Use of high-frequency electrical stimulation in gastrocutaneous fistula closure: a case report.

BACKGROUND: Gastrocutaneous fistula is a rare complication following Roux-en-Y gastric bypass, a commonly performed bariatric surgery. While most ECFs respond to conservative management, some do not close despite adequate nutritional support, infection source control, and drainage management. As such, the chronicity of these difficult-to-treat wounds can be physically and economically costly to patients. CASE REPORT: A 53-year-old female with a history of Roux-en-Y gastric bypass developed a gastrocutaneous fistula secondary to a perforated gastrojejunal ulcer, requiring immediate surgical intervention. After being discharged from the hospital, 37 days of conservative management and NPWT did not reduce the size of the fistula tract. To help control the patient's chronic abdominal pain and increase the rate of wound healing, the patient underwent treatment with HFES (20 kHz) delivered using a handheld transcutaneous electrical nerve stimulator. This electrotherapy was found to reduce the majority of the patient's pain within the first treatment session. The patient's fistula also began to decrease in size within 1 week of initiating treatment. CONCLUSION: This case report details the successful closure of a gastrocutaneous fistula after administration of HFES 3 times a week over the course of 25 days. The mechanism of action of HFES and its role in the wound healing process are also discussed.

Outpatient curettage and electrocautery as an alternative to primary surgical closure for pediatric gastrocutaneous fistulae.

BACKGROUND: The development of a gastrocutaneous fistula (GCF) after gastrostomy tube removal is a frequent complication that occurs 5%-45% of the time. Conservative therapy with chemical cauterization is frequently unsuccessful, and surgical GCF repair with open primary layered closure of the gastrotomy is often required. We describe an alternative approach of GCF closure that is an outpatient, less invasive procedure that allows patients to avoid the comorbidities of general endotracheal anesthesia and intraabdominal surgery. METHODS: This is an Institutional Review Board approved retrospective review of all patients who underwent GCF closure from January 2010 to July 2016 at a tertiary care children's hospital. Demographics including age, weight, body mass index, comorbidities, and initial indication for gastrostomy tube were recorded. Operative details such as ASA score, operative duration, type of anesthesia, and airway were noted. Based on surgeon preference, two types of operative closure were used during that time frame: primary layered closure or curettage and cautery (C&C). The latter is a procedure in which the fistula tract is first scraped with a fine curette, and then the fistula opening and tract are cauterized circumferentially. Finally, the presence of a persistent fistula and the need for formal reoperation were determined. RESULTS: Sixty-five unique patients requiring GCF closure were identified. Of those, 44 patients (67.6%) underwent primary closure and 21 patients (32.3%) underwent C&C. The success rate of primary closure was 97% with one patient experiencing wound breakdown with persistent fistula. The overall success rate of C&C was 66.7% (14/21). Among those 14 patients, 11 (52.4%) GCF patients were closed by 1 mo. An additional two patients' gastrocutaneous fistulae were closed by 4 mo (61.9%). One GCF was successfully closed with a second C&C procedure. Seven of the 21 patients (33.3%) required subsequent formal layered surgical closure. C&C had significantly shorter operative times (13.5 ± 14.7 min versus 93.4 ± 61.8, P <0.0001) and significantly shorter times in the postanesthesia care unit (101.8 ± 42.4 min versus 147 ± 86, P <0.0001). Patients were intubated with an endotracheal tube 88.6% of the time for primary closure and 23.8% of the time for C&C.Among patients admitted for an elective procedure, the average length of stay for primary closure was 1.9 d as compared to 0 d for the C&C group. Among patients who underwent C&C with a persistent fistula, there were no significant differences in time since initial creation of gastrostomy, age, body mass index, or ASA score. CONCLUSIONS: Our study verifies that primary closure remains the gold standard for persistent GCF. However, C&C is a safe, outpatient procedure that effectively treats a GCF the majority of the time in children. We suggest that in select patients, it may be an appropriate initial and definitive procedure for GCF closure.

A case of gastrojejunocolic fistula with steatohepatitis.

