Persistent Gastrocutaneous Fistula after Percutaneous Gastrostomy Tube Removal

Persistent gastrocutaneous fistula after removal of a percutaneous gastrostomy (PEG) tube is an uncommon complication [1]; the fistulous tract usually closes spontaneously within 48-72 hours. Factors involved in failure of closure are the duration of PEG tube placement, obesity, persistent cough, fibrosis of the tract, and underlying debilitating disease. Conservative approaches have included parenteral therapy, reduction of the acidic pH of the stomach, and pharmacological acceleration of the gastric emptying time [2] [3]. Traditionally, surgical therapy has been reserved for patients who prove refractory to these measures, though there have been a few reports of patients who have been managed with endoscopic clips [4] [5]. We present a patient with a persistent gastrocutaneous fistula after PEG removal who was treated endoscopically with clips placed across the internal gastric opening.

A 56-year-old man with history of laryngeal carcinoma had a Fresenius-Freka PEG tube placed in an uncomplicated procedure. He subsequently underwent a laryngopharyngectomy with reconstruction. He made a normal recovery and, 6 months later, the PEG tube was removed. However, the patient continued to experience persistent leakage from the fistulous PEG site for the next 4 weeks. There was no evidence of infection at the site. He was treated conservatively, with withdrawal of enteral feeding, institution of parenteral nutrition, and commencement of proton-pump inhibitor therapy, but the fistula failed to heal. An upper gastrointestinal endoscopy was performed under propofol sedation, which showed that the gastric end of the fistula was still patent. There was no evidence of gastroparesis or obstruction. Mechanical approximation and closure of the gastric opening was achieved with two endoclips (Olympus HX-600 - 135). Air insufflation of the stomach following this procedure did not reveal air leakage through the cutaneous site, confirming adequate closure of the internal os. Oral feeding was commenced after 2 days. On further follow-up, the fistulous tract had completely healed, and there was no further drainage.

PEG tube placement has become a fairly routine procedure for the provision of nutrition over varying periods of time, depending on the clinical situation. They are removed from patients who have been rehabilitated and who no longer need them, but unfortunately a fistula persists in some patients, more commonly in children than in adults [1] [6]. Among the various mechanisms that have been described for the pathogenesis of this complication, longer duration of PEG placement appears to be associated with a higher probability of nonclosure of the fistula [3] [7]. In addition, our patient had been on chemotherapy postoperatively, which might have delayed healing.

Suggested therapies have included cauterization of the granulation tissue around the PEG site with silver nitrate, treatment of tract infection with antibiotics, reduction of acidic reflux with proton-pump inhibitors, and the use of prokinetic agents to increase the gastric emptying time. However, these measures have enjoyed variable success. Attempted endoscopic therapies have included the use of fibrin sealant, and the deployment of endoscopic clips. Fibrin application has been tried with limited success, this depending on the degree of resulting fibrosis of the tract and the number of treatment sessions [8] [9]. The novel use of endoclips to mechanically close small iatrogenic perforations, such as those related to endoscopic procedures, has been reported [10]. In the case presented here, we required two clips to close the gastric mucosal site and prevent reflux of gastric contents through the tract, thereby facilitating healing and rapid closure of the tract. Previous studies have reported successful closure of gastrocutaneous fistulas with the application of four to five endoclips [4] [5] [10]. A recent case study described treatment of a gastrocutaneous fistula using a combination of clip application and fibrin glue injection [11]. The choice of whether the combined approach is better than a single one has yet to be determined in further studies.

The rare occurrence of gastrocutaneous fistula as a complication after PEG tube removal should be kept in mind. Endoscopic clip application is a promising and safe technique which can promote early closure of fistulas and thereby circumvent the need for surgical intervention.

Competing interests: None

References

• 1 El-Rifai N, Michaud L, Mention K. et al . Persistence of gastrocutaneous fistula after removal of gastrostomy tubes in children: prevalence and associated factors.  Endoscopy. 2004;  36 700-704
• 2 Makris J, Sheiman R G. Percutaneous treatment of a gastrocutaneous fistula after gastrostomy tube removal.  J Vasc Interv Radiol. 2002;  13 205-207
• 3 Kobak G E, McClenathan D T, Schurman S J. Complications of removing percutaneous endoscopic gastrostomy tubes in children.  J Pediatr Gastroenterol Nutr. 2000;  30 404-407
• 4 Alberti L E, Alberti-Flor J J. Endoclip-assisted closure of infected gastrocutaneous fistulas: report of two cases.  Endoscopy. 2005;  37 403
• 5 Thurairajah P, Hawthorne A B. Endoscopic clipping of a nonhealing gastrocutaneous fistula following gastrostomy removal.  Endoscopy. 2004;  36 834
• 6 Bender J S, Levison M A. Complications after percutaneous endoscopic gastrostomy removal.  Surg Laparosc Endosc. 1991;  1 101-103
• 7 Janik T A, Hendrickson R J, Janik J S, Landholm A E. Analysis of factors affecting the spontaneous closure of a gastrocutaneous fistula.  J Pediatr Surg. 2004;  39 1197-1199
• 8 Gonzalez-Ojeda A, Avalos-Gonzalez J, Mucino-Hernandez M I. et al . Fibrin glue as adjuvant treatment for gastrocutaneous fistula after gastrostomy tube removal.  Endoscopy. 2004;  36 337-341
• 9 Shand A, Pendlebury J, Reading S. et al . Endoscopic fibrin sealant injection: a novel method of closing a refractory gastrocutaneous fistula.  Gastrointest Endosc. 1997;  46 357-358
• 10 Raju G S, Gajula L. Endoclips for GI endoscopy.  Gastrointest Endosc. 2004;  59 267-279
• 11 Akhras J, Tobi M, Zagnoon A. Endoscopic fibrin sealant injection with application of hemostatic clips: a novel method of closing a refractory gastrocutaneous fistula.  Dig Dis Sci. 2005;  50 1872-1874