TY - JOUR
AU - Carlson, G L
AB - Abstract Background Reconstruction of massive contaminated abdominal wall defects associated with enteroatmospheric fistulation represents a technical challenge. An effective technique that allows closure of intestinal fistulas and reconstruction of the abdominal wall, with a good functional and cosmetic result, has yet to be described. The present study is a retrospective review of simultaneous reconstruction of extensive gastrointestinal tract fistulation and large full-thickness abdominal wall defects, using a novel pedicled subtotal thigh flap. Methods The flap, based on branches of the lateral circumflex femoral artery, was used to reconstruct the abdominal wall in six patients who were dependent on artificial nutritional support, with a median (range) of 4·5 (3–23) separate intestinal fistulas, within open abdominal wounds with a surface area of 564·5 (204–792) cm2. Intestinal reconstruction was staged, with delayed closure of a loop jejunostomy. Median follow-up was 93·5 (10–174) weeks. Results Successful healing occurred in all patients, with no flap loss or gastrointestinal complications. One patient died from complications of sepsis unrelated to the surgical treatment. All surviving patients gained complete nutritional autonomy following closure of the loop jejunostomy. Conclusion Replacement of almost the entire native abdominal wall in patients with massive contaminated abdominal wall defects is possible, without the need for prosthetic material or microvascular free flaps. The subtotal pedicled thigh flap is a safe and effective method of providing definitive treatment for patients with massive enteroatmospheric fistulation. Introduction Use of an open abdomen and topical negative-pressure wound therapy in the management of severe abdominal sepsis and trauma may result in the development of multiple intestinal fistulas within the open abdominal wound. These ‘enteroatmospheric fistulas’ remain very difficult to manage and are associated with a substantial mortality rate1,2. In patients who do survive an acute episode of severe intestinal failure associated with enteroatmospheric fistulation, reconstruction of both the intestinal tract and abdominal wall is essential to a successful outcome. Failure of reconstruction of the large contaminated abdominal wall defects resulting from enteroatmospheric fistulation is associated not only with incisional herniation and poor cosmetic and functional outcome but also with refistulation3. The ideal technique would mimic most closely the original function and structure of the abdominal wall, and therefore requires skin, innervated muscle and fascia. Currently available techniques for abdominal wall reconstruction may involve the use of autologous tissues4, including separation of components5, and flaps, as well as replacement of deficient abdominal wall with prosthetic mesh or biological implants6. Although these techniques may be of value, they also have significant limitations, notably where there are very large contaminated defects involving loss not only of abdominal wall muscle and fascia but also of abdominal skin. In such instances, the value of separation of components may be limited by the sheer size of the abdominal wall defect to be closed, and there may be insufficient skin for coverage of prosthetic or biological material. In addition, insertion of non-absorbable material such as polypropylene is inappropriate in the presence of enteric contamination, whereas absorbable material such as polyglactin is associated with a high incidence of subsequent herniation3. Biological implants, including cross-linked porcine denatured collagen, have been associated with a relatively high incidence of refistulation3 and other complications7, when used to reconstruct the abdominal wall and left in contact with intestinal suture lines. Although a variety of pedicled and free flaps have been described for the reconstruction of abdominal wall defects8–12, these flaps are generally too small for reconstruction of larger abdominal wall defects associated with enteroatmospheric fistulation and they are too thin to function as an effective replacement of the native abdominal wall. In order to address these issues the authors have developed a novel lateral subtotal thigh flap based on the lateral circumflex femoral artery (LCFA) pedicle. This flap includes the combined anterolateral thigh and tensor fascia latae (TFL) flaps, with extensions of the skin and fascia made possible by the inclusion of tissue supplied by all the perforators of the descending branch of the LCFA; this allows the flap to be taken to within 2 cm of the upper pole of the patella. The use of such an extensive