Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, 1055e1057

CASE REPORT

Treatment of intractable enterocutaneous fistulawith an island pedicled anterolateral thigh flapin 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, Taiwanb Department of Colorectal Surgery, Mackay Memorial Hospital, Taipei, Taiwanc Mackay Medicine, Nursing and Management College, Taipei, Taiwan

Received 9 January 2009; accepted 22 October 2009

KEYWORDSEnterocutaneousFistula;Crohn’s Disease;Island PedicledAnterolateral Thigh Flap

* Corresponding author. Departmentive Surgery, Mackay Memorial HospiNorth Road, Taipei, Taiwan. Tel.: þ88

E-mail address: prschang@yahoo.c

1748-6815/$-seefrontmatterª2009Britdoi:10.1016/j.bjps.2009.10.024

Summary Attempts to treat intractable enterocutaneous fistulae secondary to Crohn’sdisease are challenging and have been associated with long delays. An island pedicled antero-lateral thigh (ALT) flap has been shown to achieve adequate coverage of abdominal wall recon-struction. In this case, with the assistance of a well-vascularised flap and adequate medicalsupportive managements, the intractable enterocutaneous fistula was closed; it then healedprogressively.ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

Enterocutaneous fistulae in Crohn’s disease can be severelydebilitating, causing metabolic derangements, dehydrationand extensive skin damage. The management of thesefistulae remains challenging, especially when they lead tofull-thickness defects of the abdominal wall, which arenotoriously difficult to reconstruct.1e3 Reconstruction hasbeen attempted with a variety of local or distant flaps from

t of Plastic and Reconstruc-tal, No 92, sec2, ChungSan,6 2 25433535.om.tw (S.-H. Chang).

ishAssociationofPlastic,Reconstruc

the thigh or back, with or without incorporation of prostheticmaterials, according to the size and location of the defects.4

In this report, we present a case of Crohn’s disease withintractable enterocutaneous fistula, which was treated withan island pedicled anterolateral thigh fasciocutaneous flap,to cover a midline abdominal wall defect.

Case report

A 51-year-old woman had been diagnosed with Crohn’sdisease 8 years previously. She had relapsing regionalenteritis, for which she had undergone partial colectomy

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Figure 2 After debridement, the abdominal wall defect sizewas about 22 � 6cm range from epigastic area to pubic region.An island pedicled ALT flap about 23 � 7cm from left thigh washarvested and passed through the subcutaneous tunnel toreach the defect.

1056 S.-H. Chang et al.

with ileocolic anastomosis, first in July 2005 and again inNovember 2006. Unfortunately, she developed an intra-abdominal abscess complicated by an enterocutaneousfistula. The high output of secretions from the fistulaeroded the surrounding tissue, resulting in dehiscence ofthe abdominal wall. Several attempts at resection of thefistula and closure of the abdominal wall defect had failed.There was extensive scarring of the abdominal wallinvolving both sides of the defect from the repeated use ofretention sutures. Months after the last attempt at directclosure, the patient was referred to our department. Atthat time, there was a full-thickness abdominal wall defectwith exposure of the visceral organs (Figure 1).

Operative technique

Colorectal surgeons first closed the enterocutaneousfistula, after which we undertook reconstruction of theabdominal wall defect. Resection of unhealthy or scarredtissue left a full-thickness defect of about 23� 7 cm(Figure 2). We designed a left anterolateral thigh fas-ciocutaneous flap to cover the defect. Three skin perfora-tors were mapped by ultrasound Doppler, and a flap of anappropriate shape and size (23� 7 cm) was drawn toinclude the marked perforators (Figure 2). A medial incisionwas made and the flap perforators were identified at thefascial level. To gain a longer pedicle, a sizeable perforator5 cm distal to the midpoint was chosen. The perforator wasmusculocutaneous and thus required intramuscular dissec-tion. Because the patient had been on long-term cortico-steroid treatment, the vessels were fragile, and so, weperformed micro-dissection under a loupe. The vascularpedicle was traced to the posterior aspect of the rectusfemoris muscle, and then a tunnel was created. The flapwas passed through the tunnel beneath the rectus femoris.An extra 2e3 cm of pedicle length was gained by ligatingthe rectus femoris pedicle.13 The pedicle was thendissected to the origin of the lateral circumflex femoralartery. A wide subcutaneous tunnel was then made to reachthe 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 dehiscencewith visceral organ exposure.

