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Percutaneous endoscopic suturing: an effective treatment for gastrocutaneous fistula
NEW METHODS: Clinical Endoscopy
Percutaneous endoscopic suturing: an effective treatment for gastrocutaneous fistula Saphwat Eskaros, MD, Vishal Ghevariya, MD, Mahesh Krishnaiah, MD, Armand Asarian, MD, Sury Anand, MD Brooklyn, New York, USA
Background: Development of persistent gastrocutaneous fistula and leakage after the removal of a PEG tube is a well-known complication. Various treatments including medications to alter gastric pH, prokinetic agents, endoscopic clipping/suturing, electric and chemical cauterization, argon plasma coagulation, and fibrin sealant, have been used with variable success. Although surgical closure is the current treatment of choice, most of the elderly patients are poor surgical candidates because of multiple comorbid conditions. Objective: We describe a method of endoscopic suturing of a gastrocutaneous fistula that is a safe and costeffective alternative to surgical closure. Design: Individual case. Setting: Community hospital. Patient: One elderly patient. Interventions: By using a trocar, we placed multiple, long monofilament sutures from the skin around the gastrocutaneous fistula in criss-cross fashion. Gastric ends of these sutures were pulled from the stomach with a snare under endoscopic visualization. Suture knots were made at the gastric end of the sutures and then were pulled back from the cutaneous side. Multiple biopsy specimens were obtained from both ends of the fistula to promote granulation tissue. Final knots were made at skin level to obliterate the fistula. Result: Our procedure resulted in complete closure of a large, persistently leaking gastrocutaneous fistula in an elderly patient within 7 days. The patient tolerated the optimal rate of enteral nutrition without further leakage. Limitation: Only 1 patient. Conclusion: We believe that this method of endoscopic suturing along with de-epithelialization of the fistula tract for persistent gastrocutaneous fistula is a safe and cost-effective alternative to surgical closure.
More than 200,000 PEG tubes are placed annually in United States.1 Development of persistent gastrocutaneous fistula after removal of a PEG tube is a rare but difficult-to-manage problem. Delayed gastric emptying, poor wound healing, and flow of gastric juice through the fistula may hamper healing.2 For those in whom conservative therapy fails, surgical closure is the preferred treatment of choice. However, many of these elderly
DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.
patients are poor surgical candidates. Several case reports and case series described previously used argon beam coagulation, fibrin sealant, endoscopic clipping or suturing, simple suturing, and electrical and chemical cauterization of the fistula with variable success.3-5 Our group’s study, which used a combined approach of chemical and electric cautery and clip placement, showed some promise in a ‘recent case series.6
METHOD
Copyright ª 2009 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2009.05.002
A 98-year-old woman with multiple comorbidities had a 20F PEG tube placed for poor oral intake secondary to advanced dementia. Three months later, she developed
768 GASTROINTESTINAL ENDOSCOPY Volume 70, No. 4 : 2009
www.giejournal.org
Eskaros et al
leakage around the PEG tube. A 22F PEG tube was placed with cessation of leakage for a few weeks. Consecutively, larger diameters of PEG tubes were required (up to 28F) to prevent leakage. Conservative management with PEG tube removal, parenteral nutrition, proton pump inhibitors, and prokinetic agents did not improve leakage. An attempt to close the fistula by using chemical cauterization with silver nitrate externally, endoscopic electrocautery, and endoscopic clip placement was unsuccessful. The patient was not a surgical candidate. A detailed explanation of an upper endoscopy and percutaneous endoscopic suturing of a gastrocutaneous fistula was provided, and informed consent was obtained from the patient’s family. An upper endoscopy was performed with the patient under conscious sedation. The cutaneous side of the fistula was identified and cleaned with povidone-iodine and was anesthetized with 1% Xylocaine. During upper endoscopy, the gastric side of the fistula was identified. An 18-gauge trocar (Safety Trocar catheter; Boston Scientific Corp, Natick, Mass) was inserted through the abdominal wall next to the fistula under endoscopic visualization. A 120-cm-long 0 monofilament absorbable suture (PDS II Plus, PDPB991G; Ethicon, Somerville, NJ) was inserted through the trocar and was grasped within the stomach with a snare and pulled out through the mouth. The first 2 steps were then repeated, such that 4 monofilament sutures traversed the abdominal and gastric walls on the sides of the fistula in criss-cross fashion. These suture ends were externalized through the mouth. Two surgical knots were then made with the sutures retrieved through the mouth. The ends of the sutures exiting the abdominal wall were pulled in a way that the knot made outside the mouth was pulled into the gastric lumen to close the gastric orifice of the fistula. Multiple mucosal bites were taken circumferentially from both ends of the fistulous tract by using standard biopsy forceps to de-epithelialize the fistulous tract completely. Two surgical knots were made at skin level. Bleeding was minimal during the procedure and was controlled with pressure hemostasis. A sterile, dry dressing was applied to the sutured area. The procedure is illustrated in Figures 1 through 3. The patient was observed for leakage from the fistula and development of infection and other complications after the procedure. One dose of 1 g cefazolin was administered intravenously to prevent infection. The patient received parenteral nutrition and proton pump inhibitors after the procedure.
