The three-tube method under fluoroscopy guidance for post-gastrectomy gastric fistula

Introduction

Gastric fistula is a relatively rare but serious complication of gastrectomy. Despite the advancements in surgical technology, the incidence of gastric fistulas has remained between 0.2–8%, with a mortality rate exceeding 50% (1-5). Gastric fistulas further associate with the risk of abscess formation, which can result in recurrent infections, malabsorption, major hemorrhage due to arterial erosion, and even death secondary to organ failure.

At present, conservative treatment, endoscopic interventions, and secondary surgery have demonstrated some degree of therapeutic effects for early or small fistulas. The management of large or complicated fistulas, in contrast, has remained a challenge. Conservative treatment often associates with a long healing process, with low curative rate but high mortality rate. Endoscopic interventions are technically demanding, and are particularly unfeasible for elderly or high-risk patients given the need for general anesthesia. Secondary surgery is highly invasive, and may not be suitable for patients with severe systemic diseases. There is currently a lack of standardized treatment for complex gastric fistulas, and the application of the three-tube method for gastric fistulas has not been reported in the literature.

In this study, we aimed to evaluate the safety and effectiveness of the three-tube method under fluoroscopy guidance for the management of post-gastrectomy gastric fistulas. We present this article in accordance with the STROBE reporting checklist (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-1778/rc).

Methods

Patient selection

Patients with post-gastrectomy gastric fistulas with abscess formation treated using the three-tube method at our institute between March 2013 and October 2024 were retrospectively analyzed. All gastric fistulas were diagnosed by upper gastrointestinal (GI) contrast imaging with iodine-containing media (Omnipaque^®, GE Healthcare, Chicago, IL, USA) and spiral computed tomography (SCT, GE Revolution EVO 128-slice CT system). Exclusion criteria included (I) the presence of esophagogastric anastomotic fistulas, esophagojejunal anastomotic fistulas, or thoracogastric fistulas after esophagectomy or gastrectomy; and (II) gastric fistulas previously managed by surgical or endoscopic approaches. All relevant data, including baseline medical and surgical records, intraoperative data, and treatment outcomes were recorded.

This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of The First Affiliated Hospital of Zhengzhou University (No. 2022-KY-0024-001), and informed consent was obtained from all patients.

Preoperative preparation

Routine blood tests for liver and renal function, electrolytes, glucose level, coagulation status, infection, C-reactive protein, calcitonin, and other inflammatory indicators were performed. Anaemia, water and electrolyte imbalance, and hypoproteinemia were particularly assessed. SCT was performed to evaluate the location and size of the fistula and of the abscess cavity (Figure 1). The presence of pulmonary involvement such as inflammation, hydrothorax, and atelectasis was assessed as well.

Figure 1 Representative SCT images of a 26-year-old female patient, who remained pyrexic 4 days after sleeve gastrectomy. (A) The high-density surgical sutures (yellow arrow) and abscess cavity (black arrow). (B,C) The abscess cavity formed after subcutaneous fat liquefactive necrosis (black arrows). SCT, spiral computed tomography.

The diagnosis and measurement of fistula

Contrast swallowing measurement with digital subtraction angiography (DSA)

For the contrast swallowing assessment, patients were first instructed to swallow iodine-containing contrast medium. Subsequently, the dynamic flow of the contrast agent was real-time tracked using DSA equipment. As the contrast medium permeated through the fistula tract, it clearly delineated the overall contour of the fistula on the imaging. The maximum width of the contrast-filled fistula was then measured as the fistula diameter.

computed tomography multiplanar reconstruction (CT MPR) measurement for small fistulas

For small fistulas with a diameter <2 mm, SCT scanning was performed instead of contrast swallowing measurement, given the potential difficulty of contrast agent filling and visualization in tiny fistula tracts. The original tomographic images obtained from SCT were post-processed using MPR technology, which allowed reconstruction of images in coronal, sagittal, or customized oblique planes according to the anatomical orientation of the fistula. The diameter of the fistula was determined by measuring the widest cross-sectional area of the fistula on the reconstructed images, which could effectively display the fine structure of small fistulas and compensate for the limitations of the contrast swallowing method in evaluating micro-fistulas.

