Combined single-stage enterolysis with pedicle seromuscular bowel flaps, myocutaneous and fasciocutaneous flaps to repair recurrent enterocutaneous fistulas in complex abdominal Wall defects.

INTRODUCTION: Reconstruction of abdominal wall defects with enterocutaneous fistulas (ECF) remains challenging. The purpose of this report is to describe a single-stage approach using combined microscopic enterolysis, pedicle seromuscular bowel flaps, mesh, fasciocutaneous, and myocutaneous flaps.

METHODS: Between 1990 and 2016 a retrospective review identified a total of 18 patients with an average age of 39 years (ranging 26-59 years). Thirteen cases were associated with trauma, four were complication of previous mesh repair, and one was after an aortic dissection. Average diameter of defect size was 22 cm (ranging 20-24 cm). Surgical technique involved enterolysis using microscope magnification, a pedicle seromuscular bowel flap to reinforce the bowel anastomosis, mesh, musculocutaneous, and fasciocutaneous flaps to reconstruct the abdominal wall.

RESULTS: Fifteen patients required rotational flaps with an average skin paddle area of 442.7 cm2 (ranging 440 cm2 -260 cm2 ) and 10 patients required a serosal patch with an average length of 5 cm (ranging 4-6 cm). Complications included three wound dehiscence and one abdominal wall bulging. Flap survival was 100%. The majority of patients (12 out of 18) were able to resume normal activities, and the remaining (n = 6) were able to resume most activities. Functional outcome as assessed by 36-Item Short Form Survey (SF-36) physical function component questionnaire at 18-24 months follow up was 67.8% (ranging from 59 to 72%). Mean length of hospital stay was 2.2 weeks (ranging 1.4-2.7 weeks). Mean follow-up was 24 months (ranging 22-26 months) with clinical examination.

CONCLUSION: Microscopically assisted intra-abdominal dissection with resection of diseased bowel, replacement with well-vascularized tissue at the anastomosis site in, and reinforcement with mesh combined with pedicle musculocutaneous and fasciocutaneous flaps may be an alternative when other local reconstructive options have failed.