Closure Of Gastrocutaneous Fistula Research Articles

Use of High-Frequency Electrical Stimulation in Gastrocutaneous Fistula Closure: A Case Report

Background. Gastrocutaneous fistula is a rare complication following Roux-en-Y gastric bypass, a commonly performed bariatric surgery. While most ECFs respond to conservative management, some do not close despite adequate nutritional support, infection source control, and drainage management. As such, the chronicity of these difficult-to-treat wounds can be physically and economically costly to patients. Case Report. A 53-year-old female with a history of Roux-en-Y gastric bypass developed a gastrocutaneous fistula secondary to a perforated gastrojejunal ulcer, requiring immediate surgical intervention. After being discharged from the hospital, 37 days of conservative management and NPWT did not reduce the size of the fistula tract. To help control the patient’s chronic abdominal pain and increase the rate of wound healing, the patient underwent treatment with HFES (20 kHz) delivered using a handheld transcutaneous electrical nerve stimulator. This electrotherapy was found to reduce the majority of the patient’s pain within the first treatment session. The patient's fistula also began to decrease in size within 1 week of initiating treatment. Conclusion. This case report details the successful closure of a gastrocutaneous fistula after administration of HFES 3 times a week over the course of 25 days. The mechanism of action of HFES and its role in the wound healing process are also discussed.

S2481 Closure of Refractory Gastrocutaneous Fistula With Endoscopically Guided Percutaneous Suturing With the Use of SpyBite Biopsy Forceps

Introduction: Persistent gastrocutaneous fistula (GCF) is a rare but well-known complication of long-term Percutaneous Endoscopic Gastrostomy (PEG) tube use. To avoid invasive surgery, endoscopic closure has been used as an initial step for treatment but is not always successful. We report a case of successful GCF closure with a novel endoscopically guided percutaneous suturing technique using the SpyBite biopsy forceps. Case Description/Methods: Our case is a 28-year-old male with a history of cystic fibrosis (CF) complicated by malnutrition, requiring PEG tube placement since childhood. After starting CF therapy with elexacaftor/tezacaftor/ivacaftor and achieving optimal nutritional status, his PEG tube was removed. Unfortunately, he developed a persistent GCF. Initial attempts at closure with over-the-scope-clip and endoscopic suturing failed. The decision was made to proceed with GCF closure by endoscopically guided percutaneous suturing using the SpyBite forceps. Under endoscopic guidance, 2 16G long angiocaths were advanced into the gastric lumen, one caudal and one cranial to the fistula tract in a sterile fashion. A 2-0 silk suture was advanced through one angiocath and externalized using SpyBite biopsy forceps through the other angiocath. The angiocaths were then removed over the suture and the loop was tied down using a surgical knot. This process was repeated 2 more times along the fistula tract, 5mm from each other. Internal closure of the GCF was then performed using endoscopic suturing. One interrupted and 2 running sutures were placed along the border and cinched to reinforce the site. There were no immediate adverse events or delayed skin inflammation. The patient had no further leakage from the GCF site at follow-up 2 weeks later (Figure). Discussion: With the emergence of novel CF therapies, the dependence on feeding tubes has decreased. Unfortunately, these patients are at high risk of GCF formation after PEG tube removal. Given the difficulty in closing GCF, we advocate a multimodality approach, as described here, using transcutaneous and endoscopic suturing. In previously described endoscopically guided percutaneous suturing, the suture loop is externalized through the GCF tract or the mouth. Our technique differs in using SpyBite forceps to externalize the suture through a second catheter. This method is simple and provides a safe and effective alternative for the closure of refractory GCFs.Figure 1.: A-B: Gastrocutaneous fistula before (A) and after closure (B). C-D: 2-0 silk suture inserted through the angiocath and SpyBite forceps inserted through the second angiocath. The suture was grasped with SpyBite forceps and pulled through the second angiocath to form a loop (C: external view, D: endoscopic view) E-F: The suture was pulled externally, and a surgical knot was performed (E: external view, F: endoscopic view).