Percutaneous endoscopic suturing
Capsule Summary What is already known on this topic d
Surgical closure is the treatment of choice for a persistently leaking gastrocutaneous fistula.
What this study adds to our knowledge d
A combination of endoscopic suturing and mucosal deepithelialization was a safe and cost-effective alternative to surgical closure of a persistent gastrocutaneous fistula in an elderly woman.
100 mL of free water every 6 hours were initiated. The fistula site remained clean without any leakage. The patient tolerated a gradual increase in enteral feeding to the optimal rate without complication. Four weeks after the procedure, the gastrocutaneous fistula site remained well healed.
DISCUSSION
On day 8, the external knots were cut to prevent pressure necrosis. The rest of the suture was left in place to be absorbed. Enteral feeding at a low rate (20 mL/h) and
Development of a gastrocutaneous fistula after the removal of a PEG tube is a well-known complication. Persistent leakage from a gastrocutaneous fistula can lead to severe irritation of adjacent skin and soft tissue of the abdominal wall and may promote the development of cellulitis. Various conservative, surgical, and endoscopic methods have been described in the literature. Apparently, no one method works with sufficient efficacy. Alberti-Flor3 described successful closure of gastrocutaneous fistula by using percutaneous endoscopic suturing in 2 patients. Simple endoscopic suturing may not be sufficient for a large fistula with a well-formed tract. Our technique is a modification of this technique and involves de-epithelialization with biopsy forceps and the use of 2 surgical knots in a criss-cross fashion. Mucosal de-epithelialization promotes granulation tissue formation and thus promotes healing of the fistula. Multiple biopsy specimens obtained at both ends of the fistula further promote granulation tissue formation, thus facilitating early closure. Two surgical sutures placed in criss-cross fashion provide greater contact between de´brided surfaces of the fistula to achieve optimal healing. Van Bodegraven et al4 described the use of argon beam electrocoagulation and endoscopic clip placement for closure of an esophagopleural fistula in 1999. Argon beam electrocoagulation could be used as alternate way to achieve adequate de-epithelialization. Shand et al5 described successful closure of a gastrocutaneous fistula by using a fibrin sealant. This technique requires injection of 2 components of the sealant simultaneously into the fistula tract with a special syringe. Multiple applications were required in some cases to achieve complete closure.
www.giejournal.org
Volume 70, No. 4 : 2009 GASTROINTESTINAL ENDOSCOPY 769
RESULTS
Percutaneous endoscopic suturing
Eskaros et al
Figure 1. Percutaneous endoscopic suturing of the gastrocutaneous fistula. A schematic illustration. A, A trocar is passed through the abdominal wall into the gastric lumen. A 120-cm-long, 0 monofilament suture is inserted in the trocar, and the gastric end of the suture is externalized by using a snare under endoscopic visualization. B, The procedure is repeated to insert a total of 4 sutures in criss-cross fashion. Two surgical knots are made outside the oral cavity. C, Adequate de-epithelialization is achieved by multiple circumferential biopsies in the fistula tract. D, After adequate de-epithelialization with biopsy forceps is achieved, the cutaneous ends of the sutures are pulled back and a surgical knot is made to close the fistula.
Figure 2. Endoscopic view of the gastric end of the fistula after closure with a suture.
Figure 3. Cutaneous end of the gastrocutaneous fistula after closure with a suture.
