First report of colonoscopic closure of a gastrocolocutaneous PEG migration with over-the-scope-clip-system

How far is the endoscopist to blame for a percutaneous endoscopic gastrostomy complication?

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is a well-established, minimally invasive, and easy to perform procedure for nutrition delivery, applied to individuals unable to swallow for various reasons. PEG has a high technical success rate of insertion between 95% and 100% in experienced hands, but varying complication rates ranging from 0.4% to 22.5% of cases.

AIM

To discuss the existing evidence of major procedural complications in PEG, mainly focusing on those that could probably have been avoided, had the endoscopist been more experienced, or less self-confident in relation to the basic safety rules for PEG performance.

METHODS

After a thorough research of the international literature of a period of more than 30 years of published "case reports" concerning such complications, we critically analyzed only those complications which were considered - after assessment by two experts in PEG performance working separately - to be directly related to a form of malpractice by the endoscopist.

RESULTS

Malpractice by the endoscopist were considered cases of: Gastrostomy tubes passed through the colon or though the left lateral liver lobe, bleeding after puncture injury of large vessels of the stomach or the peritoneum, peritonitis after viscera damage, and injuries of the esophagus, spleen, and pancreas.

CONCLUSION

For a safe PEG insertion, the overfilling of the stomach and small bowel with air should be avoided, the clinician should check thoroughly for the proper trans-illumination of the light source of the endoscope through the abdominal wall and ensure endoscopically visible imprint of finger palpation on the skin at the center of the site of maximum illumination, and finally, the physician should be more alert with obese patients and those with previous abdominal surgery.

Over-the-Scope Clip in the Treatment of Gastrointestinal Leaks and Perforations

While perforations, postoperative fistulas, and leaks have traditionally led to surgical or interventional radiology consultation for management, the introduction of the over-the-scope clip has allowed increased therapeutic possibilities for endoscopists. While primarily limited to case reports and series, the over-the-scope clip successfully manages gastrointestinal bleeding, perforations, as well as postoperative leaks and fistulas. Retrospective studies have demonstrated a relatively high success rate and a low complication rate. Given the similarity to variceal banding equipment, the learning curve with the over-the-scope clip is rapid. However, given the higher risk of procedures involving the use of the over-the-scope clip, it is essential to obtain the scope in a stable position and grasp sufficient tissue with the cap using a grasping tool and/or suction. From our experience, while closure may be successful in lesions sized up to 3 cm, successful outcomes are obtained for lesions sized <1 cm. Ultimately, given the limited available data, prospective randomized trials are needed to better evaluate the utility of the over-the-scope clip in various clinical scenarios, including fistula and perforation management.

Long-Term Gastrocolocutaneous Fistula after Endoscopic Gastrostomy: How Concerned Should We Be?

Percutaneous endoscopic gastrostomy (PEG) is a safe technique for long-term enteral feeding. The most common PEG-associated adverse events are minor. Gastrocolocutaneous fistula (GCCF) results from misplacement of the PEG tube through the colon. The importance of this complication is not currently defined, and there is no clearly established therapeutic algorithm. The authors report a series of 3 cases of GCCF diagnosed and treated in a tertiary center.

Case 1

An 88-year-old man underwent PEG due to head and neck cancer. The procedure was uneventful, and the patient remained asymptomatic. After the first PEG tube substitution performed at 6 months, stool drainage through the stoma was observed. Computed tomography (CT) showed a GCCF. After tube removal, the fistula spontaneously closed, and the patient remained under nasogastric feeding until death.

Case 2

A 31-year-old man with hereditary spastic paraplegia was submitted to PEG without early complications. The patient remained asymptomatic, and 7 months later, replacement of the PEG tube was planned. Under endoscopic control, the primary tube was removed, but the balloon replacement tube, introduced through the skin, was not observed in the gastric lumen. CT displayed a GCCF that spontaneously closed after a few days. A combined laparoscopic and endoscopic approach was used to resect the fistula tracts and perform a new gastrostomy.

Case 3

A 45-year-old man with cerebral palsy was referred to PEG. Skin transillumination was only observed transiently, and the abdominal puncture was performed obliquely. The patient remained asymptomatic until the 7th month, when the primary PEG tube replacement was performed. The percutaneously placed substitution tube did not reach the stomach. GCCF was evident on CT. The fistula spontaneously closed, and the patient was referred to elective surgery for laparoscopic gastrostomy. GCCF is an uncommon complication of PEG. Its clinical course seems to be benign with patients remaining asymptomatic under ambulatory enteral feeding for long periods until PEG tube replacement. Spontaneous fistula closure is the rule in this setting. Laparoscopic gastrostomy should be considered when a new PEG is advised and cannot be safely performed due to colon interposition.

