Persistent gastrocutaneous fistula (GCF) remains a rare but known complication after gastrostomy tube removal. In children, the gold standard of treatment is surgical through an open fistula takedown. Adults, on the other hand, have a much smaller incidence rate, creating a more difficult dilemma in management.

We present an unusual case of a 42-year-old male who developed spontaneous opening of his gastrocutaneous fistula decades after its original closure in infancy. Patient initially tried both conservative management and endoscopic suturing but developed recurrence less than a year later. He was subsequently referred to General Surgery and underwent laparoscopic fistula takedown without any complications.

Gastrocutaneous fistulas in adulthood may present with various etiologies including distant histories of tube removals.

Surgical management through a minimally invasive technique provides both definitive and efficient care.

The purpose of this article is to review available literature on management of persistent ostomy following PEG tube removal. We will discuss the incidence of persistent gastrocutaneous fistula (GCF) following PEG tube removal, risk factors for their development, and management strategies that have been proposed and their efficacy.

The use of over the scope clips (OTSC) have evolved recently in the management of gastrointestinal bleeding, perforation, and fistula closures. OTSC has become more readily available and proven to be effective and safe. Suturing devices have shown promising results. Persistent gastrocutaneous fistula following PEG removal is a rare yet serious complication that can lead to continuous skin irritation and leakage of gastric contents and acid. There are several postulated risk factors but the most important of these is duration of placement. Management can include medical therapy which has recently been shown to be somewhat effective, endoscopic therapy and surgery as a last resort. Overall, the data on GCFs is limited and further study with larger sample size is needed.

Video 1.

Peristomal leakage, infection, and persisting fistula after tube removal are rare, but well-known complications in long-term percutaneous endoscopic gastrostomies (PEG). A standard treatment procedure is missing. This case series describes a procedure of tube removal, tailored antibiotic therapy and endoscopic closure with a gastropexy device after mechanical de-epithelialization of the fistulous tract.

Three patients with infected long-standing PEG (4 to 21 years) were included. The tubes were removed endoscopically and tailored antimicrobial therapy was administered over 10 to 14 days. The persisting fistula was de-epithelialized mechanically and sutured under endoscopic control with a dedicated gastropexy device 11 to 25 days thereafter. A new PEG tube was placed in the same session on a different site. After 30 days the fistula had healed completely, and the PEG worked well in all subjects.

Endoscopic sealing of a persisting fistula with a dedicated gastropexy device after thorough de-epithelialization is a promising technique that needs confirmation by larger studies.

Persistent Gastrocutaneous Fistula (GCF) is common problem encountered in the pediatric population. Several management options for intervening on pediatric persistent GCF have been described and range from open surgical management to medical management. Here we describe a novel adaptation on a previously described technique that utilizes a punch biopsy to excise the GCF we have coined as Punch Excision of Epithelialized Tracts (PEET).

The steps to this procedure include passing a punch biopsy tool over a Foley catheter. The catheter is inserted into the GCF tract, the balloon is inflated, the catheter is retracted against the abdominal wall, and the punch biopsy instrument is pushed through the skin and subcutaneous tissue circumferentially excising the tract.

Four patients at our institution have undergone GCF excision using the PEET approach. Mean duration of the GCF in our four patients was 9 months. Mean follow-up after GCF excision using the PEET approach was 7.8 months. No patients in the cohort had any post-operative complications including surgical site wound infection, emergency department visits, or re-hospitalizations related to their surgical care.

Based on our preliminary findings in this small patient cohort, we believe the PEET approach for managing persistent pediatric GCF has short-term efficacy and has the potential upside of utilizing fewer hospital resources to perform the procedure in a time-efficient manner.

This case represents an unusual, and previously unreported, complication of delayed leakage of gastric contents into the subcutaneous tissues 2 years after division of a gastrostomy tube tract during abdominoplasty. Our patient required urgent exploration for contamination control and closure of the fistula and recovered fully. Persistent gastrocutaneous fistula is uncommon in adults and even less common is recannulization of a fistula track after initial closure. A thorough review of operative history and comparison to previous imaging were crucial for appropriate diagnosis and operative planning. Formal closure of gastrostomy tube sites during scar revision and abdominoplasty may help prevent the complication of delayed gastrostomy tube tract rupture into the subcutaneous tissues.