Endoscopic clip placement to obliterate the gastric end of the fistula is an effective method. Multiple clips may be needed to obliterate the fistula, which may lead to a substantial increase in the cost of the procedure.6 Our method combines endoscopic suturing and mucosal de-epithelialization, which lead to faster closure of the fistula. Early adoption of this procedure decreases the need for parenteral nutrition, related complications, and length of hospitalization. Conservative measures have low success rates, and many patients with gastrocutaneous fistulas are poor surgical candidates. In addition, surgical closure is expensive and associated with higher postoperative morbidity and mortality. This procedure seems to be safe and cost-effective compared with a conventional approach. This method involves conscious sedation, upper endoscopy, and potential complications related to these
procedures. Multiple pinch biopsies may not adequately de´bride the fistula, leading to suboptimal granulation tissue formation. Application of argon plasma coagulation or bipolar electrocoagulation instead of performing pinch biopsies may achieve more uniform results.
770 GASTROINTESTINAL ENDOSCOPY Volume 70, No. 4 : 2009
www.giejournal.org
REFERENCES 1. McClave SA, Chang WK. Complications of enteral access. Gastrointest Endosc 2003;58:739-51. 2. Shellito PC, Malt RA. Tube gastrostomy. Techniques and complications. Ann Surg 1985;201:180-5. 3. Alberti-Flor JJ. Percutaneous-endoscopic suturing of gastrocutaneous fistula: report of 2 cases. Gastrointest Endosc 2002;56:751-3. 4. Van Bodegraven AA, Kuipers EJ, Bonenkamp H, et al. Esophagopleural fistula treated endoscopically with argon beam electrocoagulation and clips. Gastrointest Endsoc 1999;50:407-9.
Eskaros et al 5. Shand A, Pendelbury J, Reading S, et al. Endoscopic fibrin sealant injection: a novel method of closing a refractory gastrocutaneous fistula. Gastrointest Endosc 1997;46:357-8. 6. Duddempudi S, Ghevariya V, Singh M, et al. Treatment of persistently leaking post PEG tube gastrocutaneous fistula in elderly patients with combined electrochemical cautery and endoscopic clip placement. South Med J 2009 May 7 [Epub ahead of print].
www.giejournal.org
Percutaneous endoscopic suturing
Received November 13, 2008. Accepted May 1, 2009. Current affiliations: Division of Gastroenterology (S.E., V.G., M.K., S.A.), Division of Surgery (A.A.), The Brooklyn Hospital Center, Brooklyn, New York, USA. Reprint requests: Vishal Ghevariya, MD, 240 Willoughby Street, 4C, Brooklyn, NY 11201.
Volume 70, No. 4 : 2009 GASTROINTESTINAL ENDOSCOPY 771
Percutaneous endoscopic suturing: an effective treatment for gastrocutaneous fistula Saphwat Eskaros, MD, Vishal Ghevariya, MD, Mahesh Krishnaiah, MD, Armand Asarian, MD, Sury Anand, MD Brooklyn, New York, USA
Background: Development of persistent gastrocutaneous fistula and leakage after the removal of a PEG tube is a well-known complication. Various treatments including medications to alter gastric pH, prokinetic agents, endoscopic clipping/suturing, electric and chemical cauterization, argon plasma coagulation, and fibrin sealant, have been used with variable success. Although surgical closure is the current treatment of choice, most of the elderly patients are poor surgical candidates because of multiple comorbid conditions. Objective: We describe a method of endoscopic suturing of a gastrocutaneous fistula that is a safe and costeffective alternative to surgical closure. Design: Individual case. Setting: Community hospital. Patient: One elderly patient. Interventions: By using a trocar, we placed multiple, long monofilament sutures from the skin around the gastrocutaneous fistula in criss-cross fashion. Gastric ends of these sutures were pulled from the stomach with a snare under endoscopic visualization. Suture knots were made at the gastric end of the sutures and then were pulled back from the cutaneous side. Multiple biopsy specimens were obtained from both ends of the fistula to promote granulation tissue. Final knots were made at skin level to obliterate the fistula. Result: Our procedure resulted in complete closure of a large, persistently leaking gastrocutaneous fistula in an elderly patient within 7 days. The patient tolerated the optimal rate of enteral nutrition without further leakage. Limitation: Only 1 patient. Conclusion: We believe that this method of endoscopic suturing along with de-epithelialization of the fistula tract for persistent gastrocutaneous fistula is a safe and cost-effective alternative to surgical closure.
