Volume 1, Issue 2

 

Percutaneous Endoscopic Suturing:An effective treatment for Gastrocutaneous fistula.

August 2, 2010

Background

Development of persistent gastrocutaneous fistula and leakage after removal of a PEG tube is a well-known complication. Various treatments including medications to alter gastric pH, prokinetic agents, endoscopic clipping, electric & 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.

 Objectives

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. A 98-year old woman with multiple co morbidities had a 20 Fr PEG tube placed for poor oral intake secondary to advanced dementia. Three months later, she developed leakage around the PEG tube. A 22 Fr PEG tube was placed with cessation of leakage for a few weeks. Consecutively, larger diameters of PEG tubes were required (up to 28 Fr) to prevent leakage. Conservative management with PEG tube removal , parenteral nutrition, proton pump inhibitors, and prokinetic agents did not improve leakage. An attempt to close the fistula by using chemical & electric cauterization and endoscopic clipping was unsuccessful. The patient was not a surgical candidate.

Methods

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 biopsies were obtained from both ends of the fistula to promote granulation tissue. Final knots were made at the skin level to obliterate the fistula.

The patient was observed for leakage from the fistula and development of infection and other complications after the procedure. One dose of one gram Cefazolin was given intravenously to prevent infection. The patient received parenteral nutrition and proton pump inhibitors after the procedure.

On day 8, the external knots were cut to prevent pressure necrosis. The rest of the suture was left in place to be absorbed.

Results

Enteral feeding at a low rate (20 ml/hour) and 100 ml free water every six hours were initiated on day eight. The fistula site remained clean without any leakage. The patient tolerated optimal rate of nutrition without complication. Four weeks after the procedure, the fistula site remained well healed.

This procedure resulted in complete closure of a large, persistently leaking gastrocutaneous fistula in an elderly patient within seven days.

 Discussion

Persistent leakage from a non-healing gastrocutaneous fistula can lead to severe irritation of adjacent skin and soft tissue of the abdominal wall and may promote the development of cellulitis. Various conservative, surgical, and endoscopic methods have been described in the literature. Apparently, no one method works with sufficient efficacy.

 Our method combines endoscopic suturing and mucosal de-epithelialization, which lead to faster closure of the fistula. Early adoption of this procedure decreases the need for parenteral nutrition, related complications, and length of hospitalization.

Capsule Summary

What is already known on this topic

  • Surgical closure is the treatment of choice for a persistently leaking gastrocutaneous fistula.

What this study adds to our knowledge

  • A combination of endoscopic suturing and mucosal de-epithelialization was a safe and cost-effective alternative to surgical closure of a persistent gastrocutaneous fistula.

Publication

Gastrointestinal Endoscopy Journal (GIE) October 2009; 70(4): 768-771.