Successful use of a novel biological plug in the percutaneous treatment of a refractory gastro-cutaneous fistula following omental patch repair of perforated peptic ulcer

Abstract

Background: Gastro-cutaneous fistula following re-leak of omental patch repair of perforated peptic ulcer is a very rare but challenging surgical complication. We describe the use of a novel biological plug as a viable repair for gastro-cutaneous fistula that failed medical, endoscopic, and operative management. Additionally, we present a thorough literature review of reported cases of gastro-cutaneous fistulae following omental patching of peptic perforations to further highlight their treatment challenges. Summary: A 69-year-old man underwent repair of a perforated pyloric ulcer with a pedicled omental patch. After one week, patient developed a re-leak from the omental patch, and underwent a second laparotomy with repeat omental patching of the gastric perforation. Ten weeks after the second operation, the patient developed a gastro-cutaneous fistula that failed conservative management with nil per os and enteral nutrition delivered distal to the fistula site; multiple image-guided percutaneous attempts at fistula closure by interventional radiology via fibrin sealant injection and collagen-based vascular closure device; and endoscopic clipping by gastroenterology. Ultimately, this refractory gastro-cutaneous fistula was closed with a novel biological plug (Biodesign® Enterocutaneous Fistula Plug, Cook Biotech). Conclusion: Gastro-cutaneous fistulae following omental patching of perforated peptic ulcer represent a significant complication requiring a multidisciplinary management approach. The Biodesign® Enterocutaneous Fistula Plug offers a promising new tool for the non-operative treatment of refractory gastro-cutaneous fistulae.