TU1.12 Video Presentation: The OVESCO Clip for Endoscopic Treatment of Gastrocutanoeus Fistula

Abstract Background Percutaneous endoscopic gastrostomy (PEG) is an important route of nutrition in many patients. PEG removal usually leads to spontaneous closure in a few days. Gastrocutaneous fistula (GCF) after PEG removal is an uncommon complication occurring in 2% of patients. Despite its rarity, it is responsible for significant morbidity and reduced quality of life. Treatment is initially focused on medical management and endoscopic clipping, with advanced endoscopic techniques and surgery reserved for selected cases. Method We present a video presentation demonstrating successful endoscopic treatment of GCF using the OVESCO Over the Scope clip with resolution of symptoms and closure of the fistula tract. The device is a novel innovation designed to achieve tissue apposition and compression without ischaemia. It is licensed for Gastrointestinal iatrogenic defects, endoscopic perforation, bleeding and GCF. The 72 year old patient had debilitating symptoms of gastric leakage for over a year despite previous attempts at endoscopic clipping, fibrin glue and curettage of the fistula tract. Results As shown in the video, the clip achieved good opposition with no post procedural leak. The patient was reviewed at 3 and 12 months with no recurrence of their symptoms. The external cutaneous opening had closed at 3 months. The patient reported an increase in weight, improved mood and a greater quality of life following the intervention. Conclusion The OVESCO clip has been proven to facilitate successful endoscopic closure of GCF in selected patients in whom initial treatment measures have failed. This mitigates the need and risks of surgical closure.

Necrotizing soft tissue infection following use of Punch Excision of Epithelialized Tract (PEET) procedure for gastrocutaneous fistula closure

Persistent gastrocutaneous fistula (GCF) is a common complication after removal of a gastrostomy tube. Many different techniques for GCF closure have been described. A novel technique involving a punch biopsy device was recently described, called the Punch Excision of Epithelialized Tract (PEET) procedure. This case report describes a serious complication of necrotizing soft tissue infection after utilizing the PEET procedure for a GCF closure.

An Evaluation of Pediatric Gastrocutaneous Fistula Closure Through the Punch Excision of Epithelized Tract Procedure.

Persistent gastrocutaneous fistulae frequently complicate gastrostomy tube placement. A minimally invasive technique for tract closure employing balloon catheter retraction and punch excision of the epithelized tract (PEET) was recently reported. We hypothesized the PEET technique of closure would lead to decreased complications without an increased incidence of recurrence. We conducted a single-center retrospective cohort study evaluating children who underwent gastrocutaneous fistula (GCF) closure 1/1/2018-12/31/2021, comparing patients who underwent the PEET procedure to those repaired with layered closure. Procedure duration and outcomes were additionally compared to the 2018-2019 National Surgical Quality Improvement Program (NSQIP) Participant Use File (PUF) database. Sixty-two children underwent operative GCF closure, including 25 with PEET and 37 traditional layered closure. Procedural time was significantly decreased employing PEET (14 vs 26minutes, P < .0001), less than half the national median by the NSQIP PUF database of 292 GCF closures (14 vs 34.5minutes, P < .0001). Those repaired with the PEET method experienced no episodes of recurrence, surgical site infection, readmission, reoperation, or mortality within 30days of the procedure. Conversely, in traditional closure, there was a 24.3% complication rate, including 7 surgical site infections, 1 readmission, and 2 unplanned reoperations. National procedural complication rate by NSQIP PUF was 5.5%, with a 4.8% rate of surgical site infection, .3% reoperation incidence, and .3% mortality. Our study suggests GCF closure employing the PEET procedure is a safe, more efficient method of tract closure than the traditional layered closure technique.

Persistent gastro-cutaneous fistula closure with tack suture system in the setting of a severe esophageal stricture.

