Figure 1 Extensive Midline abdominal wound dehiscence with visceral organ exposure.
Figure 2 After debridement, the abdominal wall defect size was about 22 6cm range from epigastic area to pubic region. An island pedicled ALT flap about 23 7cm from left thigh was harvested and passed through the subcutaneous tunnel to reach the defect.
to avoid injury to the perforator vessels (Figure 2). The flap was sutured to the defect with 2/0 Polydioxanone (PDS) interrupted sutures for the fasciaesheath repair and 3/ 0 nylon for the skin. The donor site was closed primarily. The wound healed uneventfully except for a small enterocutaneous fistula in the right lower part of the flap. Medical management, including maintenance of fluid and electrolyte balance, corticosteroids and total parenteral nutrition, were used for 1 month postoperatively. The postoperative course was complicated by a catheter infection leading to sepsis, which was successfully treated with intravenous antibiotics. With continued appropriate medical management, the fistula gradually diminished in size and finally healed completely 2 months after the surgery (Figure 3). The patient has since had intermittent episodes of adhesion ileus, but there had been no recurrence of the fistula on follow-up 12 months postoperatively.
Figure 3 Six months followed-up. The enterocutaneous fistula was healed.
Fistula with an island pedicled anterolateral thigh flap in Crohn’s disease
Discussion Crohn’s disease is an immune-mediated illness causing inflammation of the gastrointestinal tract and leading to significant complications such as fistulae, abscesses and phlegmons secondary to microperforation of the intestine. Most cutaneous fistulae occur after surgery for the disease, either from an anastomotic leak or from an unnoticed inadvertent intestinal injury during the operation. Such cutaneous fistulae can be difficult to treat and may cause severe debilitation. The principles of management of enterocutaneous fistula include the treatment of sepsis, nutritional and metabolic support, skin care and surgical intervention to relieve distal obstruction.1e3 The reconstruction of composite abdominal defects that include the skin, rectus abdominis muscle and fascia sheath with consequent exposure of the visceral organs exposure is extremely complex. Methods advanced to solve this problem have included use of prosthetic mesh, free fascial grafts, the components separation technique, tissue expansion, local flaps and free flaps. Prosthetic mesh poses a high risk for infection and is relatively contraindicated in contaminated fields. The components separation technique is not effective in cases where there is loss of the rectus abdominis muscles and fascia; it is only suitable for small central abdominal defects.6 Reconstructive surgeons have suggested a variety of flaps to address this problem.4e8 Lesnick closed a one-sided abdominal wall defect by mobilising a pedicled musculofascial flap from the opposite side.8 Song first described the anterolateral thigh flap in 1984, and it has since been used in a wide range of procedures, including reconstruction of the abdominal wall9,10 and for free tissue transfer. Kimata et al.11 and Kuo et al.12 described reconstruction of abdominal composite defects using a free anterolateral thigh flap with and without vascularised fascia lata. Kimata et al.,11 however, stated that island pedicled anterolateral thigh flaps were only adequate for reconstruction of lower abdominal wall defects because the pedicle is too short to reach more superior defects. Spyriounis demonstrated a helpful modification: transposing the flap medial to the vascular pedicle shortens the arc of rotation as it is passed under the rectus femoris muscle before reaching the medial thigh through a subcutaneous tunnel.13 A distal perforator can also help in harvesting a longer pedicle. Yu et al. identified a distal perforator in 62% of 100 cases where an anterolateral thigh flap was elevated.14 In our patient, a sizeable distant perforator was present, which obviated the need for a flap transfer. Using the techniques we have described, the island pedicled anterolateral thigh fasciocutaneous flap can be successfully used for reconstruction of full-thickness supraumbilical abdominal defects. The healing of our patient’s chronic fistula was the result of reconstruction using a wellvascularised flap, followed by meticulous postoperative medical care. In summary, attempts to treat intractable enterocutaneous fistulae secondary to Crohn’s disease are challenging and have been associated with long delays in healing. An island pedicled anterolateral thigh flap has
1057
been shown to achieve adequate coverage for abdominal wall reconstruction. A patient with an intractable enterocutaneous fistula and large abdominal wall defect eventually achieved healing with this flap.
Ethics The study was carried out to a high ethical standard and conformed to the World Medical Association Declaration of Helsinki.
Conflict of interest statement The authors have no conflicts of interest to declare in connection with thisarticle. None of the authors has financial relationship with other people or organisations that would profit from this article.
