Gastrocutaneous fistula: etiology and treatment

An unusual presentation of gastric fistula following peptic perforation repair: A case report

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Late onset Gastrocutaneous fistulas are rare following the peptic perforation repair.

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A non-healing burst abdominal wound should be thoroughly investigated. It can be because of an underlying fistula.

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CT fistulogram is the investigation of choice to confirm the diagnosis.

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Operative intervention is difficult but the only method of cure in most of the circumstances.

Introduction

Peptic perforation repair is a common stomach surgery. This surgery has not been associated with delayed onset gastrocutaneous fistula formation. However such a complication has been reported following a variety of other stomach surgeries. We are reporting this case as it is a rare complication. Also its diagnosis and management is challenging.

Case summary

We are presenting a case of peptic perforation repair where burst abdomen happened in the immediate post-operative period. The patient was put on conservative management. He responded well to it but his abdominal wound was not healing. After a wait of four months the wound was covered with a skin graft. The graft uptake was satisfactory but a discharging ulcer appeared on it. This condition persisted for one month. Finally a computed tomography Fistulogram (CT Fistulogram) was performed. It revealed an underlying complex gastric fistula. A repeat surgery was performed.

Conclusion

A gastrocutaneous fistula diagnosed at sixth month following the peptic perforation repair and causing minimal discomfort to the patient is a rare presentation. The abdominal wound following the surgery was possibly not healing because of the underlying fistula.

Treatment of persistently leaking post PEG tube gastrocutaneous fistula in elderly patients with combined electrochemical cautery and endoscopic clip placement

OBJECTIVES

Persistent leakage from a gastrocutaneous fistula (GCF) created for the purpose of percutaneous endoscopic gastrostomy (PEG) tube placement is a common problem in elderly patients. Conservative methods often prove unsuccessful and surgical closure is usually not performed because of poor surgical risk. With advances in endoscopic technology, several nonsurgical approaches have emerged. These new methods have been reported in the past as case reports. The purpose of this study is to report a case series of eleven elderly patients with persistent leakage from gastrocutaneous fistulas who underwent combined electrochemical cautery and endoscopic clip placement.

METHODS

Eleven patients had failed conservative therapy and were deemed unsuitable candidates for surgical closure. Electric and chemical cauterization was used to de-epithelialize the fistulous tract. The edges of the internal orifice of the gastrocutaneous fistula were approximated using endoclips during an esophagogastroduodenoscopy. Patients were observed postprocedure for leakage.

RESULTS

This procedure resulted in complete closure of the gastrocutaneous fistula in nine patients (82%). One patient had partial closure of the fistula which was sealed using a new PEG tube.

CONCLUSION

Gastrocutaneous fistula is a common complication in elderly patients after removal of gastrostomy tubes. Simple endoscopic procedures have shown promising results in the treatment of this complication.

Confronting gastrocutaneous fistulas

A gastrocutaneous fistula (GCF) represents a fistula connecting the stomach with the skin. The aim of the present review is to clarify the entity of a GCF and to discuss the various treating strategies employed. In order to elucidate GCFs as an entity etiology was pointed out and relative pathogenetic mechanisms were explored. Moreover, diagnostic modalities are discussed with a special focus on GCFs following bariatric operations. Finally, the treating strategies currently employed when confronting GCFs are presented, as well as their effectiveness.

Closure of a nonhealing gastrocutanous fistula using argon plasma coagulation and endoscopic hemoclips

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.

Closure of a nonhealing gastrocutaneous fistula using an endoscopic clip

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.