More than 200,000 PEG tubes are placed annually in United States.1 Development of persistent gastrocutaneous fistula after removal of a PEG tube is a rare but difficult-to-manage problem. Delayed gastric emptying, poor wound healing, and flow of gastric juice through the fistula may hamper healing.2 For those in whom conservative therapy fails, surgical closure is the preferred treatment of choice. However, many of these elderly
DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.
patients are poor surgical candidates. Several case reports and case series described previously used argon beam coagulation, fibrin sealant, endoscopic clipping or suturing, simple suturing, and electrical and chemical cauterization of the fistula with variable success.3-5 Our group’s study, which used a combined approach of chemical and electric cautery and clip placement, showed some promise in a ‘recent case series.6
METHOD
Copyright ª 2009 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2009.05.002
A 98-year-old woman with multiple comorbidities had a 20F PEG tube placed for poor oral intake secondary to advanced dementia. Three months later, she developed
768 GASTROINTESTINAL ENDOSCOPY Volume 70, No. 4 : 2009
www.giejournal.org
Eskaros et al
leakage around the PEG tube. A 22F PEG tube was placed with cessation of leakage for a few weeks. Consecutively, larger diameters of PEG tubes were required (up to 28F) to prevent leakage. Conservative management with PEG tube removal, parenteral nutrition, proton pump inhibitors, and prokinetic agents did not improve leakage. An attempt to close the fistula by using chemical cauterization with silver nitrate externally, endoscopic electrocautery, and endoscopic clip placement was unsuccessful. The patient was not a surgical candidate. A detailed explanation of an upper endoscopy and percutaneous endoscopic suturing of a gastrocutaneous fistula was provided, and informed consent was obtained from the patient’s family. An upper endoscopy was performed with the patient under conscious sedation. The cutaneous side of the fistula was identified and cleaned with povidone-iodine and was anesthetized with 1% Xylocaine. During upper endoscopy, the gastric side of the fistula was identified. An 18-gauge trocar (Safety Trocar catheter; Boston Scientific Corp, Natick, Mass) was inserted through the abdominal wall next to the fistula under endoscopic visualization. A 120-cm-long 0 monofilament absorbable suture (PDS II Plus, PDPB991G; Ethicon, Somerville, NJ) was inserted through the trocar and was grasped within the stomach with a snare and pulled out through the mouth. The first 2 steps were then repeated, such that 4 monofilament sutures traversed the abdominal and gastric walls on the sides of the fistula in criss-cross fashion. These suture ends were externalized through the mouth. Two surgical knots were then made with the sutures retrieved through the mouth. The ends of the sutures exiting the abdominal wall were pulled in a way that the knot made outside the mouth was pulled into the gastric lumen to close the gastric orifice of the fistula. Multiple mucosal bites were taken circumferentially from both ends of the fistulous tract by using standard biopsy forceps to de-epithelialize the fistulous tract completely. Two surgical knots were made at skin level. Bleeding was minimal during the procedure and was controlled with pressure hemostasis. A sterile, dry dressing was applied to the sutured area. The procedure is illustrated in Figures 1 through 3. The patient was observed for leakage from the fistula and development of infection and other complications after the procedure. One dose of 1 g cefazolin was administered intravenously to prevent infection. The patient received parenteral nutrition and proton pump inhibitors after the procedure.
Percutaneous endoscopic suturing
Capsule Summary What is already known on this topic d
Surgical closure is the treatment of choice for a persistently leaking gastrocutaneous fistula.
What this study adds to our knowledge d
A combination of endoscopic suturing and mucosal deepithelialization was a safe and cost-effective alternative to surgical closure of a persistent gastrocutaneous fistula in an elderly woman.
100 mL of free water every 6 hours were initiated. The fistula site remained clean without any leakage. The patient tolerated a gradual increase in enteral feeding to the optimal rate without complication. Four weeks after the procedure, the gastrocutaneous fistula site remained well healed.
DISCUSSION
On day 8, the external knots were cut to prevent pressure necrosis. The rest of the suture was left in place to be absorbed. Enteral feeding at a low rate (20 mL/h) and
Development of a gastrocutaneous fistula after the removal of a PEG tube is a well-known complication. Persistent leakage from a gastrocutaneous fistula can lead to severe irritation of adjacent skin and soft tissue of the abdominal wall and may promote the development of cellulitis. Various conservative, surgical, and endoscopic methods have been described in the literature. Apparently, no one method works with sufficient efficacy. Alberti-Flor3 described successful closure of gastrocutaneous fistula by using percutaneous endoscopic suturing in 2 patients. Simple endoscopic suturing may not be sufficient for a large fistula with a well-formed tract. Our technique is a modification of this technique and involves de-epithelialization with biopsy forceps and the use of 2 surgical knots in a criss-cross fashion. Mucosal de-epithelialization promotes granulation tissue formation and thus promotes healing of the fistula. Multiple biopsy specimens obtained at both ends of the fistula further promote granulation tissue formation, thus facilitating early closure. Two surgical sutures placed in criss-cross fashion provide greater contact between de´brided surfaces of the fistula to achieve optimal healing. Van Bodegraven et al4 described the use of argon beam electrocoagulation and endoscopic clip placement for closure of an esophagopleural fistula in 1999. Argon beam electrocoagulation could be used as alternate way to achieve adequate de-epithelialization. Shand et al5 described successful closure of a gastrocutaneous fistula by using a fibrin sealant. This technique requires injection of 2 components of the sealant simultaneously into the fistula tract with a special syringe. Multiple applications were required in some cases to achieve complete closure.