References 1. Hawker PC, Givel JC, Keighley MRB, et al. Management of enterocutaneous fistulae in Crohn’s disease. Gut 1983;24: 284e7. 2. Pettit SH, Irving MH. The operative management of fistulous Crohn’s disease. Surg. Gynecol. Obstet 1988;167:223. 3. Enker WE, Block GE. The operative treatment of Crohn’s disease complicated by fistulae. Arch. Surg 1969;98:493. 4. Dibbell Jr DG, Mixter RC, Dibbell Sr DG. Abdominal wall reconstruction (the ‘mutton chop’ flap). Plast Reconstr Surg 1991;87:60e5. 5. Watson JS. Reconstruction of the anterior abdominal wall above the umbilicus using a tensor fascia latae myocutaneous island flap. Br J Plast Surg 1983;36:334e6. 6. Ramirez O, Ruas E, Dellon A. Components separation’ method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg 1990;86:519e26. 7. Jacobsen W, Petty P, Bite U, et al. Massive abdominal-wall hernia reconstruction with expanded external/internal oblique and transversalis musculofascia. Plast Reconstr Surg 1997;100: 326e35. 8. Lesnick GJ, Davids AM. Repair of surgical abdominal wall defect with a pedicled musculofascial flap. Ann Plast Surg 1953;137:569e72. 9. Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg 1984;37:149e559. 10. Koshima I, Fukuda H, Yamamoto H, et al. Free anterolateral thigh flaps for reconstruction of head and neck defects. Plast Reconstr Surg 1993;92:421e30. 11. Kimata Y, Uchiyama K, Sekido M, et al. Anterolateral thigh flap for abdominal wall reconstruction. Plast Reconstr Surg 1999; 103:1191e7. 12. Kuo YR, Kuo MH, BarbaraLutz S, et al. One-stage reconstruction of large midline abdominal wall defects using a composite free anterolateral thigh flap with vascularized fascia lata. Ann Surg 2004;239:352e8. 13. Spyriounis PK. The extended approach to the vascular pedicle of the anterolateral thigh perforator flap: anatomical and clinical study. Plast Reconstr Surg 2006;117:997. Discussion 1002e1003. 14. Yu P, Youssef A. Efficacy of the handheld doppler in preoperative identification of the cutaneous perforators in the anterolateral thigh flap. Plast. Reconstr. Surg 2006;118:928e33.
CASE REPORT
Treatment of intractable enterocutaneous fistula with an island pedicled anterolateral thigh flap in Crohn’s disease e case report Shih-Hsin Chang a,c,*, Tze-Chi Hsu b, Huang-Chuan Su a, Kwang-Yi Tung a, Hung-Tao Hsiao a a Department of Plastic and Reconstructive Surgery, Mackay Memorial Hospital, No 92, sec2, ChungSan, North Road, Taipei, Taiwan b Department of Colorectal Surgery, Mackay Memorial Hospital, Taipei, Taiwan c Mackay Medicine, Nursing and Management College, Taipei, Taiwan
Received 9 January 2009; accepted 22 October 2009
KEYWORDS Enterocutaneous Fistula; Crohn’s Disease; Island Pedicled Anterolateral Thigh Flap
Summary Attempts to treat intractable enterocutaneous fistulae secondary to Crohn’s disease are challenging and have been associated with long delays. An island pedicled anterolateral thigh (ALT) flap has been shown to achieve adequate coverage of abdominal wall reconstruction. In this case, with the assistance of a well-vascularised flap and adequate medical supportive managements, the intractable enterocutaneous fistula was closed; it then healed progressively. ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Enterocutaneous fistulae in Crohn’s disease can be severely debilitating, causing metabolic derangements, dehydration and extensive skin damage. The management of these fistulae remains challenging, especially when they lead to full-thickness defects of the abdominal wall, which are notoriously difficult to reconstruct.1e3 Reconstruction has been attempted with a variety of local or distant flaps from
the thigh or back, with or without incorporation of prosthetic materials, according to the size and location of the defects.4 In this report, we present a case of Crohn’s disease with intractable enterocutaneous fistula, which was treated with an island pedicled anterolateral thigh fasciocutaneous flap, to cover a midline abdominal wall defect.
Case report * Corresponding author. Department of Plastic and Reconstructive Surgery, Mackay Memorial Hospital, No 92, sec2, ChungSan, North Road, Taipei, Taiwan. Tel.: þ886 2 25433535. E-mail address: [email protected] (S.-H. Chang).
