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Predictive Factors for Persistent Gastrocutaneous Fistula after Removal of Gastrostomy Device in Children

Hussein Naji¹²³, Said Zeiai¹²

¹Department of Paediatric Surgery, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden

²Department of Women´s and Children´s Health, Karolinska Institut, Stockholm, Sweden

³Department of Surgery, American Hospital Dubai, Dubai, United Arab Emirates


Correspondence:

Hussein Naji

Department of Pediatric Surgery

American Hospital Dubai

PO BOX 5566, Dubai, UAE

E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

Tel: + 971 56971 4909


Abstract

Aim

Many children with gastrostomy return to normal per-oral diet and require removal of the gastrostomy device which may result in a persistent gastrocutaneous fistula. The purpose of this study was to determine the predictive factors for persistent gastrocutaneous fistula.

Patients and Method

A retrospective review of records in children who had undergone removal of gastrostomy device between 2007-2011 was performed. Persistent gastrocutaneous fistula was defined as the absence of closure of the gastrostomy one month after device removal. Factors that might be predictive for the development of a persistent gastrocutaneous fistula were studied, including age, sex, underlying disease, method of gastrostomy insertion, duration of gastrostomy device in place, and complications related to the presence of gastrostomy.

Results

A total of 66 children were included in the study. Of these, 15 developed a persistent gastrocutaneous fistula (23%). Three predictive factors were identified with significant risk. The median length of time that the gastrostomy device had been in place prior to removal was significantly longer in children who developed persistent gastrocutaneous fistula than those with spontaneous closure - 50 months (range 18-96) vs. 26 months (range 2-144), respectively, P <0.008. Age over 6 years at the time of gastrostomy removal was the second significant risk factor (P <0.003) for development of persistent gastrocutaneous fistula. The third predictive factor was being a female gender (85% of children with persistent gastrocutaneous fistula, P <0.03). No significant association was found regarding the underlying disease, method of gastrostomy insertion or complications related to gastrostomy.

Conclusions

Persistent gastrocutaneous fistula is a common complication. Duration of gastrostomy device in place, age of the patient at time of removal and female gender were identified as significant predictive factors for development of persistent gastrocutaneous fistula.

 Key words: persistent gastrocutaneous fistula, gastrostomy device removal, complications post gastrostomy.


Introduction

In the last thirty years new surgical techniques and treatments have been developed which led to many more children with different disorders being treated with gastrostomy [1-3]. At the same time new advances with rehabilitation and care have led to the successful return of a large number of these children to a normal diet perorally [4].

After removal of the gastrostomy device, the tract between the ventricle and skin closes spontaneously within few days as a natural healing process [6]. In some patients, the gastrostomy site starts to leak gastric fluid and causes skin irritation and in some cases substantial discomfort. This stoma is called persisting gastrocutaneous fistula [7]. This sort of complication is not as well studied as other complications that may develop while using a gastrostomy [3, 6-10]. The recommended treatment of choice is waiting for a spontaneous closure up to 3 months and afterwards operating the children who have not undergone such a closure [6, 11]. The purpose of this study was to determine the predictive factors for development of persistent gastrocutaneous fistula in children.

Patients and Method

A retrospective review of the records of all patients who had undergone removal of gastrostomy device between January 2007 and December 2011 at Astrid Lindgren Children`s Hospital, Karolinska Institute, Stockholm, was performed. The decision to remove the gastrostomy device was based on the clinical assessment and the nutritional status of the patient and when the gastrostomy was no longer needed. Exclusion criteria included removal of gastrostomy device because of infection or persistent leakage. The procedure was done in an outpatient setting by traction as all the patients had a balloon-type gastrostomy buttons. These buttons were either placed initially during the insertion of gastrostomy or replaced the gastrostomy tube 6-8 weeks after insertion, depending on the type of surgery.

Persistent gastrocutaneous fistula (pGCF) was defined as the absence of closure of the gastrostomy one month after device removal and required surgery to close it (Fig. 1). Factors that might be predictive for the development of a pGCF were studied, including age, sex, underlying disease, method of gastrostomy insertion, duration of gastrostomy device in place, and complications related to the presence of gastrostomy. Patients were divided into two groups: those with a spontaneous closure and those who developed a pGCF. Groups were compared statistically using Chi square test, Fishers test and Mann Whitney U test. All calculations were done with R 2.15.0. A p- value less than 0.05 was considered significant.

