Closure of a Percutaneous Endoscopic Gastrostomy-Associated Nonhealing Gastrocutaneous Fistula Using Endoscopic Hemoclips

Abstract

1Department of Medicine, McMaster University, Hamilton, Ontario; 2Department of Medicine, University of Calgary, Calgary, Alberta; 3Division of Gastroenterology, McMaster University, Hamilton, Ontario; 4Harvard School of Public Health, Harvard University, Boston, Massachusetts, USA Correspondence: Dr Frances Tse, Division of Gastroenterology, McMaster University, Room 2F53, 1200 Main Street West, Hamilton, Ontario L8N 3Z5. Telephone 905-521-2100 ext 76733, fax 905-523-6048, e-mail tsef@mcmaster.ca Received for publication April 21, 2013. Accepted May 12, 2013 Case presentation A 53-year-old man admitted for stem cell transplantation in the context of acute myeloid leukemia was referred for gastric content leakage from a persistent gastrocutaneous fistula. A percutaneous endoscopic gastrostomy (PEG) tube had been placed for four months due to suboptimal nutrition. The PEG tube was subsequently removed due to improvement in caloric intake and nutritional status. Unfortunately, drainage of gastric contents (approximately 250 mL/day) from the gastrocutaneous fistula after removal of the PEG tube persisted. This led to peristomal skin maceration and breakdown resulting in local cutaneous bleeding from the PEG tube site. Despite conservative management with bowel rest, proton pump inhibitor therapy, wound care and parenteral nutrition, drainage and bleeding from the gastrocutaneous fistula site persisted. The remainder of his medical history was noncontributory. Physical examination using subjective global assessment revealed a hemodynamically stable man with adequate nutritional status, without any examination or laboratory contraindications to endoscopy. Informed consent was obtained to proceed with an attempt to close the gastrocutaneous fistula via endoscopic hemoclips before considering surgical closure. During endoscopy, the opening of the fistula was identified in the antrum (Figure 1). Single-modality therapy was used and three hemoclips were placed in an attempt to close the fistula site (Figure 2). A stoma bag was placed over the pre-existing fistula site; no air leakage was observed at the time of endoscopy. The fistula tract closed within 24 h after the procedure with no further leakage noted. The patient was closely followed over the ensuing week. Daily clinical assessments were conducted and no evidence of gastric content was noted at the previous fistula site. The patient was kept nil per os for three days and proton pump inhibitor therapy was continued. His diet was then advanced. The lack of gastric output from the fistula tract postendoclip placement, even after the initiation of oral feeds, confirmed the successful outcome of the procedure (Figure 3).