Cutaneous Fistula from the Gastric Remnant Resulting from a Chronic Suture-associated Biofilm Infection

Abstract

A 53-year-old woman developed three chronic draining sinuses after Roux-en-Y gastric bypass; these persisted for almost 1 year despite antibiotics and local wound care. At approximately 1 year post-operatively, the drainage from the most superior sinus increased significantly and assumed a greenish hue, prompting concerns for gastrocutaneous fistula despite negative radiologic evaluation. At surgery, the patient was found to have a retained permanent multifilament suture at the base of each sinus, with associated inflammatory and fibrous tissue and a "slimy" matrix. Confocal laser scanning microscopy of both the explanted sutures and investing soft tissue revealed extensive bacterial biofilm formation. Also at surgery, a frank fistulous track was noted communicating the most superior suture/sinus to the gastric remnant, necessitating laparotomy and remnant gastrectomy in addition to removal of the foreign bodies (sutures) and concomitant panniculectomy. The patient has subsequently been free of complaint or finding for over 3 years.

Bacterial Biofilms on Implanted Suture Material Are a Cause of Surgical Site Infection

“…Two patients did require subsequent re-exploration; they are discussed at greater length below. Two patients, with major post-RYGB complications beyond a deep incisional SSI, have been described in greater detail [11,12].…”

“…In all cases, the infection remained localized to the adjacent tissues of the abdominal wall. In one early patient, the localized infection actually did progress to a frank gastrocutaneous fistula [12]. (4) ''The infection is difficult or impossible to eradicate with antibiotics despite the fact that the responsible organisms are susceptible to killing in the planktonic state.''…”

Microbiology of Explanted Suture Segments from Infected and Noninfected Surgical Patients

“…These studies further characterized the role of suture material as a foreign body, functioning as a nidus for infection in the presence of wound contamination. Recent reports by Kathju and colleagues suggest that contamination of surgical sutures at the time of implantation by biofilm-forming organisms leads to recalcitrant infection, necessitating eventual removal of the infection device (4,5). While closure technologies such as surgical sutures have not always been viewed in the same light as other implantable biomedical devices, the surface characteristics of these devices make them a susceptible substrate for bacterial adherence and/or contamination.…”

“…A heavily contaminated wound (with Ն5.0 log 10 CFU) may present acutely with incisional (wound) dehiscence. When the wound microbial burden is low (Ͻ2.0 log 10 CFU), the infection may present as a late-onset or chronic process that is nonresponsive to traditional therapeutic strategies (5,7).…”

“…There have been limited studies investigating the microbial recovery from sutures explanted from noninfected or infected clinical specimens. Those that have been conducted have involved fewer than 10 patients and were limited to a selective surgical patient population (4,5). In the present study, absorbable and nonabsorbable infected/noninfected suturing devices were explanted from 158 surgical patients representing a broad patient population and were evaluated for aerobic/anaerobic microbial recovery and biofilm formation.…”