Over-the-scope clip to close a fistula after removing a percutaneous endoscopic gastrostomy tube

Inhaltsübersicht

Percutaneous endoscopic gastrostomy (PEG) feeding is indicated in patients with increased nutritional requirements, such as patients with cystic fibrosis [1]. Refractory gastrocutaneous fistulas are a recognised complication following PEG tube removal. We describe the case of a patient with a nonhealing gastrocutaneous fistula that was successfully closed using an over-the-scope clip (OTSC).

Following PEG tube removal, a patient with cystic fibrosis had a persistent discharge and discomfort from a nonhealing gastrocutaneous fistula for 4 months ([Fig. 1]).

Fig. 1 Plastic catheter passed through the fistula tract into the stomach.

An endoscopy was performed, and the gastric aspect of the fistula was successfully closed using three Resolution endoscopic clips (Boston Scientific, USA) ([Fig. 2]).

Fig. 2 Fistula closed with endoscopic clips.

After 2 weeks of symptomatic relief, the patient’s symptoms recurred. Follow-up endoscopy revealed the absence of the initial clips, and so an alternative OTSC (Ovesco Endoscopy GmbH, Tübingen, Germany) was used ([Fig. 3]).

Fig. 3 Over-the-scope clip (OTSC) prior to clip deployment.

The margins of the fistula were apposed with graspers, and the clip then deployed by using the external hand wheel, with the patient under conscious sedation with midazolam ([Fig. 4] and [5]).

Fig. 4 Over-the-scope clip (OTSC) after clip deployment, with engorgement of the gastric mucosa.

Fig. 5 Abdominal X-ray demonstrating the over-the-scope clip (OTSC).

Immediate closure of the fistula was confirmed by the inability to flush water through the tract into the stomach.

The patient was asymptomatic for 18 weeks, after which he developed further symptoms requiring elective surgical intervention.

Several methods have been described for closing nonhealing gastrocutaneous fistulas, including endoscopic clips, fibrin sealant, sutures, and a combination of these techniques [2] [3]. Clip retention is a desirable property of endoscopic clips in this setting. Resolution clips have been reported to have significantly higher long-term retention than other commercially available clips [4], but despite their use in this patient, his symptoms recurred. However, wound healing was likely to be affected by the patient’s underlying disease.

The OTSC has been described for use in natural orifice transluminal endoscopic surgery [5]. OTSCs appear to be effective for closing acute perforations and fistulas in the short to medium term. This is the first report of the use of OTSCs to treat a nonhealing gastrocutaneous fistula following PEG removal.

Competing interests: None

Endoscopy_UCTN_Code_TTT_1AO_2AK

References

• 1 Stroud M, Duncan H, Nightingale J. British Society of Gastroenterology. Guidelines for enteral feeding in adult hospital patients.  Gut. 2003;  52 vii1-vii12
• 2 Akhras J, Tobi M, Zagnoon A. Endoscopic fibrin sealant injection with application of hemostatic clips: a novel method of closing a refractory gastrocutaneous fistula.  Dig Dis Sci. 2005;  50 1872-1874
• 3 Alberti-Flor J J. Percutaneous-endoscopic suturing of gastrocutaneous fistula: report of 2 cases.  Gastrointest Endosc. 2002;  56 751-753
• 4 Shin E J, Ko C W, Magno P. et al . Comparative study of endoscopic clips: duration of attachment at the site of clip application.  Gastrointest Endosc. 2007;  66 757-761
• 5 Schurr M O, Arezzo A, Ho C N. et al . The OTSC clip for endoscopic organ closure in NOTES: device and technique.  Minim Invasive Ther Allied Technol. 2008;  17 262-266