Treatment of Persistent Gastrocutaneous Fistula with Combined Electro-Chemical Cautery and Endoscopic Clips

Abstract

Percutaneous Gastrostomy Tube (PEG tube) placement is a common endoscopic procedure performed for short or long term enteral nutrition supplementation. With the aging population, endoscopically placed gastrostomy tubes have become a frequent presence in nursing homes and hospitals. Gastrostomy tubes provide quick access to the alimentary tract and are used routinely for feeding and administering medications in populations that are unable to effectively swallow for a variety of etiologies. Development of gastrocutaneous fistula is a potential complication after removal of PEG tube. The standard treatment for such a chronic fistula is laparotomy with surgical closure of fistula tract, but is often contraindicated because of comorbidities. Conservative treatments have been tried with limited success. Seven patients with chronic non-healing gastrocutaneous fistulas were treated with electrochemical cauterization and endoscopic clip placement. The external portion of the fistula tract was cauterized using silver nitrate and internal portion was cauterized using gold probe cautery to de-epithelialize the fistula. Once the area was successfully denuded, one or two endoscopic clips were deployed to approximate the denuded tissue. Patients were placed on intravenous proton pump inhibitors to increase intragastric pH and intravenous metoclopramide to increase gastric motility. The combined electro-chemical cautery and endoscopic clip closure resulted in either complete closure of the persistent gastrocutaneous fistula or reduction in size of the fistula allowing replacement with a standard size PEG tube. One patient had persistent leakage from the gastrocutaneous fistula that ultimately required surgical intervention. Complications following gastrostomy tube removal are infrequent, but can lead to significant morbidity and possible mortality. Conservative treatment of gastrocutaneous fistula include mechanical devices causing obstruction of the fistula or pharmacologic measures such as raising gastric pH by high does PPIs or improving gastric motility with metoclopramide. Success rate of above mentioned measures is very low in clinical practice. Jonathan et al described successful closure of chronic gastrocutaneous fistulas in three children using combined electro-chemical cauterization and endoscopic clips. This method has not been described in the adult population. Combined electro-chemical cauterization and endoscopic clip closure is an alternative to surgical closure of chronic gastrocutaneous fistula. Further studies are required to determine long term success and efficacy of such therapy.