Chronic Gastrocutaneous Fistula Research Articles

Endoscopic vacuum assisted closure of gastrocutaneous fistula after sleeve gastrectomy combined with fibrin sealant

Treatment of gastrointestinal fistulas after staple line leaks is difficult and non-invasive procedures such as endoclips, stents or endoscopic vacuum assisted closure (E-VAC) are sometimes not adequate. Fibrin sealants (FS) may promote healing, although today are used mainly to prevent anastomosis dehiscence within digestive tract. The authors present a 37-year-old female patient who developed a chronic gastrocutaneous fistula after sleeve gastrectomy for severe obesity treated successfully with a combination of E-VAC and a fibrin sealant. Long term peritoneal drainage, total parenteral nutrition, and antibiotic therapy for the next six weeks failed to close the leakage. Ultimately the fistula was closed after 6 changes of E-VAC and final implementation of a fibrin sealant. The duration of treatment was 81 days, including 34 days of E-VAC treatment and FS application. Complete closure of the fistula was visualized on gastroscopy six weeks after the treatment.

Laparoscopic revision to total gastrectomy or fistulo-jejunostomy as a definitive surgical procedure for chronic gastric fistula after laparoscopic sleeve gastrectomy.

Staple-line leaks (SLL) after sleeve gastrectomy (SG) are a rare but serious complication requiring radiologic and endoscopic interventions with varying degrees of success. When failed, a chronic gastrocutaneous fistula forms with decreasing chances of closure with time. Definitive surgical management of chronic SLL after SG include laparoscopic revision to total/subtotal gastrectomy (LTG/LSTG) or a fistulo-jejunostomy (LRYFJ), both with Roux-en-Y reconstruction. Comparison of SG revisions to LTG/LSTG versus LRYFJ as a definitive treatment for chronic SLL. High-volume bariatric unit. Retrospective review of a prospectively maintained database identified 17 patients with chronic gastric fistula after SG that were revised to either LTG/LSTG or LRYFJ between September 2011 and May 2020. Demographic characteristics, clinical data, quality of life, and laboratory values for both options were compared. Of the 17 conversions, 8 were revised to LTG/LSTG and 9 to LRYFJ. Mean age and body mass index at revision were 36.85 years (range, 21-66 yr) and 29 kg/m2 (range, 21-36 kg/m2), respectively. Average preoperative endoscopic attempts was 5 (range, 1-16). The overall average operation time of revision was 183 minutes (range, 130-275 min) with no significant difference between either conversion options. Mean follow-up time was 46.5 months (range, 1-81 mo) and was available for 10 patients (58.8%). Food intolerance was significantly better after revision to LRYFJ (n = 6/6, 100% versus n = 1/5, 20%, P < .05). There were no significant differences between revisional procedures and laboratory abnormalities. Laparoscopic revision to LRYFJ is a safe and feasible treatment for chronic SLL.

A231 Laparoscopic Repair of Chronic Gastro-cutaneous Fistula from the Excluded Stomach 19 years after Gastric Bypass

A231 Laparoscopic Repair of Chronic Gastro-cutaneous Fistula from the Excluded Stomach 19 years after Gastric Bypass

External digital pressure to enable a deeper tulip-bundle technique for endoscopic closure of a refractory chronic gastrocutaneous fistula

External digital pressure to enable a deeper tulip-bundle technique for endoscopic closure of a refractory chronic gastrocutaneous fistula

Combined endoscopic techniques for closure of a chronic post-surgical gastrocutaneous fistula: case report and review of the literature (with video)

Several techniques have been proposed to seal post-operative leaks endoscopicaly, however, chronic fibrosed fistulas remain a tenacious problem. We describe the success of a combination of minimally invasive peroral endoscopic techniques to seal and permanently close a chronic gastrocutaneous fistula complicating a laparoscopic gastric bypass, these techniques included: fistuloscopy, argon plasma coagulation, mucosal stripping and the novel over-the-scope clips.