Video 1Endoscopic video demonstrating an esophageal stricture, which was dilated, resulting in a deep tear without perforation. Previously placed hemoclips were visualized and removed. argon plasma coagulation was applied to denude the fistula epithelium. Subsequent demonstration of the use of the tack suturing system to close a persistent gastro-cutaneous PEG fistula.

Patient selection for pediatric gastrostomy tubes: Are we placing tubes that are not being used?

IntroductionIdentifying pediatric patients who may benefit from gastrostomy tube (GT) placement can be challenging. We hypothesized that many GTs would no longer be in use after 6 months. MethodsInpatient GT placements in patients < 18 years old at a tertiary children's hospital from 9/2014 to 2/2020 were included. The primary outcome was GT use <6 months (short-term). Secondary outcomes included age at placement, indication for GT, and operations for GT-related issues. ResultsFifteen percent (22/142) of GTs were used for <6 months post-operatively. The median duration of short-term GT use was 1.6 months (IQR 0.9–3.4 months). Short-term GTs were more likely to be placed in patients with traumatic brain injury (TBI) (18.2% vs. 4.2%, p = 0.03) and adolescents (≥12 years old, 22.7% vs. 4.0%, p = 0.005). Gastrocutaneous fistula closure was required in 33.3% of short-term patients who had their GTs removed (n = 6/18), with median total hospital charges of $29,989 per patient. ConclusionFifteen percent of pediatric GTs placed as inpatients were used for <6 months, more commonly among adolescents and in TBI patients. One-third of patients with short-term GTs required gastrocutaneous fistula closure. Adolescents and TBI patients may benefit from consideration of short-term nasogastric tube (NGT) feeds rather than surgical GT placement. Level of EvidenceIII

The PEET procedure: Punch Excision of Epithelialized Tracts for gastrocutaneous fistula closure

Background: Persistent Gastrocutaneous Fistula (GCF) is common problem encountered in the pediatric population. Several management options for intervening on pediatric persistent GCF have been described and range from open surgical management to medical management. Here we describe a novel adaptation on a previously described technique that utilizes a punch biopsy to excise the GCF we have coined as Punch Excision of Epithelialized Tracts (PEET). Methods: The steps to this procedure include passing a punch biopsy tool over a Foley catheter. The catheter is inserted into the GCF tract, the balloon is inflated, the catheter is retracted against the abdominal wall, and the punch biopsy instrument is pushed through the skin and subcutaneous tissue circumferentially excising the tract. Results: Four patients at our institution have undergone GCF excision using the PEET approach. Mean duration of the GCF in our four patients was 9 months. Mean follow-up after GCF excision using the PEET approach was 7.8 months. No patients in the cohort had any post-operative complications including surgical site wound infection, emergency department visits, or re-hospitalizations related to their surgical care. Conclusion: Based on our preliminary findings in this small patient cohort, we believe the PEET approach for managing persistent pediatric GCF has short-term efficacy and has the potential upside of utilizing fewer hospital resources to perform the procedure in a time-efficient manner.

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.

S2374 Getting Closure: Gastrocutaneous Fistula Repair in the Era of Endoscopic Suturing

INTRODUCTION: Formation of a gastrocutaneous fistula (GCF) is an uncommon complication following gastrostomy tube removal. GCFs rarely close spontaneously leading to nutrition support challenges and poor patient quality of life. Methods for endoscopic closure include glue injection, banding, and use of endoclips, however limited data exists about the efficacy of endoscopic suturing for GCF management. We aimed to evaluate the success of endoscopic suturing in closure of gastro-cutaneous fistulae after gastrostomy tube removal. CASE DESCRIPTION/METHODS: We performed a retrospective study using our electronic endoscopy database between 2018 and 2019. All patients during the study period who underwent endoscopic suture for closure of GCF after gastrostomy tube removal were identified. Data was collected regarding patient characteristics, co-morbid conditions as well as technical success, clinical success and procedure complication rate. Endoscopic suturing of GCF using the Apollo Overstitch system was performed six times in four patients. The average age was 69 years and 75% of patients were female. All patients had previous attempt for closure of GCF with either suturing of the skin (n = 3), bedside debridement (n = 1) or over-the-scope clip (n = 1). Debridement of the fistulous tract was performed in all patients undergoing endoscopic suturing using argon plasma coagulation and/or cytology brush. Endoscopic suturing was technically successfully in 100% of the cases and immediate post-procedure clinical success was achieved in 100% of cases. Long-term clinical success rate was achieved in 3 out of 4 patients (75%) with median follow up of 124 days. No procedure-related complications were observed. The only patient without durable clinical success had an over the scope clip in place which wasn’t able to be removed prior to suturing. DISCUSSION: Our initial experience suggests that endoscopic suturing is a safe and effective modality for closure of gastrocutaneous fistulae following gastrostomy tube removal and may be considered as first line therapy in these challenging clinical cases.Table 1.: Patient demographic data, surgical history, and periprocedural information.Table 2.: Procedural information and outcomes