musculocutaneous flap with fasciocutaneous extensions facilitates double-layer (fascia and then skin and subcutaneous tissue) direct closure of abdominal defects, and is potentially large enough to allow closure of defects from the xiphisternum to pubis. The aim of the present study was to determine the effectiveness of a staged approach, involving resection of intestinal fistulas and reconstruction of the abdominal wall with a pedicled subtotal lateral thigh flap, in the definitive management of patients with massive, heavily contaminated abdominal wall defects associated with enteroatmospheric fistulation. Specific objectives were to assess the feasibility of closure of the entire abdominal wall defect, incidence of complications, and resource implications in terms of duration of operation, and length of hospital and critical care stay. Methods Preoperative assessment and preparation Combined restoration of intestinal continuity and reconstruction of the abdominal wall was not undertaken until the patient had recovered fully from sepsis, was adequately nourished, and there was evidence of re-establishment of a neoperitoneal cavity, so that safe entry into the abdomen could be achieved without the undue risk of further unplanned enterotomy. In general, this was approximately 6 months after the open abdomen had first been established13,14. During this phase, management of the patient was centred on eradication of sepsis, correcting nutritional depletion and, subsequently, assessment of intestinal and abdominal wall anatomy by cross-sectional and contrast imaging. The development of a mature laparostomy, suitable for reconstructive surgery, was usually indicated by the appearance of extensive prolapse of the fistulating loops of bowel (Fig. 1). Fig. 1 Open in new tabDownload slide Massive contaminated abdominal wall defect associated with enteroatmospheric fistulation, demonstrating prolapsing loops of bowel The LCFA was mapped before surgery using high-resolution duplex imaging, and perforating vessels were marked immediately before operation using a hand-held Doppler probe. This demonstrated the quality of the perforators just proximal to the knee in what would become the most distal part of the flap. Identification of these low perforating vessels was essential to ensure that a long flap could be taken, especially if defects up to the xiphisternum were to be closed reliably. Operative technique Abdominal phase Careful entry into the neoperitoneal cavity was made through the intact abdominal wall, above or below the edges of the abdominal defect, and sharp dissection with the knife was used to enter the neoperitoneal cavity, taking care to avoid enterotomy. The loops of intact intestine were separated carefully, by meticulous sharp dissection, from the new ‘laparostomy’ skin, which had grown to cover the defect in the open abdomen. This skin routinely became ischaemic during the dissection as, unlike normal skin, it obtained its blood supply from the underlying intestinal loops. The fistulating loops were eventually reached within the abdominal defect, and the gastrointestinal tract was divided immediately above and below them. After mobilization and resection of the fistulating intestine, intestinal integrity was restored, where required, by intestinal anastomosis/anastomoses, but only distal to the most proximal fistula. Rarely would more than a single anastomosis be placed in circuit. Although multiple anastomoses were commonly required, these were often made in bowel of relatively poor quality and the risk of leakage would be cumulatively high. In patients with multiple anastomoses, therefore, the most proximal one was exteriorized as leakage of one would threaten both the other anastomoses and the integrity of the flap. Once reconstruction of the intestinal tract had been completed, the edges of the abdominal wall defect were resected back to healthy tissue, with no attempt to undermine tissue planes, to avoid devascularization of the skin at the edges. Thigh dissection Note was taken of the patient's body habitus with regard to ratio of thigh to abdominal length, and careful use of reverse planning was employed to ensure that the flap reached the limits of the defect (see below). Following perforator identification, the femoral triangle was marked, preserving cover of the femoral neurovascular bundle. The flap was designed such that one lateral border of the flap lay at the lateral border of the femoral triangle. Given the demonstration of adequate distal perforators (Fig. 2a), the required dimensions for the flap could be marked out. To facilitate this, the size and shape of the defect in the abdomen were measured, and a paper template created (Fig. 