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

Endoscopic removal of a weight-loss device with stoma closure using a tack-and-suture device

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Endoscopic closure of persistent gastrocutaneous fistula in children

PURPOSE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

A novel procedure for gastrocutaneous fistula closure

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) tubes have allowed for a safe and efficient way to feed patients who cannot tolerate oral feeding, yet have a functioning gastrointestinal tract. Gastrocutaneous fistulas (GCF) after PEG removal are an unusual and rare complication in adults and may be in part due to poor tissue healing, delayed gastric emptying, or increased gastric acid production. Various approaches have been reported to treat PEG-related gastric fistulas; however, their success rate is variable and patients frequently require repeat procedures or >1 technique in combination, including acid suppression therapy, silver nitrate ablation of the PEG tract lining, argon plasma coagulation, fibrin glue, and/or endoclipping. Upon our review, there have been no published case series reporting the use of endoscopic banding to close persistent GCFs after PEG removal.

STUDY DESIGN

Four patients with persistent GCFs after PEG removal were taken for esophagogastroduodenoscopy with banding of the fistula site. This procedure was chosen due to its relative ease of application. Patient follow-up was by telephone within 3 days of having the procedure and then again 1 to 2 weeks afterward, to ensure that there was no persistent leakage through the fistula tract.

RESULTS

Of the 4 patients who had persistent GCFs after PEG removal, endoscopic banding resulted in complete closure of the fistula in 3 of our 4 patients. In 1 case, banding was unsuccessful secondary to scarring from prior radiation treatment as well as having a previous PEG tube placed 1 inch from the current fistula site. In this case, a second PEG tube was placed through the original PEG stoma, leading to cessation of the gastric leak. The first case resulted in no recurrence after 3 years. The second and third cases have shown no recurrence after 3 months. The fourth case resulted in a second PEG tube to manage persistent drainage through the tract after unsuccessful banding of the site due to complex endoscopic and anatomic issues.

CONCLUSIONS

Endoscopic closure of a GCF, regardless of technique used, can help avoid surgical intervention. Anatomic changes from any previous treatment modalities may decrease the success rate of fistula banding. However, in our patients, endoscopic banding proved to be a safe and relatively simple alternative in closing persistent GCFs due to prior PEG tubes.

Endoscopic hole and clipping technique: a novel technique for closing the wide orifice of a postoperative fistula

BACKGROUND

Endoscopic clipping for closing a fistula created by surgery is often difficult because of the combination of a wide orifice and fibrosis. Creating holes for prongs of a clip may constitute a new endoscopic clipping technique for closing the wide orifice of a fistula.

OBJECTIVE

To assess the feasibility of performing the endoscopic hole and clipping technique (EHCT).

DESIGN

Experimental pilot study.

SETTING

Tertiary-care referral center.

PATIENT

This study involved 1 patient who underwent EHCT.

INTERVENTIONS

EHCT was performed.

MAIN OUTCOME MEASUREMENTS

Technical success and procedural complications of EHCT.

RESULTS

Immediately after the procedure, drainage decreased dramatically and finally decreased to 0 mL/d. There was no evidence of a leak on fluoroscopic examination, and upon 4-month follow-up, we found that no symptoms had developed in the patient.

LIMITATIONS

Single-patient pilot study.

CONCLUSIONS

EHCT is very simple and efficient. EHCT can be applied as a means of closing the orifice of a postoperative fistula that is not easily managed by simple endoscopic clipping.

Incidence and predictors of gastrocutaneous fistula in the pediatric patient

Background/Purpose. To determine the incidence, predictors, and outcomes of repair of gastrocutaneous fistulae (GCF) in pediatric patients. Methods. Patients were identified through a medical records search of all gastrostomy insertions performed from 1997–2007. Results. Of 1083 gastrostomies, 49 had GCF closure. Gastrostomy indications were reflux/aspiration (30/43 [70%]) and feeding intolerance/failure to thrive (7/43 [16%]). Gastrostomies were performed as open surgical procedures (84%) with fundoplication (66% of all cases) at an age of 0.5 ± 0.57 (median ± inter-quartile range) years. Gastrostomies were removed in outpatient settings when no longer used and were present for 2.3 ± 2.2 years, and GCF persisted for 2.0 ± 3.0 months. GCF were closed by laparotomy and stapling. GCF closure length of stay was 2.0 ± 3.3 days. Complications occurred in 6/49 patients and included infection/fever (4/6) and localized skin redness/breakdown (2/6). Conclusions. From our collected data, GCFs occur at a frequency of 4.5% and persist for 2.0 ± 3.0 months until closed. Given the complicated medical histories of patients and relatively high rate of postoperative infection/reaction (12.2%), GCF closure is not a benign, “uncomplicated” procedure. Further information describing factors determining which patients develop GCF requiring closure is needed.

Endoscopic fibrin sealing of gastrocutaneous fistulas after sleeve gastrectomy and biliopancreatic diversion with duodenal switch

BACKGROUND AND AIM

Gastrocutaneous fistulas (GCF) are uncommon complications accounting for 0.5-3.9% of gastric operations. When their management is not effective, the mortality rate is high. This study reports the conservative treatment of GCF in morbidly obese patients who underwent biliopancreatic diversion with duodenal switch.

METHODS

Ninety-six morbidly obese patients were treated in our department with biliopancreatic diversion with duodenal switch (Marceau technique) and, in six of them, a high-output GCF developed. A general protocol was applied to all patients presenting a GCF. Everyone was treated by total parenteral nutrition (TPN) and somatostatin for at least 7 days after the appearance of the leak. If the leak continued, then fibrin glue was used as a tissue adhesive. Endoscopic application of the sealant was accomplished under direct vision via a double-lumen catheter passed through a forward-viewing gastroscope.

RESULTS

All patients were treated successfully with conservative treatment (either solely with TPN and somatostatin, or with endoscopic fibrin sealing sessions). No evidence of fistula was observed at gastroscopy 3 and 24 months after therapy.

CONCLUSION

The conservative treatment of GCF following biliopancreatic diversion with duodenal switch is highly effective. All patients should enter a protocol that includes TPN and somatostatin. When the GCF persist, endoscopic sealing glue should be considered before operation because it is simple, safe, effective and, in some cases, life-saving. Therefore, conservative treatment should be employed as a therapeutic option in GCF developing after bariatric surgery.