A 51-year-old woman had been diagnosed with Crohn’s disease 8 years previously. She had relapsing regional enteritis, for which she had undergone partial colectomy
1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2009.10.024
1056
S.-H. Chang et al.
with ileocolic anastomosis, first in July 2005 and again in November 2006. Unfortunately, she developed an intraabdominal abscess complicated by an enterocutaneous fistula. The high output of secretions from the fistula eroded the surrounding tissue, resulting in dehiscence of the abdominal wall. Several attempts at resection of the fistula and closure of the abdominal wall defect had failed. There was extensive scarring of the abdominal wall involving both sides of the defect from the repeated use of retention sutures. Months after the last attempt at direct closure, the patient was referred to our department. At that time, there was a full-thickness abdominal wall defect with exposure of the visceral organs (Figure 1).
Operative technique Colorectal surgeons first closed the enterocutaneous fistula, after which we undertook reconstruction of the abdominal wall defect. Resection of unhealthy or scarred tissue left a full-thickness defect of about 23 7 cm (Figure 2). We designed a left anterolateral thigh fasciocutaneous flap to cover the defect. Three skin perforators were mapped by ultrasound Doppler, and a flap of an appropriate shape and size (23 7 cm) was drawn to include the marked perforators (Figure 2). A medial incision was made and the flap perforators were identified at the fascial level. To gain a longer pedicle, a sizeable perforator 5 cm distal to the midpoint was chosen. The perforator was musculocutaneous and thus required intramuscular dissection. Because the patient had been on long-term corticosteroid treatment, the vessels were fragile, and so, we performed micro-dissection under a loupe. The vascular pedicle was traced to the posterior aspect of the rectus femoris muscle, and then a tunnel was created. The flap was passed through the tunnel beneath the rectus femoris. An extra 2e3 cm of pedicle length was gained by ligating the rectus femoris pedicle.13 The pedicle was then dissected to the origin of the lateral circumflex femoral artery. A wide subcutaneous tunnel was then made to reach the abdominal wall defect. We used an aseptic plastic bag (used in laparoscopy) to protect the flap during transfer and
Figure 1 Extensive Midline abdominal wound dehiscence with visceral organ exposure.
Figure 2 After debridement, the abdominal wall defect size was about 22 6cm range from epigastic area to pubic region. An island pedicled ALT flap about 23 7cm from left thigh was harvested and passed through the subcutaneous tunnel to reach the defect.
to avoid injury to the perforator vessels (Figure 2). The flap was sutured to the defect with 2/0 Polydioxanone (PDS) interrupted sutures for the fasciaesheath repair and 3/ 0 nylon for the skin. The donor site was closed primarily. The wound healed uneventfully except for a small enterocutaneous fistula in the right lower part of the flap. Medical management, including maintenance of fluid and electrolyte balance, corticosteroids and total parenteral nutrition, were used for 1 month postoperatively. The postoperative course was complicated by a catheter infection leading to sepsis, which was successfully treated with intravenous antibiotics. With continued appropriate medical management, the fistula gradually diminished in size and finally healed completely 2 months after the surgery (Figure 3). The patient has since had intermittent episodes of adhesion ileus, but there had been no recurrence of the fistula on follow-up 12 months postoperatively.
Figure 3 Six months followed-up. The enterocutaneous fistula was healed.
