REPAIRING A GASTROCUTANEOUS FISTULA AFTER PEG-TUBE REMOVAL

A 69-year-old man was evaluated at the unit because of dysphagia. The upper endoscopy revealed an esophageal mass with exophytic growth in the lower third, which was obstructing 70% of the esophageal lumen. The biopsy concluded the diagnosis of adenocarcinoma originated in Barrett's esophagus. Because of the inability of per oral intake, a percutaneous endoscopic gastrostomy was placed, with the “pull” technique. After 17 days, a delimitated zone of erythema was identified around the site of gastrostomy tube placement in the abdominal wall with leaking of alimentary and gastric content. A new upper endoscopy revealed a 2 cm defect in the anterior gastric wall with visualization of the internal bumper through the gastric wall. The diagnosis of “buried bumper syndrome” was made and the gastrostomy tube was removed. After 7 days of the removal, persistence of the defect both in the skin and in the gastric wall with leakage of gastric content was identified. There were multiple attempts to close the 2-cm defect with endoscopic hemoclips. Using a double-channel scope (GIF 2T160, Olympus Medical Co, Tokyo, Japan), the procedure for closing the defect began with the placement of a 3 cm detachable snare around the defect site. Then, the snare was anchored and with hemostatic clips and tightened in order to close the defect. An air leak test revealed that the wall defect was not fully closed. In order to achieve complete endoscopic closure, N-butyl-2-cyanoacrylate was applied over the defect site among the clips. One week later, an upper endoscopy showed the complete healing of the defect.