PEG removal in head and neck cancer patients (HNCPs) is performed after treatment, in case of disease remission and after adequate oral intake is resumed. The PEG tract usually closes spontaneously within 2-3 days. Persistent gastrocutaneous fistula (GCF) is a rare complication after PEG tube removal and is characterized by the persistence of gastric leakage through the fistulous tract for more than 1 month. Our main goal was to access the incidence and the success of a treatment algorithm for GCF in HNCPs.

Retrospective unicentric study of HNCPs referred for PEG removal between 2014 and 2018. The patients with GCF were selected and their sequential treatment was reviewed.

In 331 patients with PEGs removed, 19 (5.7%) GCFs were documented. Medical therapy (4-8 weeks) was performed with clinical success (definitive closure of the GCF) in 12 (63.2%) patients. The remaining seven patients required endoscopic or surgical treatment. In four, endoscopic treatment had technical and clinical success (in three patients with fulguration of the gastric leak edges with argon plasma coagulation, silver nitrate in the path and external orifice, and closure of the internal orifice with hemoclips and in one with an over-the-scope-clip). Only three patients underwent surgery, one due to clinical failure of sequential endoscopic therapy and two had direct surgery.

GCF occurs rarely after PEG removal in HNCPs. Medical therapy is usually effective and should be maintained for at least 8 weeks. Endoscopic therapy is an effective second-line option with and surgery rarely required.

Enteral access feeding devices are placed in patients who have a functional and accessible gastrointestinal (GI) tract but are not able to consume or absorb enough nutrients to sustain adequate nutrition and hydration. For many individuals, enteral nutrition support is a lifesaving modality to prevent or treat a depleted nutrient state that can lead to tissue breakdown, compromised immune function, and poor wound healing. Psychological well-being is also affected with malnutrition and dehydration, triggering feelings of apathy, depression, fatigue, and loss of morale, negatively impacting a patient's ability for self-care. A variety of existing devices can be placed through the nares, mouth, stomach or small intestine to provide liquid nutrition, fluids, and medications directly to the GI tract. If indicated, some of the larger-bore devices may be used for gastric decompression and drainage. These enteral access devices need to be cared for properly to avert patient discomfort, mechanical device-related complications, and interruptions in the delivery of needed nutrients, hydration, and medications. Clinicians who seek knowledge about enteral access devices and actively participate in the selection and care of these devices will be an invaluable resource to any healthcare team. This article will review the types, care, proper positioning, and replacement schedules of the various enteral access devices, along with the prevention and troubleshooting of potential problems.

Gastrostomy tubes are a common adjunct to the care of vulnerable pediatric patients. This study systematically evaluates the epidemiology and risk-factors for gastrocutaneous fistulae (GCF) after gastrostomy removal in children and reviews treatment options focusing on nonoperative management (NOM).

After protocol registration (CRD-42017059565), multiple databases were searched. Studies describing epidemiology in children and GCF treatment at any age were included. Critical appraisal was performed (MINORS risk-of-bias assessment tool). One-sided meta-analysis was executed to estimate efficacy of therapeutic adjuncts using a random-effects model.

Sixteen articles evaluating pediatric GCF were identified. 44% defined GCF as persistence >1month which occurred in 31±7% of cases. Risk factors for pediatric GCF include age at gastrostomy, timing of removal, open technique, and fundoplication. Mean MINORS score was 0.60±0.16. Seventeen additional studies were identified reporting 142 patients undergoing NOM (endoscopic, systemic, and local therapies), and one pediatric comparative study was identified. Overall aggregate proportion of GCF closure after any NOM is 77% (80% success rate in local/systemic therapies; 75% success rate in endoscopic approaches). No adverse events were reported.