2b), which was then pivoted on to the thigh (Fig. 2c), to determine how far down the thigh the flap should be harvested, and how much of the thigh width would be required. The flap could then be harvested to within 2 cm of the superolateral border of the patella. Fig. 2 Open in new tabDownload slide a Intraoperative identification and marking of perforators; b,c use of paper template to ensure dimensions of flap are appropriate to size of abdominal wall defect Dissection was commenced at the lateral border of the femoral triangle vertically down to, and including, the deep investing fascia. Dissection then proceeded laterally beneath the deep fascia, to the lateral border of rectus femoris. At this stage the perforator anatomy was defined. Experience to date has been solely intramuscular, and, as such, dissection proceeded beneath the descending branch and involved dissection of the vastus lateralis off its femoral origin. At this point dissection could proceed distally to proximally, elevating the vastus lateralis with the flap (Fig. 3a). A small amount of the distal vastus lateralis was left behind, to allow lateral stabilization of the patella. The ascending and transverse branches of the LCFA were identified proximally. Although each can have separate origins from the profunda femoris, a common origin that trifurcates is more frequent15. This facilitated flap rotation for inset into the abdominal defect (Fig. 3b). Fig. 3 Open in new tabDownload slide a Mobilization of anterolateral thigh flap from donor site; b flap fully mobilized; and c flap taken under sartorius and rectus femoris with hip flexed After mobilization of the pedicle to its origin and division of TFL proximally, the flap was transposed on its pedicle medially, beneath sartorius and rectus femoris (Fig. 3c), and by flexing and internally rotating the patient's hip, thereby increasing its reach, a manoeuvre described previously8. To facilitate this procedure, the lateral cutaneous nerve of the thigh had to be divided. An incision was also made in the inguinal region to allow the pedicle to sit comfortably and to avoid tension on the pedicle. The double-barrelled stoma was brought out through a trephine made in the native abdominal wall as far away from the edges of the abdominal wall defect as was consistent with the ability of the patient to manage the stoma after surgery. Having established that the flap sat comfortably in the defect and was well vascularized, the flap was then secured by approximating the deep fascia of the thigh and iliotibial tract to the residual native abdominal wall, using continuous 1 PDS® sutures (Ethicon, Johnson & Johnson, Livingston, UK) (Fig. 4). The skin was then closed. The donor defect was finally covered with a meshed split skin graft taken from the contralateral thigh (Fig. 5). Fig. 4 Open in new tabDownload slide Anterolateral thigh flap completely filling abdominal defect Fig. 5 Open in new tabDownload slide Donor site covered with split skin graft taken from contralateral thigh Patients were routinely transferred to the intensive care unit (ICU) in the initial postoperative period, for close monitoring of cardiovascular status and flap perfusion. The leg from which the flap had been harvested was maintained at 45° of flexion and kept internally rotated, supported on a pillow, to minimize tension on the vascular pedicle. This position was maintained for the first 10 days after surgery. Progressive extension of the hip was then allowed until the patient was able to mobilize fully. Closure of the double-barrelled stoma (Fig. 6) was undertaken 4–6 months after abdominal wall reconstruction, when the patient had recovered fully, and contrast imaging had confirmed anastomotic integrity of the distal intestinal tract. In patients with proximal stomas, before stoma closure nutritional and metabolic status was maintained either by parenteral nutrition, or by distal enteral feeding, infused directly into the distal limb of the double-barrelled stoma16. Fig. 6 Open in new tabDownload slide Healed abdominal and thigh wounds, 6 months after final procedure to close double-barrelled jejunostomy Results Six patients underwent simultaneous reconstruction of the gastrointestinal tract and abdominal wall replacement with a pedicled lateral subtotal thigh flap, and were followed up for a median of 93·5 (range 10–174) weeks. Their individual details are summarized in Table 1. All patients had massive complicated abdominal wall defects after repeated surgery to deal with extensive intestinal fistulation, and all were dependent on parenteral nutrition or fistuloclysis at the time of reconstructive surgery. These patients had undergone a median of 3·5 (range 2–18) previous