- Email: [email protected]
Intra-abdominal pedicled rectus abdominis muscle flap for treatment of high-output enterocutaneous fistulae: Case reports and review of literature
Journal of Plastic, Reconstructive & Aesthetic Surgery (2013) 66, 1145e1148
CASE REPORT
Intra-abdominal pedicled rectus abdominis muscle flap for treatment of high-output enterocutaneous fistulae: Case reports and review of literature Joseph N. Carey a, Clifford C. Sheckter a, Andrew J. Watt b, Gordon K. Lee b,* a Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA b Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Stanford, CA, USA
Received 4 December 2012; accepted 12 December 2012
KEYWORDS Enterocutaneous fistula; Pedicled flap; Rectus abdominis
Summary Despite advances in nutritional supplementation, sepsis management, percutaneous drainage and surgical technique, enterocutaneous fistulae remain a considerable source of morbidity and mortality. Use of adjunctive modalities including negative pressure wound therapy and fibrin glue have been shown to improve the rapidity of fistula closure; however, the overall rate of closure remains poor. The challenge of managing chronic, high-output proximal enterocutaneous fistulae can be successfully achieved with appropriate medical management and intra-abdominal placement of pedicled rectus abdominis muscle flaps. We report two cases of recalcitrant high output enterocutaneous fistulae that were treated successfully with pedicled intra-abdominal rectus muscle flaps. Indications for pedicled intra-abdominal rectus muscle flaps include persistent patency despite a reasonable trial of non-operative intervention, failure of traditional operative interventions (serosal patch, Graham patch), and persistent electrolyte and nutritional abnormalities in the setting of a high-output fistula. ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ1 760 977 0424. E-mail address: [email protected] (G.K. Lee). 1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2012.12.008
1146
J.N. Carey et al.
Introduction Proximal, high output enterocutaneous fistulae present a significant challenge to general surgeons and plastic surgeons. They can occur as a result of multiple insults, including intestinal surgery, trauma, radiation, neoplastic conditions, chronic inflammatory conditions, and infections. Despite advances in nutritional supplementation, sepsis management, antibiotics, interventional and surgical technique, these fistulae remain a considerable source of morbidity and mortality.1 For recalcitrant fistulae, surgery remains the only curative approach. Mortality rates for surgical intervention are reported between 3% and 3.5% for all enterocutaneous fistula,2 while high-output fistulae carry a higher mortality, ranging from 5.3% to 35%, reflecting their considerable morbidity.3 Plastic surgical involvement in fistula closure is usually necessary when bolstering of repairs requires a flap from regional or distant locations. Intra-abdominal placement of rectus flaps has been described for fistulae involving the genitourinary tract,4 and all portions of the alimentary tract, including the duodenum and stomach.1,5 Deep abdominal fistulae present a particular challenge, especially when omental flaps are unavailable. We present two cases of proximal, high-output enterocutaneous fistulae that occurred following surgery. Due to the upper abdominal location and deep nature of the fistulae, intrabdominal placement of a rectus abdominis flap was utilized in order to effectively close fistula. Herein, we address use of flaps in fistula repair, and the technique of rectus abdominis flap closure of proximal enterocutaneous fistulae.
Case reports Case# 1 A 44 year-old male who developed necrotizing pancreatitis underwent debridement complicated by duodenocutaneous fistula. Over a one-year period, the patient underwent three attempts at surgical closure of the fistula, including a gastrojejunostomy for duodenal exclusion, and injection of glue by interventional radiology. Despite conservative and aggressive measures, the patient had persistent bilious output. Before a second attempt at surgical repair, the patient was medically stabilized with total parenteral nutrition (TPN) and bowel rest. Plastic surgery was consulted for placement of a flap for definitive closure. Operative technique# 1 The patient underwent laparotomy, duodenal mobilization, and primary fistula repair, followed by muscle flap bolster. The patient’s previous explorations had been performed through a bilateral subcostal incision and midline incision, so the ipsilateral rectus abdominis was used based on the inferior epigastric artery pedicle (Figure 1). General surgery performed adhesiolysis and mobilized the duodenum, identifying a 2 cm defect in the second part of the duodenum that was repaired primarily. The ipsilateral rectus abdominis was approached through the prior midline incision, which was carried over the anterior rectus sheath.
