Complex Enterocutaneous Fistula
Most enterocutaneous fistulas are caused by complications of abdominal surgery that may result from anastomotic failure, poor blood supply, or iatrogenic bowel injuries. Mortality rates are high when associated sepsis and malnutrition are uncontrolled. Fistulas that occur late and those that recur spontaneously present more difficulty and may close spontaneously in less than 30% of cases. Mortality rates in patients with complex enterocutaneous fistulas may reach 60% to 80%. When traditional conservative surgeries of fistulous tract excision, bowel mobilization, and resection with primary end-to-end anastomosis fail, a more aggressive approach is required. The rectus abdominis muscle flap has been extensively studied and used in a wide variety of abdominal, vaginal, and perineal repairs. We report successful closure of complex enterocutaneous fistulas with a rectus abdominis muscle flap in a complicated case.
Enterocutaneous fistulas are most commonly seen in the postoperative setting and can portend a difficult course for the patient. Morbidity associated with fistulas is significant and includes malnutrition, dehydration, skin excoriation, abscess formation, and sepsis. Mortality rates are high and range from 15% to 43%; the principle causes of death are sepsis and associated malnutrition. Particularly difficult to manage are complex fistulas or those associated with large abdominal wall defects. Mortality rates in these cases may reach 60% to 80%. The initial management of enterocutaneous fistulas consists of bowel rest, total parenteral nutrition (TPN), and delineation of the anatomy of the fistula. Even under ideal conditions, fistulas may fail to close or may recur. Complicated fistulas will close spontaneously in <30% of cases. When operative intervention is indicated, the recommended procedure is resection of the involved segment of bowel with primary anastomosis. Cases in which patients have previously had extensive bowel resection, or in which the fistula is associated with a large abdominal wall defect, defy traditional operative management. In these difficult cases, vascularized muscle flaps may be helpful in closing enterocutaneous fistulas. We detail such a case.
Most enterocutaneous fistulas are caused by complications of abdominal surgery that may result from anastomotic failure, poor blood supply, or iatrogenic bowel injuries. Mortality rates are high when associated sepsis and malnutrition are uncontrolled. Fistulas that occur late and those that recur spontaneously present more difficulty and may close spontaneously in less than 30% of cases. Mortality rates in patients with complex enterocutaneous fistulas may reach 60% to 80%. When traditional conservative surgeries of fistulous tract excision, bowel mobilization, and resection with primary end-to-end anastomosis fail, a more aggressive approach is required. The rectus abdominis muscle flap has been extensively studied and used in a wide variety of abdominal, vaginal, and perineal repairs. We report successful closure of complex enterocutaneous fistulas with a rectus abdominis muscle flap in a complicated case.
Enterocutaneous fistulas are most commonly seen in the postoperative setting and can portend a difficult course for the patient. Morbidity associated with fistulas is significant and includes malnutrition, dehydration, skin excoriation, abscess formation, and sepsis. Mortality rates are high and range from 15% to 43%; the principle causes of death are sepsis and associated malnutrition. Particularly difficult to manage are complex fistulas or those associated with large abdominal wall defects. Mortality rates in these cases may reach 60% to 80%. The initial management of enterocutaneous fistulas consists of bowel rest, total parenteral nutrition (TPN), and delineation of the anatomy of the fistula. Even under ideal conditions, fistulas may fail to close or may recur. Complicated fistulas will close spontaneously in <30% of cases. When operative intervention is indicated, the recommended procedure is resection of the involved segment of bowel with primary anastomosis. Cases in which patients have previously had extensive bowel resection, or in which the fistula is associated with a large abdominal wall defect, defy traditional operative management. In these difficult cases, vascularized muscle flaps may be helpful in closing enterocutaneous fistulas. We detail such a case.
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