Gastrocutaneous Fistula Research Articles

Extracellular Matrix Enterocutaneous Fistula Plugs Show Promise for Low-Flow Colocutaneous and Enterocutaneous Fistulae

PurposeTo evaluate extracellular matrix enterocutaneous fistula plugs (ECMFPs) in treatment of enteric fistulae at a single institution. Materials and MethodsThe study included 18 patients who had an ECMFP placed between 2012 and 2018 with treatment follow-up through July 2020. Median patient age was 52.5 years (interquartile range, 11.5 y). There were 28 ECMFP procedures performed on 19 separate fistulae. Fistulae locations were gastrocutaneous (n = 4), enterocutaneous (n = 9), and colocutaneous (n = 6). Descriptive statistics were used to define closure rates, recurrence rates, and complications. ResultsFistula closure was achieved in 1 of 4 gastrocutaneous (25%), 4 of 9 enterocutaneous (44%), and 3 of 6 colocutaneous (50%) locations. The median time from procedure to fistula tract closure was 29 days interquartile range 25 days. The median time from ECMFP placement to fistula recurrence was 28 days (interquartile range 27 days). Of the fistulae that eventually closed, 6 of 8 closed after the first attempt (75%), and 2 closed after the second attempt (25%). Of the procedures that resulted in complete closure, 7 of 8 were categorized as low flow, and 1 of 8 was categorized as high flow. Complications were seen in 4 patients (23%), with major complications in 3 patients (17%). ConclusionsLow-flow fistulae originating from the small bowel are most likely to have complete closure. High-flow and/or gastrocutaneous fistulae are less likely to benefit from this intervention. In patients who are not surgical candidates or who have failed surgical management, ECMFPs may provide a solution.

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

S2361 Endoscopic Ultrasound-Guided Gastrojejunostomy for the Treatment of Benign Gastric Outlet Obstruction

INTRODUCTION: We present a case of a successful endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) for the treatment of benign gastric outlet obstruction (GOO). CASE DESCRIPTION/METHODS: A 37 year-old obese (BMI 80) female with history of an open cholecystectomy presented with nausea and vomiting. Imaging demonstrated a GOO with an obstructive lesion seen at the site of her prior cholecystectomy. An EUS with fine-needle aspiration demonstrated chronic inflammatory changes without evidence of malignancy, and she was discharged with a percutaneous gastrojejunostomy (PEG-J) tube. The patient required frequent PEG-J revisions complicated by the location of the PEG insertion coupled with a deformed pylorus. In order to overcome the anatomy, an ultra-slim bronchoscope was instead used to serve as a rigid steering catheter to advance the wire into the distal small bowel. Unfortunately, despite a longer J-tube, she returned shortly after with a dislodged PEG-J tube, and EUS-GJ was performed given the extensive attempts of revisions. The upper endoscope was advanced under fluoroscopic guidance, and contrast was injected defining the stricture. Water with methylene blue was infused to distend the small bowel. The upper endoscope was exchanged for a linear echoendoscope after which a 19-gauge needle was used to puncture the small bowel from stomach, and methylene blue was aspirated confirming location. An electrocautery-enhanced lumen apposing metal stent (LAMS) was deployed resulting in successful creation of a gastrojejunostomy. The lumen of the LAMS was then dilated with a balloon dilator under fluoroscopic guidance. The stent was then secured in place with the OverStitch device. The patient’s PEG-J was removed and her gastrocutaneous fistula closed using an over the scope clip. The patient tolerated a regular diet without any complications and was discharged. DISCUSSION: Our case highlights the use of bronchoscope to navigate deformed sites that would otherwise be difficult with a flexible angiocatheter. Secondly, it highlights the emergence of EUS-GJ as an innovative alternative to surgical gastrojejunostomy and enteral stenting in benign or malignant GOO. Studies suggests EUS-GJ to be superior to the conventional therapy as it is less invasive and provides lower GOO recurrence and reintervention rates. The EUS-GJ in our patient was technically successful and allowed for resumption of an oral diet, and it signifies EUS-GJ is an effective and potentially safe alternative to conventional treatments of GOO.Figure 1.: Fluoscopic images of navigating through the site of gastric outlet obstruction.Figure 2.: Needle puncture of jejunum under echosonography.Figure 3.: Post-LAMS deployment in gastric body.

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.

Malignant Leakage After Sleeve Gastrectomy: Endoscopic and Surgical Approach.

