Treatment of persistently leaking post PEG tube gastrocutaneous fistula in elderly patients with combined electrochemical cautery and endoscopic clip placement

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.

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.

The PEET procedure: Punch Excision of Epithelialized Tracts for gastrocutaneous fistula closure

BACKGROUND

Persistent Gastrocutaneous Fistula (GCF) is common problem encountered in the pediatric population. Several management options for intervening on pediatric persistent GCF have been described and range from open surgical management to medical management. Here we describe a novel adaptation on a previously described technique that utilizes a punch biopsy to excise the GCF we have coined as Punch Excision of Epithelialized Tracts (PEET).

METHODS

The steps to this procedure include passing a punch biopsy tool over a Foley catheter. The catheter is inserted into the GCF tract, the balloon is inflated, the catheter is retracted against the abdominal wall, and the punch biopsy instrument is pushed through the skin and subcutaneous tissue circumferentially excising the tract.

RESULTS

Four patients at our institution have undergone GCF excision using the PEET approach. Mean duration of the GCF in our four patients was 9 months. Mean follow-up after GCF excision using the PEET approach was 7.8 months. No patients in the cohort had any post-operative complications including surgical site wound infection, emergency department visits, or re-hospitalizations related to their surgical care.

CONCLUSION

Based on our preliminary findings in this small patient cohort, we believe the PEET approach for managing persistent pediatric GCF has short-term efficacy and has the potential upside of utilizing fewer hospital resources to perform the procedure in a time-efficient manner.

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.

Persistent Peristomal Leakage from Percutaneous Endoscopic Gastrostomy Successfully Treated with Argon Plasma Coagulation

Introduction

Percutaneous endoscopic gastrostomy is a safe and effective technique and its use is widely spread. Peristomal leakage may occur within the first few days after gastrostomy tube placement and also in the mature gastrostomy tract. The initial treatment involves conservative measures. If the leakage does not resolve, different endoscopic interventions could be necessary with consequent impairing of enteral nutrition and, in some cases, the need of creating a new gastro-cutaneous fistula.

Case Report

We present 4 consecutive cases complicated with late peristomal leakage and medical treatment failure. These patients underwent upper digestive endoscopy, and circumferential fulguration of the mucosa surrounding the tube with pulsed argon plasma coagulation (APC) at 50 W and 1 L/min flow rate was performed. Additional long through-the-scope clips were applied in 2 cases, since the inner orifice remained enlarged, in order to obtain a better closure. Complete leakage and skin changes resolution occurred between 2 and 6 weeks after the procedure (mean 3.5 weeks). The overall mean follow-up was 19 months after the endoscopic procedure (maximum 30 months, minimum 10 months). There was no recurrence of leakage.

Conclusion

The use of APC alone or combined with long through-the-scope clips in large internal stoma orifice resolved persistent leakage from percutaneous endoscopic gastrostomy in all 4 presented cases without complications. In our case series, this technique appeared to be an effective, safe, and relatively low-cost alternative to the treatment of persistent peristomal leakage of the mature gastrostomy tract.

The Efficacy of Over-the-Scope Clip Closure for Gastrointestinal Iatrogenic Perforation During Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography for Pancreaticobiliary Diseases

BACKGROUND

Intestinal perforation is a severe adverse event during pancreaticobiliary endoscopy. The use of over-the-scope clip (OTSC) has recently increased; however, the efficacy of OTSC during pancreaticobiliary endoscopy has not been well studied.

AIMS

To evaluate the efficacy of OTSC for the closure of gastrointestinal iatrogenic perforation during pancreaticobiliary endoscopy.

PATIENTS AND METHODS

This was a retrospective multicenter cohort study conducted at 3 tertiary care centers. The inclusion criteria were patients who had gastrointestinal perforation during endoscopic procedures for pancreaticobiliary diseases and underwent perforation closure using OTSC. The primary outcome was the clinical success rate. Secondary outcomes were technical success rates, adverse event rates, and the duration until the start of oral intake after OTSC.

