Gautam Maddineni, MD1, Zohair Ahmed, DO, MBA2, Navkiran Randhawa, DO3, Aamer Abbass, MD4, Augustine Salami, MD5 1Florida State University, Cape Coral, FL; 2Kansas City University, Cape Coral, FL; 3Medical College of Georgia at Augusta University, Augusta, GA; 4LPG Gastroenterology, Cape Coral, FL; 5LPG Gastroenterology, Fort Myers, FL
Introduction: Percutaneous gastrostomy tube (PEG tube) placement is a common endoscopic procedure that offers enteral nutrition supplementation for certain patients, whether for short or long durations. The procedure is generally regarded as safe. However, the emergence of a Gastrocutaneous Fistula(GF) is a potential complication. Traditionally, GF has been addressed through surgery. The Over-the-scope clip (OTSC) was developed as a tool for endoscopically closing gastrointestinal defects and has now become a viable treatment option for GF. We report a case of successfully closing a GF using OTSC.
Case Description/Methods: A 68-year-old female patient with a prior history of anoxic brain injury arrived at the emergency department with facial swelling. The Gastroenterology team was notified because of a blocked PEG tube and a non-healing infected old ostomy site. Furthermore, there was a drainage of gastric contents from the previous Gastrojejunal (GJ) site that had been inserted four months earlier. The patient underwent esophagogastroduodenoscopy(EGD) and endoscopic closure of the fistula. The superior GF was identified to the left of the gastrostomy tube(Fig1). An ERCP guidewire was passed through the fistula and could be seen externally. The fistulous tract and the surrounding stomach tissue were treated using argon plasma coagulation. An Ovesco 11/6t over-the-scope clip was loaded onto the scope(Fig2) but encountered difficulty advancing down the esophagus due to the patient's chronic torticollis. Therefore, a 12 to 15mm CRE TTS wire-guided balloon was used to dilate the sphincter to 15mm, and the scope clip was advanced behind the balloon into the esophagus. The clip was positioned at the fistulous tract (Fig3) and deployed after identifying it by the cauterized mucosa. Interventional Radiology placed another GJ tube on the same day, and the patient could resume tube feedings within 24 hours without any issues.
Discussion: In this report, we present a case involving the repair of a gastrocutaneous fistula using OTSC. Clinical success rates for OTSC in treating GF are estimated to be approximately 40% to 50%. The persistent irritation caused by gastric secretions complicates the closure of these fistulas through conservative methods, potentially leading to local cellulitis, sepsis, and fatal outcomes. The OTSC system has proven to be a safe and effective tool for addressing persistent post-PEG GF.
Figure: Figure 1: Gastrocutaneous fistula due to chronic PEG tube placement Figure 2: Over the scope clip Figure 3: Gapped tissue pulled into the transparent OTSC applicator cap carrying the clip.
Disclosures:
Gautam Maddineni indicated no relevant financial relationships.
Zohair Ahmed indicated no relevant financial relationships.
Navkiran Randhawa indicated no relevant financial relationships.
Aamer Abbass indicated no relevant financial relationships.
Augustine Salami indicated no relevant financial relationships.
Gautam Maddineni, MD1, Zohair Ahmed, DO, MBA2, Navkiran Randhawa, DO3, Aamer Abbass, MD4, Augustine Salami, MD5. P4552 - Revolutionizing PEG Tube Fistula Closure: The Innovative Over-the-Scope Clip System, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.