Figure 1 Rectus muscle flap elevated based on inferior pedicle due to prior superior pedicle devascularization from Chevron incision. Surgeon’s fingers illustrating flap course through rectus fascia below arcuate line.
The rectus muscle was mobilized, and a separate transverse incision was made in the transversalis fascia to pass the muscle flap to the epigastrium. The muscle was secured to the duodenum in a circular manner with 3-0 polydioxanone sutures in a seromuscular fashion, and passed full thickness through the muscle. The patient was maintained on TPN and bowel rest for 14 days postoperatively. An upper gastrointestinal series at six months postoperatively shows intact anastomosis without peritoneal extravasation (Figure 2).
Case# 2 A morbidly obese 29 year-old female underwent gastric bypass for body mass reduction. The postoperative course was complicated by a gastro-cutaneous fistula that resolved after two years of conservative treatment. A year after fistula closure, the patient underwent open cholecystectomy complicated by a ventral hernia that was repaired with mesh. The incision eventually dehisced and evolved into another gastro-cutaneous fistula. Conservative
Figure 2 Upper GI series showing intact anastomosis without peritoneal extravasation six months postoperatively.
Intra-abdominal pedicled rectus abdominis muscle flap for treatment of high-output enterocutaneous fistulae
1147
management was trialed for a year with one intensive care unit admission for vancomycin resistant enterococcus (VRE) abdominal sepsis. Four years after the initial bariatric surgery, plastic surgery was consulted for assisting in definitive closure. Operative technique# 2 The patient underwent laparotomy, lysis of adhesions, and primary repair of the gastric fistula by general surgery. The rectus sheath was entered though a midline incision, and the muscle was isolated circumferentially. The muscle was then divided inferiorly after confirming Doppler signal from the super epigastric artery pedicle (Figure 3). The muscle was passed into the abdomen through a rent in the posterior sheath. Any evidence of remaining tract was excised, and the muscle was inset circumferentially around the stomach using 3-0 vicryl suture. For extra bolster, an omental flap was encircled around the rectus muscle. It was secured with 3-0 vicryl suture ensuring that no elements could herniate. The incision dehisced at postoperative day five, and after a week of vacuum assisted closure, the patient went to surgery for wound revision. Both flaps were intact without evidence of alimentary drainage. The prior incision was excised and reclosed. Three weeks following the initial flap placement, the patient was discharged ambulating with enteral feeds. There has been no recurrence of fistula or enteral leakage in two years (Figure 4).
Discussion The clinical course of proximal enterocutaneous fistulae is often protracted and replete with multiple operative and interventional procedures. A series by Martinez et al.6
Figure 4 Upper GI series showing intact anastomosis without peritoneal extravasation two years postoperatively.