Fluoroscopy-guided three-tube insertion

The three-tube insertions were performed under fluoroscopy guidance, with local anesthesia and mild sedation. Lidocaine or oxybuprocaine hydrochloride gel was applied to the nasal, oral, pharyngeal, and esophageal mucosae 10 minutes prior to the procedure. All patients were positioned supine on the DSA table (Siemens AG, Erlangen, Germany).

For patients with a large range of pus cavity (usually >10 mm), branching of fistula tract, viscous pus, ineffective nasal drainage or the emergence of new pus cavity, and patients who cannot tolerate nasal cannula placement (such as nasal septum deviation, history of severe nasal bleeding), we used percutaneous catheterization for drainage.

Insertion of three tubes

A 0.035-inch guidewire (Terumo Corporation, Tokyo, Japan) and a 5 F vertebral artery catheter (Johnson & Johnson Cordis, Miami, FL, USA) were passed through one nostril and advanced through the pharynx and esophagus, across the gastric fistula, and into the upper jejunum. The catheter was withdrawn, and a nasojejunal feeding tube was subsequently introduced. A catheter and guidewire were advanced through the contralateral nasal cavity into the gastric antrum, where a decompression tube was subsequently introduced. A negative pressure drum was connected for continuous drainage of gastric content. A 5 F straight multi-lateral hole catheter (Merit Medical Systems, South Jordan, UT, USA) and/or a pig-tail catheter (Merit Medical Systems) was inserted into the lower pole of the abscess cavity.

Insertion of a percutaneous abscess drainage tube

A percutaneous drainage tube was inserted in addition to the transnasal drainage tube if (I) there was presence of a large abscess cavity, highly viscous pus, and gastric content in the abscess cavity; or (II) the transnasal drainage tube was unavailable or ineffective. Percutaneous puncture and drainage tube placement were performed under DynaCT guidance. Surgical drainage tubes that were correctly positioned were simply replaced without the need for further percutaneous puncture.

Following disinfection and administration of 2% lidocaine, an 18 G puncture needle was advanced into the abscess. An 8–10.2 F multi-lateral hole external drainage tube (Cook Medical Inc., Bloomington, IN, USA) was then introduced along a guidewire, and was positioned at the lower pole of the cavity (Figure 2).

Figure 2 Contrast radiography images of the same patient. (A) Leakage of the contrast agent into the abdominal cavity through the proximal fistula of the greater curvature of the gastric remnant (black arrow). (B) The location and size of the abscess cavity on angiography with a 5 F vertebral artery catheter (red arrow). (C) The nasojejunal feeding tube and gastrointestinal decompression tube placed in the proximal jejunum and gastric antrum, respectively (blue arrows). (D) A 5 F pigtail catheter and a 10 F multi-lateral hole catheter placed in the abscess cavity (yellow arrows).

Postoperative treatment

Pus (3–5 mL) was sampled through the drainage tube for bacterial culture and antibiotic sensitivity testing. All drainage tubes were connected to a continuous negative pressure device, with pressure maintained at 150–300 mmHg. In the presence of highly viscous pus, intermittent flushing with metronidazole or normal saline was performed. Enteral feeding was provided according to the patient’s needs, and was slowly titrated to prevent abdominal distension, diarrhea, and reflux. Angiography was performed on days 5–7 to assess for the position of the drainage tube and for the size of the abscess. Adjustments were made where necessary.

All clinically stable patients were discharged with the tubes in-situ, and were followed-up by outpatient visits or telephone. Repeat upper GI contrast imaging was performed every 3–4 weeks. Drainage tubes were replaced when necessary, and were removed upon evidence of fistula and abscess healing. Following removal of the drainage tube, the fistula was assessed 5–7 days later via gastroscopy or upper GI contrast imaging. Where complete fistula healing was observed, the remaining tubes were removed, and oral intake was resumed.

