How to clip a gastrocutaneous fistula

We present a simple, yet effective, approach for surgically managing chronic gastrocutaneous fistulas. This procedure can be easily performed under local anaesthesia if needed. Our derived experience is largely based on gastrocutaneous fistulas, but we have also used this approach on small bowel fistulas. Gastrocutaneous fistulas are typically iatrogenic. They can occur after either gastric surgery or as a persistent tract after gastrostomy tube removal. The incidence of this complication after PEG (percutaneous endoscopic gastrostomy) removal is unknown in adults, but has been found to be 39–44% in children.1, 2 The enteric discharge produced can irritate the surrounding skin, causing maceration, skin barrier breakdown, and pain. There may be concurrent local or patient factors that preclude spontaneous closure of these tracts, such as increased duration of gastrostomy tube placement.1, 2 Concomitant delayed gastric emptying, partial distal obstruction, malnutrition, and gastric acid hypersecretion may also play a role.3 There is a significantly lower rate of spontaneous closure if the tract remains open more than 1 week after tube removal, so early intervention is not unreasonable.2 Management options include conservative, endoscopic and surgical. Proton pump inhibitors may aid healing via reduced fistula output and less acidic secretions.3, 4 Endoscopic treatment options can include argon plasma coagulation of the internal orifice and clipping with over-the-scope clips, with silver nitrate cautery to the external opening simultaneously.5 Surgery is typically thought of as a last-line approach. Reported surgical protocols are mostly for excision of fistula tract down to stomach, requiring laparotomy or laparoscopy.5 Percutaneous endoscopic suturing has also been documented in case reports with some success, but requires gastroscopy.6 No previous reports document a durable approach that can be done under local anaesthesia. One common feature of our referred gastrocutaneous fistulas is that they presented 3–12 months after removal of device, after one or more failed attempts at endoscopic closure. This technique has been trialled in five patients and resulted in fistula closure in all cases. The technique is reproducible and easily learnt by new surgeons or trainees. It is also easy to deploy, as it does not require a general anaesthetic or gastroscopy. Our experience is limited to gastrocutaneous fistulas and enterocutaneous fistulas (small bowel) of chronic nature. Simon Bennet: Data curation; project administration; writing – original draft; writing – review and editing. Kevin Lah: Conceptualization; writing – review and editing. James Tan: Conceptualization; writing – review and editing. Hou Kiat Lim: Conceptualization; methodology; project administration; supervision; writing – review and editing.