Outpatient endoscopic closure of persistent gastrocutaneous fistula with hemoclips in pediatric patients

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.

Laparoscopic management of persistent gastrocutaneous fistula after feeding gastrostomy appliance removal in children

Background

Feeding gastrostomy is widely used in children that have troubles of swallowing and need to stablish enteral feeding. There are several methods for creation of that stoma. After the children gain their normal ability of swallowing, this tube or appliance is removed. Failure of spontaneous closure of gastrostomy opening after removal of the tube was reported with an incidence of 0.5 to 3.9%. The purpose of authors was to study laparoscopic management of persistent gastrocutaneous fistula after failure of conservative measures.

Results

There were 19 patients, 12 males. Main cause for feeding gastrostomy was neurological. Most feeding gastrostomy tubes were inserted endoscopically. The mean operative time was 57 ± 10.2 min. The mean time of full oral intake was 24 ± 3.5 h. No wound infection had developed. There was no recurrence of fistula after management.

Conclusion

Laparoscopic management of persistent gastrocutaneous fistula is safe, feasible, and associated with no recurrence of fistula.

Gastrocutaneous fistulae in children - A systematic review and meta-analysis of epidemiology and treatment options

BACKGROUND

Gastrostomy tubes are a common adjunct to the care of vulnerable pediatric patients. This study systematically evaluates the epidemiology and risk-factors for gastrocutaneous fistulae (GCF) after gastrostomy removal in children and reviews treatment options focusing on nonoperative management (NOM).

METHODS

After protocol registration (CRD-42017059565), multiple databases were searched. Studies describing epidemiology in children and GCF treatment at any age were included. Critical appraisal was performed (MINORS risk-of-bias assessment tool). One-sided meta-analysis was executed to estimate efficacy of therapeutic adjuncts using a random-effects model.

RESULTS

Sixteen articles evaluating pediatric GCF were identified. 44% defined GCF as persistence >1month which occurred in 31±7% of cases. Risk factors for pediatric GCF include age at gastrostomy, timing of removal, open technique, and fundoplication. Mean MINORS score was 0.60±0.16. Seventeen additional studies were identified reporting 142 patients undergoing NOM (endoscopic, systemic, and local therapies), and one pediatric comparative study was identified. Overall aggregate proportion of GCF closure after any NOM is 77% (80% success rate in local/systemic therapies; 75% success rate in endoscopic approaches). No adverse events were reported.

CONCLUSION

Persistent GCF complicates the management of gastrostomies in 1/3 of children with predictable risk factors. Several treatment options exist that obviate the need for general anesthesia. Their efficacy is unclear. Further prospective investigations are clearly warranted.

LEVEL OF EVIDENCE

III - Systematic Review and Meta-Analysis Based on Retrospective Case Control Studies.