Criteria for treatment success

Clinical success was defined as complete resolution of the fistula and abscess cavity, with resumption of oral feeding, and the lack of recurrence for ≥3 months. Technical success was defined as proper tube placement and effective drainage, allowing for resolution of infective symptoms. Clinical failure was defined as either fistula recurrence within 3 months, poor treatment response necessitating secondary surgery, or death by any cause. Cured was defined as complete resolution of the fistula and abscess cavity, restoration of oral feeding, and no recurrence within ≥3 months. Improved was defined as alleviation of clinical symptoms, reduction in fistula orifice diameter, or shrinkage of the abscess cavity on follow-up CT or contrast radiography 2–3 weeks after abscess aspiration treatment. Inefficacy was defined as no improvement in clinical symptoms, and no change in fistula orifice diameter or abscess cavity scope on follow-up CT or contrast radiography 2–3 weeks after abscess aspiration treatment. Cured is considered as clinical success.

Results

Patients

A total of 40 patients were included in our study (Table 1). Among them, 31 (77.5%) were male and 9 (22.5%) were female, with ages ranging from 26 to 82 years (mean 65.0±10.0 years). The index gastrectomy was performed for either bariatric or malignancy management. The fistula diameter was 7.7±4.6 mm (Table 2).

Interventional outcomes

The adjustment time of the abscess drainage tube was 3.0 [interquartile range (IQR), 2.0, 4.3] times, and the median indwelling duration was 2.7 (IQR, 1.6, 8.0) months. The interventional three-tube method achieved both clinical success (80%) and technical success (100%).

Clinical efficacy

The drainage volume of pus was gradually decreased over 1–5 days. The appearance of the drainage fluid changed from cloudy to clear. Within 1–3 days, body temperature normalized, and significant improvement in physical and mental status was observed. Within 3–5 days, a reduction in leukocyte levels and inflammatory markers, as well as improvement in anemia, electrolyte disturbances, and hypoproteinemia, was reported. Pulmonary examination remained unremarkable. At 5–7 days post-procedure, repeat angiography indicated shrinkage and disappearance of the abscess cavity (Figure 3), while repeat SCT demonstrated degrees of improvement in pulmonary inflammation and hydrothorax (Figure 4). The median fistula healing time was 3.3 (IQR, 2.3, 9.0) months.

Figure 3 Contrast radiography images of the same patient after 1 week. (A) The size of the abscess cavity on angiography with a 5 F straight multi-lateral hole catheter (black arrow). (B) The size of the abscess cavity on angiography with a 10 F multi-lateral hole drainage tube (black arrow).

Figure 4 The SCT images at 1-month follow-up. (A-C) Resolution of both the abdominal and subcutaneous abscess cavities. SCT, spiral computed tomography.

Follow-up

The median follow-up duration was 20 months, with a range of 3–60 months. During the follow-up period, 32 patients were cured with no recurrence of the fistula, 6 patients survived with indwelling catheters, and 2 patients were lost to follow-up. Six patients survived with indwelling catheters. All six patients had malignant tumors (including 4 cases of esophageal cancer and 2 cases of gastric fundus and cardia cancer). Among them, 4 patients received preoperative/postoperative chemotherapy, and 2 patients received radiotherapy. The fistula orifice diameter of all six patients was >8 mm, with 2 cases having a diameter >10 mm. There were 2 cases of intermediate fistulas and 4 cases of late fistulas. The drainage volume of all six patients was >100 mL/d, with 1 case having a drainage volume >150 mL/d. In terms of fistula type, 3 cases were gastric stump fistulas involving both the thoracic cavity and abdominal cavity, 1 case was a gastric stump mediastinal fistula, and 2 cases were gastric stump thoracic fistulas. As for catheter-related complications, 5 patients experienced drainage tube obstruction, and 1 patient had drainage tube displacement (Table 3).

