Closure of a nonhealing gastrocutaneous fistula using an endoscopic clip.

Abstract: Gastrocutaneous fistula after gastrostomy tube removal may persist for a prolonged period. We present a case of a 58-year-old woman with a GCF that had persisted for 5 months following the removal of an endoscopically-placed gastrostomy tube (PEG). Conservative therapy with anti-acid medications and administering motility agents was unsuccessful. For the closure of the GCF, the endoscopic metal clips were used to close the fistula.

Key Words: gastrocutaneous fistula, endoscopically-placed metal clips

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Persistent gastrocutaneous fistula (GCF) after gastrostomy tube removal is a well-recognized sequela of long-term use, with a reported incidence of 2 to 44%. (1-3) Conservative therapy with [H.sub.2]-blockers and motility agents, as well as mechanical plugging of the fistula, has had mixed success. For this reason, persistent GCF usually requires surgical correction. We present the use of endoscopically-placed metal clips to rapidly close an intractable gastrocutaneous fistula that resulted from gastrostomy tube removal.

Case Report

A 58-year-old woman was referred to the gastroenterology division with a GCF that had persisted for 5 months following the removal of an endoscopically-placed gastrostomy tube (PEG). Five years earlier, the patient developed neurologic deficits, swallowing dysfunction and persistent nausea, vomiting and neurologic complications secondary to Lyme disease. This required the placement of a PEG tube. The patient required use of the gastrostomy tube for 4 1/2 years. When no longer needed, the PEG tube was removed by simple traction without any initial complications. One month later, the patient presented with drainage of gastric contents from a gastrocutaneous fistula with associated local skin edema and erythema. Over a period of 6 weeks, an attempt was made to close the GCF by increasing gastric pH with lansoprazole and ranitidine and administering cisapride and metoclopramide to improve gastric emptying. These measures were unsuccessful. The patient therefore underwent endoscopy with the placement of metal clips. On endoscopy, a large fistula opening was present in the body of the stomach (Fig. 1). Two Resolution[TM] endoclips (Boston Scientific, Natick, MA) were used to engage and then oppose the opposite margins of the internal GCF opening (Fig. 2). Closure of the fistula was suggested when intragastric air insufflation did not result in obvious external leakage. Examination after 1 month revealed a well-healed external fistula tract without any seepage of gastric contents. Follow-up at 3 months showed complete healing of the fistula.

Discussion

Frequently, PEG tubes are used to provide long-term but not permanent enteral nutrition. Although the communication between the stomach and skin usually closes within a few hours to days after gastrostomy tube removal, a persistent GCF may develop in 2 to 44% of patients. (4) A persistent GCF has been defined as persistence of the gastrostomy tract a month after gastrostomy tube removal. (1) This is more common when the gastrostomy tube has been in place for greater than 9 to 11 months. (1) The aim of conservative medical therapy is to increase gastric emptying, increase gastric pH, and decrease intragastric pressure. (5,6) Kobak et al (5) achieved fistula closure in 53% of cases using an H2 antagonist after tract cauterization with silver nitrate. Other investigators have described minimally invasive procedures, including the application of collagen plugs with mixed results. (7,8) Surgical correction is reserved for gastrocutaneous fistulas intractable to other forms of therapy. (9,10)

[FIGURE 1 OMITTED]

Hayashi et al in Japan first described over 20 years ago the application of an endoclip as a therapeutic endoscopic maneuver. (11) Improvement in clip design has permitted a variety of routine clinical applications that include the treatment of gastrointestinal bleeding, as well as the intraluminal closure of tissue defects, perforations and anastomotic leaks. There has been only one previously reported case of closure of a nonhealing gastrocutaneous fistula using endoscopic clips. (12)

[FIGURE 2 OMITTED]

The Resolution[TM] endoclips consist of stainless steel clips with prongs. When fully opened, the distance between the clip prongs measure 11 mm. Clips are applied with a clip applicator device. The advantage of the Resolution[TM] endoclip is that it is engineered to enable opening and closing up to five times before deployment, aiding in repositioning of the clip. For the closure of the fistula tract in this report, the endoclip was used to grasp the margins of the defect and approximate the tissue.

Conclusion

We believe that the placement of endoclips may prove useful in patients with refractory gastrocutaneous fistulas, should be considered first-line therapy, and in many patients should preclude the need for surgery.

References

1. Gordon JM, Langer JC. Gastrocutaneous fistula in children after removal of gastrostomy tube: incidence and predictive factors. J Pediatr Surg 1999;34:1345-1346.

2. Haws EB, Sieber WK, Kiesewetter WB. Complications of tube gastrostomy in infants and children. 15-year review of 240 cases. Ann Surg 1966;164:284-290.

3. Mahajan L, Oliva L, Wyllie R, et al. The safety of gastrostomy in patients with Crohn's disease. Am J Gastroenterol 1997;92:985-988.

4. Aronian JM, Redo SF. Gastrocutaneous fistula after tube gastrostomy. Incidence in infants and children. N Y State J Med 1974;74:2364-2366.

5. Kobak GE, McClenathan DT, Schurman SJ. Complications of removing percutaneous endoscopic gastrostomy tubes in children. J Pediatr Gastroenterol & Nutr 2000;30:404-407.

6. Deruyter L, Van Blerk M, Cadiere GB, et al. Treatment of high-output gastric fistulas with omeprazole. Hepatogastroenterology 1991;38:83-86.

7. Lomis NN, Miller FJ, Loftus TJ, et al. Refractory abdominal-cutaneous fistulas or leaks: percutaneous management with a collagen plug. J Am Coll Surg 2000;190:588-592.

8. Gonzalez-Ojeda A, Avalos-Gonzalez J, Mucino-Hernandez MI, et al. Fibrin glue as adjuvant treatment for gastrocutaneous fistula after gastrostomy tube removal. Endoscopy 2004;36:337-341.

9. Pearlstein L, Jones CE, Polk HC Jr. Gastrocutaneous fistula: etiology and treatment. Ann Surg 1978;187:223-226.

10. Bender JS, Levison MA. Complications after percutaneous endoscopic gastrostomy removal. Surg Laparosc Endosc 1991;1:101-103.

11. Hayashi T, Yonezawa M, Kawabara T. The study on staunch clip for the treatment by endoscopy. Gastroenterol Endosc 1975;17:92-101.

12. Thurairajah P, Hawthorne AB. Endoscopic clipping of a nonhealing gastrocutaneous fistula following gastrostomy removal. Endoscopy 2004;36:834.

Ali A. Siddiqui, MD, Thomas Kowalski, MD, and Sidney Cohen, MD

From the Division of Gastroenterology, Department of Internal Medicine, Thomas Jefferson Medical School, Philadelphia, PA.

Reprint requests to Ali A. Siddiqui, MD, VA North Texas Health Care System (111B1), 4500 S. Lancaster Road, Dallas, TX 75216. Email: [e-mail]

Accepted May 17, 2006.

RELATED ARTICLE: Key Points

* Gastrocutaneous fistula after gastrostomy tube removal may persist for a prolonged period. In the past, surgery was the only definitive therapy.

* A much less invasive way to close the fistula is endoscopically-placed metal clips in the stomach at the site of the fistulous opening.