Outpatient Curettage and Electrocautery as an Alternative to Primary Surgical Closure for Pediatric Gastrocutaneous Fistulae

BACKGROUND The development of a gastrocutaneous fistula (GCF) after gastrostomy tube removal is a frequent complication that occurs 5%-45% of the time. Conservative therapy with chemical cauterization is frequently unsuccessful, and surgical GCF repair with open primary layered closure of the gastrotomy is often required. We describe an alternative approach of GCF closure that is an outpatient, less invasive procedure that allows patients to avoid the comorbidities of general endotracheal anesthesia and intraabdominal surgery. METHODS This is an Institutional Review Board approved retrospective review of all patients who underwent GCF closure from January 2010 to July 2016 at a tertiary care children's hospital. Demographics including age, weight, body mass index, comorbidities, and initial indication for gastrostomy tube were recorded. Operative details such as ASA score, operative duration, type of anesthesia, and airway were noted. Based on surgeon preference, two types of operative closure were used during that time frame: primary layered closure or curettage and cautery (C&C). The latter is a procedure in which the fistula tract is first scraped with a fine curette, and then the fistula opening and tract are cauterized circumferentially. Finally, the presence of a persistent fistula and the need for formal reoperation were determined. RESULTS Sixty-five unique patients requiring GCF closure were identified. Of those, 44 patients (67.6%) underwent primary closure and 21 patients (32.3%) underwent C&C. The success rate of primary closure was 97% with one patient experiencing wound breakdown with persistent fistula. The overall success rate of C&C was 66.7% (14/21). Among those 14 patients, 11 (52.4%) GCF patients were closed by 1 mo. An additional two patients' gastrocutaneous fistulae were closed by 4 mo (61.9%). One GCF was successfully closed with a second C&C procedure. Seven of the 21 patients (33.3%) required subsequent formal layered surgical closure. C&C had significantly shorter operative times (13.5 ± 14.7 min versus 93.4 ± 61.8, P <0.0001) and significantly shorter times in the postanesthesia care unit (101.8 ± 42.4 min versus 147 ± 86, P <0.0001). Patients were intubated with an endotracheal tube 88.6% of the time for primary closure and 23.8% of the time for C&C.Among patients admitted for an elective procedure, the average length of stay for primary closure was 1.9 d as compared to 0 d for the C&C group. Among patients who underwent C&C with a persistent fistula, there were no significant differences in time since initial creation of gastrostomy, age, body mass index, or ASA score. CONCLUSIONS Our study verifies that primary closure remains the gold standard for persistent GCF. However, C&C is a safe, outpatient procedure that effectively treats a GCF the majority of the time in children. We suggest that in select patients, it may be an appropriate initial and definitive procedure for GCF closure.