Prognostic factors for fistula healing

A Cox proportional hazards model was applied to analyze factors associated with gastric stump fistula healing and fistula orifice closure. Risk factors for postoperative healing of gastric stump fistula are summarized in Table 4. Age (P=0.136), gender (P=0.736), and primary disease (P=0.153) were excluded from the Cox regression model, while fistula size (P=0.003), fistula output (P=0.024), fistula type (P=0.041), fistula location (P=0.015), time to diagnosis (P=0.021), and preoperative/postoperative chemoradiotherapy (P=0.036) were included. Multivariate Cox analysis revealed that fistula size (P=0.001), fistula output (P=0.007), fistula type (P=0.011), time to diagnosis (P=0.003), and preoperative/postoperative chemoradiotherapy (P<0.001) were significantly correlated with healing time, whereas fistula location (P=0.482) showed no statistical association with healing time. These findings suggest that fistula size, fistula output, fistula type, time to diagnosis, and preoperative/postoperative chemoradiotherapy may influence anastomotic fistula healing (Table 4).

Analysis of key indicators in subgroups with different primary diseases

Healing time across subgroups: esophageal cancer subgroup (28.3±10.2) > gastric fundus and cardia cancer subgroup (24.1±8.7) > bariatric surgery subgroup (15.2±5.3). Abscess size across subgroups: esophageal cancer subgroup (5.6±1.3) > gastric fundus and cardia cancer subgroup (4.8±1.1) > bariatric surgery subgroup (3.5±0.8). Treatment success rate across subgroups: esophageal cancer subgroup (75.0%) < gastric fundus and cardia cancer subgroup (88.9%) < bariatric surgery subgroup (100.0%). Gastric stump fistulas associated with the esophageal cancer subgroup exhibited the poorest outcomes in terms of healing time, abscess size, and treatment success rate; the gastric fundus and cardia cancer subgroup had intermediate prognosis, while the bariatric surgery subgroup achieved the most favorable outcomes (Table 5).

Discussion

Gastric fistulas may develop due to a multitude of causes. Mechanical factors such as stapler misfiring, direct tissular injury, excessive tissue decompression due to undersized cartridge selection, and full-thickness oversewing of staple-lines have been reported (6). Ischemic factors include improper vascularization, and thermal injuries to the stomach wall (7). Patients with distal stenosis are likely to develop proximal leaks, due to impaired gastric emptying impairment, which lead to increased intraluminal pressure and decreased gastric tube compliance (8). Experience of the surgeon and the number of procedures performed have been reported to inversely associate with gastric leaks as well (9).

The management of large gastric fistulas and abscesses remains a challenge, and no standardized treatment plans currently exist. Current therapeutic options include conservative treatment, endoscopic interventions, and secondary surgical treatment. Conservative interventions mainly involve nutritional support, infection control, and surgical drainage. However, standard surgical drainage techniques are mainly passive, which often results in ineffective and incomplete abscess drainage. At the same time, eversion of the gastric mucosa often occurs due to the negative pressure in the pleural cavity, rendering fistulas difficult to heal. Endoscopic interventions involve the use of metal clamps for fistula closure; however, the procedure is often challenged by the presence of gastric mucosal oedema, which can itself result in high failure rate. Drainage tubes can be placed via endoscopic techniques, as described by Jaruvongvanich et al. (10), but may be unfeasible for patients with small fistulas or esophageal stenosis. Secondary surgery is indicated upon failure of endoscopic interventions. Open total gastrectomy has been reported as a viable option for complex and extensive fistulas (11). However, given the invasiveness of surgery, the morbidity and mortality rates are often high, particularly among elderly patients (12). Moreover, surgeries are often contraindicated in systemically unwell patients. Furthermore, there remains a >10% probability of leaks after secondary surgery (13).