Fístulas enterocutâneas pós-operatórias: análise de 39 pacientes

OBJETIVO: As fístulas enterocutâneas podem ocorrer de forma espontânea ou no período pós-operatório. A fístula pós-operatória representa mais de 90% de todas as fístulas intestinais e estão quase sempre relacionadas com alguma das principais complicações da cirurgia do aparelho digestivo. De acordo com os fatores de risco e as características destas fístulas, têm sido propostas diferentes classificações prognósticas. Este estudo tem por objetivo analisar o resultado do tratamento de pacientes portadores de fístulas enterocutâneas pós-operatórias. MÉTODO: Foram analisados 39 pacientes submetidos a tratamento cirúrgico que desenvolveram fístula enterocutânea. Havia 27 pacientes do sexo masculino (69,2%) e 12 do sexo feminino (30,8%) com média de idade de 45,8 anos. Os fatores de risco considerados foram sepse, nível da albumina sérica, débito da fístula, idade do paciente e cirurgia de emergência. RESULTADOS: Sepse esteve presente em 13 pacientes com 61,5% de mortalidade, fístula de alto débito em 23 pacientes com 30,4% de mortalidade, idade acima de 60 anos em 14 pacientes com 28,5% de mortalidade e a albumina sérica baixa na admissão também esteve relacionada com mortalidade. CONCLUSÃO: Os autores concluem que a presença de sepse não controlada foi o fator mais importante de mortalidade.

Postoperative peritonitis originating from the duodenum: operative management by intubation and continuous intraluminal irrigation

BACKGROUND

The mortality rate associated with postoperative peritonitis remains high, especially when the source of infection cannot be eradicated. Such is the case with peritonitis arising from the duodenum, as primary closure is futile and intubation alone may be followed by local complications.

METHODS

Forty-nine consecutive patients with postoperative peritonitis originating from a duodenal leak and a mean Acute Physiology And Chronic Health Evaluation II score of 17.7 were treated according to the following procedure: a three-channelled spiral drain was inserted through the leak and extraluminal drains were placed near the duodenal defect. Intraluminal irrigation was undertaken immediately through the infusion channel of the spiral drain.

RESULTS

Eleven patients died and 26 suffered complications. The mean duration of intubation was 21 days.

CONCLUSION

Intubation with intraluminal irrigation has proved effective in a homogeneous group of patients with peritonitis due to duodenal leakage.

Radiologic investigation and treatment of gastrointestinal fistulas

Diagnostic radiology has assumed an increasingly prominent role in the diagnosis, investigation, and treatment of gastrointestinal fistulas during the past 15 years. This development largely has been the result of the application of computed tomography and ultrasonography to the diagnosis of intra-abdominal inflammatory processes and the use of these cross-sectional imaging modalities to guide percutaneous abscess drainage by the interventional radiologist. Effective percutaneous techniques have been developed that allow many gastrointestinal fistulas to be managed nonoperatively with less morbidity and mortality.

General management of gastrointestinal fistulas. Recognition, stabilization, and correction of fluid and electrolyte imbalances

Gastrointestinal fistulas are unfortunate complications of a number of disease states, such as inflammatory bowel disease and tumors, or may result from complications of surgical intervention. Fistulas may be associated with significant morbidity and mortality, much of which is a result of fluid losses and electrolyte imbalances. Thus, attention to these issues is a critical component of the management of patients with gastrointestinal fistulas. The management of gastrointestinal fistulas is divided into three phases: diagnosis/recognition, stabilization/investigation, and treatment. The major goal of the stabilization phase is the correction of fluid losses and electrolyte abnormalities. This phase must be carried out expeditiously to reduce the associated complications. Knowledge of the electrolyte content of various secretions of the gastrointestinal tract is essential to guide this phase of management. Early control of infectious foci, with drainage of abscesses if present, is of great importance. Esophageal fistulas most commonly result from instrumentation of the esophagus and are diagnosed by radiographic imaging studies. Nonoperative therapy is an option in select patients, but aggressive surgical intervention is often required. Dehydration is often associated with these injuries and must be corrected. Gastric and duodenal fistulas are most commonly iatrogenic and may be associated with significant fluid losses. Careful measurement of the fistula effluent is important. Nutritional support is begun following correction of fluid and electrolyte abnormalities. Pancreatic fistulas are often high volume fistulas and are associated with significant skin breakdown if they are cutaneous. The use of a somatostatin analogue may decrease the volume of the fistula to allow healing. Small intestinal fistulas often result from postoperative complications and require careful attention to electrolyte abnormalities. Spontaneous closure often obviates surgical intervention. Colonic fistulas are less often associated with complications than are other fistulas of the gastrointestinal tract. The stabilization phase in the management of patients with gastrointestinal fistulas is a critical time during which careful attention to fluid and electrolyte losses can result in reduced morbidity and mortality from these difficult management problems.