RESULTS

Ten patients were treated by OTSC from January 2013 to December 2017. In 2 out of 10, the perforations could not be closed completely. In the remaining 8, perforations were closed completely, but intestinal obstruction caused by OTSC occurred in 1 patient. The clinical success rate was 80% (8/10). The technical and adverse event rates were 80% (8/10) and 10% (1/10), respectively. A median resumption timing of oral intake was 5 days (range, 3 to 10 d).

CONCLUSION

OTSC is considered as effective management for perforations during pancreaticobiliary endoscopy, although careful consideration is required for the indication of OTSC.

Gastrointestinal fistula endoscopic closure techniques

With the improvement in flexible endoscopic technology and the availability of new endoscopic devices, current endoscopic therapies spare many patients who would otherwise undergo surgical repair of gastrointestinal fistulas. These endoscopic techniques include gastrointestinal stents, endoscopic suturing, cardiac septal occluders, endo-sponge, vacuum therapy and others. This review elaborates on the indications, evidence, procedural details, efficacy, and complications of various endoscopic techniques for the management of gastrointestinal fistulas.

Gastrocutaneous fistulae in children - A systematic review and meta-analysis of epidemiology and treatment options

BACKGROUND

Gastrostomy tubes are a common adjunct to the care of vulnerable pediatric patients. This study systematically evaluates the epidemiology and risk-factors for gastrocutaneous fistulae (GCF) after gastrostomy removal in children and reviews treatment options focusing on nonoperative management (NOM).

METHODS

After protocol registration (CRD-42017059565), multiple databases were searched. Studies describing epidemiology in children and GCF treatment at any age were included. Critical appraisal was performed (MINORS risk-of-bias assessment tool). One-sided meta-analysis was executed to estimate efficacy of therapeutic adjuncts using a random-effects model.

RESULTS

Sixteen articles evaluating pediatric GCF were identified. 44% defined GCF as persistence >1month which occurred in 31±7% of cases. Risk factors for pediatric GCF include age at gastrostomy, timing of removal, open technique, and fundoplication. Mean MINORS score was 0.60±0.16. Seventeen additional studies were identified reporting 142 patients undergoing NOM (endoscopic, systemic, and local therapies), and one pediatric comparative study was identified. Overall aggregate proportion of GCF closure after any NOM is 77% (80% success rate in local/systemic therapies; 75% success rate in endoscopic approaches). No adverse events were reported.

CONCLUSION

Persistent GCF complicates the management of gastrostomies in 1/3 of children with predictable risk factors. Several treatment options exist that obviate the need for general anesthesia. Their efficacy is unclear. Further prospective investigations are clearly warranted.

LEVEL OF EVIDENCE

III - Systematic Review and Meta-Analysis Based on Retrospective Case Control Studies.

Over-the-scope-clip closure of long lasting gastrocutaneous fistula after percutaneous endoscopic gastrostomy tube removal in immunocompromised patients: A single center case series

Over-the-scope-clips (OTSC®) have been shown to be an effective and safe endoscopic treatment option for the closure of gastrointestinal perforations, leakages and fistulae. Indications for endoscopic OTSC® treatment have grown in number and also include gastro cutaneous fistula (GCF) after percutaneous endoscopic gastrostomy (PEG) tube removal. Non-healing GCF is a rare complication after removal of PEG tubes and may especially develop in immunosuppressed patients with multiple comorbidities. There is growing evidence in the literature that OTSC® closure of GCF after PEG tube removal is emerging as an effective, simple and safe endoscopic treatment option. However current evidence is limited to the geriatric population and short standing GCF, while information on closure of long standing GCF after PEG tube removal in a younger population with significant comorbidities is lacking. In this retrospective single-center case-series we report on five patients undergoing OTSC® closure of chronic GCF after PEG tube removal. Four out of five patients were afflicted with long lasting, symptomatic fistulae. All five patients suffered from chronic disease associated with a catabolic metabolism (cystic fibrosis, chemotherapy for neoplasia, liver cirrhosis). The mean patient age was 43 years. The mean dwell time of PEG tubes in all five patients was 808 d. PEG tube dwell time was shortest in patient 5 (21 d). The mean duration from PEG tube removal to fistula closure in patients 1-4 was 360 d (range 144-850 d). The intervention was well tolerated by all patients and no adverse events occured. Successful immediate and long-term fistula closure was accomplished in all five patients. This single center case series is the first to show successful endoscopic OTSC® closure of long lasting GCF in five consecutive middle-aged patients with significant comorbidities. Endoscopic closure of chronic persistent GCF after PEG tube removal using an OTSC® was achieved in all patients with no immediate or long-term complications. OTSC® is a promising endoscopic treatment option for this condition with a potentially high immediate and long term success rate in patients with multiple comorbidities.

