Case Report of International Journal of Case Reports
Successful use of a novel biological plug in the percutaneous treatment of a refractory gastro-cutaneous fistula following omental patch repair of perforated peptic ulcer
Allan Stolarski, MD1,2, Katherine He MD1,3, Ducksoo Kim MD4,5, Gentian Kristo, MD1,3
1Department of Surgery, Veterans Affairs Boston Healthcare System, Boston, MA, USA; 2Department of Surgery, Boston Medical Center, Boston University Medical School, Boston, MA, USA; 3Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA; 4Department of Interventional Radiology, Veterans Affairs Boston Healthcare System, Boston, MA, USA; 5Department of Interventional Radiology, Boston Medical Center, Boston University Medical School, Boston, MA, USA
Background: Gastro-cutaneous fistula following re-leak of omental patch repair of perforated peptic ulcer is a very rare but challenging surgical complication. We describe the use of a novel biological plug as a viable repair for gastro-cutaneous fistula that failed medical, endoscopic, and operative management. Additionally, we present a thorough literature review of reported cases of gastro-cutaneous fistulae following omental patching of peptic perforations to further highlight their treatment challenges.
Summary: A 69-year-old man underwent repair of a perforated pyloric ulcer with a pedicled omental patch. After one week, patient developed a re-leak from the omental patch, and underwent a second laparotomy with repeat omental patching of the gastric perforation. Ten weeks after the second operation, the patient developed a gastro-cutaneous fistula that failed conservative management with nil per os and enteral nutrition delivered distal to the fistula site; multiple image-guided percutaneous attempts at fistula closure by interventional radiology via fibrin sealant injection and collagen-based vascular closure device; and endoscopic clipping by gastroenterology. Ultimately, this refractory gastro-cutaneous fistula was closed with a novel biological plug (Biodesign® Enterocutaneous Fistula Plug, Cook Biotech).
Conclusion: Gastro-cutaneous fistulae following omental patching of perforated peptic ulcer represent a significant complication requiring a multidisciplinary management approach. The Biodesign® Enterocutaneous Fistula Plug offers a promising new tool for the non-operative treatment of refractory gastro-cutaneous fistulae.
Keywords: perforated peptic ulcer, omental patch, gastro-cutaneous fistula, fistula plug.
How to cite this article:
Allan Stolarski, Katherine He, Ducksoo Kim, Gentian Kristo. Successful use of a novel biological plug in the percutaneous treatment of a refractory gastro-cutaneous fistula following omental patch repair of perforated peptic ulcer. International Journal of Case Reports, 2020 4:121. DOI: 10.28933/ijcr-2020-02-2505
1. Mithilesh KS, Sudipta M, Tushar SM, Apurba B. An unusual presentation of gastric fistula following peptic perforation repair: A case report. International Journal of Surgery Case Reports. 56 (2019) 29–31.
2. Kouklakis G, Zezos P, Liratzopoulos N, Simopoulos C, et al. Endoscopic treatment of a gastrocutaneous fistula using the over-the-scope-clip system: a case report. Diagn Ther Endosc. 2011;2011:384143.
3. Maghsoudi H, Ghaffari A. Generalized peritonitis requiring re-operation after leakage of omental patch repair of perforated peptic ulcer. Saudi J Gastroenterol. 2011;17(2):124–128.
4. Rose D. One hundred and fourteen fistulas of the GI tract treated with total parenteral nutrition. Surg Gynecol Obstetr. 1986;163:345-50,
5. Kumar K, Pai D, Srinivasan K, Ananthakrishnan N, et al. Factors contributing to releak after surgical closure of perforated duodenal ulcer by Graham’s Patch. Trop Gastroenterol. 2002 Oct-Dec;23(4):190-2.
6. Bowling K, Balcombe A, Rait J, Andrews S. Technique to manage persistent leak from a prepyloric ulcer where a distal gastrectomy is not appropriate. Journal of Surgical Case Reports. 2015 Aug;2015(8).
7. Gupta S, Kaushik R, Sharma R, Attri A. The management of large perforations of duodenal ulcers. BMC Surgery. 2005;5:15.
8. Saurabh S, Vinaykumar NT, Omprakash SR, Samir UR. Comparison of operative procedures for re-leaks duodenal perforation: a cross-sectional analysis from a tertiary care hospital in a developing country. Int Surg J. 2016 Aug;3(3):1314-1317.
9. Papavramidis TS, Mantzoukis K, Michalopoulos M. Confronting gastrocutaneous fistulas. Ann Gastroenterol 2011; 24 (1): 16-19.
10. González-Ojeda A, Avalos-González J, Muciño-Hernández MI, Arenas-Márquez H, et al. Fibrin glue as adjuvant treatment for gastrocutaneous fistula after gastrostomy tube removal. Endoscopy. 2004 Apr;36(4):337-41.
11. Pianta M, Vargas P, Niedmann J. Closure of bronchopleural fistula with Angio-Seal. Cardiovasc Intervent Radiol 2011; 34 Suppl 2:S236-9.
12. Lyon JW, Hodde JP, Hucks D, Changkuon DI. First experience with the use of a collagen fistula plug to treat enterocutaneous fistulas. J Vasc Interv Radiol. 2013 Oct;24(10):1559-65.
13. Crespo Vallejo E, Martinez-Galdamez M, Del Olmo Martínez L, Crespo Brunet E, Santos Martin E. Percutaneous treatment of a duodenocutaneous high-flow fistula using a new biological plug. Diagn Interv Radiol. 2015;21(3):247–251.
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