found that among all variables, enterocutaneous fistula recurrence was significantly correlated with high output (>200 mL/day) and proximal location (non-colonic). Majority of enterocutaneous fistulae are a result of prior abdominal surgery with less common, but significant causes including trauma, peptic ulcer, cancer, and inflammatory bowel diseases.1,7 With failure of the initial conservative approaches, some inventive newer procedures have been trialed and proven effective, including negative pressure wound therapy,8 medical therapy with octreotide,7 and minimally invasive approaches using tissue adhesives and platelet gels.9 However, in the event of complicated highoutput fistulae, such as those in our patients, surgical approaches must be considered. Surgical planning for definitive repair of enterocutaneous fistulae includes optimizing nutritional status and delineating fistula anatomy. Bolstering the fistula repair with healthy vascularized tissue is common practice, and usually involves local tissue such as intercostal muscle in the chest, local muscle flaps in the neck, and muscle or fasciocutaneous flaps in the abdomen. However, when the fistula resides in an anatomically unfavorable position, such as the duodenum, stomach, or any deep position in the abdomen, bolstering with locally healthy tissue becomes difficult, and distant flap coverage becomes a viable option. Incorporation of vascularized muscle flaps in the setting of fistula repair has been proven to be useful especially in the setting of recurrent fistula after repair,1 as evidenced in urology studies.4 For enterocutaneous fistulae in the pelvis, pedicled flaps including thigh flaps and gluteal flaps10 have been shown to be effective. In the setting of high output fistulae, placement of rectus abdominis flaps has been shown to be effective in the setting of persistent peptic ulcer disease5 as a method of closing the duodenum after failed omentopexy, and in the setting of severe trauma.1
Conclusion Figure 3 Rectus muscle flap elevated based on superior pedicle. The rent at flap base provided flap entrance into abdomen.
The utility of the rectus muscle flap has shown to be physiologically effective in the setting of intestinal leak and
1148 trauma; thus, we thought to expand the indication to chronic proximal enterocutaneous fistulae. In the setting of high output enterocutaneous fistulae that have failed multiple conservative and operative approaches, definitive fistula closure is possible with the utilization of intrabdominal placement of a pedicled rectus abdominis muscle flap. Care must be taken to optimize the patient physiologically and nutritionally, and an effective primary closure with vascularized tissue can be undertaken successfully.
J.N. Carey et al.
2.
3.
4.
Ethical approval
5.
Not applicable.
6.
Funding None.
7.
Conflict of interest
8.
None.
References 1. Mauldin JM, Ciraulo DL, Guest DP, Smith PW, Lett DE, Barker DE. Contralateral rectus abdominis myofascial transposition flap closure of an anterior abdominal wall lateral duodenal cutaneous fistula after shotgun injury to the
9.
10.
abdomen. J Trauma Inj Infect Crit Care 2006 Jun;60(6): 1353e7. Hollington P, Mawdsley J, Lim W, Gabe SM, Forbes A, Windsor AJ. An 11-year experience of enterocutaneous fistula. Br J Surg 2004;91:1646e51. Dudrick SJ, Maharaj AR, McKelvey AA. Artificial nutritional support in patients with gastrointestinal fistulas. World J Surg 1999;23:570e6. McGrath JS, MacDermott SP. Use of pedicled rectus abdominis muscle flap to protect against fistula formation after bladder neck closure. BJU Int 2005 Feb;95(3):450e1. Chander J, Lal P, Ramteke VK. Rectus abdominis muscle flap for high-output duodenal fistula: novel technique. World J Surg 2004 Feb;28(2):179e82. Martinez JL, Luque-de-Leo ´n E, Ballinas-Oseguera G, Mendez JD, Jua ´rez-Oropeza MA, Roma ´n-Ramos R. Factors predictive of recurrence and mortality after surgical repair of enterocutaneous fistula. J Gastrointest Surg 2012 Jan;16(1): 156e63. Draus Jr JM, Huss SA, Harty NJ, Cheadle WG, Larson GM. Enterocutaneous fistula: are treatments improving? Surgery 2006;140:570e8. Piazza RC, Armstrong SD, Vanderkolk W, Eriksson EA, Ringler SL. A modified “fistula-VAC” technique: management of multiple enterocutaneous fistulas in the open abdomen. Plast Reconstr Surg 2009 Dec;124(6):453ee5e. Scala M, Spagnolo F, Strada P, Santi P. Regenerative surgery for the definitive surgical repair of enterocutaneous fistula. Plast Reconstr Surg 2012 Feb;129(2):391ee2e. Chang SH, Hsu TC, Su HC, Tung KY, Hsiao HT. Treatment of intractable enterocutaneous fistula with an island pedicled anterolateral thigh flap in Crohn’s disease e case report. J Plast Reconstr Aesthetic Surg JPRAS 2010 Jun;63(6):1055e7.