New endoscopic suturing device for closure of chronic gastrocutaneous fistula in an immunocompromised patient

New endoscopic suturing device for closure of chronic gastrocutaneous fistula in an immunocompromised patient

Endoscopic closure of GI fistulae by using an over-the-scope clip (with videos)

Preclinical studies have demonstrated the over-the-scope clip (OTSC) to be feasible and safe for closure of gastric, duodenal, and colonic perforations. A retrospective clinical study demonstrated the feasibility and preliminary safety of the OTSC for the treatment of GI bleeding and closure of acute GI perforations. Because the OTSC allows rapid and easy endoscopic organ wall closure, we hypothesized that it might be a useful tool to close GI fistulae. Case series. Academic medical center. Four consecutive patients with GI fistulae. In all patients, a 12-mm OTSC, in combination with the dedicated twin grasper, anchor device, or endoscopic suction, was used to facilitate endoscopic closure. In 2 cases, OTSCs allowed complete closure of a posttraumatic esophagopulmonary fistula and a chronic gastrocutaneous fistula. Leak tests and follow-up examination demonstrated complete leakproof closures. In 1 esophagopulmonary fistula and 1 jejunocutaneous fistula, the initial closure attempts using OTSCs were not successful because of chronic fibrotic changes and scarring at the fistula site. Both OTSCs were removed by using an endoscopic grasping forceps. The mean procedure time was 54 minutes (range 24-93 minutes). There were no procedure-related complications. Small sample size. The OTSC seems to be a feasible device to close chronic fistulae of the GI tract. It can achieve leakproof, full-thickness closure of transmural defects. Nevertheless, in circumstances of severe fibrosis and scarring, complete incorporation of the defect into the applicator cap and successful OTSC application might not be possible.

Total gastrectomy for failed treatment with endotherapy of chronic gastrocutaneous fistula after sleeve gastrectomy

e a g w m m s l 8 Sleeve gastrectomy has spread rapidly as a single standalone surgical procedure for the treatment of morbid obesity. It is considered a rapid procedure with good short-term results and low morbidity, although it can be associated with serious complications such as leakage at the esophagogastric junction. Little is known about this complication and its treatment. It can usually be treated with coated self-expandable stents; however, when this fails, leakage at the angle of His can be challenging for the surgeon, requiring complex surgical procedures.

Management of anastomotic leaks after Roux-en- Y bypass using self-expanding polyester stents

Background To analyze the outcomes of a series of endoscopically placed polyester self-expanding polyflex stents (SEPSs) for the management of anastomotic leaks after Roux-en- Y bypass. Anastomotic leaks after gastric bypass cause significant morbidity and mortality. Covered polyester SEPSs might have a role in the treatment of these leaks. Methods A retrospective chart review was performed from January 2006 to November 2006 that included all acute and chronic leaks treated with SEPSs. Results A total of 6 patients were treated with stents, with a mean procedure time of 22 minutes. Of these 6 patients, 5 had acute postoperative leaks and 1 had a chronic fistula. Five patients started oral intake 1–6 days after their procedure. All acute leaks had complete healing at a median of 44 days. The patient with a chronic gastrocutaneous fistula required revisional surgery for fistula closure. In addition, 5 patients had stent migration, and 3 required stent replacement. Conclusion An endoscopically placed SEPS provides a less-invasive alternative to treat acute anastomotic leaks after Roux-en- Y bypass while simultaneously allowing oral intake. The results of this case series have demonstrated this treatment to be safe and effective.

Treatment of Persistent Gastrocutaneous Fistula with Combined Electro-Chemical Cautery and Endoscopic Clips

