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Elmahdi A, Eisa M, Martindale R, Omer E. Persistent Ostomy Following Percutaneous Endoscopic Gastrostomy Removal: Treatment Strategies. Curr Gastroenterol Rep 2024; 26:53-56. [PMID: 38194110 DOI: 10.1007/s11894-023-00912-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2023] [Indexed: 01/10/2024]
Abstract
PURPOSE OF REVIEW The purpose of this article is to review available literature on management of persistent ostomy following PEG tube removal. We will discuss the incidence of persistent gastrocutaneous fistula (GCF) following PEG tube removal, risk factors for their development, and management strategies that have been proposed and their efficacy. RECENT FINDINGS The use of over the scope clips (OTSC) have evolved recently in the management of gastrointestinal bleeding, perforation, and fistula closures. OTSC has become more readily available and proven to be effective and safe. Suturing devices have shown promising results. Persistent gastrocutaneous fistula following PEG removal is a rare yet serious complication that can lead to continuous skin irritation and leakage of gastric contents and acid. There are several postulated risk factors but the most important of these is duration of placement. Management can include medical therapy which has recently been shown to be somewhat effective, endoscopic therapy and surgery as a last resort. Overall, the data on GCFs is limited and further study with larger sample size is needed.
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Affiliation(s)
- Alsiddig Elmahdi
- Virginia Commonwealth University Health Systems, Richmond, VA, USA
| | - Mohamed Eisa
- Allegheny Center for Digestive Health, Allegheny Health Network, Pittsburgh, PA, USA
| | - Robert Martindale
- Department of Surgery, Oregon Health Sciences University, Portland, OR, USA
| | - Endashaw Omer
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, 530 S Jackson St ACB bldg 3rd floor, 40202, Louisville, KY, USA.
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Baruah A, Kee Song LMW, Buttar NS. Endoscopic management of fistulas, perforations, and leaks. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2015. [DOI: 10.1016/j.tgie.2016.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Pierog A, Martinez M, Mencin A. Outpatient endoscopic closure of persistent gastrocutaneous fistula with hemoclips in pediatric patients. Gastrointest Endosc 2014; 80:1190-3. [PMID: 25281501 DOI: 10.1016/j.gie.2014.07.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 07/17/2014] [Indexed: 12/11/2022]
Affiliation(s)
- Anne Pierog
- Division of Pediatric Gastroenterology, New York Medical College, Valhalla, New York, USA
| | - Mercedes Martinez
- Pediatric Gastroenterology, Hepatology, and Nutrition, Columbia University Medical Center, New York, New York, USA
| | - Ali Mencin
- Pediatric Gastroenterology, Hepatology, and Nutrition, Columbia University Medical Center, New York, New York, USA
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Rahman FN, Stavas JM. Interventional radiologic management and treatment of enterocutaneous fistulae. J Vasc Interv Radiol 2014; 26:7-19; quiz 20. [PMID: 25443456 DOI: 10.1016/j.jvir.2014.09.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 09/10/2014] [Accepted: 09/13/2014] [Indexed: 12/15/2022] Open
Abstract
Enterocutaneous fistulae (ECFs) are abnormal sinus tract communications between the alimentary system and skin surface that can cause significant management problems and cost to the health care system. Interventional radiology can play an important role in diagnosis and treatment when conventional measures fail and additional surgery is difficult or poses a high risk. The management of patients with fistulae requires operator ingenuity and dedication, a multidisciplinary team approach, and an understanding of the pathophysiology. This article reviews the major issues in ECF management and the role of interventional radiology.
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Affiliation(s)
- Feraz N Rahman
- Division of Vascular and Interventional Radiology, University of North Carolina, 101 Manning Dr., CB 7510, Chapel Hill, NC 27599-7510
| | - Joseph M Stavas
- Division of Vascular and Interventional Radiology, University of North Carolina, 101 Manning Dr., CB 7510, Chapel Hill, NC 27599-7510.
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Cambj Sapunar L, Sekovski B, Matić D, Tripković A, Grandić L, Družijanić N. Percutaneous embolization of persistent low-output enterocutaneous fistulas. Eur Radiol 2012; 22:1991-7. [PMID: 22544294 DOI: 10.1007/s00330-012-2461-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 02/19/2012] [Accepted: 03/01/2012] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To present and retrospectively evaluate the technique of percutaneous embolization of chronic enterocutaneous fistulas (ECFs) using n-butyl-2-cyanoacrylate and Lipiodol under fluoroscopic guidance. METHODS Six patients with a total of seven post-operative low-output ECFs of the large intestine were treated. After fistulography a hydrophilic guide wire and a catheter were advanced through the ECF into the intestine. After dilation of the bowel with saline and contrast medium, the catheter was withdrawn into the enteric orifice and glue together with Lipiodol was injected while simultaneously pulling the catheter. RESULTS Complete closure of all seven fistulas was achieved. There were no peri-procedural complications. In one patient 1 month following embolization a low-output enteric discharge was observed, but the ECF spontaneously healed 5 days later. In one patient 18 months after the embolization a new perforation due to diverticulitis close to the embolization site occurred and resection of the sigmoid colon was performed. One patient needed reoperation due to a recurrence of rectal carcinoma. CONCLUSIONS In our series of patients, the presented technique of percutaneous embolization proved to be efficacious and easy to perform. It may have potential as a first-line treatment of low-output ECFs but a prospective study with a larger series of patients and a longer follow-up is required.