laparotomies to deal with the cause of intestinal fistulation and there were 50 separate identifiable intestinal fistulas in six patients, with a median of 4·5 (range 3–23) per patient. One patient had fistulation involving both small and large intestine. Four of the patients had undergone previous attempts to reconstruct the abdominal wall with prosthetic material. The median defect size after resection of infected prosthetic material was 564·5 (range 204–792) cm2. No patient required more than a unilateral flap to fill the abdominal wall defect completely. Even the largest defect (792 cm2), extending from xiphoid to pubis, could be filled comfortably with a single pedicled flap. Table 1 Summary of data for individual patients Patient no. . Age (years) . Sex . Aetiology . Interval between fistulation and reconstructive surgery (weeks) . No. and type of fistulas . Prosthetic material . Defect surface area (cm2) . Outcome . 1 63 M Complication of open prostatectomy, colonic injury, abdominal dehiscence, multiple small bowel fistulas 43 21 ileal, 2 colonic None 204 Necrosis of abdominal wall skin above flap. Healed, nutritionally independent. Incisional hernia at junction of flap and abdominal wall 2 50 M Anastomotic leak after sigmoid colectomy for cancer. Multiple small intestinal fistulation into open abdominal wound 76 3 jejunal, 2 ileal Cross-linked porcine dermal collagen 540 Healed, nutritionally independent 3 60 M Anastomotic leak after anterior resection for rectal cancer. Multiple small intestinal fistulation into open abdominal wound 159 7 jejunal, 4 ileal None 510 Infection at junction of flap and abdominal wall. Healed after debridement. Nutritionally independent 4 43 F Penetrating bowel injury. Postoperative fistulation. Recurrent intestinal fistula through infected Prolene™ mesh 79 4 jejunal Prolene™ 792 Died, from ventilator-associated pneumonia, intracranial sepsis and hydrocephalus. Flap healed but still dependent on total parenteral nutrition 5 51 M Disintegrative colitis. Postoperative jejunal and ileal fistulation. Refistulation after attempted reconstructive surgery 77 3 jejunal Cross-linked porcine dermal collagen 684 Healed, nutritionally independent 6 40 M Duodenal ulcer, incisional hernia, fistulation after abdominal wall reconstruction 40 4 jejunal Prolene™ 589 Healed, nutritionally independent Patient no. . Age (years) . Sex . Aetiology . Interval between fistulation and reconstructive surgery (weeks) . No. and type of fistulas . Prosthetic material . Defect surface area (cm2) . Outcome . 1 63 M Complication of open prostatectomy, colonic injury, abdominal dehiscence, multiple small bowel fistulas 43 21 ileal, 2 colonic None 204 Necrosis of abdominal wall skin above flap. Healed, nutritionally independent. Incisional hernia at junction of flap and abdominal wall 2 50 M Anastomotic leak after sigmoid colectomy for cancer. Multiple small intestinal fistulation into open abdominal wound 76 3 jejunal, 2 ileal Cross-linked porcine dermal collagen 540 Healed, nutritionally independent 3 60 M Anastomotic leak after anterior resection for rectal cancer. Multiple small intestinal fistulation into open abdominal wound 159 7 jejunal, 4 ileal None 510 Infection at junction of flap and abdominal wall. Healed after debridement. Nutritionally independent 4 43 F Penetrating bowel injury. Postoperative fistulation. Recurrent intestinal fistula through infected Prolene™ mesh 79 4 jejunal Prolene™ 792 Died, from ventilator-associated pneumonia, intracranial sepsis and hydrocephalus. Flap healed but still dependent on total parenteral nutrition 5 51 M Disintegrative colitis. Postoperative jejunal and ileal fistulation. Refistulation after attempted reconstructive surgery 77 3 jejunal Cross-linked porcine dermal collagen 684 Healed, nutritionally independent 6 40 M Duodenal ulcer, incisional hernia, fistulation after abdominal wall reconstruction 40 4 jejunal Prolene™ 589 Healed, nutritionally independent Prolene™ (Ethicon, Johnson & Johnson, Livingston, UK). Open in new tab Table 1 Summary of data for individual patients Patient no. . Age (years) . Sex . Aetiology . Interval between fistulation and reconstructive surgery (weeks) . No. and type of fistulas . Prosthetic material . Defect surface area (cm2) . Outcome . 