Nonoperative Closure of Persistent Gastrocutaneous Fistulas in Children with 2-Octylcyanoacrylate

Introduction

Gastrostomy tube (GT) placement, as a means to provide enteral nutrition, is a commonly performed pediatric surgical procedure. Once adequate oral nutritional intake is achieved or the tube is no longer required for medication delivery or other indications, the simple removal of the GT is usually sufficient to allow the gastrocutaneous fistula to close. Factors associated with a delay or failure of spontaneous gastrocutaneous fistula closure include the size of the GT, the length of time the GT has been indwelling, nutritional status, the presence of a foreign body, the underlying disease process, and other comorbidities, such as chronic pulmonary disease. ¹ A persistent gastrocutaneous fistula (pGCF) occurs when the removal of the GT does not result in spontaneous closure following a period of observation and local care. A pGCF is associated with significant soft-tissue morbidity and may compromise nutritional goals.^1,2 While occlusive techniques have been described, these are often not effective, leading to the need to excise the fistulous tract and, primarily, close the gastrotomy and soft tissues under general anesthesia. ²

In this article, we report a novel use of a tissue adhesive, 2-octylcyanoacrylate (2OC) (Dermabond; Ethicon, Sommerville, NJ), to achieve the closure of pGCF in children. Multiple studies have demonstrated that wound closure with 2OC is comparable with other standard wound-closure techniques. 2OC has also been used for rapid nail fixation after nail-bed repair, skin-graft fixation, temporary otoplasty, as a wound sealant, for treating oral aphthous ulcers, and in the treatment of corneal perforations.^3–7 The use of 2OC is well-tolerated and associated with few complications.^8–12

Materials and Methods

Following approval by the Institutional Review Board, the families of children presenting to the pediatric surgery division for the management of a pGCF were offered closure with the tissue adhesive, 2OC. Seven children underwent 2OC therapy, and the following data were retrospectively reviewed: 1) diagnostic indication for gastrostomy-tube placement, 2) age of child at time of 2OC therapy, 3) technique used to place the gastrostomy tube, 4) size of gastrostomy tube, 5) time of indwelling gastrostomy tube prior to removal, 6) success of 2OC therapy, and 7) length of follow-up after 2OC therapy.

Results

All 7 children who presented to the pediatric surgery clinic following removal of their GT had a pGCF of greater than 1 month in duration. Each of the 7 children underwent 2OC application in the clinic. The range of presentation with a pGCF was 4–7 weeks following appliance removal. The 2OC therapy was well tolerated, without complication, in all the cases (Fig. 1). Four children (57%) had complete 2OC closure, and 3 eventually required operative repair of the pGCF. Of the 4 children in whom the 2OC was successful, the indwelling GT had been in situ for an average of 17.3 versus 28.7 months in those children who failed therapy. The GT size was 12–14 Fr in those children who were successfully closed versus 2 of 3 children who failed closure had a GT size of 16 Fr. The diagnostic indication for GT placement, age of the child at the time of 2OC therapy, and GT placement technique did not appear to influence the effectiveness of 2OC therapy. The mean length of follow-up after 2OC was 16 months (Table 1).

OPEN IN VIEWER

FIG. 1.

The GF site is cleaned with alcohol and adhesive remover to ensure that the orifice is clean, dry, and free of any foreign body. If granulation tissue is present, silver nitrate is applied prior to the application of 2OC. (A) 12-Fr pGCF with persistent drainage for a period of 4 weeks following removal of the appliance. (B) The pGCF has been covered and occluded with 2OC. (C) Four weeks following 1 application of 2OC.

Discussion

A gastrocutaneous fistula that fails to close spontaneously after GT removal is defined as persistent.^1,8 A pGCF is associated with a number of situations, especially the length of time the GT is indwelling, with 45% of patients with a GT for greater than 6 months developing a pGCF. ⁸ The management of pGCF is often resource intensive, requiring a period of local wound care, followed by operative repair under general anesthesia. Cyanoacrylate tissue adhesives were first described in 1949 by Airdis, but those short-chain compounds caused local inflammation and had poor degradation properties. ³ The eight-carbon alkyl derivative, 2-octylcyanoacrylate (2OC), was designed as an alternative to correct some of these deficiencies.^4–6 2OC has a breaking strength similar to that of a 5-0 monofilament suture, with improved cosmetic results, and it can be applied in an out-patient-setting clinic without local anesthesia. ⁴ The use of 2OC is very safe and efficacious, with rare reported adverse effects, including wound dehiscence, infection, and allergic skin reactions.^4–6

The aim of this study was to analyze our recent experience in using 2OC tissue adhesive in the management of children with pGCF. We found that 2OC can successfully close pGCF in these patients. Four of the 7 children did not require operative intervention. None of the children suffered an adverse reaction to 2OC therapy. It does appear that, in this small study, 2OC therapy is more successful in children with smaller GT (less than or equal to 12–14 Fr) and a shorter indwelling time period (mean, 17.2 months). A larger study may be able to further differentiate other factors that may influence the efficacy of this technique.

Conclusions

This is the first study evaluating the utilization of 2OC as an occlusion technique for closure of children with pGCF. This technique was safe and effective in a majority of these patients. The 2OC technique is cost effective, can obviate the need for general anesthesia and can be performed in an outpatient setting. Additionally, the use of 2OC did not complicate subsequent surgical management of non-responsive pGCF. It should be considered as part of the initial management of this condition.