Closure of a large high-output gastrocutaneous fistula with combined postpyloric feeding and aggressive medical therapy

Prevention and management of major complications in percutaneous endoscopic gastrostomy

Background

Percutaneous endoscopic gastrostomy is a commonly used endoscopic technique where a tube is placed through the abdominal wall mainly to administer fluids, drugs and/or enteral nutrition. Several placement techniques are described in the literature with the ‘pull’ technique (Ponsky-Gardener) as the most popular one. Independent of the method used, placement includes a ‘blind’ perforation of the stomach through a small acute surgical abdominal wound. It is a generally safe technique with only few major complications. Nevertheless these complications can be sometimes life-threatening or generate serious morbidity.

Method

A narrative review of the literature of major complications in percutaneous endoscopic gastrostomy.

Results

This review was written from a clinical viewpoint focusing on prevention and management of major complications and documented scientific evidence with real cases from more than 20 years of clinical practice.

Conclusions

Major complications are rare but prevention, early recognition and popper management are important.

Laparoscopic management of persistent gastrocutaneous fistula after feeding gastrostomy appliance removal in children

Background

Feeding gastrostomy is widely used in children that have troubles of swallowing and need to stablish enteral feeding. There are several methods for creation of that stoma. After the children gain their normal ability of swallowing, this tube or appliance is removed. Failure of spontaneous closure of gastrostomy opening after removal of the tube was reported with an incidence of 0.5 to 3.9%. The purpose of authors was to study laparoscopic management of persistent gastrocutaneous fistula after failure of conservative measures.

Results

There were 19 patients, 12 males. Main cause for feeding gastrostomy was neurological. Most feeding gastrostomy tubes were inserted endoscopically. The mean operative time was 57 ± 10.2 min. The mean time of full oral intake was 24 ± 3.5 h. No wound infection had developed. There was no recurrence of fistula after management.

Conclusion

Laparoscopic management of persistent gastrocutaneous fistula is safe, feasible, and associated with no recurrence of fistula.

Management of gastrocutaneous fistulas following gastrostomy: surgery as a therapeutic option

Gastrocutaneous fistulas (GCF) following removal of gastrostomy tubes are an uncommon complication with many therapeutic options. It is a drawback that concerns both patient and surgeon, hindering the decision to perform an invasive treatment. Despite emerging minimally invasive procedures, we must not forget that surgery continues to be the standard treatment when they all fail.

Endoscopic titanium clip closure of gastric fistula after splenectomy: A case report

This report describes a 52-year-old male patient with blunt abdominal traumatic rupture of the spleen due to injuries sustained in an automobile accident. Following splenectomy, the patient developed a gastric fistula. He underwent a long period of conservative treatment, including antibiotics and total parenteral nutrition, which was ineffective. The fistula could not be closed and titanium clip closure using a gastroscopy was then performed in order to close the fistula. After endoscopic therapy and clipping surgery, the patient’s general condition improved significantly, and he had no post-procedural abdominal complications. On post-clipping day 6, the gastric fistula was completely closed as shown by X-ray examination of the upper digestive tract. The patient was discharged from hospital and no complications were observed during the six-month follow-up period. Our report suggests that titanium clip closure using endoscopy may be the choice of treatment in patients with a gastric fistula.

Endoscopic closure of a refractory gastrocutaneous fistula using a novel over-the-scope Padlock clip following de-epithelialisation of the fistula tract

Persistent gastrocutaneous fistula (GCF) is a difficult to manage complication following gastrostomy tube removal, with leakage resulting in distressing sequelae including cutaneous injury, infection and dehydration. Many such patients are high-risk for invasive surgery and, to date, endoscopic closure techniques, including clipping systems, have limitations. We present the case of a 62-year-old woman with persistently leaking GCF 6 months postgastrostomy tube removal, despite maximal antisecretory therapy and postpyloric feeding, and describe failed attempted endoscopic closure with conventional clips. Treatment options were discussed and informed consent was given for an attempt at endoscopic closure using a novel radial closure device ('Padlock clip') combined with surgical de-epithelialisation, with the understanding that this device has never previously been used in this setting. At follow-up 2 weeks postprocedure, the patient was asymptomatic with complete healing of the GCF. This approach has advantages over other endoscopic closure techniques and can be considered as an alternative approach to GCF closure.