Our treatment strategy for gastric stump fistulas with abscess formation should be contextualized against mainstream interventions, with key differences in indications, efficacy, and safety profiles as follows: percutaneous pigtail catheter drainage is preferred for isolated, accessible abscesses, with a drainage success rate of ~90% for pleural effusions and abscesses, but it fails to address the fistula itself and carries risks of tube occlusion (0.7%) and pneumothorax (2.8%), making it insufficient for combined fistula-abscess lesions (14). Endoluminal stents [self-expandable metal stent (SEMS), lumen-apposing metal stent (LAMS)] achieve technical success in 92.3% of tracheoesophageal fistula cases, but SEMS has a clinical success rate of only 53.8% for fistula closure due to high migration and aspiration rates (38.5%) (15); LAMS shows promise for bariatric surgery-related fistulas (93.75% clinical success) but is limited by tissue ingrowth and stent-related pain. Endoscopic internal drainage outperforms closure strategies (86% vs. 63% primary success) for fistulas with >5 cm collections (16), yet it relies on long-term drain placement and cannot achieve definitive fistula closure. Endoscopic suturing/over-the-scope clip (OTSC) yields 100% technical success for GI fistulas, but clinical success drops to 53–55.1% due to 46% recurrence rates (17); it also requires general anesthesia and is unsuitable for critically ill patients with cardiopulmonary comorbidities. Exploratory laparoscopy/re-operation enables direct debridement and fistula repair but carries a mortality rate of up to 50% in contaminated mediastinal/pleural spaces (18), with >10% postoperative leakage risk, making it inappropriate for patients with poor physical status and extensive infection. In contrast, our integrated approach addresses both the fistula and concurrent abscess while avoiding the invasiveness of surgery and the high complication rates of stents/OTSC, particularly for patients with combined thoracic-abdominal fistulas and multiple comorbidities.

Considering these, our study proposed the use of fluoroscopy to aid the precise placement of three tubes, the nasojejunal feeding tube, the GI decompression tube, and the abscess drainage tube for the management of post-gastrectomy gastric fistulas (19). Early enteral nutrition support allows for reverse catabolism and creates the nutritional conditions essential for fistula healing. It also accelerates the recovery of intestinal peristalsis, and avoids intestinal bacterial translocation and sepsis (20). Nasojejunal tube placement under fluoroscopy is simple, and minimizes the risk of trauma and complications related to surgical jejunostomy and endoscopic gastrostomy (21-23). This may, in turn, minimize hospitalization cost by avoiding the need for total parenteral nutrition and long hospital stays (24,25). GI decompression is another important measure to promote fistula healing, by preventing the overflow of gastric content through the fistula into the abscess cavity (26), and by reducing wall tension to promote soft tissue retraction in the case of postoperative gastroparesis (27). Another key treatment measure for post-gastrectomy gastric fistula is the timely and effective drainage of pus. Accurate placement of the drainage tube is thereby essential, and was thus achieved by fluoroscopy guidance in our study. The abscess drainage tube not only allows for timely and effective suction of pyogenic effusion and potential gastric content to prevent further erosion of the abscess cavity, but also enables regular flushing of the purulent content with normal saline or metronidazole to further promote drainage.

Mainstream international clinical nutrition guidelines provide stratified recommendations for the indwelling duration of nasoenteral feeding tubes: The 2022 guidelines from the European Society for Clinical Nutrition and Metabolism (ESPEN) state that nasogastric tubes are only suitable for short-term enteral nutrition (maximum 4–6 weeks), and the National Institute for Health and Care Excellence (NICE) guidelines also confirm 4 weeks as the upper limit for their short-term use; beyond this period, conversion to long-term access such as percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejunostomy (PEJ) is recommended. Nasoenteric tubes are routinely recommended for a maximum indwelling duration of 4–8 weeks, and those exceeding 8 weeks also need to be replaced with PEJ. In terms of catheter materials, rubber catheters should be retained for ≤7 days, silicone catheters for 21–30 days, and polyurethane catheters can be extended to 2–3 months but require weekly assessment, which does not serve as a basis for long-term use. In this study, the median indwelling time of nasojejunal feeding tubes and nasogastric decompression tubes reached 2.7 months (IQR, 1.6–8.0 months), significantly exceeding the upper limit of short-term use specified in the guidelines.