Outpatient curettage and electrocautery as an alternative to primary surgical closure for pediatric gastrocutaneous fistulae

BackgroundThe development of a gastrocutaneous fistula (GCF) after gastrostomy tube removal is a frequent complication that occurs 5%-45% of the time. Conservative therapy with chemical cauterization is frequently unsuccessful, and surgical GCF repair with open primary layered closure of the gastrotomy is often required. We describe an alternative approach of GCF closure that is an outpatient, less invasive procedure that allows patients to avoid the comorbidities of general endotracheal anesthesia and intraabdominal surgery. MethodsThis is an Institutional Review Board approved retrospective review of all patients who underwent GCF closure from January 2010 to July 2016 at a tertiary care children's hospital. Demographics including age, weight, body mass index, comorbidities, and initial indication for gastrostomy tube were recorded. Operative details such as ASA score, operative duration, type of anesthesia, and airway were noted. Based on surgeon preference, two types of operative closure were used during that time frame: primary layered closure or curettage and cautery (C&C). The latter is a procedure in which the fistula tract is first scraped with a fine curette, and then the fistula opening and tract are cauterized circumferentially. Finally, the presence of a persistent fistula and the need for formal reoperation were determined. ResultsSixty-five unique patients requiring GCF closure were identified. Of those, 44 patients (67.6%) underwent primary closure and 21 patients (32.3%) underwent C&C. The success rate of primary closure was 97% with one patient experiencing wound breakdown with persistent fistula. The overall success rate of C&C was 66.7% (14/21). Among those 14 patients, 11 (52.4%) GCF patients were closed by 1 mo. An additional two patients’ gastrocutaneous fistulae were closed by 4 mo (61.9%). One GCF was successfully closed with a second C&C procedure. Seven of the 21 patients (33.3%) required subsequent formal layered surgical closure. C&C had significantly shorter operative times (13.5 ± 14.7 min versus 93.4 ± 61.8, P <0.0001) and significantly shorter times in the postanesthesia care unit (101.8 ± 42.4 min versus 147 ± 86, P <0.0001). Patients were intubated with an endotracheal tube 88.6% of the time for primary closure and 23.8% of the time for C&C.Among patients admitted for an elective procedure, the average length of stay for primary closure was 1.9 d as compared to 0 d for the C&C group. Among patients who underwent C&C with a persistent fistula, there were no significant differences in time since initial creation of gastrostomy, age, body mass index, or ASA score. ConclusionsOur study verifies that primary closure remains the gold standard for persistent GCF. However, C&C is a safe, outpatient procedure that effectively treats a GCF the majority of the time in children. We suggest that in select patients, it may be an appropriate initial and definitive procedure for GCF closure.

Cautery Is Key: A Case of Recalcitrant Gastrocutaneous Fistula (GCF) Closed by Electrocautery

Introduction: Percutaneous endoscopic gastrostomy (PEG) tubes provide durable enteral nutrition in patients unable to maintain adequate per oral intake.Conservative closure methods may prove unsuccessful and surgical closure is not without risk. Several endoscopic closure methods have been described with varying success. We describe a case of persistent GCF closed via unique methods. Case: A 53-year old female with spinal cord injury underwent PEG placement for dysphagia. Several years later, her dysphagia resolved and the PEG was removed with manual traction. She experienced daily, large volume leakage through the GCF 6 weeks after tube removal. Examination was notable for granulation tissue around the fistula. Given the failure of GCF closure with conservative measures (i.e. PPI & topical silver nitrate), an EGD was performed. The EGD revealed an 8mm diameter, 15mm deep fistula in the gastric body. Due to evident growth of gastric mucosa in the GCF, ablation of the entire tract lining was performed using the Wilson Cook 7 Fr Quicksilver probe (Effect 2, 20 Watts); subsequently 4 ECs were applied. Externally, the opening was cauterized with silver nitrate and filled with fibrin glue. The patient was NPO for 24 hours and placed on BID PPI. Two days post-procedure she continued to have drainage from the fistula site but by day 3 the drainage ceased and follow-up over the next 6 weeks confirmed successful closure of the tract. Discussion: Several endoscopic techniques have been described to treat persistent GCF. These modalities have their limitations when used alone: ECs maintain superficial grasp of the mucosa only and fibrin glue has minimal efficacy. BPC (bipolar cautrey) causes acute injury to the mucosa resulting in release of cytokines and interleukins, promoting inflammation and transforming a chronically epithelialized site into one of acute inflammation. This promotes healing via the standard pathways involved in repair of acute injuries. In our case, the delay of GCF closure by 2 days post-procedure suggests against the effectiveness of glue and clips in this patient, and rather, supports our hypothesis; BPC catalyzed an acute inflammatory state at the GCF site along with de-epithelization of the GCF tract, promoting closure. For small fistulas, cautery alone may be sufficient for healing and more cost effective than over the scope clips or endoscopic stitching techniques, although further studies will be needed to substantiate these outcomes.

