Endoscopic Management of Gastrojejunal and Jejunocutaneous Fistulae: A Percutaneous Endoscopic Gastrostomy Complication in a Pediatric Patient

Abstract

Introduction: Percutaneous endoscopic gastrostomy (PEG) is a method of gastric feeding access that has had increasing use by pediatric surgeons in recent years. Known risks of the procedure include bleeding, infection, and accidental placement into the liver, colon, and small bowel.1–3 Endoscopic management of PEG complications is a rapidly evolving field.4,5 This video describes the use of endoscopic techniques to manage a PEG complication in a pediatric patient. Materials and Methods: The patient was a 15-year-old boy who suffered a stroke resulting in ventilator and tube feed dependence. For long-term feeding access, the patient underwent a (PEG) procedure. The patient had difficulty tolerating gastric tube feeds and the decision was made to convert the gastrostomy to a gastrojejunostomy. Fifty-nine days after the initial PEG procedure, the patient was taken to the operating room for conversion to a gastrojejunostomy tube. After PEG removal, attempts were made to place a guidewire through the tract into the stomach. However, the guidewire did not go in the expected direction. Fluoroscopic and endoscopic evaluation raised concern for communication with the small bowel. An advanced surgical endoscopist was then consulted. The gastrostomy site was identified and traversed with an ultraslim endoscope. The gastrostomy site entered immediately into small bowel. A jejunocutaneous fistula was noted on the opposite site of the bowel, suggesting that the original PEG had traversed a loop of small bowel in a through-and-through manner. The tracts appeared stable and there was no evidence of contamination or insufflation leaking into the peritoneal cavity. Attention was then turned to closing the jejunocutaneous fistula, which could only be accessed through the gastrojejunal fistula. Given that only an ultraslim endoscope, without a proper working channel for the desired intervention, could access the site, an endoclip device was affixed to the side of the ultraslim endoscope. The jejunocutaneous fistula was then closed with five endoclips. Next, the gastrojejunal fistula was closed using an over-the-scope clip. Fluoroscopic evaluation with air insufflation demonstrated complete closure. Finally, to afford enteral access, a PEG was performed using the pull technique. Endoscopic and fluoroscopic observation confirmed good positioning. Results: An upper gastrointestinal contrast study on postoperative day 3 demonstrated no signs of fistula or leak. Tube feeds were initiated and slowly advanced to goal by postoperative day 7. The patient tolerated his gastric tube feeds and had no further surgical complications. Conclusion: This case has several key learning points. First, it demonstrates the high clinical suspicion for PEG complication that must be held when a patient fails to tolerate feeds. Second, it demonstrates how the skilled use of endoscopic and surgical principles can provide minimally invasive definitive management of PEG complications. Next, this case demonstrates how a thorough understanding of the benefits and drawbacks of available endoscopic tools can lead to innovative solutions to difficult problems. Finally, this case demonstrates the advanced care that can be offered to patients when a multidisciplinary approach is utilized. C.G.D., D.J.M., A.Y.T., and M.C.S.: No competing financial interests exist. E.M.P.: Speaking/teaching: Cook Biotech, Inc., C.R. Bard, Inc., Boston Scientific Corp. Ovesco; Research Support: C.R. Bard, Inc.; Consultant: Boston Scientific Corp., Actuated Medical, Inc., Medtronic, Baxter, Surgimatrix, CMR Surgical; Royalties: UpToDate, Inc., Springer. Runtime of video: 7 mins 45 secs This video was presented as a video presentation at the 2020 American College of Surgeons Virtual Clinical Congress, on October 3, 2020.