Laparoscopic-Assisted Takedown of a Gastrocutaneous Fistula

A gastrocutaneous fistula is an abnormal connection between the stomach and skin, most commonly occurring after removal of a gastrostomy feeding tube. This video demonstrates the surgical technique of laparoscopic takedown of a gastrocutaneous fistula, performed in conjunction with upper endoscopy. The patient is a pediatric patient with a history of gastrostomy tube placement and Nissen fundoplication for reflux during infancy. Despite removal of the tube, the fistula persisted. Prior endoscopic interventions, including over-the-scope clip placement, were unsuccessful. Due to ongoing drainage and patient preference for definitive closure, surgical intervention was pursued.

Gastrocutaneous fistula; laparoscopic; gastrostomy tube; closure; endoscopic.

This patient has a complex medical history, including gastrostomy tube placement and Nissen fundoplication in infancy for reflux, as well as tetralogy of Fallot status post repair. Although the gastrostomy tube was later removed, she developed a persistent gastrocutaneous fistula that intermittently drained gastric fluid for several years. An endoscopic attempt using an over-the-scope clip failed to achieve closure.

Given the chronic nature of the fistula and continued drainage, the patient elected to undergo surgical takedown. Preoperative imaging (CT scan and upper endoscopy) demonstrated pledgets from the prior fundoplication that had eroded intraluminally, along with evidence of a persistent G-tube tract. Physical examination revealed a midline scar and a depressed area at the prior gastrostomy site, with visible drainage.

Gastrocutaneous fistulas are a rare, long-term complication following percutaneous endoscopic gastrostomy (PEG) tube removal, occurring in 2–44% of pediatric patients.¹ Typically, these tracts close spontaneously within 24–72 hours post-removal. The most significant risk factor for a persistent fistula is the duration the tube remains in place, with tubes in place longer than 8 months associated with increased risk of non-closure.¹

Treatment options range from conservative management to surgical intervention.

Conservative management may include:

• Gastric acid suppression (e.g., H₂ blockers or PPIs).
• Silver nitrate ablation of the fistula tract to disrupt epithelialization and encourage closure.
• Observation.

Endoscopic management techniques can involve:

• Argon plasma coagulation (APC) to ablate the tract.²
• Hemoclips or over-the-scope clips to approximate tissue and promote closure.^2,3

Surgical Takedown, either via open, laparoscopic, or robotic approach, is typically reserved for persistent cases refractory to medical and endoscopic interventions.⁴

The goal of conservative and endoscopic management is to reduce gastric acidity and pressure while promoting healing of the tract. However, the success of these methods can be variable, especially in chronic or epithelialized tracts.³

In this case, surgical takedown was pursued after failure of both conservative and endoscopic methods. Surgical excision of the fistula offers definitive resolution but carries the inherent risks of invasive intervention, including anesthesia and postoperative complications. In this patient’s case, the benefits outweighed the risks, given the chronic symptoms and quality-of-life impact.

Gastrocutaneous fistulas, though rare, represent a challenging complication after PEG tube removal.^1,4 Management should follow a stepwise algorithm, progressing from least to most invasive options. In many cases, conservative and endoscopic approaches are sufficient, particularly for patients with significant comorbidities who may not tolerate general anesthesia. However, in cases where symptoms persist and prior interventions fail, surgical closure remains the most definitive and durable solution.^3,4

The decision-making process must be individualized, considering patient comorbidities, symptom burden, and previous treatment attempts. This case highlights the importance of comprehensive evaluation and the role of minimally-invasive surgery in the management of chronic gastrocutaneous fistulas.

• Upper endoscope with associated equipment (CO₂ insufflation, suction, monitor/tower).
• Laparoscopic instruments including 30-degree camera, 5-mm and 12-mm trocars, graspers, scissors, insufflation tubing.
• Laparoscopic staplers.
• Sutures for fascial and skin closure.

The authors have no conflicts of interest to disclose.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.