Percutaneous Gastrostomy Tube (PEG tube) placement is a common endoscopic procedure performed for short or long term enteral nutrition supplementation. With the aging population, endoscopically placed gastrostomy tubes have become a frequent presence in nursing homes and hospitals. Gastrostomy tubes provide quick access to the alimentary tract and are used routinely for feeding and administering medications in populations that are unable to effectively swallow for a variety of etiologies. Development of gastrocutaneous fistula is a potential complication after removal of PEG tube. The standard treatment for such a chronic fistula is laparotomy with surgical closure of fistula tract, but is often contraindicated because of comorbidities. Conservative treatments have been tried with limited success. Seven patients with chronic non-healing gastrocutaneous fistulas were treated with electrochemical cauterization and endoscopic clip placement. The external portion of the fistula tract was cauterized using silver nitrate and internal portion was cauterized using gold probe cautery to de-epithelialize the fistula. Once the area was successfully denuded, one or two endoscopic clips were deployed to approximate the denuded tissue. Patients were placed on intravenous proton pump inhibitors to increase intragastric pH and intravenous metoclopramide to increase gastric motility. The combined electro-chemical cautery and endoscopic clip closure resulted in either complete closure of the persistent gastrocutaneous fistula or reduction in size of the fistula allowing replacement with a standard size PEG tube. One patient had persistent leakage from the gastrocutaneous fistula that ultimately required surgical intervention. Complications following gastrostomy tube removal are infrequent, but can lead to significant morbidity and possible mortality. Conservative treatment of gastrocutaneous fistula include mechanical devices causing obstruction of the fistula or pharmacologic measures such as raising gastric pH by high does PPIs or improving gastric motility with metoclopramide. Success rate of above mentioned measures is very low in clinical practice. Jonathan et al described successful closure of chronic gastrocutaneous fistulas in three children using combined electro-chemical cauterization and endoscopic clips. This method has not been described in the adult population. Combined electro-chemical cauterization and endoscopic clip closure is an alternative to surgical closure of chronic gastrocutaneous fistula. Further studies are required to determine long term success and efficacy of such therapy.

Combined endoscopic cautery and clip closure of chronic gastrocutaneous fistulas

Chronic gastrocutaneous fistula with intermittent drainage is a common outcome after removing long-standing gastrostomy tubes. The standard treatment is surgery with laparotomy and excision of the fistula tract. This study describes the results of an endoscopic closure technique by using a combination of electrocautery and metal clips. Three patients with gastrocutaneous fistulas (duration 3 months to 3 years) after gastrostomy tube removal were treated endoscopically by electrocautery of the tract and application of metal clips. Treatment resulted in complete fistula closure in two patients and partial closure in a third patient. Combined endoscopic therapy with electrocautery and clipping may be an alternative to surgical closure of chronic gastrocutaneous fistulas.

Gastrectomy for Complications of Bariatric Procedures.

BACKGROUND: Major complications of modern bariatric operations are infrequent but can be quite disabling to the patient and pose therapeutic challenges to the surgeon. We present our experience with five patients who underwent gastrectomy for complications following gastric reduction procedures. PATIENTS AND METHODS: Between 1991 and 1995, four women and one man, average age 46.8 years (34-66), underwent total gastrectomy and Roux-en-Y end-to-side esophagojejunostomy (4), or near-total gastrectomy with esophagogastrostomy (1). The decision to perform total gastrectomy was based on the poor quality of the remaining gastric pouch and the surgeon's judgement. Preoperative diagnoses included gastric outlet obstruction secondary to anastomotic ulcer or stricture, gastroesophageal reflux with esophagitis, chronic gastrocutaneous fistula, and iatrogenic linitis secondary to gastric wrap with mesh. Preoperatively, the patients complained of intolerable nausea, vomiting, abdominal pain, and dysphagia. RESULTS: in the five patients who underwent total or near-total gastrectomy, there was no operative mortality or morbidity; however, one patient (near-total gastrectomy) has required a second operation for pyloroplasty. Although one patient was lost to follow-up 6 months after surgery, the average follow-up for the remaining four patients is 2 years. These four patients were interviewed and all report complete satisfaction with their surgery and much improvement in their symptoms. Presently, they consume an average of three meals per day (range 2-6), with each meal measuring about 2 cups in size. All report the sensation of satiety after meals. All patients receive supplemental iron, B12, and multivitamins. From a nutritional standpoint, there has not been a significant change in the levels of albumin, total protein, hematocrit, weight and BMI since total gastrectomy. CONCLUSIONS: In our experience, total gastrectomy with Roux-en-Y end-to-side esophagojejunostomy is an appropriate therapy with low morbidity and mortality in highly selected patients with complications resulting from gastric reduction procedures.