Persistent GCF complicates the management of gastrostomies in 1/3 of children with predictable risk factors. Several treatment options exist that obviate the need for general anesthesia. Their efficacy is unclear. Further prospective investigations are clearly warranted.

III - Systematic Review and Meta-Analysis Based on Retrospective Case Control Studies.

Over-the-scope-clips (OTSC®) have been shown to be an effective and safe endoscopic treatment option for the closure of gastrointestinal perforations, leakages and fistulae. Indications for endoscopic OTSC® treatment have grown in number and also include gastro cutaneous fistula (GCF) after percutaneous endoscopic gastrostomy (PEG) tube removal. Non-healing GCF is a rare complication after removal of PEG tubes and may especially develop in immunosuppressed patients with multiple comorbidities. There is growing evidence in the literature that OTSC® closure of GCF after PEG tube removal is emerging as an effective, simple and safe endoscopic treatment option. However current evidence is limited to the geriatric population and short standing GCF, while information on closure of long standing GCF after PEG tube removal in a younger population with significant comorbidities is lacking. In this retrospective single-center case-series we report on five patients undergoing OTSC® closure of chronic GCF after PEG tube removal. Four out of five patients were afflicted with long lasting, symptomatic fistulae. All five patients suffered from chronic disease associated with a catabolic metabolism (cystic fibrosis, chemotherapy for neoplasia, liver cirrhosis). The mean patient age was 43 years. The mean dwell time of PEG tubes in all five patients was 808 d. PEG tube dwell time was shortest in patient 5 (21 d). The mean duration from PEG tube removal to fistula closure in patients 1-4 was 360 d (range 144-850 d). The intervention was well tolerated by all patients and no adverse events occured. Successful immediate and long-term fistula closure was accomplished in all five patients. This single center case series is the first to show successful endoscopic OTSC® closure of long lasting GCF in five consecutive middle-aged patients with significant comorbidities. Endoscopic closure of chronic persistent GCF after PEG tube removal using an OTSC® was achieved in all patients with no immediate or long-term complications. OTSC® is a promising endoscopic treatment option for this condition with a potentially high immediate and long term success rate in patients with multiple comorbidities.

Percutaneous endoscopic gastrostomy (PEG) has become the method of choice for mid-to long-term enteral feeding. The majority of complications that occur are minor, but the rare major complications may be life threatening. Some complications occur soon after tube placement, others develop later, when the gastrostomy tract has matured. Older patients with comorbidities and infections appear to be at a greater risk of developing complications. Apart from being aware of indications and contraindications, proper technique of PEG placement, including correct positioning of the external fixation device, and daily tube care are important preventive measures. Adequate management of anticoagulation and antithrombotic agents is important to prevent bleeding, and administration of broad spectrum antibiotics prior to the procedure helps prevent infectious complications. Early recognition of complications enables prompt diagnosis and effective therapy.

A 50-year-old woman had a percutaneous endoscopic gastrostomy (PEG) tube placed after surgery for pharyngeal cancer. After 21 months, the PEG tube was removed due to improvement of per-oral ingestion. She had taken prednisolone for 31 years for systemic lupus erythematosus. The post-PEG fistula did not close spontaneously. The cause of the fistula was slow wound healing and gastrostomy site inflammation due to long-term steroid therapy. We were able to close the fistula with an over-the-scope clipping (OTSC) system. This case suggests that OTSC is useful for closing persistent post-PEG fistulas in patients receiving long-term prednisolone therapy.

The incidence of persistent gastrocutaneous fistula (GCF) after removal of gastrostomy tubes in pediatric patients is estimated to be up to 44 %. Our aim was to review the outcomes of GCF closure by an endoscopic technique that utilizes cautery and endoclips.

A retrospective analysis of patients who underwent endoscopic treatment for persistent GCF from January 2010 to September 2013 was performed. This technique utilized esophagogastroduodenoscopy with cauterization of the fistula track and endoclipping of the gastric mucosa.