Salvage of a failed open gastrocutaneous fistula repair with an endoscopic over-the-scope clip

Abstract Once enteral access via gastrostomy tube (G-tube) is no longer indicated, the tube is typically removed in clinic with a high probability of spontaneous closure. When spontaneous closure is not achieved, the formation of a gastrocutaneous fistula (GCF) is possible. The incidence of GCF is directly related with the length of time the tube has been placed. When conservative management fails, surgical intervention is the standard treatment. Endoscopic techniques have been described for primary closure of GCF in adults including banding and cauterizing of the fistula tract with placement of a standard endoscopic clip. Over-the-scope clips (OTSC) have recently been reported in primary GCF closure in children (Wright et al., 2015). In patients with skin irritation surrounding a GCF making surgical repair difficult, endoscopic OTSC closure provides particular benefit. It is our belief that this is the first case report of endoscopically salvaging a leak from a failed open GCF repair.

Endoscopic closure of gastrocutaneous fistula with an AMPLATZER(TM) septal occluder device.

Gastrocutaneous fistulas are rare and difficult to treat complications with an incidence of 1.7–4% in patients who have undergone bariatric surgery, and are associated with high morbidity and mortality rates with difficult management problems [Nguyen et al. 2001]. They mostly occur after iatrogenic gastric injury, breakdown of a gastroenteric anastomosis, or disruption of stapler suture lines [Papavramidis et al. 2008]. Treatment is varied and dependent on the size of the fistula as well as its time course in relation to surgery, and on the patient’s underlying conditions.

The Role of Medication in Spontaneous Gastrocutaneous Fistula Closure.

Factors precipitating persistence of gastrocutaneous fistulas (GCFs) are not clearly understood. The role of proton pump inhibitors (PPIs) or histamine receptor antagonists in GCF closure is not yet studied. We aimed to identify whether these medications influence spontaneous GCF closure. Retrospective review was performed on children who underwent gastrostomy tube insertion and removal from January 2010 to February 2013. Spontaneous GCF closure rates and medication use during gastrostomy tube removal were investigated. Of the 97 patients included, 48 had spontaneous GCF closure, whereas 49 required operative closure. When comparing these two groups, no significant difference existed in spontaneous GCF closure rates among patients who were on ranitidine, PPIs, or both (p = 0.09, p = 0.83, p = 0.06 respectively). Spontaneous closure occurred more in older patients (2.7 ± 4.1 vs. 0.9 ± 1.6 years, p < 0.01) and in patients without fundoplication at time of tube insertion (12.5 vs. 30.6%, p = 0.05). There were more laparoscopic placements in the group that closed spontaneously (83 vs. 61%, p = 0.02). Mean gastrostomy tube presence was longer in patients who required surgery than those with spontaneous closures (18.7 ± 10.3 vs. 35.5 ± 36.6 months, p < 0.01). Ranitidine or PPI use upon removal of gastrostomy tubes does not seem to facilitate spontaneous GCF closure in children.

Initial results of endoscopic gastrocutaneous fistula closure in children using an over-the-scope clip.