Figure 1: Persistent gastrocutaneous fistula after removal of gastrostomy button

9.1.3.1

Results

During the study period 329 patients had a gastrostomy device inserted, with 114 placed endoscopically, 102 laparoscopically and 113 with open surgical technique. The study group included 66 patients whose gastrostomy devices were removed. Of these, 51 gastrostomy sites closed spontaneously and 15 developed a pGCF (23%) which were subsequently operated to close the fistula. Comparison of the two groups regarding the underlying disease, method of gastrostomy insertion and complications showed no significant effect on the development of pGCF (Table 1).

Table I: The studied predictive factors and their respective P value.

 

Spontaneous closure

 

pGCF

 

- value

 

Number of patients

 

51

 

15 (23%)

 

Type of operative technique: PEG

Open

Laparoscopy

 

 

26

18

7

 

 

7

6

2

 

 

0,71

Length  of  time  gastrostomy  device  in place

(median and range in months)

 

26 (2-144)

 

50 (18-96)

 

0,008

 

Age (median and range in years)

 

Boys

 

5,4 (1-18)

 

26

 

11(3-18)

 

3

 

0,003

 

 

0,03

Girls

25

12

Underlying disease

0,07

Neurologic disease

6

4

 

Tumour

 

12

 

3

 

Gastrointestinal disease

 

14

 

2

 

Swallowing problems

 

5

 

1

Respiratory disease

4

0

 

Cardiovascular disease

 

2

 

3

 

Others

 

8

 

2

The median length of time that the gastrostomy device had been in place prior to removal was significantly longer in the group who developed pGCF - 50 months (range 18-96) than in the group with a spontaneous closure - 26 months (range 2-144) (P < 0.008). The median age of the patients at the time of gastrostomy device removal was 5.4 years (range 1-18) for the group with spontaneous closure and 11 years (range 3-18) for the pGCF group. Only 3 patients of 15 (20%) were under 6 years of age at the time of gastrostomy device removal and developed pGCF compared with 32 of 51 (63%) patients who were under 6 years of age with spontaneous closure (P < 0.003). There was a female predominance in the group who developed pGCF (80%) which was statistically significant compared to the group of spontaneous closure (50%) (P < 0.003).

Discussion

There are many studies in the literature specifically targeted the complications of gastrostomy but only few of these studies had attempted to determine the predictive factors for the development of pGCF after removal of the gastrostomy device [4, 6-7, 11-13]. The reported incidence of pGCF varied between 16-45% [4, 6-7, 11]. In our study, the incidence was 23% and it is in accordance with other studies.

In this study, the major predictive factor for the development of pGCF was the length of time that the gastrostomy device had been in place before removal. All patients who had their gastrostomy device removed within 18 months were closed spontaneously. The median length of time for the pGCF group was 50 months (range 18-96) compared to 26 (range 2-144) for the group with spontaneous closure. This factor was evident in some studies like Gordon et al [7] who demonstrated that 9 months was the apparent threshold for the gastrostomy to close spontaneously. El-Rifai et al [6] noticed that the duration of gastrostomy placement was significantly longer in patients who went to develop pGCF. Other studies could not find a significant difference regarding the duration of gastrostomy placement [11].

Wyrick et al. [14] demonstrated that patients with device placed at 1.8 months of age were more likely to develop pGCF compare to those with device placed at 8.9 months of age. We studied the age of patients at the time of device removal and found that there is a risk to develop pGCF when the age of the patient is older than 6 years at the time of device removal. Only 3 (20%) patients (out of 15) were under 6 years of age at the time of device removal and developed pGCF. In the second group with spontaneous closure, there were 32 (63%) patients (out of 51) under 6 years of age at the time of device removal and all ended with spontaneous closure.

The gender of the patient was not found to be a risk factor in other studies [7, 11, 14] and our finding of a female gender to be a risk factor may be affected by the small number of our patients. We suggest a large multicenter study to further investigate this and other factors. The fact that the type of surgical technique of gastrostomy insertion whether it was percutaneous or open surgical had no effect on gastrostomy closure was demonstrated by El-Rifai et al [6] and Gordon et al [7], and was confirmed by our results. Our study, like others [6-7,11] showed that the underlying disease of the patient had no significant effect on the development of pGCF. The limitations of this report were being a retrospective, single-institutional, lack of a control population and short follow up time for some patients. In addition, the small number of patients who developed pGCF might influence our results regarding the age and gender factors.

Conclusion

Persistent gastrocutaneous fistula is common after removal of gastrostomy device. Duration of gastrostomy device in place, age of the patient at time of removal and female gender were identified as significant predictive factors for development of pGCF. These findings may be useful for surgeons to detect patients that require early closure of pGCF.

 

 

 

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