CASE REPORT
Intra-abdominal pedicled rectus abdominis muscle flap for treatment of high-output enterocutaneous fistulae: Case reports and review of literature Joseph N. Carey a, Clifford C. Sheckter a, Andrew J. Watt b, Gordon K. Lee b,* a Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA b Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Stanford, CA, USA
Received 4 December 2012; accepted 12 December 2012
KEYWORDS Enterocutaneous fistula; Pedicled flap; Rectus abdominis
Summary Despite advances in nutritional supplementation, sepsis management, percutaneous drainage and surgical technique, enterocutaneous fistulae remain a considerable source of morbidity and mortality. Use of adjunctive modalities including negative pressure wound therapy and fibrin glue have been shown to improve the rapidity of fistula closure; however, the overall rate of closure remains poor. The challenge of managing chronic, high-output proximal enterocutaneous fistulae can be successfully achieved with appropriate medical management and intra-abdominal placement of pedicled rectus abdominis muscle flaps. We report two cases of recalcitrant high output enterocutaneous fistulae that were treated successfully with pedicled intra-abdominal rectus muscle flaps. Indications for pedicled intra-abdominal rectus muscle flaps include persistent patency despite a reasonable trial of non-operative intervention, failure of traditional operative interventions (serosal patch, Graham patch), and persistent electrolyte and nutritional abnormalities in the setting of a high-output fistula. ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ1 760 977 0424. E-mail address: [email protected] (G.K. Lee). 1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2012.12.008
1146
J.N. Carey et al.
Introduction Proximal, high output enterocutaneous fistulae present a significant challenge to general surgeons and plastic surgeons. They can occur as a result of multiple insults, including intestinal surgery, trauma, radiation, neoplastic conditions, chronic inflammatory conditions, and infections. Despite advances in nutritional supplementation, sepsis management, antibiotics, interventional and surgical technique, these fistulae remain a considerable source of morbidity and mortality.1 For recalcitrant fistulae, surgery remains the only curative approach. Mortality rates for surgical intervention are reported between 3% and 3.5% for all enterocutaneous fistula,2 while high-output fistulae carry a higher mortality, ranging from 5.3% to 35%, reflecting their considerable morbidity.3 Plastic surgical involvement in fistula closure is usually necessary when bolstering of repairs requires a flap from regional or distant locations. Intra-abdominal placement of rectus flaps has been described for fistulae involving the genitourinary tract,4 and all portions of the alimentary tract, including the duodenum and stomach.1,5 Deep abdominal fistulae present a particular challenge, especially when omental flaps are unavailable. We present two cases of proximal, high-output enterocutaneous fistulae that occurred following surgery. Due to the upper abdominal location and deep nature of the fistulae, intrabdominal placement of a rectus abdominis flap was utilized in order to effectively close fistula. Herein, we address use of flaps in fistula repair, and the technique of rectus abdominis flap closure of proximal enterocutaneous fistulae.
Case reports Case# 1 A 44 year-old male who developed necrotizing pancreatitis underwent debridement complicated by duodenocutaneous fistula. Over a one-year period, the patient underwent three attempts at surgical closure of the fistula, including a gastrojejunostomy for duodenal exclusion, and injection of glue by interventional radiology. Despite conservative and aggressive measures, the patient had persistent bilious output. Before a second attempt at surgical repair, the patient was medically stabilized with total parenteral nutrition (TPN) and bowel rest. Plastic surgery was consulted for placement of a flap for definitive closure. Operative technique# 1 The patient underwent laparotomy, duodenal mobilization, and primary fistula repair, followed by muscle flap bolster. The patient’s previous explorations had been performed through a bilateral subcostal incision and midline incision, so the ipsilateral rectus abdominis was used based on the inferior epigastric artery pedicle (Figure 1). General surgery performed adhesiolysis and mobilized the duodenum, identifying a 2 cm defect in the second part of the duodenum that was repaired primarily. The ipsilateral rectus abdominis was approached through the prior midline incision, which was carried over the anterior rectus sheath.
