What is the management approach for a gastrocutaneous fistula?

Management of Gastrocutaneous Fistula

The management of gastrocutaneous fistula requires a multidisciplinary team approach with initial control of sepsis, nutritional optimization, and determination of fistula output to guide whether medical therapy or surgical intervention is needed. 1, 2

Initial Assessment and Management

Control of Sepsis

• First priority: Identify and treat any associated infection or abscess
  • Intravenous antibiotics for infection control 1
  • Radiological drainage of any collections where possible 1
  • Anti-TNF therapy should only be started after abscesses have been treated with antibiotics and drainage 1
  • One-third of patients on anti-TNF therapy develop intra-abdominal abscesses 2

Nutritional Optimization

• Assess nutritional status - malnutrition (BMI <20 kg/m²) is an independent risk factor for poor outcomes 2
• For high-output fistulae: Partial or exclusive parenteral nutrition 2, 3
• For low-output fistulae: Enteral nutrition may be sufficient 2
• Biochemical optimization before definitive management 1

Management Based on Fistula Output

Low-Output Fistulae

• Medical therapy may be sufficient 1
  • Immunomodulator and biological therapy (anti-TNF) can be effective 1
  • Consider proton pump inhibitors and prokinetics to reduce gastric discharge 3
  • Somatostatin analogues may help reduce output 3

High-Output Fistulae

• Usually require surgical intervention 1, 2
  • Medical therapy is less likely to be successful 1
  • Preoperative optimization of nutrition and control of sepsis is essential 1, 2

Factors Affecting Treatment Choice

Favorable for Medical Management

• Low-volume output 1
• Associated with active inflammation (especially in Crohn's disease) 1
• Simple tract (single, non-complex) 1
• No associated strictures 1

Indications for Surgical Management

• High-volume output 1
• Multiple fistula tracts 1
• Associated strictures 1
• Postoperative fistulae (less likely to respond to medical therapy) 1
• Failed medical management 1

Non-Surgical Closure Techniques for Persistent Fistulae

• Tissue adhesives like 2-octylcyanoacrylate have shown 57% success rate in children 4
• Percutaneous endoscopic suturing - effective alternative to surgical closure 5
• De-epithelialization of the fistula tract followed by direct tract sclerosis 6

Monitoring and Follow-up

• Regular assessment of nutritional status 2
• Monitor for signs of sepsis or abscess formation 1
• Assess fistula output regularly to guide ongoing management 1

Pitfalls and Caveats

• Avoid excessive lateral traction on gastrostomy tubes to prevent enlargement of the stoma 1
• Fungal colonization can lead to tube degradation - consider polyurethane rather than silicone tubes 1
• For fistulae following gastrostomy tube removal, spontaneous closure typically occurs within 72 hours; persistent fistulae may require intervention 1
• Risk factors for persistent gastrocutaneous fistula include immune suppression, prior infection at the gastrostomy site, malnutrition, and delayed gastric emptying 1

Remember that increasing complexity of the fistula is associated with adverse outcomes including mortality, emphasizing the importance of appropriate and timely management 1.