Management of Persistent Fistula After Gastrectomy?
Management of Persistent Fistula After Gastrectomy?
My patient underwent a total gastrectomy and had a feeding tube placed at the time of surgery. The tube was removed in the postoperative phase, but after 4 months a fistula persists. The patient is too emaciated to withstand another laparotomy. Any suggestions on management of this patient?
Sarda Dinesh, MD
The persistence of enteric drainage following the removal of a feeding catheter is a rare, but potentially serious, surgical complication. In a prospective study of over 2000 patients treated with a needle catheter jejunostomy, prolonged leakage was encountered only once. In general, the management of the problem described in this case should follow the same algorithm as used for other types of enterocutaneous fistulas. Initially, all contributing factors should be identified and corrected, including distal obstruction, adjacent abscess, foreign body (eg, suture, mesh), or primary disease (eg, Crohn's, malignancy).
Nonoperative measures (ie, bowel rest, octreotide) should be used early to control fistula output, protect the surrounding skin, and promote healing. If closure is delayed (> 1 month), more aggressive therapy is warranted. Fibrin sealant has recently been approved for use in the United States and can be infused directly into the fistula if the process is not complicated by mucosal eversion or the presence of an adjacent abscess. Alternatively, fistuloscopy has been recommended, by which a 5-mm choledochoscope is used to intubate, debride, and then obliterate the fistula with fibrin sealant and gelfoam. While both of these techniques appear interesting and are presumably low-risk, neither is supported by reports of either large cohorts or well-controlled comparisons, and should be used with due caution.
Enterocutaneous fistulas that are intractable to nonoperative therapy are generally best treated by resection of a short segment of the involved small bowel and primary anastomosis. When the necessary laparotomy is considered too risky because of major comorbidities, several extra-abdominal approaches can be considered. The first is recommended for problematic "bud" fistulas in which substantial external epithelialization is already present at the terminus of a short fistula tract. Repair can be performed under local anesthesia and includes excision of the excess granulation tissue, mobilization and closure of the bowel mucosa and serosa, and application of a split-thickness skin graft over the suture line. Recurrence has been reported in approximately 40% of cases, but little is actually lost when the procedure is unsuccessful. Longer fistula tracts usually require a more extensive dissection with subsequent isolation and closure of the fistula over a Malecot catheter and reinforcement of this closure with a rectus abdominis muscle flap. Experience with both approaches is extremely limited; it would seem prudent to advise prospective patients of this fact.
My patient underwent a total gastrectomy and had a feeding tube placed at the time of surgery. The tube was removed in the postoperative phase, but after 4 months a fistula persists. The patient is too emaciated to withstand another laparotomy. Any suggestions on management of this patient?
Sarda Dinesh, MD
The persistence of enteric drainage following the removal of a feeding catheter is a rare, but potentially serious, surgical complication. In a prospective study of over 2000 patients treated with a needle catheter jejunostomy, prolonged leakage was encountered only once. In general, the management of the problem described in this case should follow the same algorithm as used for other types of enterocutaneous fistulas. Initially, all contributing factors should be identified and corrected, including distal obstruction, adjacent abscess, foreign body (eg, suture, mesh), or primary disease (eg, Crohn's, malignancy).
Nonoperative measures (ie, bowel rest, octreotide) should be used early to control fistula output, protect the surrounding skin, and promote healing. If closure is delayed (> 1 month), more aggressive therapy is warranted. Fibrin sealant has recently been approved for use in the United States and can be infused directly into the fistula if the process is not complicated by mucosal eversion or the presence of an adjacent abscess. Alternatively, fistuloscopy has been recommended, by which a 5-mm choledochoscope is used to intubate, debride, and then obliterate the fistula with fibrin sealant and gelfoam. While both of these techniques appear interesting and are presumably low-risk, neither is supported by reports of either large cohorts or well-controlled comparisons, and should be used with due caution.
Enterocutaneous fistulas that are intractable to nonoperative therapy are generally best treated by resection of a short segment of the involved small bowel and primary anastomosis. When the necessary laparotomy is considered too risky because of major comorbidities, several extra-abdominal approaches can be considered. The first is recommended for problematic "bud" fistulas in which substantial external epithelialization is already present at the terminus of a short fistula tract. Repair can be performed under local anesthesia and includes excision of the excess granulation tissue, mobilization and closure of the bowel mucosa and serosa, and application of a split-thickness skin graft over the suture line. Recurrence has been reported in approximately 40% of cases, but little is actually lost when the procedure is unsuccessful. Longer fistula tracts usually require a more extensive dissection with subsequent isolation and closure of the fistula over a Malecot catheter and reinforcement of this closure with a rectus abdominis muscle flap. Experience with both approaches is extremely limited; it would seem prudent to advise prospective patients of this fact.
Source...