Figure 1 Rectus muscle flap elevated based on inferior pedicle due to prior superior pedicle devascularization from Chevron incision. Surgeon’s fingers illustrating flap course through rectus fascia below arcuate line.
The rectus muscle was mobilized, and a separate transverse incision was made in the transversalis fascia to pass the muscle flap to the epigastrium. The muscle was secured to the duodenum in a circular manner with 3-0 polydioxanone sutures in a seromuscular fashion, and passed full thickness through the muscle. The patient was maintained on TPN and bowel rest for 14 days postoperatively. An upper gastrointestinal series at six months postoperatively shows intact anastomosis without peritoneal extravasation (Figure 2).
Case# 2 A morbidly obese 29 year-old female underwent gastric bypass for body mass reduction. The postoperative course was complicated by a gastro-cutaneous fistula that resolved after two years of conservative treatment. A year after fistula closure, the patient underwent open cholecystectomy complicated by a ventral hernia that was repaired with mesh. The incision eventually dehisced and evolved into another gastro-cutaneous fistula. Conservative
Figure 2 Upper GI series showing intact anastomosis without peritoneal extravasation six months postoperatively.
Intra-abdominal pedicled rectus abdominis muscle flap for treatment of high-output enterocutaneous fistulae
1147
management was trialed for a year with one intensive care unit admission for vancomycin resistant enterococcus (VRE) abdominal sepsis. Four years after the initial bariatric surgery, plastic surgery was consulted for assisting in definitive closure. Operative technique# 2 The patient underwent laparotomy, lysis of adhesions, and primary repair of the gastric fistula by general surgery. The rectus sheath was entered though a midline incision, and the muscle was isolated circumferentially. The muscle was then divided inferiorly after confirming Doppler signal from the super epigastric artery pedicle (Figure 3). The muscle was passed into the abdomen through a rent in the posterior sheath. Any evidence of remaining tract was excised, and the muscle was inset circumferentially around the stomach using 3-0 vicryl suture. For extra bolster, an omental flap was encircled around the rectus muscle. It was secured with 3-0 vicryl suture ensuring that no elements could herniate. The incision dehisced at postoperative day five, and after a week of vacuum assisted closure, the patient went to surgery for wound revision. Both flaps were intact without evidence of alimentary drainage. The prior incision was excised and reclosed. Three weeks following the initial flap placement, the patient was discharged ambulating with enteral feeds. There has been no recurrence of fistula or enteral leakage in two years (Figure 4).
Discussion The clinical course of proximal enterocutaneous fistulae is often protracted and replete with multiple operative and interventional procedures. A series by Martinez et al.6
Figure 4 Upper GI series showing intact anastomosis without peritoneal extravasation two years postoperatively.
found that among all variables, enterocutaneous fistula recurrence was significantly correlated with high output (>200 mL/day) and proximal location (non-colonic). Majority of enterocutaneous fistulae are a result of prior abdominal surgery with less common, but significant causes including trauma, peptic ulcer, cancer, and inflammatory bowel diseases.1,7 With failure of the initial conservative approaches, some inventive newer procedures have been trialed and proven effective, including negative pressure wound therapy,8 medical therapy with octreotide,7 and minimally invasive approaches using tissue adhesives and platelet gels.9 However, in the event of complicated highoutput fistulae, such as those in our patients, surgical approaches must be considered. Surgical planning for definitive repair of enterocutaneous fistulae includes optimizing nutritional status and delineating fistula anatomy. Bolstering the fistula repair with healthy vascularized tissue is common practice, and usually involves local tissue such as intercostal muscle in the chest, local muscle flaps in the neck, and muscle or fasciocutaneous flaps in the abdomen. However, when the fistula resides in an anatomically unfavorable position, such as the duodenum, stomach, or any deep position in the abdomen, bolstering with locally healthy tissue becomes difficult, and distant flap coverage becomes a viable option. Incorporation of vascularized muscle flaps in the setting of fistula repair has been proven to be useful especially in the setting of recurrent fistula after repair,1 as evidenced in urology studies.4 For enterocutaneous fistulae in the pelvis, pedicled flaps including thigh flaps and gluteal flaps10 have been shown to be effective. In the setting of high output fistulae, placement of rectus abdominis flaps has been shown to be effective in the setting of persistent peptic ulcer disease5 as a method of closing the duodenum after failed omentopexy, and in the setting of severe trauma.1
Conclusion Figure 3 Rectus muscle flap elevated based on superior pedicle. The rent at flap base provided flap entrance into abdomen.
