A Novel 'Rendez-vous' Technique for Persistent Gastrocutaneous Fistula Closure

Aims A gastrocutaneous (GC) fistula is a rare but challenging adverse event that can occur after the removal of a Percutaneous Endoscopic Gastrostomy (PEG) tube [1]. Modern endoscopic techniques such as over-the-scope clipping has become a popular alternative over traditional surgical closure for resolving this issue [2]. However, some fistulas fail to close despite endoscopic interventions and would normally require open surgery. Here, we devised a new “rendezvous” method, involving a combination of endoscopic and surgical approaches, to close recalcitrant fistulas.

Methods This is a case-series study of patients between 2019 and 2024 at a tertiary care centre. Four patients with persistent GC fistulas after long-term PEG use have been treated with this “rendezvous” technique. 3 out of the 4 patients had previous failed GC fistula closure attempts via endoscopic over-the-scope clipping alone. This technique utilises both endoscopic over-the-scope clipping and extraperitoneal surgical excision of the fistula tract to avoid the risks of open surgery while ensuring fistula closure. Only the extraperitoneal portion of the tract is excised so that the stomach is not detached from the abdominal wall. This is to avoid leakage of gastric contents into the peritoneal cavity and thus, reducing the risk of intra-abdominal collections compared to traditional surgery. On the gastric side, the mucosal edges are released with an endoscopic knife prior to over-the-scope clipping of the fistula opening.

Results We reported a 100% success rate with no immediate adverse events and no recurrences within 2 years of closure in a case series of 4 patients with persistent GC fistulas. Three of these patients suffered from neurological disorders and required long-term PEG tubes. One patient required long-term PEG feeding following post-operative adverse events. The timeline between PEG tube placement and fistula closure spanned between 4 to 18 years with a mean of 10.25 years.

Conclusions The novel “rendezvous” technique has shown success in the closure of persistent GC fistulas in a series of highly co-morbid patients following long-term PEG use. This novel technique is a less-invasive alternative to traditional surgery, yet with similar efficacy in our small case-series. Furthermore, this method has shown a higher persistent closure rate compared to endoscopic clipping alone. We aim to perform larger number of this procedure to confirm its safety and efficacy in the future.

Publication History

Article published online:
27 March 2025

• References

• 1 Bhurwal A.. et al. ‘Gastrointestinal fistula endoscopic closure techniques’. Annals of Gastroenterology 2020; 33 pp 1-9
• 2 Papavramidis T.S., Mantzoukis K., Michalopoulos N.. 2011 Confronting gastrocutaneous fistulas, Annals of gastroenterology. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3959466/#:~:text=Introduction-,A%20gastrocutaneous%20fistula%20(GCF)%20represents%20a%20fistula%20connecting,the%20stomach%20and%20the%20skin (Accessed: 30 April 2024).