Endoscopic closure of persistent gastrocutaneous fistulae, after percutaneous endoscopic gastrostomy (PEG) tube placement, using the over-the-scope-clip system

Abstract

Objectives:The Over-The-Scope-Clip (OTSC) has had an evolving role in endoscopic closure of gastrointestinal wall defects, in hemostasis of primary or postinterventional bleeding, and approximation of postbariatric surgery defects. Rapid and effective closure of gastrocutaneous (GC) fistulae using this device has been recently described in the literature. The aim of this study was to evaluate the technical feasibility, efficacy and safety of OTSC as an effective tool in the management of persistent GC fistulae secondary to a complication of percutaneous endoscopic gastrostomy (PEG) tube placement. Method: In this multicenter prospective observational study, we describe our experience with OTSC in the closure of persistent GC fistulas secondary to PEG tube placement. Patients with GC fistulas were sequentially enrolled with a mean age of 84 years. Primary treatment outcome was the immediate successful closure of GC fistula and resolution of leak. Secondary outcome was no recurrence of the fistula and leaks on follow up. Results: A total of 10 patients were enrolled over the study period. Mean age was 84.4 ± 8.75 years. The primary treatment outcome was achieved in all the patients undergoing this intervention. Secondary outcome was observed in 9/10 (90%) subjects. No procedural complications were reported. Larger fistulae (>2.5 cm) and those with significant fibrosis were more difficult to close with the OTSC system. The mean follow-up time after OTSC application was 43.7 ± 20.57 days. A limitation of this study was that there was no control group. Conclusions: OTSC application is a safe and effective endoscopic approach for the closure of persistent GC fistulae secondary to a complication of PEG tube placement.

Over-the-scope-clip closure of long lasting gastrocutaneous fistula after percutaneous endoscopic gastrostomy tube removal in immunocompromised patients: A single center case series

“…Even though the number of patients in our case series is relatively small, our high closure success rate (100%) is in accordance with the success rate presented by Singhal et al[ 2 ] (90%). These results stand in clear contrast to the low long-term success rate of 30% published by our group for inflammatory fistulae[ 26 ].…”

“…Geriatric patients are prone to suffer from persisting GCF suggesting that age itself is a risk factor for impaired natural closure of the PEG tunnel. Our mean patient age (43 ± 24 years) was significantly lower compared to the only existing comparable case series by Singhal et al[ 2 ] (mean age 84.4 ± 8.75 years). Yet, all of our patients suffered from chronic disease associated with a catabolic metabolism.…”

“…The application spectrum of the over-the-scope-clip (OTSC ® ) has continually evolved from hemostasis to closure of gastrointestinal perforations, leakages and fistulae including anorectal lesions[ 1 - 7 ]. OTSC ® s have been proven to be an effective and safe endoscopic treatment option in these conditions[ 2 , 8 - 10 ]. Emerging indications include fixation of self-expandable metallic stent (SEMS) and diameter reduction of gastrojejunal anastomosis after gastric bypass.…”

“…Even though various risk factors for the development of GCF such as stomal infection, delayed gastric emptying, acid hypersecretion, malnutrition, catabolic metabolism, tumors, immunosuppression and consecutive impaired wound healing have been discussed, the only evidence-based risk factor is a duration of gastrostomy > 6 mo leading to epithelialization and persistence of the gastrostomy channel[ 18 , 19 ]. Existing case series on OTSC ® application for GCF closure generally focus on closure of short standing GCFs in the setting of infection in geriatric populations[ 2 , 8 ]. We here report on our experience with OTSC ® closure of long standing GCF in middle-aged patients with significant comorbidities.…”

Management of early PEG tube dislodgement: simultaneous endoscopic closure of gastric wall defect and PEG replacement

“…At first, clinical observation, nasogastric decompression, intravenous antibiotics and hyperalimentation were employed to allow the gastrotomy defect to close spontaneously 5 6. In 2004, closure of the gastric wall defect using endoscopic clips was first described by Dr. Sugawa and associates 25 26. Since then, endoscopic suturing has been used for the same purpose 7 9 27.…”