Complications of percutaneous endoscopic gastrostomy

Percutaneous endoscopic gastrostomy (PEG) has become the method of choice for mid-to long-term enteral feeding. The majority of complications that occur are minor, but the rare major complications may be life threatening. Some complications occur soon after tube placement, others develop later, when the gastrostomy tract has matured. Older patients with comorbidities and infections appear to be at a greater risk of developing complications. Apart from being aware of indications and contraindications, proper technique of PEG placement, including correct positioning of the external fixation device, and daily tube care are important preventive measures. Adequate management of anticoagulation and antithrombotic agents is important to prevent bleeding, and administration of broad spectrum antibiotics prior to the procedure helps prevent infectious complications. Early recognition of complications enables prompt diagnosis and effective therapy.

Endoscopic closure of a refractory gastrocutaneous fistula using a novel over-the-scope Padlock clip following de-epithelialisation of the fistula tract

Persistent gastrocutaneous fistula (GCF) is a difficult to manage complication following gastrostomy tube removal, with leakage resulting in distressing sequelae including cutaneous injury, infection and dehydration. Many such patients are high-risk for invasive surgery and, to date, endoscopic closure techniques, including clipping systems, have limitations. We present the case of a 62-year-old woman with persistently leaking GCF 6 months postgastrostomy tube removal, despite maximal antisecretory therapy and postpyloric feeding, and describe failed attempted endoscopic closure with conventional clips. Treatment options were discussed and informed consent was given for an attempt at endoscopic closure using a novel radial closure device ('Padlock clip') combined with surgical de-epithelialisation, with the understanding that this device has never previously been used in this setting. At follow-up 2 weeks postprocedure, the patient was asymptomatic with complete healing of the GCF. This approach has advantages over other endoscopic closure techniques and can be considered as an alternative approach to GCF closure.

Endoscopic closure of persistent gastrocutaneous fistulae, after percutaneous endoscopic gastrostomy (PEG) tube placement, using the over-the-scope-clip system

OBJECTIVES

The Over-The-Scope-Clip (OTSC) has had an evolving role in endoscopic closure of gastrointestinal wall defects, in hemostasis of primary or postinterventional bleeding, and approximation of postbariatric surgery defects. Rapid and effective closure of gastrocutaneous (GC) fistulae using this device has been recently described in the literature. The aim of this study was to evaluate the technical feasibility, efficacy and safety of OTSC as an effective tool in the management of persistent GC fistulae secondary to a complication of percutaneous endoscopic gastrostomy (PEG) tube placement.

METHOD

In this multicenter prospective observational study, we describe our experience with OTSC in the closure of persistent GC fistulas secondary to PEG tube placement. Patients with GC fistulas were sequentially enrolled with a mean age of 84 years. Primary treatment outcome was the immediate successful closure of GC fistula and resolution of leak. Secondary outcome was no recurrence of the fistula and leaks on follow up.

RESULTS

A total of 10 patients were enrolled over the study period. Mean age was 84.4 ± 8.75 years. The primary treatment outcome was achieved in all the patients undergoing this intervention. Secondary outcome was observed in 9/10 (90%) subjects. No procedural complications were reported. Larger fistulae (>2.5 cm) and those with significant fibrosis were more difficult to close with the OTSC system. The mean follow-up time after OTSC application was 43.7 ± 20.57 days. A limitation of this study was that there was no control group.