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Affiliation(s)
- Liana Cambj Sapunar
- Department of Diagnostic and Interventional Radiology, University Hospital Split, Spinciceva 1, 21 000 Split, Croatia.
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Parlak E, Dişibeyaz S, Köksal AS, Umit H, Ulaş M. A new approach to gastrointestinal fistula closure: endoloop and clips technique using double endoscope. Eur J Gastroenterol Hepatol 2012; 24:464-7. [PMID: 22410716 DOI: 10.1097/meg.0b013e32834f6017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Several endoscopic techniques have been described for closure of gastrointestinal fistulas. Herein, we describe a case of iatrogenic gastric fistula successfully treated with a new approach by simultaneous insertion of two endoscopes and using the endoloop and endoclips technique.
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Affiliation(s)
- Erkan Parlak
- Department of Gastroenterology, Turkey Yüksek İhtisas Education and Training Hospital, Ankara, Turkey
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Lee JK, Stein SL. Radiographic and endoscopic diagnosis and treatment of enterocutaneous fistulas. Clin Colon Rectal Surg 2011; 23:149-60. [PMID: 21886464 DOI: 10.1055/s-0030-1262982] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The management of enterocutaneous fistulas continues to be a challenging postoperative complication. Understanding the anatomy of the fistula optimizes its evaluation and management. Diagnostic radiology has always played an important role in this task. The use of plain radiography with contrasted studies and fistulograms is well documented in the earliest investigations of fistulas and they continue to be helpful techniques. The imaging techniques have evolved rapidly over the past 15 years with the introduction of cross-sectional imaging, ultrasound and endoscopy. The purpose of this chapter is to review both the diagnostic and therapeutic roles of fistulograms, small bowel follow-through, computed tomography, magnetic resonance imaging, ultrasound, and endoscopy in the setting of acquired enterocutaneous fistulas.
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Affiliation(s)
- Jennifer K Lee
- Department of Surgery, University Hospitals, Case Medical Center, Cleveland, Ohio
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Double endoloop technique for hole closure on the gastrointestinal tract: human application. Clin Gastroenterol Hepatol 2011; 9:e104-5. [PMID: 21459159 DOI: 10.1016/j.cgh.2011.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2011] [Revised: 03/08/2011] [Accepted: 03/21/2011] [Indexed: 02/07/2023]
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Endoscopic Management of Drain Inclusion in the Gastric Pouch after Gastrojejunal Leakage after Laparoscopic Roux-en-Y Gastric Bypass for the Treatment of Morbid Obesity (LRYGBP). DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2010; 2010:891345. [PMID: 20634928 PMCID: PMC2903945 DOI: 10.1155/2010/891345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2010] [Accepted: 05/01/2010] [Indexed: 01/12/2023]
Abstract
Background. Drain inclusion inside the gastric pouch is rare and can represent an important source of morbidity and mortality associated with laparocopic Roux-en-Y gastric bypass (LRYGBP). These leaks can become chronic and challenging. Surgical options are often unsuccessful. We present the endoscopic management of four patients with drain inclusion.
Patients. All four obese morbidly patients underwent LRYGBP and presented a gastro-jejunal fistula after acute anastomotic leakage. During follow-up endoscopy the drain was found inside the gastric pouch. It was moved into the abdominal cavity. Fistula debit reduced significantly and closed. Results. Gastric leak closure in less than 24 hours was achieved in all, with complete resolution of symptoms. These patients benefited exclusively from endoscopic treatment. Conclusions. Endoscopy is useful and technically feasible in chronic fistulas. This procedure is a less invasive alternative to traditional surgical revision. Other therapeutic strategies can be used such as clips and fibrin glue. Drains should not be placed in contact with the anastomosis or stapled lines. Drain inclusion must be suspected when fistula debit suddenly arises. If so, endoscopy is indicated for diagnostic accuracy. Under endoscopy vision, the drain is gently removed from the gastric reservoir leading to sudden and complete resolution of the fistula.