to avoid injury to the perforator vessels (Figure 2). The flapwas 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 enter-ocutaneous fistula in the right lower part of the flap.Medical management, including maintenance of fluid andelectrolyte balance, corticosteroids and total parenteralnutrition, were used for 1 month postoperatively. Thepostoperative course was complicated by a catheterinfection leading to sepsis, which was successfully treatedwith intravenous antibiotics. With continued appropriatemedical management, the fistula gradually diminished insize and finally healed completely 2 months after thesurgery (Figure 3). The patient has since had intermittentepisodes of adhesion ileus, but there had been no recur-rence of the fistula on follow-up 12 months postoperatively.

Figure 3 Six months followed-up. The enterocutaneousfistula was healed.

Fistula with an island pedicled anterolateral thigh flap in Crohn’s disease 1057

Discussion

Crohn’s disease is an immune-mediated illness causinginflammation of the gastrointestinal tract and leading tosignificant complications such as fistulae, abscesses andphlegmons secondary to microperforation of the intestine.Most cutaneous fistulae occur after surgery for the disease,either from an anastomotic leak or from an unnoticedinadvertent intestinal injury during the operation. Suchcutaneous fistulae can be difficult to treat and may causesevere debilitation. The principles of management ofenterocutaneous fistula include the treatment of sepsis,nutritional and metabolic support, skin care and surgicalintervention to relieve distal obstruction.1e3

The reconstruction of composite abdominal defects thatinclude the skin, rectus abdominis muscle and fascia sheathwith consequent exposure of the visceral organs exposure isextremely complex. Methods advanced to solve thisproblem have included use of prosthetic mesh, free fascialgrafts, the components separation technique, tissueexpansion, local flaps and free flaps. Prosthetic mesh posesa high risk for infection and is relatively contraindicated incontaminated fields. The components separation techniqueis not effective in cases where there is loss of the rectusabdominis muscles and fascia; it is only suitable for smallcentral abdominal defects.6

Reconstructive surgeons have suggested a variety offlaps to address this problem.4e8 Lesnick closed a one-sidedabdominal wall defect by mobilising a pedicled muscu-lofascial flap from the opposite side.8 Song first describedthe anterolateral thigh flap in 1984, and it has since beenused in a wide range of procedures, including reconstruc-tion of the abdominal wall9,10 and for free tissue transfer.Kimata et al.11 and Kuo et al.12 described reconstruction ofabdominal composite defects using a free anterolateralthigh flap with and without vascularised fascia lata.

Kimata et al.,11 however, stated that island pedicledanterolateral thigh flaps were only adequate for recon-struction of lower abdominal wall defects because thepedicle is too short to reach more superior defects. Spyr-iounis demonstrated a helpful modification: transposing theflap medial to the vascular pedicle shortens the arc ofrotation as it is passed under the rectus femoris musclebefore reaching the medial thigh through a subcutaneoustunnel.13 A distal perforator can also help in harvestinga longer pedicle. Yu et al. identified a distal perforator in62% of 100 cases where an anterolateral thigh flap waselevated.14 In our patient, a sizeable distant perforator waspresent, which obviated the need for a flap transfer.

Using the techniques we have described, the islandpedicled anterolateral thigh fasciocutaneous flap can besuccessfully used for reconstruction of full-thickness supra-umbilical abdominal defects. The healing of our patient’schronic fistula was the result of reconstruction using a well-vascularised flap, followed by meticulous postoperativemedical care.

In summary, attempts to treat intractable enter-ocutaneous fistulae secondary to Crohn’s disease are chal-lenging and have been associated with long delays inhealing. An island pedicled anterolateral thigh flap has

been shown to achieve adequate coverage for abdominalwall reconstruction. A patient with an intractable enter-ocutaneous fistula and large abdominal wall defect even-tually achieved healing with this flap.

Ethics

The study was carried out to a high ethical standard andconformed to the World Medical Association Declaration ofHelsinki.

Conflict of interest statement

The authors have no conflicts of interest to declare inconnection with thisarticle. None of the authors hasfinancial relationship with other people or organisationsthat would profit from this article.

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