The utility of the rectus muscle flap has shown to be physiologically effective in the setting of intestinal leak and
1148 trauma; thus, we thought to expand the indication to chronic proximal enterocutaneous fistulae. In the setting of high output enterocutaneous fistulae that have failed multiple conservative and operative approaches, definitive fistula closure is possible with the utilization of intrabdominal placement of a pedicled rectus abdominis muscle flap. Care must be taken to optimize the patient physiologically and nutritionally, and an effective primary closure with vascularized tissue can be undertaken successfully.
J.N. Carey et al.
2.
3.
4.
Ethical approval
5.
Not applicable.
6.
Funding None.
7.
Conflict of interest
8.
None.
References 1. Mauldin JM, Ciraulo DL, Guest DP, Smith PW, Lett DE, Barker DE. Contralateral rectus abdominis myofascial transposition flap closure of an anterior abdominal wall lateral duodenal cutaneous fistula after shotgun injury to the
9.
10.
abdomen. J Trauma Inj Infect Crit Care 2006 Jun;60(6): 1353e7. Hollington P, Mawdsley J, Lim W, Gabe SM, Forbes A, Windsor AJ. An 11-year experience of enterocutaneous fistula. Br J Surg 2004;91:1646e51. Dudrick SJ, Maharaj AR, McKelvey AA. Artificial nutritional support in patients with gastrointestinal fistulas. World J Surg 1999;23:570e6. McGrath JS, MacDermott SP. Use of pedicled rectus abdominis muscle flap to protect against fistula formation after bladder neck closure. BJU Int 2005 Feb;95(3):450e1. Chander J, Lal P, Ramteke VK. Rectus abdominis muscle flap for high-output duodenal fistula: novel technique. World J Surg 2004 Feb;28(2):179e82. Martinez JL, Luque-de-Leo ´n E, Ballinas-Oseguera G, Mendez JD, Jua ´rez-Oropeza MA, Roma ´n-Ramos R. Factors predictive of recurrence and mortality after surgical repair of enterocutaneous fistula. J Gastrointest Surg 2012 Jan;16(1): 156e63. Draus Jr JM, Huss SA, Harty NJ, Cheadle WG, Larson GM. Enterocutaneous fistula: are treatments improving? Surgery 2006;140:570e8. Piazza RC, Armstrong SD, Vanderkolk W, Eriksson EA, Ringler SL. A modified “fistula-VAC” technique: management of multiple enterocutaneous fistulas in the open abdomen. Plast Reconstr Surg 2009 Dec;124(6):453ee5e. Scala M, Spagnolo F, Strada P, Santi P. Regenerative surgery for the definitive surgical repair of enterocutaneous fistula. Plast Reconstr Surg 2012 Feb;129(2):391ee2e. Chang SH, Hsu TC, Su HC, Tung KY, Hsiao HT. Treatment of intractable enterocutaneous fistula with an island pedicled anterolateral thigh flap in Crohn’s disease e case report. J Plast Reconstr Aesthetic Surg JPRAS 2010 Jun;63(6):1055e7.