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Avalos-González J, Portilla-deBuen E, Leal-Cortés CA, Orozco-Mosqueda A, Estrada-Aguilar MDC, Velázquez-Ramírez GA, Ambriz-González G, Fuentes-Orozco C, Guzmán-Gurrola AE, González-Ojeda A. Reduction of the closure time of postoperative enterocutaneous fistulas with fibrin sealant. World J Gastroenterol 2010; 16:2793-800. [PMID: 20533600 PMCID: PMC2883136 DOI: 10.3748/wjg.v16.i22.2793] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess whether the use of fibrin sealant shortens the closure time of postoperative enterocutaneous fistulas (ECFs).
METHODS: The prospective case-control study included 70 patients with postoperative ECFs with an output of < 500 mL/d, a fistulous tract of > 2 cm and without any local complication. They were divided into study (n = 23) and control groups (n = 47). Esophageal, gastric and colocutaneous fistulas were monitored under endoscopic visualization, which also allowed fibrin glue application directly through the external hole. Outcome variables included closure time, time to resume oral feeding and morbidity related to nutritional support.
RESULTS: There were no differences in mean age, fistula output, and follow-up. Closure-time for all patients of the study group was 12.5 ± 14.2 d and 32.5 ± 17.9 d for the control group (P < 0.001), and morbidity related to nutritional support was 8.6% and 42.5%, respectively (P < 0.01). In patients with colonic fistulas, complete closure occurred 23.5 ± 19.5 d after the first application of fibrin glue, and spontaneous closure was observed after 36.2 ± 22.8 d in the control group (P = 0.36). Recurrences were observed in 2 patients because of residual disease. One patient of each group died during follow-up as a consequence of septic complications related to parenteral nutrition.
CONCLUSION: Closure time was significantly reduced with the use of fibrin sealant, and oral feeding was resumed faster. We suggest the use of fibrin sealant for the management of stable enterocutaneous fistulas.
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Keshaw H, Thapar N, Burns AJ, Mordan N, Knowles JC, Forbes A, Day RM. Microporous collagen spheres produced via thermally induced phase separation for tissue regeneration. Acta Biomater 2010; 6:1158-66. [PMID: 19733702 DOI: 10.1016/j.actbio.2009.08.044] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2009] [Revised: 08/10/2009] [Accepted: 08/31/2009] [Indexed: 11/29/2022]
Abstract
Collagen is an abundant protein found in the extracellular matrix of many tissues. Due to its biocompatibility, it is a potentially ideal biomaterial for many tissue engineering applications. However, harvested collagen often requires restructuring into a three-dimensional matrix to facilitate applications such as implantation into poorly accessible tissue cavities. The aim of the current study was to produce a conformable collagen-based scaffold material capable of supporting tissue regeneration for use in wound repair applications. Microporous collagen spheres were prepared using a thermally induced phase separation (TIPS) technique and their biocompatibility was assessed. The collagen spheres were successfully cross-linked with glutaraldehyde vapour, rendering them mechanically more stable. When cultured with myofibroblasts the collagen spheres stimulated a prolonged significant increase in secretion of the angiogenic growth factor, vascular endothelial growth factor (VEGF), compared with cells alone. Control polycaprolactone (PCL) spheres failed to stimulate a similar prolonged increase in VEGF secretion. An enhanced angiogenic effect was also seen in vivo using the chick embryo chorioallantoic membrane assay, where a significant increase in the number of blood vessels converging towards collagen spheres was observed compared with control PCL spheres. The results from this study indicate that microporous collagen spheres produced using TIPS are biologically active and could offer a novel conformable scaffold for tissue regeneration in poorly accessible wounds.
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Affiliation(s)
- Hussila Keshaw
- Biomaterials and Tissue Engineering Group, Centre for Gastroenterology & Nutrition, University College London, London, UK
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Wood J, Leong S, McCarter M, Pearlman N, Stiegmann G, Gonzalez RJ. Endoscopic-assisted closure of persistent gastrocutaneous fistula with a porcine fistula plug: report of a new technique. Surg Innov 2010; 17:53-6. [PMID: 20097672 DOI: 10.1177/1553350609359921] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Persistent gastrocutaneous (GC) fistula is a rare but problematic complication of gastrostomy feeding tube removal. Several techniques for nonoperative fistula closure have been attempted with mixed results. None has proven both satisfactorily simple and consistently effective. The authors present a case of persistent GC fistula treated by a simple outpatient endoscopic-assisted procedure using a porcine anal fistula plug. The procedure requires only basic endoscopic skills, similar to percutaneous gastrostomy tube placement, and it involves minimal operative time and risk to the patient. This technique offers a potential solution to the troublesome problem of persistent GC fistula.