1 63 M Complication of open prostatectomy, colonic injury, abdominal dehiscence, multiple small bowel fistulas 43 21 ileal, 2 colonic None 204 Necrosis of abdominal wall skin above flap. Healed, nutritionally independent. Incisional hernia at junction of flap and abdominal wall 2 50 M Anastomotic leak after sigmoid colectomy for cancer. Multiple small intestinal fistulation into open abdominal wound 76 3 jejunal, 2 ileal Cross-linked porcine dermal collagen 540 Healed, nutritionally independent 3 60 M Anastomotic leak after anterior resection for rectal cancer. Multiple small intestinal fistulation into open abdominal wound 159 7 jejunal, 4 ileal None 510 Infection at junction of flap and abdominal wall. Healed after debridement. Nutritionally independent 4 43 F Penetrating bowel injury. Postoperative fistulation. Recurrent intestinal fistula through infected Prolene™ mesh 79 4 jejunal Prolene™ 792 Died, from ventilator-associated pneumonia, intracranial sepsis and hydrocephalus. Flap healed but still dependent on total parenteral nutrition 5 51 M Disintegrative colitis. Postoperative jejunal and ileal fistulation. Refistulation after attempted reconstructive surgery 77 3 jejunal Cross-linked porcine dermal collagen 684 Healed, nutritionally independent 6 40 M Duodenal ulcer, incisional hernia, fistulation after abdominal wall reconstruction 40 4 jejunal Prolene™ 589 Healed, nutritionally independent Patient no. . Age (years) . Sex . Aetiology . Interval between fistulation and reconstructive surgery (weeks) . No. and type of fistulas . Prosthetic material . Defect surface area (cm2) . Outcome . 1 63 M Complication of open prostatectomy, colonic injury, abdominal dehiscence, multiple small bowel fistulas 43 21 ileal, 2 colonic None 204 Necrosis of abdominal wall skin above flap. Healed, nutritionally independent. Incisional hernia at junction of flap and abdominal wall 2 50 M Anastomotic leak after sigmoid colectomy for cancer. Multiple small intestinal fistulation into open abdominal wound 76 3 jejunal, 2 ileal Cross-linked porcine dermal collagen 540 Healed, nutritionally independent 3 60 M Anastomotic leak after anterior resection for rectal cancer. Multiple small intestinal fistulation into open abdominal wound 159 7 jejunal, 4 ileal None 510 Infection at junction of flap and abdominal wall. Healed after debridement. Nutritionally independent 4 43 F Penetrating bowel injury. Postoperative fistulation. Recurrent intestinal fistula through infected Prolene™ mesh 79 4 jejunal Prolene™ 792 Died, from ventilator-associated pneumonia, intracranial sepsis and hydrocephalus. Flap healed but still dependent on total parenteral nutrition 5 51 M Disintegrative colitis. Postoperative jejunal and ileal fistulation. Refistulation after attempted reconstructive surgery 77 3 jejunal Cross-linked porcine dermal collagen 684 Healed, nutritionally independent 6 40 M Duodenal ulcer, incisional hernia, fistulation after abdominal wall reconstruction 40 4 jejunal Prolene™ 589 Healed, nutritionally independent Prolene™ (Ethicon, Johnson & Johnson, Livingston, UK). Open in new tab The median (range) length of total hospital stay for all patients was 46 (23–79) days and length of stay in the ICU or high-dependency unit was 17 (9–77) days. The median duration of operation was 770 (710–930) min. One patient died 77 days after surgery, as a result of intracranial sepsis associated with ventilator-associated pneumonia. There were no complications related to healing of the abdominal wound at any stage of this patient's postoperative recovery. Of the five surviving patients, three were fed successfully in the postoperative period via the double-barrelled jejunostomy, following satisfactory distal contrast radiology, and two were fed intravenously pending closure of double-barrelled stomas. All patients who survived regained complete nutritional autonomy following closure of the stoma. One patient developed a surgical-site infection at the lower edge of the flap and its junction with native abdominal wall, requiring debridement and drainage, after which the flap healed uneventfully. No patient suffered from flap necrosis or loss and no patient developed further intestinal fistulation. All patients achieved apparently normal mobility. One patient developed an incisional hernia at the junction of the flap and native abdominal wall, but did not require treatment. Discussion Despite considerable advances in the management of patients with intestinal fistulas, fistulation within the open abdomen (enteroatmospheric fistulation) remains extremely challenging to manage, with mortality rates in the acute phase continuing, even recently, to exceed 20 per cent, principally as a result of abdominal sepsis2. Management of a massive abdominal wall defect filled with fistulating intestinal loops in patients who survive the acute phase of illness is no less challenging. The patients described in the present study represent an extreme end of a spectrum of complex intestinal failure, presenting to a specialist unit, as indicated by the significant number of previous failed operations, the large number of intestinal fistulas and the very