In this study, the prolonged nasoenteral tube access demonstrated favorable safety and acceptability in patients with gastric stump fistulas. This benefit was attributed to the advantages of precise nasoenteral tube positioning, monthly imaging re-evaluation, timely tube adjustment or replacement, and close follow-up. Additionally, enhanced mucosal protection and immune monitoring for patients undergoing chemoradiotherapy further reduced the risk of complications. However, long-term indwelling of nasogastric/nasoenteral tubes still exerted multi-dimensional adverse effects on patients, including decreased comfort such as nasal mucosal compression injury, pharyngeal foreign body sensation, and psychological anxiety; increased infection risk due to nasal bacterial colonization and catheter displacement (especially in chemoradiotherapy patients); and impairment of nasal and GI mucosal integrity as well as delayed fistula healing caused by catheter mechanical stimulation. We well balanced the demand for enteral nutrition and the potential risks of long-term intubation through individualized measures such as optimized fixation methods, regular tube replacement, and early assessment of extubation indications. Among patients with long-term intubation, a total of 5 cases (12.5%) experienced catheter obstruction and 1 case (2.5%) had catheter displacement, all of which were successfully resolved through timely tube flushing, imaging confirmation of position, and repositioning. Overall, there were no fatal adverse events caused by long-term intubation in this cohort, and all complications were controlled via standardized nursing interventions.

Gastric stump fistulas related to esophageal cancer had the poorest outcomes in healing time, abscess size, and treatment success rate; those associated with gastric fundus and cardia cancer showed intermediate prognosis; and bariatric surgery-related cases had the best outcomes. This disparity is mainly due to the weak blood supply at the anastomotic site after esophageal cancer surgery, combined with mucosal and vascular damage from chemoradiotherapy, which slows granulation tissue growth. The abundant reticular blood supply in the gastric fundus and cardia region can partially compensate for such damage, leading to moderate healing speed. Bariatric surgery patients, without tumor or chemoradiotherapy-related injuries, have the strongest tissue repair capacity. Pathogenically, chemoradiotherapy impairs fistula healing through multiple pathways: it directly damages GI mucosa and blood vessels to reduce tissue repair ability, and induces immunosuppression to increase fistula infection risk and promote abscess formation and expansion (28). Moreover, most esophageal cancer patients receive radical chemoradiotherapy for advanced tumors, presenting with poor nutritional status, severe anatomical damage at the esophagogastric junction, and chemoradiotherapy toxicity, making them high-risk for delayed healing. In contrast, bariatric surgery patients are mostly young and middle-aged, free of tumor or chemoradiotherapy exposure, with good baseline health and strong tissue repair, thus achieving better healing outcomes (29). These findings suggest that perioperative nutritional support, preventive anti-infection, and mucosal protection should be strengthened for esophageal or gastric fundus and cardia cancer patients undergoing chemoradiotherapy to reduce the risk of poor fistula healing.

The limitations of our study were the retrospective design and the small sample size. The study results are susceptible to selection bias and recall bias. By the end of follow-up, some patients had not yet experienced endpoint events, so the fistula healing rate and cause-specific mortality may be biased. In this study, some patients had a long healing time, and the factors related to fistula healing need to be further verified. Multi-centered large sample studies are thus warranted to verify the effectiveness and safety of our proposed interventional three-tube method for the management of post-gastrectomy gastric fistulas.

Conclusions

Our study demonstrated that fluoroscopy-guided three-tube placement is safe, minimally invasive, simple, and effective. This interventional approach thereby carries the potential as a novel therapeutic option for post-gastrectomy gastric fistulas.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://qims.amegroups.com/article/view/10.21037/qims-2025-1778/rc

Data Sharing Statement: Available at https://qims.amegroups.com/article/view/10.21037/qims-2025-1778/dss

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-1778/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of The First Affiliated Hospital of Zhengzhou University (No. 2022-KY-0024-001), and informed consent was obtained from all patients.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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