Repair of duodenal fistula with rectus abdominis muscle 'pull-in' flap

Objective: Large duodenal fistulae are difficult to repair, due to complex duodenal anatomy. Musculoepithelial flaps are conventionally used for reconstruction of large soft tissue defects. This is the first study reporting clinical use of rectus abdominis muscle (RAM) pull-in flap for repair of duodenal fistulae.
Materials and Method: Six patients of duodenal fistulae (resulting from leakage of peptic perforation repair) underwent repair using right RAM pull-in flap, based on superior epigastric artery. Rectus abdominis muscle flap, after being harvested, was tied to naso-gastric tube (brought out of duodenal fistula) that was then pulled back in the stomach. Muscle was then anchored to the edges of duodenal fistula with few interrupted 2-0 vicryl sutures.
Results: Duodenal fistulae healed within 3-5 days in all the cases except one, in which some bile continued to leak for 20 days. One patient died within 12 h of second surgery.
Discussion: Rectus abdominis muscle pull-in flap for closure of duodenal defect is a simple, technically easy and dependable procedure, which can be performed, quickly in critically ill patients. It can be used for repair of a large duodenal defect with friable edges when omentum is not available or when other conventional methods are impractical.