A 53-year-old man with a history of hypoxic brain damage and diabetes mellitus underwent
insertion of a percutaneous endoscopic gastrostomy (PEG) tube because of difficulty
in swallowing and accompanying malnutrition. At 2 weeks after the PEG procedure, he
suddenly developed diarrhea and vomiting of feculent material, which was also found
from PEG tube aspiration. An immediate fistulogram showed the tipp of the PEG tube
in the transverse colon and a gastrocolic fistulous tract formation without peritoneal
leakage. After 10 days of total parenteral nutrition and systemic antibiotics, a follow-up
gastroscopy demonstrated complete healing of the gastrocolic fistula. After an enema
had been administered, colonoscopy was undertaken in an attempt to remove the PEG
tube. After the external PEG tube had been cut, and the internal tube had been pulled
using a polypectomy snare, the 7-mm opening of the colocutaneous fistula was revealed
(Figure [1]). Considering the high risk of delayed wound healing and infection related to the
patient's diabetes, we tried to close the fistulous opening endoscopically using a
metallic clip. The open clip prong was easily applied to close the fistulous opening
after some deflation of the air. Closure was ascertained by rapid expansion of the
colon with air insufflation (Figure [2]). At 6 hours after the procedure, the patient was restarted on a liquid diet orally
and 3 days later he was discharged without significant sequalae.
Figure 1 After the external part of the percutaneous endoscopic gastrostomy (PEG) tube had
been cut, on the other side, the 7-mm opening of the colocutaneous fistula and the
closed gastrocolic fistula with granulation tissue in the transverse colon were noted
Figure 2 A clip was easily applied to the center of the fistula margin, and successful closure
of the colocutaneous fistula was ascertained by rapid expansion of the colon with
high-pressure air insufflation
Cutaneous-colo-gastric fistula is a rare complication after PEG insertion [1]
[2]. If a cutaneous-colo-gastric fistula is confirmed, reinsertion of the PEG is not
recommended because it might accelerate frank perforation and peritonitis [3]. In the absence of peritonitis, this type of fistula is satisfactorily managed nonsurgically
[2]. However, Stefan et al. [4] reported a case of a persistent gastrocolic fistula after the removal of a PEG tube
and this fistulous tract was excised by operation. Furthermore, the conservative approach
needs several days or weeks for the complete healing of the colocutaneous fistula
[2]
[5], and may delay the start of oral feeding and consequently prolong hospital stay.
As with our patient, endoscopic management using a metallic clip would provide for
a more rapid blockage of feculent leakage as well as an earlier trial of oral feeding.
Therefore, our experience has shown that this endoscopic therapy can be a safe and
cost-effective alternative treatment modality for a colocutaneous fistula, especially
in patients with a risk of delayed wound healing or infection.