large size of the abdominal wall defects. It is unlikely that sufficient experience of these challenging and complex cases would be gained outside a specialist tertiary referral centre. The techniques described are therefore appropriate to the level of complexity and expertise available, and would clearly not be needed in the management of the majority of patients with otherwise uncomplicated postoperative intestinal fistulation. The goal of reconstructive surgery includes both restoration of enteral autonomy as well as restoration of a functionally and cosmetically acceptable abdominal wall. Although simple primary closure, and near and far suturing techniques may be sufficient for patients with fistulation in relatively modest abdominal wall defects17, larger defects and more extensive fistulation are commonly encountered in patients who have undergone management of the open abdomen with topical negative-pressure therapy18. Reconstruction of both the intestinal tract and a large, heavily contaminated abdominal wall defect creates major problems for the surgeon. These patients present a complex triad of prolonged illness, challenging nutritional problems associated with the use of long-term parenteral nutrition and/or fistuloclysis, and a massive abdominal wall defect, heavily contaminated by intestinal fistulation and, frequently, infected prosthetic mesh associated with previous failed attempts at surgical reconstruction. The further use of synthetic non-absorbable material is inappropriate because of the risk of infection and, although biological implants have been advocated in this setting, the results have been poor, with a considerable incidence of refistulation3. Indeed, four of the six patients in the present series had previously undergone failed attempts to reconstruct the abdominal wall with various types of prosthetic material, including biological implants, which had been associated with intestinal fistulation, abdominal wall infection and implant extrusion at the margins of the defect. The need to remove all of the permanent, infected material at the same time as resection of the intestinal fistulas leaves the patient with a massive abdominal wall defect, without sufficient abdominal wall muscle or skin to close over the gut. Although separation of components is an extremely valuable technique for reconstruction of abdominal wall defects too large to close primarily, and can often gain up to 20 cm of total width in the abdominal wound5, the size of the defects in the present series, and the simultaneous lack of viable skin to fill the abdominal wall defect, was felt to preclude its satisfactory use. Although abdominal wall transplantation has been advocated to enable abdominal closure in patients undergoing intestinal transplantation with simultaneous abdominal wall defects19,20, this would have been inappropriate in the present patients because of the concomitant need to administer immunosuppression in individuals who already had significant, chronic abdominal wall infection. In the present series, the requirement to provide well vascularized, healthy host tissue that would fill the abdominal wall defect and be safe to leave in direct continuity with the gastrointestinal tract therefore seemed best met by the use of an autologous flap. Although the use of autologous flaps for reconstruction of the abdominal wall has been reviewed previously4, the present technique involved several refinements that considerably extend the effectiveness and versatility of this approach. The TFL flap was first described by Wangensteen21 as a method of reconstructing the abdomen, but the flap tends to be relatively small and problems have been reported with reliability of its tip, which has a relatively poor blood supply. Although a larger pedicled flap based on the anterolateral thigh has been described previously11, pedicled flaps have generally been found to be inadequate to cover the supraumbilical abdomen22–24. Although recent modification of the pedicled anterolateral thigh flap, based on the use of thigh perforators, has been claimed to generate larger flaps25, the defects requiring closure in that study were, with one exception, less than 200 cm2 in surface area, whereas all but one of the defects that required closure in the present study were at least two or three times larger than this. In addition, the flaps described previously were either cutaneous or fasciocutaneous, making postoperative abdominal herniation more likely. Although good results have also been described for reconstruction of large abdominal defects using a technique in which a subtotal thigh flap (free or pedicled) is combined with a biological implant, to increase the size of the fascial