Gastric leak occurs after sleeve gastrectomy (SG) in 2% of cases. Most staple-line disruptions (SLD) can be successfully treated with first-line endoscopic procedures. Less favorable situations may lead to more complex therapeutic strategies, like conversion to Roux-en-Y gastric bypass (RYGBP). The aim of our study is to predict the factors of endoscopic treatment failure and to assess the safety of conversion to RYGBP. We included all patients treated in two centers of academic excellence (n = 100) between 2013 and 2017 who had a malignant SLD after SG. A "malignant" leakage met one of the following poor prognosis criteria suggested in the literature: unsuccessfully treated by the first-line endoscopic treatment; generalized peritonitis; anatomical anomalies; gastro-cutaneous or gastro-pleural fistula (GCF/GPF); or chronic leaks (> 4weeks). No deaths occurred during the follow-up (20 ± 12months). The endoscopy reported an anatomically abnormal gastric tube in 35 (35%) patients (stenosis [n = 21 (21%)], twist [n = 9 (9%)], or both [n = 5 (5%)]). We could maintain the SG in place in 92% of cases without stenosis, twist, or GCF/GPF. Conversion to RYGBP due to leakage was necessary in 37 (37%) patients. Stenosis, twist, or GCF/GPF significantly prevented healing in multivariate analysis (respectively: p = 0.020, OR = 0.17, and p < 0.001, OR = 0.07-logistic regression). Endoscopy is the treatment of choice for the management of chronic leaks after SG. The association of anatomical anomalies and GCF/GPF should lead to consideration of conversion to RYGBP.

Gastrocutaneous fistulas after PEG removal in adult cancer patients: frequency and treatment options.

PEG removal in head and neck cancer patients (HNCPs) is performed after treatment, in case of disease remission and after adequate oral intake is resumed. The PEG tract usually closes spontaneously within 2-3days. Persistent gastrocutaneous fistula (GCF) is a rare complication after PEG tube removal and is characterized by the persistence of gastric leakage through the fistulous tract for more than 1month. Our main goal was to access the incidence and the success of a treatment algorithm for GCF in HNCPs. Retrospective unicentric study of HNCPs referred for PEG removal between 2014 and 2018. The patients with GCF were selected and their sequential treatment was reviewed. In 331 patients with PEGs removed, 19 (5.7%) GCFs were documented. Medical therapy (4-8weeks) was performed with clinical success (definitive closure of the GCF) in 12 (63.2%) patients. The remaining seven patients required endoscopic or surgical treatment. In four, endoscopic treatment had technical and clinical success (in three patients with fulguration of the gastric leak edges with argon plasma coagulation, silver nitrate in the path and external orifice, and closure of the internal orifice with hemoclips and in one with an over-the-scope-clip). Only three patients underwent surgery, one due to clinical failure of sequential endoscopic therapy and two had direct surgery. GCF occurs rarely after PEG removal in HNCPs. Medical therapy is usually effective and should be maintained for at least 8weeks. Endoscopic therapy is an effective second-line option with and surgery rarely required.

A simplified laparoscopic-assisted gastrostomy technique: a single center experience

BackgroundAlthough percutaneous endoscopic gastrostomy (PEG) is considered simple and effective, major complications have been reported because of the partly blind placement technique. Laparoscopic gastrostomy was described to overcome most of the problems and the contraindications of PEG. Various modifications have been reported to anchor the stomach to the abdominal wall.This study aims at highlighting a single center experience using a simplified technique for gastrostomy and evaluates its outcome.ResultsThe age of the patients ranged from 7 days to 3 years (mean 11.75 ± 12 months in group A and 16 ± 3 months in group B). The mean body weight at time of gastrostomy was 6.5 ± 4.6 kg in group A and 7.5 ± 2 in group B. The mean operative time was 24.8 ± 4 min in group A and 25 ± 1.6 in group B, ranging from 18 to 31 min. The incidence of gastrostomy-related complications was 20% (three cases) in group A versus 12.5% (one case) among patients included in group B. Yet, this difference was statistically insignificant (p = 0.651). No major complications were reported apart from persistent gastrocutaneous fistula in one out of eight cases followed after removal of the gastrostomy (12.5%). There is no significant difference in the outcome either in neonates or in patients less than 5 kg.ConclusionsThe described simple technique of laparoscopic-assisted gastrostomy is easy, effective, and with a very low incidence of complications. It is also equally safe in neonates and children less than 5 kg.

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

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.

Management of gastrocutaneous fistulas following gastrostomy: surgery as a therapeutic option.

Gastrocutaneous fistulas (GCF) following removal of gastrostomy tubes are an uncommon complication with many therapeutic options. It is a drawback that concerns both patient and surgeon, hindering the decision to perform an invasive treatment. Despite emerging minimally invasive procedures, we must not forget that surgery continues to be the standard treatment when they all fail.

