Fibrin Glue as Adjuvant Treatment for Gastrocutaneous Fistula after Gastrostomy Tube Removal

Gastrocutaneous fistulas are infrequent after gastrostomy tube removal. However, if the fistulous tract remains permeable, even low-volume output can produce significant cutaneous burns. The use of biodegradable adhesives has been described, where fibrin glue is applied directly over the fistulous tract or under the guidance of procedures such as upper or lower gastrointestinal endoscopy or fistuloscopy. We studied the use of fibrin glue in five consecutive adult patients with gastrocutaneous fistulas after gastrostomy tube removal, with no complications that might impede spontaneous closure. A comparison group included seven patients treated during the preceding 2 years with conservative medical management, who were not treated with fibrin glue. There was no difference between the two groups with regard to age and gender, nor with regard to type of gastrostomy (surgical or endoscopic). The mean output volume from the fistulas was 151.4 ± 146.1 ml/24 h in the study group and 115.0 ± 42.7 ml/24 h in the control group, which was not significantly different (P = 0.80). The duration of previous conservative treatment was 93.8 ± 85.1 days for the study group and 95.8 ± 80.7 days for the control group and this also did not differ significantly (P = 0.93). The time to achieve total fistula closure was 7.0 ± 3.1 days in the study group and 32.7 ± 15.7 days in the control group. This difference was statistically significant (P < 0.004). The time required before oral feeding could be recommenced after spontaneous or induced closure was similar in the two groups, at 2.8 ± 1.3 days and 4.71 ± 2.36 days, respectively. Endoscopic guidance allows direct instillation of fibrin glue via the external opening through the whole fistulous tract. This procedure reduces the time required for the closure of gastrocutaneous fistulas.