Intra-abdominal sepsis: the role of surgery

The role of the surgeon in intra-abdominal sepsis is multifactorial. A comprehensive understanding of the incidence and pathophysiology of diseases which cause intra-abdominal sepsis is the key to the diagnosis and treatment of such ailments. In simplest terms, the aetiology has two basic mechanisms: (a) violation of the 'bug-body barrier' and (b) obstruction to the flow of a body fluid with subsequent bacterial overgrowth. Either of these mechanisms may affect any of the organs within the abdomen, leading to sepsis. The peritoneal cavity is a dynamic structure which responds to insults in certain predictable manners which notify the alert physician that danger is present. Recognition of these signs through history and physical examination are the most important aspects of diagnosis. Confirmation of suspicions can be obtained with radiological modalities, but they are not a substitute for clinical judgement. Treatment of intra-abdominal sepsis should always begin with resuscitation and systemic antibiotics. Alleviation of the septic source is mandatory, and this may be achieved either operatively or non-operatively (i.e. percutaneous or endoscopic procedures). When the patient does not improve after the initial procedure, then a missed focus of infection must be investigated. In some cases, a planned or staged second operation may be needed to further debride necrotic tissue. Antibiotics should be of adequate spectrum and bioavailability to kill the species of bacteria most likely to cause the infection. This regimen may be altered when culture and sensitivity reports are completed. Finally, patients whose immune system function has been altered by disease or treatment must be assumed very ill until proven otherwise. These are general guidelines in the management of patients with intra-abdominal sepsis. Individual cases may necessitate slight modifications, but all require a high level of vigilance and expertise in order to combat a very lethal disease.

Gastrocutaneous fistulas associated with pancreatic abscesses. An aggressive entity

Previous reports of gastrocutaneous fistulas emphasize their benign nature and the probability of spontaneous healing without the need for surgical closure. In distinct contrast we report our experiences with six patients whose gastrocutaneous fistulas were caused by fulminant pancreatitis and pancreatic abscesses. High-output acid fistulas appeared days to weeks after drainage of left upper quadrant-infected collections. None occurred at the time of initial abscess drainage. Most originated high on the greater curvature of the stomach and traversed the abscess cavity. Three of six patients had previous splenectomies, but these operations were remote in time from the appearance of the fistula. Nonoperative management was successful in only two of six patients. Massive hemorrhage from the fistula tract contributed to the deaths of three patients. The pathogenesis of these fistulas appears to be consequent to gastric injury resulting from adjacent pancreatic inflammation. We conclude that (1) gastrocutaneous fistulas associated with pancreatitis are unlikely to heal even with drainage of the abscesses and are often complicated by hemorrhage, (2) surgical closure of the fistula will often be necessary and should not be unreasonably delayed, and (3) when performed in a semi-elective setting, resection of the damaged gastric segment, perhaps with an omental or serosal patch to buttress the gastric suture line, has a good chance of success.

Postoperative peritonitis due to gastric and duodenal fistulas. Operative management by continuous intraluminal infusion and aspiration: report of 23 cases

A new surgical procedure is presented for the management of postoperative peritonitis due to a leak from a suture line in the stomach or the duodenum. At re-operation, an intraluminal unit made of three silicone tubes is inserted through the fistula into the bowel lumen. Extraluminal drains are placed near the fistula. A Witzel jejunostomy is constructed in order to provide continuous high energy enteral support. Intraluminal infusion and aspiration starts immediately after operation. Twenty-three patients have been treated according to this technique. Five died (22 per cent): one from mediastinitis and four from complications unrelated to the fistula. Three (13 per cent) patients developed recurrent abdominal abscesses and underwent re-operation for drainage with no mortality. In the first 2 weeks after operation, most of the discharge was collected by the extraluminal drains. Thereafter the intraluminal unit collected the majority of the fluid, thus allowing the extraluminal drains to be removed. At an average time of 27 days after operation the intraluminal unit was withdrawn. The external fistula created by this technique healed spontaneously in 15 of the 18 survivors, and was surgically closed in three, with no complication. This procedure prevents the recurrence of intra-abdominal sepsis and local complications due to the enzymatic action of the gastroduodenal secretions.