Incidence and predictors of gastrocutaneous fistula in the pediatric patient

Subcutaneous Perforation of Recurrent Gastric Fistula After Abdominoplasty with Scar Revision

This case represents an unusual, and previously unreported, complication of delayed leakage of gastric contents into the subcutaneous tissues 2 years after division of a gastrostomy tube tract during abdominoplasty. Our patient required urgent exploration for contamination control and closure of the fistula and recovered fully. Persistent gastrocutaneous fistula is uncommon in adults and even less common is recannulization of a fistula track after initial closure. A thorough review of operative history and comparison to previous imaging were crucial for appropriate diagnosis and operative planning. Formal closure of gastrostomy tube sites during scar revision and abdominoplasty may help prevent the complication of delayed gastrostomy tube tract rupture into the subcutaneous tissues.

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.

Fundoplication with gastrostomy vs gastrostomy alone: a systematic review and meta-analysis of outcomes and complications

PURPOSE

We compare the outcomes of fundoplication with gastrostomy vs gastrostomy alone and review the need for subsequent fundoplication after the initial gastrostomy alone.

METHODS

We searched studies published from 1969 to 2016 for comparative outcomes of concomitant fundoplication with gastrostomy (FGT) vs gastrostomy insertion alone (GT) in children. Gastrostomy methods included open, laparoscopic, and endoscopic procedures. Primary aims were minor and major complications. Secondary aims included post-operative reflux-related complications, fundoplication specific complications, and need for subsequent fundoplication after GT.

RESULTS

We reviewed 447 studies; 6 observational studies were included for meta-analysis, encompassing 2730 children undergoing GT (n = 1745) or FGT (n = 985). FGT was associated with more minor complications [19.9 vs 11.4%, OR 2.02, 95% confidence interval (CI) 1.43-2.87, p ≤ 0.0001, I ² = 0%], minor complications requiring revision (6.8 vs 3.0%, OR 2.27, 95% CI 1.28-4.05, p = 0.005, I ² = 0%), and more overall complications (21.3 vs 12.0%, OR 1.99, 95% CI 1.43-2.78, p < 0.0001, I ² = 0%). Incidence of major complications (1.8 vs 2.0%, OR 1.39, 95% CI 0.62-3.11, p = 0.42, I ² = 5%) and reflux-related complications (8.8 vs 10.3%, OR 0.75, 95% CI 0.35-1.68, p = 0.46, I ² = 0%) in both groups was similar. Incidence of subsequent fundoplication in GT patients was 8.6% (mean).

CONCLUSIONS

Gastrostomy alone is associated with fewer minor and overall complications. Concomitant fundoplication does not significantly reduce reflux-related complications. As few patients require fundoplication after gastrostomy, current evidence does not support concomitant fundoplication.

Risk Factors for a Persistent Gastrocutaneous Fistula Following Gastrostomy Device Removal: A Tertiary Center Experience

AIM

The aim of this study is to identify the risk factors for a persistent gastrocutaneous fistula (GCF) after gastrostomy device (GD) removal in children.

MATERIALS AND METHODS

A retrospective analysis of 59 patients that underwent GD insertion and removal over an 11-year period (2005-2015). Patients were divided into two Groups (A and B) according to persistence or closure of the gastrocutaneous tract. Data included patient demographics, comorbidities, age at insertion, gastrostomy site infections, size and type of device, duration of placement, and method of insertion and removal. Statistical analysis was done using Chi-square test and ANOVA test where P < 0.05 was considered statistically significant.

RESULTS

A total of 34 patients (Group A) developed a GCF post-GD removal. The gastrostomy tract closed spontaneously in 25 patients (Group B). Underlying comorbidities did not influence spontaneous closure. Younger age at insertion (<2 years), longer duration of device placement, open gastrostomy insertion, upsizing the GD, changing a gastrostomy tube to a button, and site infections were significant risk factors for a persistent GCF.

CONCLUSIONS

Risk analysis of persistent GCF is important for patient counseling before removal or replacement of the GD. We have identified a number of potentially reversible risk factors for a persistent GCF and have made recommendations accordingly.

Endoscopic closure of a refractory gastrocutaneous fistula using a novel over-the-scope Padlock clip following de-epithelialisation of the fistula tract

Persistent gastrocutaneous fistula (GCF) is a difficult to manage complication following gastrostomy tube removal, with leakage resulting in distressing sequelae including cutaneous injury, infection and dehydration. Many such patients are high-risk for invasive surgery and, to date, endoscopic closure techniques, including clipping systems, have limitations. We present the case of a 62-year-old woman with persistently leaking GCF 6 months postgastrostomy tube removal, despite maximal antisecretory therapy and postpyloric feeding, and describe failed attempted endoscopic closure with conventional clips. Treatment options were discussed and informed consent was given for an attempt at endoscopic closure using a novel radial closure device ('Padlock clip') combined with surgical de-epithelialisation, with the understanding that this device has never previously been used in this setting. At follow-up 2 weeks postprocedure, the patient was asymptomatic with complete healing of the GCF. This approach has advantages over other endoscopic closure techniques and can be considered as an alternative approach to GCF closure.

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.

Persistent gastrocutaneous fistula: factors affecting the need for closure

PURPOSE

The occurrence of gastrocutaneous fistula (GCF) is a well-known complication after gastrostomy tube placement. We explore multiple factors to ascertain their impact on the rate of persistent GCF formation.

METHODS

We retrospectively reviewed patient records for all gastrostomies (GT) constructed at our institution from 2007 to 2011. Association of GCF with method of placement, concomitant fundoplication, neurologic findings, duration of therapy, and demographics was evaluated using logistic regression.

RESULTS

Nine hundred fifty patients had GTs placed, of which 148 patients had GTs removed and 47 (32%) of 148 required surgical closure secondary to persistent GCF. Laparoscopic and open procedures comprised 79 (53%) of 148 and 69 (47%) of 148, respectively. Seventeen (22%) patients in the laparoscopic group developed persistent GCF, compared to 30 (43%) in the open group (P=0.035, OR=2.52). Seventy-one patients had concomitant Nissen fundoplication. Thirty-one (44%) developed GCF, compared to 16 (21%) without a Nissen (P=0.002, OR=4.94). Patients with button in place for 303 days had persistent GCF incidence of 23%, compared to 45% at 540 days (P<0.001, OR=3.51) and 50% at 850 days (P=0.011, OR=4.51). Patients with device placed at 1.8 months of age were more likely to develop GCF compared to those with device placed at 8.9 months of age (P=0.017, OR=2.35).

CONCLUSION

Open operations, concurrent Nissen and younger age at placement were all statistically significant factors causing persistent GCF.

Closure of a large high-output gastrocutaneous fistula with combined postpyloric feeding and aggressive medical therapy

Widening of the exit site of a percutaneous gastrostomy tube is a rare but difficult to manage complication, which leads to significant morbidity as a result of caustic material leak and associated cutaneous injury. Such defects fail to close with conservative measures such that invasive (surgical or endoscopic) intervention is often required. The authors present a 49-year-old woman with neurological dysphagia, 2 years after gastrostomy tube insertion with several months' history of leakage and widening of the hole at the exit site. Following gastrostomy tube removal; the patient was left with a large, high-output gastrocutaneous fistula which was treated aggressively with measures to reduce gastric discharge including 'nil-by-mouth', bypassing the stomach with distal feeding, administration of a somatostatin analogue, high-dose proton pump inhibitor and prokinetics with the aim of preoperatively downsizing the wound. This novel approach led to complete closure of the large gastrocutaneous fistula, obviating the need for surgical intervention.