Closure of a Persistent Non-healing Gastrocutaneous Fistula (GCF) With a Porcine Biodegradable Fistula Plug (FP) and an Over-The-Scope Clipping Device

Abstract

Introduction: A 50yo M with a history of tonsillar cancer s/p chemoradiation and subsequent complications related to osteoradionecrosis of the left mandible required long-term placement of a PEG tube (24Fr). After removal the patient developed a persistent GCF. Attempts to close the site with endoclips were unsuccessful due to large size and difficulty opposing the edges of the internal defect. A large 14mm diameter over-the-scope clip was tried but could not be passed across a cervical esophageal radiation stricture. Due to extensive induration of the peristomal area, abdominal wall suture was not feasible. After disrupting the lining of the fistula tract with a cytology brush, a FP (7mm diameter) was placed in antegrade fashion percutaneously through the abdominal wall defect under direct endoscopic guidance. The distal tip of the trimmed fistula plug was secured internally with a 11mm over-the-scope clip. No sutures were required. Immediate closure of the GCF was achieved. Three weeks later, the fistula plug remains in place and is dissolving without leakage. Discussion: PEG tube tracts usually close spontaneously within a few days after removal. Infrequently, a GCF develops. Before attempts at endoscopic closure, disrupting the lining within the fistula tract with a brush or silver nitrate may be enough to facilitate closure if the tract is small. Potential endoscopic management options for refractory GCF usually include through-the-scope endoclips, over-the-scope clipping devices or endoscopic suturing devices. Percutaneous trans-abdominal suture placement or the use of tissue adhesives such as the fibrin sealant may also be considered when feasible. The use of a FP for GCF closure using a technique similar to PEG tube placement has been described in which the FP is pulled through the GCF by a percutaneously placed snare with base of plug located internally within stomach. This method requires sutures to be placed between either the internal and / or external buttons to secure the FP, which can be technically difficult. To our knowledge, this report is the first to describe this variation of technique in which a FP was used to close a large GCF secured internally with an over-the-scope clip. Conclusion: FP can be feasible alternative to consider for refractory GCF. They can be secured internally with an over-the-scope clipping device without the need for sutures.Figure 1