COMBINED METHOD FOR TREATING GASTROCUTANEOUS FISTULA AFTER PERCUTANEOUS ENDOSCOPIC GASTROSTOMY REMOVAL

Método combinado para tratamento de fístula gastrocutânea após remoção de gastrostomia endoscópica

A 56-year-old woman with food leaking by gastrocutaneous fistula (GCF), after removal of a 20 Fr percutaneous endoscopic gastrostomy (PEG), unresponsive to clinical treatment. She had PEG for 6 months, due to dysphagia and weight loss, related to squamous cell carcinoma of the esophagus and treatment with chemotherapy and radiotherapy.

We chose to close the ostomy with a simple hybrid technique, electrocoagulation associated with percutaneous suture guided by endoscopy. (^E-VIDEO*). The procedure was performed with the patient under deep sedation and local anesthesia. Upper digestive endoscopy was performed identifying the gastric orifice of the GCF. (Figure 1). Initially electrocoagulation of the orifice, using coagulation current 40 Watts followed by percutaneous punctures on each corner of the GCF with a 14G peripheral intravenous catheter. (Figure 2). Subsequently a 3-0 nylon monofilament suture folded in half is passed through the catheter, forming the “loop” aspect. (Figure 3). The next step is to introduce a second 3-0 monofilament suture on the opposite corner catheter. This last suture should be guided by a biopsy forceps through the priorly formed suture “loop” under direct endoscopy view. (Figure 4). Once the first suture loop is pulled, the second suture will form a second loop on the gastric side with its booth extremities on the skin side, allowing the GCF to be closed by tying a surgical knot. (Figure 5).

FIGURE 1
Upper digestive endoscopy was performed identifying the gastric orifice of the gastrocutaneous fistula.

FIGURE 2
Percutaneous punctures on each corner of the gastrocutaneous fistula with a 14G peripheral intravenous catheter.

FIGURE 3
“Loop” aspect.

FIGURE 4
Last suture should be guided by a biopsy forceps through the priorly formed suture “loop” under direct endoscopy view.

FIGURE 5
Surgical knot.

In the follow up, patient returns after 15 days to remove the surgical knot with resolution of the GCF, without leakage of diet by GCF.

The opening of the wall after removal of PEG usually closes in about 1 to 3 days¹. Persistent GCF after PEG removal is rare and uncommon in adults². Surgical treatment has been largely replaced by endoscopy and several techniques have been described³. Electrocoagulation deepithelialize the tract and promote healing⁴ and the suture causes mechanical closure⁵. The combined method for closing PEG with electrocoagulation associated with suture is simple, safe and has good results.

REFERENCES

• ¹
  Hucl T, Spicak J. Complications of percutaneous endoscopic gastrostomy. Best Pract Res Clin Gastroenterol. 2016;30:769-81.
• ²
  Omer J. Deen, Keely R. Parisian, Campbell Harris, Donald F Kirby. A Novel Procedure for Gastrocutaneous Fistula Closure. J Clin Gastroenterol. 2013;47:608-11.
• ³
  Hameed H, Kalim S, Khan YI. Closure of a nonhealing gastrocutanous fistula using argon plasma coagulation and endoscopic hemoclips. Can J Gastroenterol Hepatol. 2009;23:217e9.
• ⁴
  Duddempudi S, Ghevariya V, Singh M, Krishnaiah M, Anand S. Treatment of persistently leaking post PEG tube gastrocutaneous fistula in elderly patients with combined electrochemical cautery and endoscopic clip placement. South Med J. 2009;102:585-8.
• ⁵
  Alberti-Flor JJ. Percutaneous-endoscopic suturing of gastrocutaneous fistula: report of two cases. Gastrointest Endosc. 2002;56:751-53.

• *
  E-VIDEO: https://youtu.be/m5tyMpP8FgU

• Disclosure of funding: no funding received

Publication Dates

• Publication in this collection
  10 Dec 2021
• Date of issue
  Oct-Dec 2021

History

• Received
  26 Apr 2021
• Accepted
  16 June 2021