Late closure by secondary intention of a large gastrocutaneous fistula after complicated percutaneous endoscopic gastrostomy

Late closure by secondary intention of a large gastrocutaneous fistula after complicated percutaneous endoscopic gastrostomy

2150 Successful Endoscopic Closure of a Pyeloduodenal Fistula Using the Over-the-Scope Clip System

INTRODUCTION: Approximately 100 cases of pyeloduodenal fistula (PDF) have been reported in the literature. PDF most often results from pyelonephritis due to nephrolithiasis, when inflammation extends to the duodenum given its relative immobility and lack of posterior peritoneal covering. Diagnosis of a PDF is usually made with computed tomography (CT) of the abdomen with contrast. The mainstay of therapy for PDF is nephrectomy and primary closure of the duodenum. We are presenting the second documented case of endoscopic closure of a PDF using the over-the-scope clip (OTSC) system and the third case of endoscopically treated PDF. This method provides an alternative to open surgery. CASE DESCRIPTION/METHODS: A 62 year old female presented with sharp, severe abdominal pain. She denied back pain, hematuria, fever, and dysuria. She had no significant past medical history and did not take any medications. CT abdomen and pelvis demonstrated a large right-sided staghorn calculus extending into the renal pelvis. The patient underwent percutaneous nephrolithotomy, which was complicated by perforation of the renal pelvis and abdominal compartment syndrome. Subsequently, a proximal ureteral stricture was refractory to stenting and balloon dilation. CT urography demonstrated a PDF (Image 1). After placement of a metallic ureteral stent and nephrostomy tube, a nephrostogram was negative for extravasation, so the patient underwent EGD to evaluate for the resolution of the PDF. During the procedure, iohexol contrast and methylene blue were inserted via nephrostomy tube, and fluoroscopic imaging showed contrast in the right kidney and bladder without extravasation. However, on endoscopy, methylene blue extravasation led to identification of two mucosal defects in the anterior duodenal sweep (Image 2). The larger defect was closed using the helix tissue retractor and OTSC system (12/6 t-type) (Image 3). The smaller defect was closed with 2 hemostasis clips. Follow-up renal scan and CT imaging showed no evidence of contrast extravasation. DISCUSSION: The OTSC is an innovative endoscopic technique most often used for hemostasis and for treatment of endoscopic or surgical complications (e.g., fistula, leakage, or perforation). Most reports document successful OTSC use for fistula closure including gastrocutaneous and esophageal fistulas. Our case is, to our knowledge, the second ever documented PDF closure using the OTSC system.

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

Late closure by secondary intention of a large gastrocutaneous fistula after complicated percutaneous endoscopic gastrostomy

Late closure by secondary intention of a large gastrocutaneous fistula after complicated percutaneous endoscopic gastrostomy

Atypical and Life-threatening Crohn’s Disease Following Colectomy: A Case Report

The purpose of this case study was to describe successful treatment of atypical and life-threatening CD due to enterocutaneous fistulas with short-bowel syndrome and multiorgan failure after partial colectomy. After an urgent colectomy for an inflammatory colon tumor, a 64-year-old woman with a history of CD and multiple comorbidities developed acute small bowel ischemia. Following an extended bowel resection, she developed a severe surgical site infection, entero- and gastrocutaneous fistulas, multiorgan failure, and short bowel syndrome. Her care included intensive medical and nutritional treatment as well as negative pressure wound therapy (NPWT) using continuous negative pressure of -80 mm Hg. She not only survived, but she also achieved complete wound closure and restoration of digestive tract continuity and metabolic control. She was discharged with a central venous catheter on total parenteral nutrition. In this case study, a good outcome was observed using intensive medical treatment, nutritional therapy, and conservative surgical treatment that included NPWT for a patient with CD and major comorbidities who developed postoperative complications.

Mo1303 PERSISTENT GASTROCUTANEOUS FISTULAS AFTER PERCUTANEOUS ENDOSCOPIC GASTROSTOMY TUBE REMOVAL IN HEAD AND NECK CANCER PATIENTS WITH EARLY FEEDING AND DOUBLE-DOSE PPI: A PROSPECTIVE COHORT STUDY WITH A HISTORICAL CONTROL GROUP

Percutaneous endoscopic gastrostomy (PEG) removal is required in head and neck cancer patients (HNCP), after chemoradiotherapy ends and adequate oral intake is reacquired. The PEG tract usually closes spontaneously within 48-72 hours. Persistent gastro-cutaneous fistula (PGCF) is an uncommon complication of PEG removal.

