Use of the rectus abdominis muscle flap for repair of enterocutaneous fistulae: a case series.

A fistula is considered complex when abdominal connective tissue and fascia are lost due to infection or debridement, exposure to caustic substances or retraction, as seen in the prolonged open abdomen. These fistulae are essentially enteroatmospheric, because they have no corresponding abdominal wall fat or fascia between the bowel lumen and the outside world. They often occur after bowel is exposed for a prolonged period of time and can exist as either small or large intestinal fistulae. In the literature, the mortality of these patients is noted to be as high as 80% with a nearly universal morbidity.1 Early control and characterization of the fistulae are imperative as these patients can easily become malnourished and septic. Because the spontaneous closure rate of these fistulae is exceedingly low ( 30% in some series), creative management and assistance in closure are often necessary.1,2 Although the recommended surgical management technique is resection of the involved fistulous bowel with reapproximation of the patient’s fascia, the complex fistula does not permit this occasionally.3,4 These are the cases that are more demanding in terms of both surgical and medical management. Complex wound care arrangements, skin grafting, and various devices and techniques have been identified to help gain control and assist in closure of the enterocutaneous fistula.5 When those techniques fail or the patient is deemed unable to undergo further extensive wound care and multiple attempts at closure, one option to provide a vascularized pedicle of tissue for closure of the fistula is the rectus abdominis muscle flap. The purpose of this discussion is to describe in detail the technique itself, explain its rationale for use, and present our first six consecutive cases along with their outcomes using this technique.