defect that can be repaired26, the defects in this study were no bigger than those repaired in the present study (median 500 versus 564·5 cm2 respectively), without the need to use prosthetic material. In addition, all but two of the defects repaired by Lin and Butler26 were large acute and uncontaminated defects associated with resection of abdominal wall for tumour, which represents a considerably different problem to that described in the present study, where the defects were very heavily contaminated by open loops of fistulating bowel and were longstanding. These differences may be of considerable importance, given the poor results reported previously for recurrent fistulation when biological materials were used in this setting. Free flaps based on TFL alone27, or combined with the anterolateral thigh10, have also been used successfully to reconstruct large abdominal wall defects, but they require microsurgical reconstruction of the vascular supply. This might be an option, but one that seems unsuited to chronically unwell patients who are already facing lengthy abdominal surgical procedures. The present study has demonstrated that reliable results in massive abdominal defects, up to and including defects extending from xiphisternum to pubis, can be obtained using a single pedicled subtotal lateral thigh flap, without the need for bilateral flaps or a free flap requiring lengthy microsurgical reconstruction. The present technique involves bringing the flap up on two pedicles from both the transverse and descending branches of the LCFA to ensure satisfactory and reliable vascularization. Sarabahi and colleagues28 described raising the skin of the whole thigh on the TFL pedicle only, leaving a strip of skin to cover the neurovascular bundle. They reasoned that the flap survives on the choke vessels between adjacent angiosomes, but reported only one case and it is currently unclear whether their technique, which seems unlikely to be technically simpler, quicker or associated with fewer complications than that described in the present paper, would be equally reliable. Although skin necrosis is a potential concern with the use of large flaps on long pedicles, the only skin loss observed in the present study was in the native skin of the epigastrium (as opposed to the flap) in the first patient in the series. This occurred after the reach of the flap was compromised by loss of the transverse branch of the LCFA during flap dissection, necessitating lower positioning of the flap and more extensive lateral dissection of the skin of the upper abdomen, to allow direct closure of the epigastric wound, presumably leading to a degree of devascularization. Since modifying the flap to exclude intramuscular dissection by harvesting the flap with vastus lateralis, the viability of all skin and full healing has been maintained. Successful robust closure of massive full-thickness contaminated abdominal wall defects can be achieved using a large pedicled subtotal lateral thigh flap based on the LCFA pedicle. The flap can reach the xiphisternum provided that a low perforating vessel is preserved and, by passing the flap beneath rectus femoris and sartorius, additional reach can be achieved by flexing and internally rotating the patient's hip. When combined with simultaneous staged reconstructive gastrointestinal surgery, this technique provides a satisfactory means of simultaneous and definitive treatment for massive enteroatmospheric fistulation. Disclosure The authors declare no conflict of interest. References 1 Schein M . Intestinal fistulas and the open management of the septic abdomen . Arch Surg 1990 ; 125 : 1516 – 1517 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Rao M , Burke D, Finan PJ, Sagar PM. The use of vacuum-assisted closure of abdominal wounds: a word of caution . Colorectal Dis 2007 ; 9 : 266 – 268 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Connolly PT , Teubner A, Lees NP, Anderson ID, Scott NA, Carlson GL. Outcome of reconstructive surgery for intestinal fistula in the open abdomen . Ann Surg 2008 ; 247 : 440 – 444 . Google Scholar Crossref Search ADS PubMed WorldCat 4 de Vries Reilingh TS , Bodegom ME, van Goor H, Hartman EH, van der Wilt GJ, Bleichrodt RP. 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This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
TI - Autologous reconstruction of massive enteroatmospheric fistulation with a pedicled subtotal lateral thigh flap
JF - British Journal of Surgery
DO - 10.1002/bjs.8759
DA - 2012-05-30
UR - https://www.deepdyve.com/lp/oxford-university-press/autologous-reconstruction-of-massive-enteroatmospheric-fistulation-bRgP70Ur7z
SP - 964
EP - 972
VL - 99
IS - 7
DP - DeepDyve
ER -