Rectus abdominis muscle flap for high-output duodenal fistula: novel technique

Duodenal fistula after closure of peptic ulcer perforation, though rare, is difficult to manage and carries a high mortality. The high mortality is associated with the poor nutritional status of the patient, high output from the fistula, and late development of peritonitis and septicemia. The various techniques described in the literature for the closure of the postsurgical external duodenal fistulas range from conservative management with total parenteral nutrition (TPN), serosal patch repair, and Roux-en- Y procedures to radical surgery like Billroth II gastrectomy. Total parenteral nutrition achieves spontaneous closure in 70% to 80% of cases, but it is very expensive and requires prolonged hospitalization. In addition, some surgical procedures have yielded poor results in our setting, so we sought a new modality of treatment. We describe a novel technique for repair of postsurgical external fistula of the duodenum with a rectus abdominis muscle flap. The rectus abdominis muscle is detached from its superior attachment and mobilized from the rectus sheath. The flap, based on the deep inferior epigastric artery, is raised and sutured to the duodenal fistula with thick silk sutures. We treated six patients with post-surgical duodenal fistulas with this technique between 1995 and 2002. The leak was completely sealed in all patients. One patient died of septicemia. We recommend this technique for the management of postsurgical external duodenal fistula as an alternative to other surgical techniques.