CONCLUSIONS

OTSC application is a safe and effective endoscopic approach for the closure of persistent GC fistulae secondary to a complication of PEG tube placement.

Endoscopic closure of persistent gastrocutaneous fistula in children

PURPOSE

The incidence of persistent gastrocutaneous fistula (GCF) after removal of gastrostomy tubes in pediatric patients is estimated to be up to 44 %. Our aim was to review the outcomes of GCF closure by an endoscopic technique that utilizes cautery and endoclips.

METHODS

A retrospective analysis of patients who underwent endoscopic treatment for persistent GCF from January 2010 to September 2013 was performed. This technique utilized esophagogastroduodenoscopy with cauterization of the fistula track and endoclipping of the gastric mucosa.

RESULTS

Sixteen patients underwent endoscopic treatment for persistent GCF. Mean age at time of endoscopy was 7.5 ± 5.5 (1.1-17) years. Gastrostomy tubes were in place for mean of 5.4 ± 5.2 (0.5-14.2) years prior to removal. The average time from gastrostomy tube removal to first endoscopic clipping was 6.7 ± 9 (0.1-28.9) months. Seven patients (44 %) had successful closure after one endoclipping procedure. Six patients underwent a second endoclipping procedure, with three successful closures. Four patients (25 %) required surgical closure for persistent fistulas and 2 (13 %) have continued drainage.

CONCLUSIONS

While endoscopy with cautery and endoclipping proves to be safe, many patients require multiple procedures and may require surgical closure. Patient selection and refinement of this technique may improve outcomes.

Enterocutaneous Fistula From A Billroth II Afferent Limb: Successful Closure With Endoclips

Recently, indications for endoscopic clips have expanded to include closure of gastrointestinal fistulae and perforations. A 62-year-old man with remote history of surgery for peptic ulcer underwent right hemicolectomy for a large hepatic flexure mass with proximal colonic dilatation. During surgery, inadvertent pinpoint duodenotomy of the afferent Billroth II limb resulted in a duodeno-cutaneous fistula. Despite total parental nutrition, cutaneous bile drainage persisted. The duodenal fistula was closed during upper endoscopy using three endoclips. Cutaneous bile drainage stopped, and the abdominal wall defect healed. This is the first published case of endoclip closure of an iatrogenic duodenal fistula from a Billroth II afferent limb.

A novel procedure for gastrocutaneous fistula closure

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) tubes have allowed for a safe and efficient way to feed patients who cannot tolerate oral feeding, yet have a functioning gastrointestinal tract. Gastrocutaneous fistulas (GCF) after PEG removal are an unusual and rare complication in adults and may be in part due to poor tissue healing, delayed gastric emptying, or increased gastric acid production. Various approaches have been reported to treat PEG-related gastric fistulas; however, their success rate is variable and patients frequently require repeat procedures or >1 technique in combination, including acid suppression therapy, silver nitrate ablation of the PEG tract lining, argon plasma coagulation, fibrin glue, and/or endoclipping. Upon our review, there have been no published case series reporting the use of endoscopic banding to close persistent GCFs after PEG removal.

STUDY DESIGN

Four patients with persistent GCFs after PEG removal were taken for esophagogastroduodenoscopy with banding of the fistula site. This procedure was chosen due to its relative ease of application. Patient follow-up was by telephone within 3 days of having the procedure and then again 1 to 2 weeks afterward, to ensure that there was no persistent leakage through the fistula tract.

RESULTS

Of the 4 patients who had persistent GCFs after PEG removal, endoscopic banding resulted in complete closure of the fistula in 3 of our 4 patients. In 1 case, banding was unsuccessful secondary to scarring from prior radiation treatment as well as having a previous PEG tube placed 1 inch from the current fistula site. In this case, a second PEG tube was placed through the original PEG stoma, leading to cessation of the gastric leak. The first case resulted in no recurrence after 3 years. The second and third cases have shown no recurrence after 3 months. The fourth case resulted in a second PEG tube to manage persistent drainage through the tract after unsuccessful banding of the site due to complex endoscopic and anatomic issues.