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Affiliation(s)
- James Wood
- University of Colorado at Denver, Aurora, CO, USA
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Closure of a nonhealing gastrocutanous fistula using argon plasma coagulation and endoscopic hemoclips. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2009; 23:217-9. [PMID: 19319387 DOI: 10.1155/2009/973206] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A case in which a gastrocutaneous fistula developed after percutaneous endoscopic gastrostomy tube placement is presented. The fistula was first managed conservatively, then was closed by argon plasma coagulation and hemoclip placement. The patient was observed and was discharged once the gastrocutaneous fistula closed.
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Papavramidis TS, Kotzampassi K, Kotidis E, Eleftheriadis EE, Papavramidis ST. Endoscopic fibrin sealing of gastrocutaneous fistulas after sleeve gastrectomy and biliopancreatic diversion with duodenal switch. J Gastroenterol Hepatol 2008; 23:1802-5. [PMID: 18713299 DOI: 10.1111/j.1440-1746.2008.05545.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Theodossis S Papavramidis
- Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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Siddiqui AA, Kowalski T, Cohen S. Closure of a nonhealing gastrocutaneous fistula using an endoscopic clip. South Med J 2007; 100:75-6. [PMID: 17269533 DOI: 10.1097/smj.0b013e31802f86a2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Gastrocutaneous fistula after gastrostomy tube removal may persist for a prolonged period. We present a case of a 58-year-old woman with a GCF that had persisted for 5 months following the removal of an endoscopically-placed gastrostomy tube (PEG). Conservative therapy with anti-acid medications and administering motility agents was unsuccessful. For the closure of the GCF, the endoscopic metal clips were used to close the fistula.
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Affiliation(s)
- Ali A Siddiqui
- Division of Gastroenterology, Department of Internal Medicine, Thomas Jefferson Medical School, Philadelphia, PA, USA.
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Papavramidis ST, Eleftheriadis EE, Papavramidis TS, Kotzampassi KE, Gamvros OG. Endoscopic management of gastrocutaneous fistula after bariatric surgery by using a fibrin sealant. Gastrointest Endosc 2004; 59:296-300. [PMID: 14745411 DOI: 10.1016/s0016-5107(03)02545-8] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Gastrocutaneous fistula is an uncommon and difficult to treat complication that occurs in 0.5% to 3.9% of patients who undergo gastric surgery. Sepsis usually follows, and, when it is not managed effectively, the associated mortality rate can be as high as 85%. A fibrin sealant was used to endoscopically manage gastrocutaneous fistulas that developed in 3 morbidly obese patients after bariatric surgery. METHODS Two of 14 (14.29%) patients who underwent vertical gastroplasty (MacLean procedure) developed a non-healing gastrocutaneous fistula. In addition, one of 24 (4.17%) patients who had a biliopancreatic diversion with preservation of pylorus developed a gastrocutaneous fistula. Endoscopic application of a fibrin sealant was performed under direct vision via a double-lumen catheter passed through a forward-viewing endoscope. OBSERVATIONS Treatment was successful in all patients after one or more endoscopic sessions in which the fibrin sealant was applied; no evidence of fistula was found at follow-up endoscopy. CONCLUSIONS Endoscopic closure of gastrocutaneous fistula with human fibrin tissue sealant is simple, safe, and effective, and, in some cases, can be life-saving. Endoscopic application of fibrin sealant should be considered a therapeutic option for treatment of gastrocutaneous fistula that develops after bariatric surgery.
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Affiliation(s)
- Spiros T Papavramidis
- Aristotelian University of Thessaloniki, Department of Surgery III, AHEPA Hospital, Thessaloniki, Macedonia, Greece
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Makris J, Sheiman RG. Percutaneous treatment of a gastrocutaneous fistula after gastrostomy tube removal. J Vasc Interv Radiol 2002; 13:205-7. [PMID: 11830628 DOI: 10.1016/s1051-0443(07)61940-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Gastrocutaneous fistula formation is a potential complication resulting from nonsurgical gastrostomy or gastrojejunostomy tube removal. Limited success in conservative treatment has been achieved with either mechanical obstruction of the tract or pharmacologically based increase in gastric pH and improvement of gastric emptying. A case of successful conservative percutaneous treatment of a gastrocutaneous fistula with use of the sequence of initial tract de-epithelialization followed by direct tract sclerosis and mechanical obstruction is presented in this article.
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Affiliation(s)
- Joseph Makris
- Department of Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, Massachusetts 02215, USA
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Lee SO, Jeong YJ. Colonoscopic clipping of fecal fistula that occurred as a postoperative complication in patients with perforated appendicitis: two case reports. Gastrointest Endosc 2001; 54:245-7. [PMID: 11474403 DOI: 10.1067/mge.2001.114411] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- S O Lee
- Division of Gastroenterology of the Department of Internal Medicine and the Department of Surgery, Chonbuk National University Medical School, Chonju, Korea
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