Gastrocutaneous fistula (GCF) occurs commonly in pediatric patients after removal of long-term gastrostomy tubes. Although open repair is generally successful, endoscopic approaches may offer benefits in terms of incisional complications, postoperative pain, and procedure time. In addition, endoscopic approaches may offer particular benefit in patients with varied degrees of skin irritation or erosion surrounding a GCF, making surgical repair difficult, or patients with significant comorbidities, making minimal intervention and anesthesia time preferable. Over-the-scope (OSC) clips are a new technology that enables endoscopic closure of intestinal fistulas up to 2 cm in diameter. Six pediatric patients underwent endoscopic GCF closure using OSC clips under Institutional Review Board approval. The procedure was technically successful in 5 of 6 cases with an average operating time of 29 minutes. The technical failure required an open revision, whereas all other patients reported full healing of the GCF site at 1 month. All successful cases were performed as outpatients without postoperative narcotics. In addition, all patients reported high satisfaction with the procedure and cosmetic results. Endoscopic GCF closure using an OSC clip is technically feasible in the pediatric population. Based on limited cases with a 1-month follow-up, the functional and cosmetic results of technically successful cases are excellent. Endoscopic GCF closure is a potential alternative to standard surgical closure in patients with skin irritation or erosion and/or significant comorbidities.

Endoscopic closure of persistent gastrocutaneous fistula in children.

The incidence of persistent gastrocutaneous fistula (GCF) after removal of gastrostomy tubes in pediatric patients is estimated to be up to 44 %. Our aim was to review the outcomes of GCF closure by an endoscopic technique that utilizes cautery and endoclips. A retrospective analysis of patients who underwent endoscopic treatment for persistent GCF from January 2010 to September 2013 was performed. This technique utilized esophagogastroduodenoscopy with cauterization of the fistula track and endoclipping of the gastric mucosa. Sixteen patients underwent endoscopic treatment for persistent GCF. Mean age at time of endoscopy was 7.5 ± 5.5 (1.1-17) years. Gastrostomy tubes were in place for mean of 5.4 ± 5.2 (0.5-14.2) years prior to removal. The average time from gastrostomy tube removal to first endoscopic clipping was 6.7 ± 9 (0.1-28.9) months. Seven patients (44 %) had successful closure after one endoclipping procedure. Six patients underwent a second endoclipping procedure, with three successful closures. Four patients (25 %) required surgical closure for persistent fistulas and 2 (13 %) have continued drainage. While endoscopy with cautery and endoclipping proves to be safe, many patients require multiple procedures and may require surgical closure. Patient selection and refinement of this technique may improve outcomes.

Investigating the Role of Medication in Spontaneous Gastrocutaneous Fistula Closure

Investigating the Role of Medication in Spontaneous Gastrocutaneous Fistula Closure

Use of OTSC Device System for Closure of Fistulas in the Alimentary Tract – A Case Series

ObjectiveWe report our experience – a case series with the Over the Scope Clip (OTSC), Bear claw, a novel and new tool for the endoscopic entrapment of tissue for closure of fistula and perforations. DesignSingle-center. SettingTertiary referral academic gastroenterology unit and center for advanced therapeutic endoscopy. PatientCase I – referred for endoscopic treatment for the closure of gastrocutaneous fistula (GC).Case II – referred for endoscopic treatment for the closure of colo-vaginal fistula.Case III – referred for endoscopic treatment for the closure of GC fistula. InterventionThe OTSC system was mounted on the tip of the scope and passed down to the level of the fistula. The targeted site of the fistula was grasped with the tissue anchoring tripod and pulled into the cap with concomitant scope channel suction. Once the tissue was trapped in the cap, the Bear claw was deployed. Main outcome measurementsNA. ResultsAll patients recovered. No complication or recurrence noted. Case I showed successful results with closure of the fistula. Case II fistula was not closed due to the cavity beneath the fistula probably abscess formation – which prevented the healing of the fistula site despite of the closure with OTSC. Case III fistula did not close successfully due to the larger diameter of the fistula which was greater than 1 cm. ConclusionWith several new devices being introduced, it is difficult to judge the implementation of one tool over the others. This device has shown promising results for fistula closure if used knowing the limitation of the product.