S2481 Closure of Refractory Gastrocutaneous Fistula With Endoscopically Guided Percutaneous Suturing With the Use of SpyBite Biopsy Forceps

Abstract

Introduction: Persistent gastrocutaneous fistula (GCF) is a rare but well-known complication of long-term Percutaneous Endoscopic Gastrostomy (PEG) tube use. To avoid invasive surgery, endoscopic closure has been used as an initial step for treatment but is not always successful. We report a case of successful GCF closure with a novel endoscopically guided percutaneous suturing technique using the SpyBite biopsy forceps. Case Description/Methods: Our case is a 28-year-old male with a history of cystic fibrosis (CF) complicated by malnutrition, requiring PEG tube placement since childhood. After starting CF therapy with elexacaftor/tezacaftor/ivacaftor and achieving optimal nutritional status, his PEG tube was removed. Unfortunately, he developed a persistent GCF. Initial attempts at closure with over-the-scope-clip and endoscopic suturing failed. The decision was made to proceed with GCF closure by endoscopically guided percutaneous suturing using the SpyBite forceps. Under endoscopic guidance, 2 16G long angiocaths were advanced into the gastric lumen, one caudal and one cranial to the fistula tract in a sterile fashion. A 2-0 silk suture was advanced through one angiocath and externalized using SpyBite biopsy forceps through the other angiocath. The angiocaths were then removed over the suture and the loop was tied down using a surgical knot. This process was repeated 2 more times along the fistula tract, 5mm from each other. Internal closure of the GCF was then performed using endoscopic suturing. One interrupted and 2 running sutures were placed along the border and cinched to reinforce the site. There were no immediate adverse events or delayed skin inflammation. The patient had no further leakage from the GCF site at follow-up 2 weeks later (Figure). Discussion: With the emergence of novel CF therapies, the dependence on feeding tubes has decreased. Unfortunately, these patients are at high risk of GCF formation after PEG tube removal. Given the difficulty in closing GCF, we advocate a multimodality approach, as described here, using transcutaneous and endoscopic suturing. In previously described endoscopically guided percutaneous suturing, the suture loop is externalized through the GCF tract or the mouth. Our technique differs in using SpyBite forceps to externalize the suture through a second catheter. This method is simple and provides a safe and effective alternative for the closure of refractory GCFs.Figure 1.: A-B: Gastrocutaneous fistula before (A) and after closure (B). C-D: 2-0 silk suture inserted through the angiocath and SpyBite forceps inserted through the second angiocath. The suture was grasped with SpyBite forceps and pulled through the second angiocath to form a loop (C: external view, D: endoscopic view) E-F: The suture was pulled externally, and a surgical knot was performed (E: external view, F: endoscopic view).