A man in his 30s, who had undergone retrocolic Billroth II reconstruction for perforated duodenal ulcer, presented with watery diarrhea for 2 years and suspected fatty liver. He was referred to our hospital for management of chronic diarrhea, weight loss, hepatopathy and hypoalbuminemia. Initial upper and lower gastrointestinal endoscopies were negative. Since a small bowel lesion was suspected, peroral single-balloon enteroscopy was performed, which identified feces-like residue near the Billroth II anastomotic site and a connection to the colon separate from the afferent and efferent loops. Transanal single-balloon enteroscopy identified a fistula between the gastrojejunal anastomosis and transverse colon, with the scope reaching the stomach transanally. Barium enema confirmed flow of contrast medium from the transverse colon through the fistula to the anastomotic site, allowing the diagnosis of gastrojejunocolic fistula. Liver biopsy showed relatively severe steatohepatitis (Brunt's classification: stage 2-3, grade 3). Resection of the anastomotic site and partial transverse colectomy were performed to remove the fistula, followed by Roux-en-Y reconstruction. Postoperatively, watery diarrhea resolved and the stools became normal. Hepatopathy and hypoproteinemia improved. One year later, liver biopsy showed marked improvement of steatosis. This case demonstrated marked improvement of both diarrhea/nutritional status and steatohepatitis after treatment of gastrojejunocolic fistula, suggesting that the fistula caused non-alcoholic steatohepatitis.

Gastrojejunocolic fistula in a 49 year-old male.

Gastrojejunocolic fistula is an unusual finding in patients with colon neoplams because long evolution time is required for its appearance. The methods of diagnosis have been and continue under discussion, being the barium enema the most accepted nowadays. Gastrocolic fistula is characterized by a declining incidence due to the new methods of diagnosis. An early detection of the tumour is completely necessary to prevent complications like fistulas or malnutrition. We present a case report of gastrojejunocolic fistula in a 49 year-old patient with colon carcinoma.

Outcomes in the management of gastrocolic fistulas: a single surgical unit's experience.

BACKGROUND/AIMS: Gastrocolic fistula has been associated with a variety of diseases. Causative factors are most commonly gastric/colonic cancers and benign gastric ulcers. Treatment modalities may change according to etiology. METHODS: In this study, we present our cases with gastrocolic fistula and the treatment modalities utilized for this uncommon complication. The records of the patients with gastrocolic fistula between November 1996 and June 2006 were retrospectively analyzed. RESULTS: Six patients with a mean age of 57.5 were determined. Of these, four had malignancy and two had gastric ulcer. The predominant symptoms were diarrhea and vomiting, weight loss, and abdominal pain. Diagnostic studies included barium enema, endoscopy, barium meal, colonoscopy, and computed tomography. After preoperative nutritional support, en-bloc resection of the involved gastrocolic region (4), simple excision (1), and wedge resection of the gastric part and closure of the colonic wall (1) were performed. One patient died of respiratory disorders and there was only one recurrence. In our series, therapeutic management for this unusual disorder included various resection procedures such as simple excision, which may result in recurrence, and wedge resection or en-bloc resection for benign cases, whereas en-bloc resection and reconstruction procedures remained the most applied management for malignant cases. En-bloc resection followed by combination of adjuvant chemotherapy results in long disease-free survival. CONCLUSION: Gastrocolic fistula should be suspected in patients with chronic diarrhea and vomiting of unknown cause with a high suspicion of gastrointestinal malignancy.

Treatment of upper gastrointestinal fistula and leakage with personal stage nutrition support.

AIM: To investigate the feasibility of treatment for upper gastrointestinal fistula and leakage with personal stage nutrition support. METHODS: Forty-three patients with upper gastrointestinal fistula and leakage were randomly divided into two groups. Patients in group A were treated with personal stage nutrition support and patients in group B were treated with total parental nutrition (TPN) in combination with operation. Nutritional states of the candidates were evaluated by detecting albumin (Alb) and pre-Alb. The balance between nutrition and hepatic function was evaluated by measurement of aspartate aminotransferase (AST), alanine aminotransferase (ALT) and total bilirubin (Tbill) before and after operation. At the same time their complications and hospitalized time were surveyed. RESULTS: Personal stage nutrition support improved upper gastrointestinal fistula and leakage. The nutrition state and hepatic function were better in patients who received personal stage nutrition support than in those who did not receive TPN. There was no significant difference in the complication and hospitalized time in the two groups of patients. CONCLUSION: Upper gastrointestinal fistula and leakage can be treated with personal stage nutrition support which is more beneficial for the post-operation recovery and more economic than surgical operation.

[Gastrojejunocolic fistula--a rare complication of stomach surgery]. / Fistula gastrojejunocolica--complicatie rara a chirurgiei stomacului.