Gastrocolocutaneous Fistula: An Unusual Case of Gastrostomy Tube Malfunction with Diarrhea

A gastrocolocutaneous fistula is a rare complication of percutaneous endoscopic gastrostomy (PEG). We report a case of a gastrocolocutaneous fistula presenting with intractable diarrhea and gastrostomy tube malfunction. A 62-year-old woman with a history of multiple system atrophy was referred to us because of PEG tube malfunction. Twenty days prior to presentation, the patient started developing sudden diarrhea within minutes after starting PEG feeding. Fluoroscopy revealed that the balloon of the PEG tube was located in the lumen of the transverse colon with the contrast material filling the colon. Subsequently, the PEG tube was removed and the opening of the gastric site was endoscopically closed using hemoclips. Clinicians should be aware of gastrocolocutaneous fistula as one of the complications of PEG insertion. Sudden onset of diarrhea, immediately after PEG feedings, might suggest this complication, which can be effectively treated with endoscopic closure.

An unexpected cause of transient diarrhea

Migration of percutaneous endoscopic gastrostomy (PEG) tube to colon with gastro-colonic-cutaneous fistula formation is a rare complication of the procedure. Transient episodic diarrhea following each PEG tube feeding is typical of this complication. We present a 72-year-old man with cerebrovascular disease and scoliosis who encountered episodes of transient diarrhea after each PEG tube feeding. His diarrhea was refractory to medications. Colonoscopy demonstrated a mal-positioned PEG in the transverse colon. Computed tomogram (CT) of abdomen further confirmed the finding. After removal of the migrated PEG, his diarrhea had ceased completely. The gastro-colonic-cutaneous fistula was further managed with endoscopic clipping method with no complications encountered during follow up.

PEG closure in the second attempt

This case report demonstrates successful endoscopic treatment of a persistent gastrocutaneous fistula after removal of a percutaneous endoscopic gastrostomy (PEG) in a 21-year-old patient with mucoviscidosis after lung transplantation. Because the initial OTSC clip (gastric) did not close the fistula sufficiently, we had to remove it and replace it with a larger OTSC clip (colon) in a second intervention. That clip finally sufficiently closed the fistula.

Wandering Gastrostomy

Percutaneous endoscopic gastrostomy (PEG) is a relatively safe and effective method of providing nutrition to patients with neurologic deficits or proximal gastrointestinal pathology. Complications that follow this common procedure include dislodgement, dysfunction, infection, gastric/colonic perforation, bleeding, peritonitis, or death. The emergency physician should be aware of the complications and symptoms/signs associated for appropriate management of these patients. We present a case of a young lady who developed a cerebral infarction following amniotic fluid embolism during her cesarean section and had undergone a PEG tube placement. She developed displacement of this PEG tube and underwent another PEG tube placement. She later presented to us with PEG tube migration into the transverse colon and required surgical removal of the same PEG tube.

Multipurpose use of the over-the-scope-clip system (“Bear claw”) in the gastrointestinal tract: Swiss experience in a tertiary center

AIM: To evaluate the outcome of over-the-scope-clip system (OTSC) for endoscopic treatment of various indications in daily clinical practice in Switzerland.

METHODS: This prospective, consecutive case series was conducted at a tertiary care hospital from September 2010 to January 2014. Indications for OTSC application were fistulae, anastomotic leakage, perforation, unroofed submucosal lesion for biopsy, refractory bleeding, and stent fixation in the gastrointestinal (GI) tract. Primary technical success was defined as the adequate deployment of the OTSC on the target lesion. Clinical success was defined as resolution of the problem; for instance, no requirement for surgery or further endoscopic intervention. In cases of recurrence, retreatment of a lesion with a second intervention was possible. Complications were classified into those related to sedation, endoscopy, or deployment of the clip.

RESULTS: A total of 28 OTSC system applications were carried out in 21 patients [median age 64 years (range 42-85), 33% females]. The main indications were fistulae (52%), mostly after percutaneous endoscopic gastrostomy tube removal, and anastomotic leakage after GI surgery (29%). Further indications were unroofed submucosal lesions after biopsy, upper gastrointestinal bleeding, or esophageal stent fixation. The OTSC treatments were applied either in the upper (48%) or lower (52%) GI tract. The mean lesion size was 8 mm (range: 2-20 mm). Primary technical success and clinical success rates were 85% and 67%, respectively. In 53% of cases, the suction method was used without accessories (e.g., twin grasper or tissue anchor). No endoscopy-related or OTSC-related complications were observed.

CONCLUSION: OTSC is a useful tool for endoscopic closure of various GI lesions, including fistulae and leakages. Future randomized prospective multicenter trials are warranted.