References

• 1 Petersen P I, Kruse A. Complications of percutaneous endoscopic gastrostomy.  Eur J Surg. 1997;  163 351-356
• 2 Arenas-Márquez H, Anaya-Prado R, Hurtado H. et al . Summary: Mexican consensus on the integral management of digestive tract fistula. Conference review Ixtapa-Zihuatanejo, México, August 21-23, 1997.  Nutrition. 1999;  15 235-238
• 3 Berry S M, Fischer J E. Enterocutaneous fistulas.  Curr Probl Surg. 1994;  31 469-76
• 4 Makris J, Sheiman R. Percutaneous treatment of a gastrocutaneous fistula after gastrostomy tube removal.  J Vasc Int Radio. 2002;  13 205-207
• 5 Derueyter L, Van Blerk M, Cardiere G B. et al . Treatment of high-output of gastric fistula with omeprazole.  Hepatogastroenterology. 1991;  38 (Suppl 1) 83-86
• 6 Berry S M, Fisher J E. Classifications and pathophysiology of enterocutaneous fistula.  Surg Clin N Am. 1996;  76 1009-1018
• 7 Arenas-Márquez H, Anaya-Prado R, González-Ojeda A. et al . Gastrointestinal fistulas: clinical and nutritional management. In: Rombeau JL, Rolandelli RH (eds) Clinical nutrition: parenteral nutrition. 3rd edn. Philadelphia; WB Saunders 2001: 258-281
• 8 Meguid M M, Campos A. Nutritional management of patients with gastrointestinal fistula.  Surg Clin N Am. 1996;  76 1035-1080
• 9 Tarazi R, Coutsoftides T, Steiger E, Fazio V W. Gastric and cutaneous fistulas.  World J Surg. 1983;  7 463-473
• 10 Chung M A, Wanebo H J. Surgical management and treatment of gastric and duodenal fistulas.  Surg Clin N Am. 1996;  76 1137-1146
• 11 Rubelowsky J, Machiedo G W. Reoperative versus conservative management for gastrointestinal fistulae.  Surg Clin N Am. 1991;  71 147-157
• 12 Lomis N H, Miller F J, Lotfus T J. et al . Refractory abdominal-cutaneous fistula: percutaneous management with a collagen plug.  J Am Coll Surg. 2000;  190 588-592
• 13 Hedelin H, Nilson A E, Teger-Nilsson A C, Thorsen G. Fibrin occlusion of fistulae postoperatively.  Surg Gynecol Obstet. 1982;  154 366-368
• 14 Groithl H, Scheele J. First experiences with endoscopic application of fibrin tissue adhesive in the upper gastrointestinal tract.  Surg Endosc. 1987;  1 93-97
• 15 Scheule A M, Beierlein W, Lorenz H, Ziemer G. Repeated anaphylactic reactions to aprotinin in fibrin sealant.  Gastrointest Endosc. 1998;  48 83-85
• 16 Schlag G, Redl H. Fibrin sealant: efficacy, quality and safety. In: Waclawczek HW (ed) Progress in fibrin sealing. Berlin; Springer Verlag 1989: 3-20
• 17 Lange V, Maiwald G, Souvatzi T, Meyer G. Endoscopic approaches for occlusion of fistulae. In: Schlag G, Wayand W (eds) Fibrin sealing in surgical and non-surgical fields. Endoscopy. Berlin; Springer Verlag 1995: 50-57
• 18 Thomas H A. Radiologic investigation and treatment of gastrointestinal fistula.  Surg Clin N Am. 1996;  76 1081-1094
• 19 Hwang T L, Chen M F. Randomised trial of fibrin tissue glue for low-output enterocutaneous fistula.  Br J Surg. 1996;  83 112
• 20 Campos A, Andrade D, Campos G. et al . A multivariate model to determine prognostic factors in gastrointestinal fistula.  J Am Coll Surg. 1999;  188 483-490
• 21 Jung M, Manegold B C, Rands W. Endoscopic therapy for gastrointestinal fistulae with fibrin tissue sealant. In: Waclawiczek HW (ed) Progress in fibrin sealing. Berlin; Springer Verlag 1989: 45-59
• 22 Redl H, Schlag G. Properties of different tissue sealants with special emphasis on fibrinogen-based preparations. In: Schlag G, Redl H (eds) Fibrin sealant in operative medicine. Berlin; Springer Verlag 1990: 27-38
• 23 Cellier C, Landi B, Faye A. et al . Upper gastrointestinal tract fistulae: endoscopic obliteration with fibrin sealant.  Gastrointest Endosc. 1996;  44 731-733
• 24 Eleftheriadis E, Tzartinoglou E, Kotzampassi K, Aletras H. Early endoscopic fibrin sealing of high-output postoperative enterocutaneous fistulas.  Acta Chir Scand. 1990;  156 625-628
• 25 Rabago L R, Ventosa N, Castro J L. et al . Endoscopic treatment of fistulas with biological fibrin glue.  Endoscopy. 2002;  34 632-638
• 26 Kurakawa T, Okushiba S, Kadoya M. et al . Selective occlusion with fibrin glue under fistuloscopy: seven cases of postoperative management for intractable complex fistulas.  Endoscopy. 2002;  34 220-222
• 27 Shand A, Pendlbury J, Reading S. et al . Endoscopic fibrin sealant injection: a novel method of closing a refractory gastrocutaneous fistula.  Gastrointest Endosc. 1997;  46 357-358
• 28 Marone G, Santoro L M, Torre V. Successful endoscopic sealing of gastrointestinal fistulae.  Surg Endosc. 1988;  2 116
• 29 Jung M, Manegold C. Therapy of gastrointestinal fistulae with fibrin sealant. In: Schlag G, Wayand W (eds) Fibrin sealing in surgical and non-surgical fields. Endoscopy. Berlin; Springer Verlag 1995: 58-64
• 30 La Torre F, Pascarella G, Nicolai A P. et al . Use of human fibrin glue (Tissucol) in the treatment of recurrent fistulae.  G Chir. 1995;  16 257-258