Closure of a large high-output gastrocutaneous fistula with combined postpyloric feeding and aggressive medical therapy

Widening of the exit site of a percutaneous gastrostomy tube is a rare but difficult to manage complication, which leads to significant morbidity as a result of caustic material leak and associated cutaneous injury. Such defects fail to close with conservative measures such that invasive (surgical or endoscopic) intervention is often required. The authors present a 49-year-old woman with neurological dysphagia, 2 years after gastrostomy tube insertion with several months’ history of leakage and widening of the hole at the exit site. Following gastrostomy tube removal; the patient was left with a large, high-output gastrocutaneous fistula which was treated aggressively with measures to reduce gastric discharge including ‘nil-by-mouth’, bypassing the stomach with distal feeding, administration of a somatostatin analogue, high-dose proton pump inhibitor and prokinetics with the aim of preoperatively downsizing the wound. This novel approach led to complete closure of the large gastrocutaneous fistula, obviating the need for surgical intervention.