A Prospective Evaluation of Non-Operative Treatments for Gastrocutaneous Fistulae in Children

A Prospective Evaluation of Non-Operative Treatments for Gastrocutaneous Fistulae in Children

Persistent Fistula after Sleeve Gastrectomy: A Chronic Dilemma

Background: There is no time limit for the occurrence of leaks after sleeve gastrectomy LSG, and very late ones might evolve versus persistent, chronic fistulas. The aim of this retrospective study was to analyze the incidence, treatment and outcomes of persistent, chronic fistulas occurred or treated in a bariatric Center of Excellence IFSO-EC (CoE) and to establish a standardized approach. Materials Methods: between 2011-2018, nine cases of postoperative leaks occurred on a total of 1365 LSG performed (0.65%), 7 of them having late presentations (onset over 10 days postoperative). Chronic, persistent fistulas were identified and analyzed, including one gastro-bronchial and one gastro-cutaneous fistulas. Results: We present three peculiar cases of very late, chronic type III fistulas, with onset at 6-84 months after primary LSG and their management, including conservative, interventional radiology and endoscopy and surgical therapies. Conclusions: the management of late, chronic type III fistula is variable, with no standard algorithm to follow, but it should be planned based on the clinical evaluation, time of diagnosis, available resources, multidisciplinary approach and expertise. This emphasises again the necessity of a bariatric CoE that can guarantee a better diagnose and treatment, based on the use of wide, available resources, both professional and material.

PEG use in patients with squamous cell carcinoma.

I read with great interest the paper by Sousa M. Tumor seeding of the fistula tract should be suspected in patients with a previous history of esophageal or nasopharynx squamous cell carcinoma who have undergone a Percutaneous Endoscopic Gastrostomy (PEG) with a persistent gastrocutaneous fistula. Especially after the use of an OTSC. In fact, the "pull technique" for PEG tube placement should not be used in this context.

A231 - Robot assisted takedown of gastrocutaneous fistula and conversion of sleeve gastrectomy to RNY gastric bypass

A231 - Robot assisted takedown of gastrocutaneous fistula and conversion of sleeve gastrectomy to RNY gastric bypass

FINDING OF MEGAESOPHAGUS ON POINT-OF-CARE ULTRASOUND

SESSION TITLE: Imaging SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 pm - 02:15 pm INTRODUCTION: A whole body approach to point-of-care ultrasound (POCUS) in the ICU along with a good history and physical exam is essential to making a diagnosis and guiding treatment. We present a patient with known achalasia and peptic ulcer disease who presented to the ICU for hematemesis and hypotension. POCUS was effectively used to identify acute megaesophagus. CASE PRESENTATION: A 51 year old female with a history of achalasia with esophageal dilation and Heller myotomy 1 year prior, hiatal hernia with Nissen fundoplication 5 months prior, presented with coffee ground emesis. She underwent an esophagogastroduodenoscopy (EGD) which showed a possible Mallory Weiss tear versus a Cameron lesion. An adherent clot was removed with a snare, and it was injected with epinephrine and endoclips were placed. The esophageal mucosa appeared very friable. Two days later, she had hematemesis with tachycardia and hypotension to systolic blood pressure of 70mmHg. A hemoglobin was paradoxically elevated to 8.9g/dL compared to 7.9g/dL earlier that day. The hemoglobin decreased to 6.3g/dL in a few hours which responded to fluid and blood transfusion. A chest xray immediately prior to ICU transfer showed a new mediastinal opacification (Figure 1). A POCUS was performed by the critical care fellow to determine the cause of abdominal distention and hypotension (Figure 2). The ultrasound findings were suspicious for a significantly dilated esophagus. Based on this finding, a CT chest, abdomen and pelvis with IV contrast was performed. The esophagus was markedly distended throughout its course and contained pooling oral contrast and debris consistent with megaesophagus (Figure 3). The patient was offered esophagectomy with colonic interposition. She refused intervention at the time and during a future elective admission, she had a total esophagectomy, feeding jejunostomy, resection of gastro-cutaneous fistula and pyloroplasty. DISCUSSION: POCUS is often compartmentalized with the critical care physician focusing on 1 organ system (reference 1). In this hypotensive patient, limiting the bedside ultrasound evaluation to a basic cardiac examination would not have been adequate. Knowing this patients history and applying it to her acute presentation puts acute esophageal pathology at the top of the differential diagnosis. Using the ultrasound to locate additional mediastinal structure revealed an abnormally dilated esophagus posterior to the left atrium. This was best seen from a right midaxillary approach. The POCUS exam expedited a CT study and urgent evaluation by a surgical team. CONCLUSIONS: POCUS can be performed by ICU providers to successfully make diagnoses without transporting critically ill patients. With continued success, POCUS interpretation in the ICU will gain further credibility and reduce the number of additional imaging studies ICU patients receive (reference 2). Reference #1: Narasimhan, Mangala., Koenig, Seth., Mayho, Paul. A Whole-Body Approach to Point of Care Ultrasound. Chest 2016; 150(4):772-776 Reference #2: Oks, Margarita., Cleven, Krystal., Cardenas-Garcia, Jose. et al. The Effect of Point-of-Care Ultrasonography on Imaging Studies in the Medical ICU. Chest 2016; 146(6):1574-1577 DISCLOSURES: No relevant relationships by Morium Akthar, source=Web Response No relevant relationships by Scott Ferrara, source=Web Response No relevant relationships by Anne Sutherland, source=Web Response