CONCLUSIONS

Endoscopic closure of a GCF, regardless of technique used, can help avoid surgical intervention. Anatomic changes from any previous treatment modalities may decrease the success rate of fistula banding. However, in our patients, endoscopic banding proved to be a safe and relatively simple alternative in closing persistent GCFs due to prior PEG tubes.

Endoscopic treatment of a gastrocutaneous fistula using the over-the-scope-clip system: a case report

The over-the-scope-clip (OTSC; Ovesco Endoscopy GmbH, Tuebingen, Germany) system is a newly designed method for the mechanical compression of large areas in the gastrointestinal tract. So far, indications for OTSC application are hemostasis of primary or postinterventional bleeding, closure of iatrogenic full-thickness or covered perforations. Recently closure of gastrointestinal tract fistulas using this device has been described. A 44-year-old man developed a gastrocutaneous fistula after surgical treatment for a perforated gastric ulcer. We describe the successful endoscopic closure of the fistula using the OTSC system. The patient's clinical followup was uneventful. Fistula closure was successfully implemented as it was documented by imaging and endoscopic examinations performed on the 2nd day and 6th week after the application of the clip. Endoscopic application of the OTSC device was safe and effective for the treatment of a gastrocutaneous fistula.

Recurrent tense pneumoperitoneum due to air influx via abdominal wall stoma of a PEG tube

A 70 years old male on ventilatory and circulatory support for sepsis and non ST segment elevation myocardial infarction developed abdominal distension 14 d after placement of a percutaneous endoscopic gastrostomy tube for enteral feeding. Radiography revealed free air in the abdomen and gastrograffin (G) study showed no extravasation into the peritoneum. The G tube was successfully repositioned with mechanical release of air. Imaging showed complete elimination of free air but the patient had a recurrence of pneumoperitoneum. Mechanical release of air with sealing of the abdominal wound was performed. Later, the patient was restarted on tube feeding with no complications. This case demonstrates a late complication of pneumoperitoneum with air leakage from the abdominal wall stoma.

Percutaneous endoscopic suturing: an effective treatment for gastrocutaneous fistula

BACKGROUND

Development of persistent gastrocutaneous fistula and leakage after the removal of a PEG tube is a well-known complication. Various treatments including medications to alter gastric pH, prokinetic agents, endoscopic clipping/suturing, electric and chemical cauterization, argon plasma coagulation, and fibrin sealant, have been used with variable success. Although surgical closure is the current treatment of choice, most of the elderly patients are poor surgical candidates because of multiple comorbid conditions.

OBJECTIVE

We describe a method of endoscopic suturing of a gastrocutaneous fistula that is a safe and cost-effective alternative to surgical closure.

DESIGN

Individual case.

SETTING

Community hospital.

PATIENT

One elderly patient.

INTERVENTIONS

By using a trocar, we placed multiple, long monofilament sutures from the skin around the gastrocutaneous fistula in criss-cross fashion. Gastric ends of these sutures were pulled from the stomach with a snare under endoscopic visualization. Suture knots were made at the gastric end of the sutures and then were pulled back from the cutaneous side. Multiple biopsy specimens were obtained from both ends of the fistula to promote granulation tissue. Final knots were made at skin level to obliterate the fistula.

RESULT

Our procedure resulted in complete closure of a large, persistently leaking gastrocutaneous fistula in an elderly patient within 7 days. The patient tolerated the optimal rate of enteral nutrition without further leakage.

LIMITATION

Only 1 patient.

CONCLUSION

We believe that this method of endoscopic suturing along with de-epithelialization of the fistula tract for persistent gastrocutaneous fistula is a safe and cost-effective alternative to surgical closure.