The gastrojejunocolic fistula represents a clinical entity that occurs very rarely following gastro-jejunal anastomoses and manifests itself clinically and paraclinically by a severe malabsorption syndrome. The results of the physiopathological approach may be summed up as follows: reduced level of seric proteins, fluid and electrolytic depletion, deficiencies in the absorption of the vitamins soluble in fats and water, which may all vary from mildness to severeness, depending on the flow rate of the fistula. Most often, the diagnosis is set by performing barium enema, which is positive for all cases, whereas the barium passage is less efficient, enabling diagnosis in only 33% of the cases. The radiological image may be reduced on principle to one single sign: the abnormal fistulous trajectory (barium passes from the stomach directly into the colon or the enema fills the gastric lumen). It is recommended that surgical treatment be performed in a single stage, by resecting the entire fistula and re-establishing the gastro-jejunal and colic continuity. We report a case of gastrojejunocolic fistula in a patient that underwent 2/3 gastric resection for gastric ulcer 9 years ago.

[Gastrocolic fistula - a rare cause of cachexia and polyneuropathy]. / Gastrokolische Fistel als seltene Ursache von Kachexie und Polyneuropathie.

Gastrocolic fistula is a rare clinical disorder which in the past most often occurred after gastric surgery or carcinoma of the gastrointestinal tract. However, during the last decade an increasing number of cases after benign gastric ulcers have been described. Most common symptoms have been weight loss, abdominal pain, diarrhea and copremesis. A 49-year-old cachectic patient presented with a 2-year history of abdominal discomfort and diarrhea. He reported a weight loss of 32 kg during this period and was finally unable to move because of exhaustion. Furthermore, he suffered of burning paresthesia of the legs and the abdomen. His medical history included a Billroth II operation because of recurrent ulcer disease in 1987. Barium enema revealed a gastrocolic fistula which caused small bowel bacterial overgrowth with villous atrophy and malabsorption and development of polyneuropathy. The fistula was surgically resected, and postoperatively, the patient improved and regained his weight. Gastrocolic fistula is a rare cause of diarrhea and should be considered in clinical practice. Barium enema is superior to endoscopy in detecting gastrocolic fistula.

Fístula gastrocólica / Gastrocolic fistula

A case of gastrocolic fistula (GCF) in a patient with duodenal stenosis who had previously undergone gastroenteric anastomosis is reported. The patient went through hemigastrectomy, partial colectomy and segmental enterectomy with bloc resection. Reconstruction was carried out through Billroth II gastrojejunostomy, jejunojejunostomy and end-to-end anastomosis of the colon. The patient had good post-operative evolution and was discharged from hospital seven days after surgery. GCF should be suspected in patients presenting weight loss, diarrhea and fecal vomiting, mainly with history of peptic ulcer surgery, gastric or colonic malignancy and use of steroidal and nonsteroidal antiinflamatory drugs. Barium enema is the choice test for diagnosis, however, the benign or malignant nature of the lesion should always be evaluated through high digestive endoscopy. Clinical treatment with oral H2-antagonists and discontinuing ulcerogenic medications might be indicated in some cases; surgical treatment is indicated in cases of malignant disease and might be indicated in cases of peptic disease as it treats GCF and also the baseline disease. Some advise upwards colostomy at first. The most used technique is bloc resection, including the fistulous tract, hemigastrectomy and partial colectomy. Gastrectomy, fistulous tract excision and colon suturing may be performed in some cases. The mortality rate is related to metabolic disorders and the recurrence with the use of antiinflammatory drugs

Gastrocolic fistula. A review of 15 cases and an update of the literature.

Gastrocolic fistulas are not common. We review the 10-year experience in our center of 15 cases that emphasize the changing pattern of this disease. The female-to-male ratio was 2:1, with a mean age of 55. Even though we are affiliated with the regional cancer center, the commonest cause of a fistula was benign gastric ulceration. Sixty percent of those with peptic ulcer and a fistula had not had previous gastric surgery. Barium enema was the most accurate investigation, showing the fistula in 10 of 10. Barium meal showed it in seven of eight, and the fistula was seen in seven of 10 patients who had endoscopy. Eleven patients were operated on, and only one was treated "medically." Three deaths occurred, two from advanced carcinoma and one from myocardial infarction.

[Gastrojejunocolic fistula. Report of 5 cases].

Gastrojejunocolic fistula is rare complication of recurrent peptic ulcer disease after gastrectomy and gastrojejunostomy. This paper reported five cases of gastrojejunocolic fistula. It's etiological, clinical, and surgical features were briefly discussed. The symptoms of gastrojejunocolic fistula are diarrhea, upper abdominal pain, gastrointestinal bleeding, fecal vomiting, anasarca, and weight loss. The physical examinations and laboratory studies revealed malnutrition. The diagnosis is most reliably and frequently made by barium enema and gastroscopy. Surgical treatment of gastrojejunocolic fistula includes one-stage resection, complete remove of antral mucosa; vagotomy; partial re-resection of the gastric stump; excision of the fistulous connection with the colon. TPN or TEN should be administered in patients suffering from malnutrition with TEN as the first choice in those when a nasoenteric tube could placed into the jejunum.