www.giejournal.org
Volume 70, No. 4 : 2009 GASTROINTESTINAL ENDOSCOPY 769
RESULTS
Percutaneous endoscopic suturing
Eskaros et al
Figure 1. Percutaneous endoscopic suturing of the gastrocutaneous fistula. A schematic illustration. A, A trocar is passed through the abdominal wall into the gastric lumen. A 120-cm-long, 0 monofilament suture is inserted in the trocar, and the gastric end of the suture is externalized by using a snare under endoscopic visualization. B, The procedure is repeated to insert a total of 4 sutures in criss-cross fashion. Two surgical knots are made outside the oral cavity. C, Adequate de-epithelialization is achieved by multiple circumferential biopsies in the fistula tract. D, After adequate de-epithelialization with biopsy forceps is achieved, the cutaneous ends of the sutures are pulled back and a surgical knot is made to close the fistula.
Figure 2. Endoscopic view of the gastric end of the fistula after closure with a suture.
Figure 3. Cutaneous end of the gastrocutaneous fistula after closure with a suture.
Endoscopic clip placement to obliterate the gastric end of the fistula is an effective method. Multiple clips may be needed to obliterate the fistula, which may lead to a substantial increase in the cost of the procedure.6 Our method combines endoscopic suturing and mucosal de-epithelialization, which lead to faster closure of the fistula. Early adoption of this procedure decreases the need for parenteral nutrition, related complications, and length of hospitalization. Conservative measures have low success rates, and many patients with gastrocutaneous fistulas are poor surgical candidates. In addition, surgical closure is expensive and associated with higher postoperative morbidity and mortality. This procedure seems to be safe and cost-effective compared with a conventional approach. This method involves conscious sedation, upper endoscopy, and potential complications related to these
procedures. Multiple pinch biopsies may not adequately de´bride the fistula, leading to suboptimal granulation tissue formation. Application of argon plasma coagulation or bipolar electrocoagulation instead of performing pinch biopsies may achieve more uniform results.
770 GASTROINTESTINAL ENDOSCOPY Volume 70, No. 4 : 2009
www.giejournal.org
REFERENCES 1. McClave SA, Chang WK. Complications of enteral access. Gastrointest Endosc 2003;58:739-51. 2. Shellito PC, Malt RA. Tube gastrostomy. Techniques and complications. Ann Surg 1985;201:180-5. 3. Alberti-Flor JJ. Percutaneous-endoscopic suturing of gastrocutaneous fistula: report of 2 cases. Gastrointest Endosc 2002;56:751-3. 4. Van Bodegraven AA, Kuipers EJ, Bonenkamp H, et al. Esophagopleural fistula treated endoscopically with argon beam electrocoagulation and clips. Gastrointest Endsoc 1999;50:407-9.
Eskaros et al 5. Shand A, Pendelbury J, Reading S, et al. Endoscopic fibrin sealant injection: a novel method of closing a refractory gastrocutaneous fistula. Gastrointest Endosc 1997;46:357-8. 6. Duddempudi S, Ghevariya V, Singh M, et al. Treatment of persistently leaking post PEG tube gastrocutaneous fistula in elderly patients with combined electrochemical cautery and endoscopic clip placement. South Med J 2009 May 7 [Epub ahead of print].
www.giejournal.org
Percutaneous endoscopic suturing
Received November 13, 2008. Accepted May 1, 2009. Current affiliations: Division of Gastroenterology (S.E., V.G., M.K., S.A.), Division of Surgery (A.A.), The Brooklyn Hospital Center, Brooklyn, New York, USA. Reprint requests: Vishal Ghevariya, MD, 240 Willoughby Street, 4C, Brooklyn, NY 11201.
Volume 70, No. 4 : 2009 GASTROINTESTINAL ENDOSCOPY 771