Refractory Gastrocutaneous Fistula Research Articles

Refractory gastrocutaneous fistula after gastrostomy removal successfully treated with submucosal dissection and endoscopic suture.

Refractory gastrocutaneous fistula after gastrostomy removal successfully treated with submucosal dissection and endoscopic suture.

Refractory gastrocutaneous fistula treated by two-stage surgery: a case report

BackgroundGastrocutaneous fistulas are a rare complication of enterocutaneous fistulas and can be caused by intestinal injury, infection, and anastomotic leakage. They are typically treated conservatively or endoscopically; however, for large or difficult-to-treat gastrocutaneous fistulas, surgical intervention is required. Herein, we present a case of a huge gastrocutaneous fistula that was successfully treated with a two-stage surgery performed using open abdomen management.Case presentationA 61-year-old man with a perforated gastric ulcer underwent omental filling as an emergency surgery. Post-operative leakage led the development of a 10-cm gastrocutaneous fistula. He was transferred to our hospital for the treatment of gastrocutaneous fistula. Furthermore, nutritional therapy was administered for dehydration, electrolyte abnormalities, metabolic acidosis, and acute kidney injury due to the high-output nature of the fistula. Moreover, owing to the intraperitoneal severe adhesion and poor nutritional status, two-stage surgery was planned. In the first stage, extensive dissection of the adhesions, distal gastrectomy reconstruction with Roux-en-Y anastomosis, and jejunostomy were performed. Furthermore, open abdomen management was conducted to check for the presence of unexpected complications due to extensive dissection of the adhesion and anastomotic leakage. Subsequently, in the second stage of the surgery, abdominal closure was performed on the 9th day after gastrectomy.ConclusionOpen abdomen management may be effective for huge gastrocutaneous fistulas with extensive adhesions that require surgical intervention.

Closure of refractory gastrocutaneous fistula with endoscopically guided percutaneous suturing with the use of miniature biopsy forceps.

Video 1Closure of a refractory gastrocutaneous fistula with endoscopically guided percutaneous suturing with the use of miniature biopsy forceps.

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).

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.

919 Novel Hybrid Technique for Closure of Refractory Gastrocutaneous Fistula: Endoscopically-Guided Percutaneous Suturing

The reported incidence of a persistent gastrocutaneous fistula (GCF) after PEG tube removal is less than 5% in adults. There are many factors associated with persistent GCF, such as poor nutritional status, long duration of tube placement, and gastrointestinal motility disorder. There is no standard treatment for persistent GCF and the management is challenging. Conservative medical management is associated with poor results. Fistulotomy or gastrectomy are definite therapies; however, patients are usually poor candidates for surgical therapy, which is associated with high rates of morbidity.

Endoluminal closure of gastrogastric fistula

Gastrogastric fistulas have a reported incidence of 1.3%–12% after gastric bypass for treatment of morbid obesity. The fistula can occur as a result of incomplete division of the stomach or staple line dehiscence, in the setting of a chronic or perforated marginal ulcer, or as a sequela of staple line leak. In the acute setting, patients can present with tachycardia, fevers, and abdominal pain. However, the development of a gastrogastric fistula in a chronic setting is more subtle: Patients may experience weight regain, postprandial abdominal pain with associated marginal ulcers, and esophageal reflux. Management traditionally consists of surgical revision with associated morbidity [ [1] Corcelles R. Jamal M.H. Daigle C.R. Rogula T. Brethauer S.A. Schauer P.R. Surgical management of gastrogastric fistula. Surg Obes Relat Dis. 2015; 11: 1227-1232 Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar ]. Here we report on a treatment option that consists of endoscopic intervention with complete closure of the fistula with added benefits of same-day surgery, decreased operative time, no incisions, and minimal morbidity [ 2 Kantsevoy S.V. Thuluvath P.J. Successful closure of a chronic refractory gastrocutaneous fistula with a new endoscopic suturing device (with video). Gastrointest Endosc. 2012; 75: 688-690 Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar , 3 Kumar N. Thompson C.C. Transoral outlet reduction for therapy of weight regain after gastric bypass: long-term follow-up. Gastrointest Endosc. Epub 2015 sep 5; Google Scholar ].