Fistula with an island pedicled anterolateral thigh flap in Crohn’s disease
Discussion Crohn’s disease is an immune-mediated illness causing inflammation of the gastrointestinal tract and leading to significant complications such as fistulae, abscesses and phlegmons secondary to microperforation of the intestine. Most cutaneous fistulae occur after surgery for the disease, either from an anastomotic leak or from an unnoticed inadvertent intestinal injury during the operation. Such cutaneous fistulae can be difficult to treat and may cause severe debilitation. The principles of management of enterocutaneous fistula include the treatment of sepsis, nutritional and metabolic support, skin care and surgical intervention to relieve distal obstruction.1e3 The reconstruction of composite abdominal defects that include the skin, rectus abdominis muscle and fascia sheath with consequent exposure of the visceral organs exposure is extremely complex. Methods advanced to solve this problem have included use of prosthetic mesh, free fascial grafts, the components separation technique, tissue expansion, local flaps and free flaps. Prosthetic mesh poses a high risk for infection and is relatively contraindicated in contaminated fields. The components separation technique is not effective in cases where there is loss of the rectus abdominis muscles and fascia; it is only suitable for small central abdominal defects.6 Reconstructive surgeons have suggested a variety of flaps to address this problem.4e8 Lesnick closed a one-sided abdominal wall defect by mobilising a pedicled musculofascial flap from the opposite side.8 Song first described the anterolateral thigh flap in 1984, and it has since been used in a wide range of procedures, including reconstruction of the abdominal wall9,10 and for free tissue transfer. Kimata et al.11 and Kuo et al.12 described reconstruction of abdominal composite defects using a free anterolateral thigh flap with and without vascularised fascia lata. Kimata et al.,11 however, stated that island pedicled anterolateral thigh flaps were only adequate for reconstruction of lower abdominal wall defects because the pedicle is too short to reach more superior defects. Spyriounis demonstrated a helpful modification: transposing the flap medial to the vascular pedicle shortens the arc of rotation as it is passed under the rectus femoris muscle before reaching the medial thigh through a subcutaneous tunnel.13 A distal perforator can also help in harvesting a longer pedicle. Yu et al. identified a distal perforator in 62% of 100 cases where an anterolateral thigh flap was elevated.14 In our patient, a sizeable distant perforator was present, which obviated the need for a flap transfer. Using the techniques we have described, the island pedicled anterolateral thigh fasciocutaneous flap can be successfully used for reconstruction of full-thickness supraumbilical abdominal defects. The healing of our patient’s chronic fistula was the result of reconstruction using a wellvascularised flap, followed by meticulous postoperative medical care. In summary, attempts to treat intractable enterocutaneous fistulae secondary to Crohn’s disease are challenging and have been associated with long delays in healing. An island pedicled anterolateral thigh flap has
1057
been shown to achieve adequate coverage for abdominal wall reconstruction. A patient with an intractable enterocutaneous fistula and large abdominal wall defect eventually achieved healing with this flap.
Ethics The study was carried out to a high ethical standard and conformed to the World Medical Association Declaration of Helsinki.
Conflict of interest statement The authors have no conflicts of interest to declare in connection with thisarticle. None of the authors has financial relationship with other people or organisations that would profit from this article.
References 1. Hawker PC, Givel JC, Keighley MRB, et al. Management of enterocutaneous fistulae in Crohn’s disease. Gut 1983;24: 284e7. 2. Pettit SH, Irving MH. The operative management of fistulous Crohn’s disease. Surg. Gynecol. Obstet 1988;167:223. 3. Enker WE, Block GE. The operative treatment of Crohn’s disease complicated by fistulae. Arch. Surg 1969;98:493. 4. Dibbell Jr DG, Mixter RC, Dibbell Sr DG. Abdominal wall reconstruction (the ‘mutton chop’ flap). Plast Reconstr Surg 1991;87:60e5. 5. Watson JS. Reconstruction of the anterior abdominal wall above the umbilicus using a tensor fascia latae myocutaneous island flap. Br J Plast Surg 1983;36:334e6. 6. Ramirez O, Ruas E, Dellon A. Components separation’ method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg 1990;86:519e26. 7. Jacobsen W, Petty P, Bite U, et al. Massive abdominal-wall hernia reconstruction with expanded external/internal oblique and transversalis musculofascia. Plast Reconstr Surg 1997;100: 326e35. 8. Lesnick GJ, Davids AM. Repair of surgical abdominal wall defect with a pedicled musculofascial flap. Ann Plast Surg 1953;137:569e72. 9. Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg 1984;37:149e559. 10. Koshima I, Fukuda H, Yamamoto H, et al. Free anterolateral thigh flaps for reconstruction of head and neck defects. Plast Reconstr Surg 1993;92:421e30. 11. Kimata Y, Uchiyama K, Sekido M, et al. Anterolateral thigh flap for abdominal wall reconstruction. Plast Reconstr Surg 1999; 103:1191e7. 12. Kuo YR, Kuo MH, BarbaraLutz S, et al. One-stage reconstruction of large midline abdominal wall defects using a composite free anterolateral thigh flap with vascularized fascia lata. Ann Surg 2004;239:352e8. 13. Spyriounis PK. The extended approach to the vascular pedicle of the anterolateral thigh perforator flap: anatomical and clinical study. Plast Reconstr Surg 2006;117:997. Discussion 1002e1003. 14. Yu P, Youssef A. Efficacy of the handheld doppler in preoperative identification of the cutaneous perforators in the anterolateral thigh flap. Plast. Reconstr. Surg 2006;118:928e33.