Gastric fistulas in Crohn's disease. Report of cases.

Nine cases of gastric fistula occurring in patients with Crohn's disease were treated at The Mount Sinai Hospital over the past three decades. Six cases were found in a review of 1480 patients with Crohn's disease admitted between 1960 and 1983. Three others seen at this institution outside the time frame of the author's study have also been included. Among six new cases, five with cologastric fistula occurred among 907 patients with Crohn's disease involving the colon (0.6 percent), while only one with ileogastric fistula was encountered among 1211 patients with ileal disease (0.08 percent). Fistulas between the stomach and colon always originated in an area of colitis, usually passing from distal transverse colon to greater curvature, but occasionally from midtransverse colon to antrum. The only pathognomonic clinical features were feculent vomiting, eructations, or odor. Diagnosis usually was made by barium enema or, less frequently, by upper gastrointestinal series; rarely, the gastric fistula was found unexpectedly at surgery. The conventional and recommended therapy is colectomy with wedge excision of the stomach. Medical treatment with 6-mercaptopurine has been completely successful in one patient and intermittently successful in a second patient.

Fístulas enterocutáneas; Apoyo nutricional; Modalidad importante en el tratamiento / Enterocutaneous fistulas at the nutritional support important treatment

Se presenta la experiencia en el tratamiento y manejo de 41 fístulas enterocutáneas por la Unidad de Soporte Nutricional del Hospital Universitario de Caracas, durante 1985-1987. Con el enfoque multidisciplinario se obtuvo 80.4% de cierre de las fístulas. La sepsis no controlada sigue siendo la mayor causa de fracasos y muertes con 19.5%. Aún así es una mejoría dramática de lo que era la incidencia de muerte antes de la aparición del Soporte Nutricional

Gastrocolic fistulas.

Sixteen patients were treated for gastrocolic fistula arising as a complication of peptic ulcer (11 cases), colonic perforation (2), gastric cancer (1), colonic cancer (1) or pancreatitis (1). The predominant symptoms were diarrhoea, weight loss and abdominal pain. Barium meal and barium enema were the most reliable means of diagnosis, and no fistula was gastroscopically demonstrable. A one-stage en bloc resection of the involved gastrocolic region was performed in eight cases. Other operations were simple excision (3), gastric resection with closure of the colonic wall (2) and colectomy with closure of the gastric wall (2). In one case cure was achieved with cimetidine, without surgical intervention. Four patients died postoperatively and two had recurrence of fistula.

The management of Crohn's colitis with colonogastric fistula. Report of a case.

Colonogastric fistula, more commonly called "gastrocolic," is a rare complication of Crohn's colitis. The 17th incidence of this fistula is reported. Fecal halitosis is a prominent symptom. Barium enema is the most accurate diagnostic tool. Colonoscopy plays a role in delineating surgical therapy. The stomach resection is described. Because of its pathogenesis, the authors prefer to call this "colonogastric" fistula, rather than gastrocolic fistula.

Tratamento de las fístulas enterocutaneas: nutricción y cirugia / Treatment of the enterocutaneous fistulas: nutrition and surgery

Entre Enero de 1976 y Diciembre de 1984, 62 casos de fístulas enterocutáneas fueron tratados en el Hospital universitario de Caracas. La causa más frecuente fue: dehiscencia anastomótica en 36 casos (60 por ciento). La mayoría fueron fístulas de mal pronóstico: alto gasto (60 por ciento), cáncer (70 por ciento), diábetes (12 por ciento). En el 72,5 por ciento se utilizó alimentación parenteral, en promedio por 30 días. Se necesitó una operación en el 58 por ciento (36 casos). El 77,7 por ciento de los cuales fueron operados para tratar la fístula (en el 64,29 por ciento de estos se realizó resección intestinal y anastomosis término terminal) y 22,3 por ciento para tratar la sepsis (drenaje de abscesos intrabdominales en el 62,5 por ciento de estos últimos). Hubo 18 muertes (29 por ciento), la mayoría de las cuales ocurrieron antes de 1980: 12 casos (66,6 por ciento). Concluimos que la mejor rata de supervivencia, después de 1980, se explica tanto porque el soporte nutricional se hace mejor y más organizadamente, como porque permite el uso más agresivo y racional de la cirugía, para el control de la sépsis y cierre de la fístula