Enterocutaneous Fistula Plug Placement as a Successful Endoscopic Intervention for Management of a Refractory Gastrocutaneous Fistula: ACG Clinical Vignette Award Presidential Poster

Introduction: Chronic gastrocutaneous fistulae (GCF) can tremendously impact patients’ health and quality of life. Multiple endoscopic interventions have been reported to assist in GCF closure including clips, cyanoacrylate, tissue adhesives, and endoscopic suturing. Porcine small intestine submucosa (SIS) Biodesign® Enterocutaneous Fistula Plug (EFP) (Cook Medical, Bloomington, IN) is designed to assist with the closure of enterocutaneous fistulae. We report this case to share our experience of using this device for the closure of a refractory GCF. Methods: A 46-year-old female developed a splenic abscess 7 months after sleeve gastrectomy, requiring laparotomy with splenectomy and percutaneous drain placement that led to formation of a GCF. A partially covered esophageal stent was placed at an outside hospital to aid with closure. Retrieval attempt 2 months later was unsuccessful due to robust tissue ingrowth. Upon referral to our medical center, 2 overlapping fully covered stents were placed inside the partially covered stent with 1-2 cm of overlap on the distal and proximal ends with the intent of causing pressure necrosis on ingrown tissue to facilitate removal of the partially covered stent. All 3 stents were removed after 2 weeks; the fistula was observed in the proximal stomach about 15 mm distal to the GEJ. Surgical consultation was obtained but surgical repair was declined. At a subsequent EGD, the GCF tract was abraded with a brush and treated with Argon Plasma Coagulation for de-epithelialization. Over-the-scope clip (OTSC, Ovesco Endoscopy USA, Los Gatos, CA) closure was then performed with apparent technical success. Unfortunately, the fistula continued to drain and this persisted for few months; as such, closure with the Biodesign EFP was elected. After tract dilation, a 22 Fr Wilson Cook Biodesign® EFP was passed over the guidewire and deployed into the tract, with good seating of the internal retention disk confirmed endoscopically. Results: The patient had no further fistula drainage and the external aspect of the fistula was noted to be well-healed at a follow-up office visit one month later. Conclusion: Leaks leading to formation of fistulous tracts are a known complication after bariatric surgery. Insertion of porcine SIS to facilitate closure has been reported in cases of refractory enterocutanoeous and perinanal fistulae. A SIS product developed specifically for enterocutaneous fistulae has recently been developed and FDA approved. In our case, this wire-guided SIS EFP was successful in closing a chronic GCF when other modalities had failed.

Successful closure of a chronic refractory gastrocutaneous fistula with a new endoscopic suturing device (with video)

A PEG tube was placed in a 66-year-old man with unresectable squamous cell tongue and soft palate carcinoma. The PEG was removed in October 2009, and since that time, he had a persistent gastrocutaneous fistula with leakage of gastric content. Multiple attempts to close the fistula using endoscopic clips and glue had failed.

M1407: Transpyloric Feeding (TP) Tube Promotes Closure of Refractory, Non-Healing Gastrocutaneous (GC) Fistulae Following Removal of Percutaneous Endoscopic Gastrostomy (PEG) Tube

Gastrocutaneous fistula commonly develop following removal of PEG feeding tubes. However, healing and closure of the fistula occurs in most cases. Rarely, persistent leakage is a sign of non-healing or refractory gastrocutaneous fistula. Several operative techniques have been utilized to achieve healing of GC fistula. These include surgical closure or endoscopic approaches as fibrin glue, endoclipping, laser, electrochemical cautery etc.

Endoscopic Fibrin Sealant Injection with Application of Hemostatic Clips: A Novel Method of Closing a Refractory Gastrocutaneous Fistula

Endoscopic Fibrin Sealant Injection with Application of Hemostatic Clips: A Novel Method of Closing a Refractory Gastrocutaneous Fistula

3501 Endoscopic fibrin sealant injection with application of hemostatic clips: a novel method of closing a refractory gastrocutaneous fistula.

Background: Management of non-healing gastrocutanous fistula is difficult especially in debilitated patients. Methods: On an elderly man with advanced stage esophageal cancer and sever oxygen-dependent lung disease; who had persistent acid leakage from the percutaneous endoscopic gastrostomy site, small stripes of absorbable fiber(Surgicel)were introduced from the cutaneous side of the fistula and fibrin sealant(Tisseel® VH)with its two components was endoscopically injected through a specially designed syringe(Duploject® applicator) and catheter (Duplocath® 180, Immuno AG,Vienna, Austria) in addition to applying of four hemeostatic clips(Rotatable clip fixing device HX-5LR-1. Olympus,America INC,Melville,N.Y) on the gastric aspect of the fistula. Results: stopping of the leakage was successful,permanent and prevented more morbidity with no complication. Conclusion: We believe that our new technique is a novel and successful one, but large study is needed to define the proper candidates and success rate.

Endoscopic fibrin sealant injection: a novel method of closing a refractory gastrocutaneous fistula

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