A New Extraperitoneal Method for Entero-atmospheric Fistula Closure Using a Free Muscle Flap

Treatment of an entero-atmospheric fistula (EAF) is challenging and associated with significant morbidity and mortality. For an EAF with protrusion of mucosa, chances for spontaneous closure are minimal. Standard surgical procedures may be associated with a high risk for complications in patients with a hostile abdomen. This article describes a new method for extraperitoneal closure of an EAF in a patient with a hostile abdomen. A free segmental latissimus dorsi musculocutaneous flap was harvested on its thoracodorsal pedicle, leaving the remaining muscle innervated. The flap was anastomosed to the internal mammary vessels. The muscle was sutured into the fistula opening using a parachute technique and temporarily immobilized with a negative wound pressure device. The skin of the flap was used for monitoring and later replaced by a skin graft. The postoperative course was uneventful. At 24 months follow-up, there were no signs of recurrences. The patient had no pain and had no defecation problems. Extraperitoneal closure of an EAF with a segmental free latissimus dorsi muscle flap sutured into the fistula opening with a parachute technique may be a new promising technique in patients where standard surgical procedures are associated with too high a risk for complications and where a local pedicled muscle flap is not available. The advantages of this method are that no laparotomy is required, the intestinal lumen is not reduced in diameter, and that no bowel resection is performed, which is a particular advantage in cases with a short bowel syndrome.