Gastrocutaneous fistulas after PEG removal in adult cancer patients: frequency and treatment options

Investigation of tube replacement cases of percutaneous transesophageal gastro-tubing in cancer patients

PURPOSE

Percutaneous transesophageal gastro-tubing (PTEG) is an interventional radiology technique used for enteral feeding, or drainage in malignant bowel syndrome cases, serving as an alternative to percutaneous gastrostomy. Despite its safety and effectiveness in improving quality of life, comprehensive studies on PTEG tube replacement are limited. This study aimed to investigate the cases of PTEG tube replacement.

MATERIAL AND METHODS

This single-center retrospective cohort study was conducted at the National Cancer Center Hospital, Tokyo, Japan. Data were collected from patients who underwent PTEG for malignant bowel obstruction or enteral feeding and then required tube replacement between January 1, 2014 and December 31, 2023. Patient characteristics, duration of tube indwelling, PTEG tube tip position, causes of replacement, and whether dilation or re-PTEG was performed during replacement were analyzed, excluding patients who were transferred or deceased before the initial replacement. Statistical analyses were performed using the Chi-square, Fisher's exact, and Mann-Whitney U tests, with significance set at P < 0.05.

RESULTS

Of 236 patients who underwent PTEG, 56 required an initial tube replacement. The mean age was 55 years, with 51.8 % of patients predominantly male. The primary indication for PTEG was decompression (52 patients). The median tube indwelling duration was 31 days, with the tube tip positioned in the gastric or duodenal in 64.3 % of cases. The most frequent reason for common replacement procedures, performed in 44 patients, was tube dysfunction. Replacement due to accidental removal in 12 patients led to higher rates of dilation or re-PTEG. The duration after accidental removal significantly affected the necessity for dilation or re-PTEG.

CONCLUSION

This study on initial PTEG tube replacement in cancer patients indicated that tube dysfunction is the primary reason for replacement, and accidental removal is more likely to require dilation or re-PTEG.

Laparoscopic resection of a spontaneous gastrocutaneous fistula in an adult - A case report

INTRODUCTION

Persistent gastrocutaneous fistula (GCF) remains a rare but known complication after gastrostomy tube removal. In children, the gold standard of treatment is surgical through an open fistula takedown. Adults, on the other hand, have a much smaller incidence rate, creating a more difficult dilemma in management.

PRESENTATION OF CASE

We present an unusual case of a 42-year-old male who developed spontaneous opening of his gastrocutaneous fistula decades after its original closure in infancy. Patient initially tried both conservative management and endoscopic suturing but developed recurrence less than a year later. He was subsequently referred to General Surgery and underwent laparoscopic fistula takedown without any complications.

DISCUSSION

Gastrocutaneous fistulas in adulthood may present with various etiologies including distant histories of tube removals.

CONCLUSION

Surgical management through a minimally invasive technique provides both definitive and efficient care.

How to clip a gastrocutaneous fistula

We present a simple, yet effective, approach for surgically managing chronic gastrocutaneous fistulas. This procedure can be easily performed under local anaesthesia if needed. Our derived experience is largely based on gastrocutaneous fistulas, but we have also used this approach on small bowel fistulas.

Persistent Ostomy Following Percutaneous Endoscopic Gastrostomy Removal: Treatment Strategies

PURPOSE OF REVIEW

The purpose of this article is to review available literature on management of persistent ostomy following PEG tube removal. We will discuss the incidence of persistent gastrocutaneous fistula (GCF) following PEG tube removal, risk factors for their development, and management strategies that have been proposed and their efficacy.

RECENT FINDINGS

The use of over the scope clips (OTSC) have evolved recently in the management of gastrointestinal bleeding, perforation, and fistula closures. OTSC has become more readily available and proven to be effective and safe. Suturing devices have shown promising results. Persistent gastrocutaneous fistula following PEG removal is a rare yet serious complication that can lead to continuous skin irritation and leakage of gastric contents and acid. There are several postulated risk factors but the most important of these is duration of placement. Management can include medical therapy which has recently been shown to be somewhat effective, endoscopic therapy and surgery as a last resort. Overall, the data on GCFs is limited and further study with larger sample size is needed.

Endoscopic removal of a weight-loss device with stoma closure using a tack-and-suture device

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Jejunojejunal intussusception of a sutured enterotomy site after takedown and primary repair of persistent enterocutaneous fistula: a case report

Enterocutaneous fistula (ECF) is a common complication of many abdominal surgeries. Although most ECF resolve spontaneously, there are many factors that can lead to persistence of the fistula. Management of persistent enterocutaneous fistula usually involves surgery with recurrence of fistula being the most common complication. Here we describe a case of 67-year-old female who presented with intussusception following repair of a persistent enterocutaneous. Given the rare finding of intussusception in adults, this case report presents an interesting complication.

Gastroenterologist's Guide to Gastrostomies

Gastroenterologists are frequently consulted for evaluation feeding tube placement, or for management of complications in an existing feeding tube. Though a frequent topic of consultation for GI Fellows, there are few comprehensive resources for feeding tube placement and troubleshooting available. In this review, we discuss different types of feeding tubes, when each should be considered, and various methods and techniques for placement. Considerations for when one type, method, technique, or specialty may be preferred over the other will be discussed. Additionally, we discuss management of the many complications of indwelling feeding tubes. Our goal is to create a comprehensive review for gastroenterologists to cover clinically relevant questions related to feeding tube placement and management.

Multi-layer endoscopic suturing: a novel method of gastric fistula closure

Background and study aims  Current endoscopic methods of treating gastric fistulas are either too complex or have high rates of recurrence. We aimed to provide a novel endoscopic method for robust fistula closure. Patients and methods  This was a single-center, retrospective study of five patients who underwent multi-layer endoscopic suturing for closing of a chronic fistula (> 4 weeks). Devitalization of the fistula tract was achieved with argon plasma coagulation, followed by endoscopic suturing of the fistula. Then, endoscopic suturing of the gastric wall surrounding the fistula was performed, creating an overlay of healthy gastric mucosa around the fistula. Results  Technical success (fistula closure on the day of the procedure) was achieved in all five patients, with no complications. After a median follow up of 5 months (range 2-23 months), there was a 100 % clinical success rate (no fistula recurrence). Conclusions  Our single-operator method of multi-layer endoscopic suturing provides a robust fistula closure with minimal to no risk of recurrence. In light of limitations of current fistula closure methods, further investigations are warranted to better define long-term outcomes with it compared to alternative methods.

Prevention and management of major complications in percutaneous endoscopic gastrostomy

Background

Percutaneous endoscopic gastrostomy is a commonly used endoscopic technique where a tube is placed through the abdominal wall mainly to administer fluids, drugs and/or enteral nutrition. Several placement techniques are described in the literature with the ‘pull’ technique (Ponsky-Gardener) as the most popular one. Independent of the method used, placement includes a ‘blind’ perforation of the stomach through a small acute surgical abdominal wound. It is a generally safe technique with only few major complications. Nevertheless these complications can be sometimes life-threatening or generate serious morbidity.

Method

A narrative review of the literature of major complications in percutaneous endoscopic gastrostomy.

Results

This review was written from a clinical viewpoint focusing on prevention and management of major complications and documented scientific evidence with real cases from more than 20 years of clinical practice.

Conclusions

Major complications are rare but prevention, early recognition and popper management are important.