Sixteen patients underwent endoscopic treatment for persistent GCF. Mean age at time of endoscopy was 7.5 ± 5.5 (1.1-17) years. Gastrostomy tubes were in place for mean of 5.4 ± 5.2 (0.5-14.2) years prior to removal. The average time from gastrostomy tube removal to first endoscopic clipping was 6.7 ± 9 (0.1-28.9) months. Seven patients (44 %) had successful closure after one endoclipping procedure. Six patients underwent a second endoclipping procedure, with three successful closures. Four patients (25 %) required surgical closure for persistent fistulas and 2 (13 %) have continued drainage.

While endoscopy with cautery and endoclipping proves to be safe, many patients require multiple procedures and may require surgical closure. Patient selection and refinement of this technique may improve outcomes.

Gastrocutaneous fistula (GCF) occurs commonly in pediatric patients after removal of long-term gastrostomy tubes. Although open repair is generally successful, endoscopic approaches may offer benefits in terms of incisional complications, postoperative pain, and procedure time. In addition, endoscopic approaches may offer particular benefit in patients with varied degrees of skin irritation or erosion surrounding a GCF, making surgical repair difficult, or patients with significant comorbidities, making minimal intervention and anesthesia time preferable. Over-the-scope (OSC) clips are a new technology that enables endoscopic closure of intestinal fistulas up to 2 cm in diameter. Six pediatric patients underwent endoscopic GCF closure using OSC clips under Institutional Review Board approval. The procedure was technically successful in 5 of 6 cases with an average operating time of 29 minutes. The technical failure required an open revision, whereas all other patients reported full healing of the GCF site at 1 month. All successful cases were performed as outpatients without postoperative narcotics. In addition, all patients reported high satisfaction with the procedure and cosmetic results. Endoscopic GCF closure using an OSC clip is technically feasible in the pediatric population. Based on limited cases with a 1-month follow-up, the functional and cosmetic results of technically successful cases are excellent. Endoscopic GCF closure is a potential alternative to standard surgical closure in patients with skin irritation or erosion and/or significant comorbidities.

An over-the-scope clip (OTSC) device was designed for closure of acute perforations, fistulas, leaks, and non-variceal gastrointestinal bleeding. Previous data show a high rate of early fistula closure using the OTSC; however, data on long-term fistula closure are scant. We report our experience using an OTSC for closure of chronic gastrointestinal fistulas.

Retrospective review of all patients, who underwent OTSC placement at Mayo Clinic Rochester and Virginia Mason Medical Center for closure of chronic fistulas from October 2011 to September 2012, was performed. Initial technical success was defined by lack of contrast extravasation immediately after OTSC placement. Delayed success was defined by resolution of the fistula without the need for additional therapies. Recurrent fistula was defined by the recurrence of symptoms and/or re-demonstration of fistula after initial success.

Forty-seven unique patients (24 men; mean age 57 ± 14 years) underwent 60 procedures using the OTSC for closure of gastrointestinal fistulas. Fistula locations were: small bowel (n = 18), stomach (n = 16), colo-rectum (n = 10), and esophagus (n = 3). Fistulas related to previous percutaneous endoscopic gastrostomy/jejunostomy (n = 10) or prior bariatric procedure (n = 10) were the most common etiologies. Initial technical success occurred in 42/47 (89%) index cases; however, 19/41 (46%) patients developed fistula recurrence at a median of 39 days (IQR 26-86 days). The retained OTSC was present adjacent to the fistula in 16/19 (84%) at repeat intervention. Patients were followed for a median length of 178 days (IQR 63-326 days), and only 25/47 (53%) patients demonstrated delayed clinical success using OTSC.

Initial technical fistula closure can be achieved using OTSCs. Recurrent fistulas at the same location occur in approximately 50% of cases despite frequent OTSC clip retention.

Percutaneous endoscopic gastrostomy (PEG) is the preferred route of feeding and nutritional support in patients with a functional gastrointestinal system who require long-term enteral nutrition. Besides its well-known advantages over parenteral nutrition, PEG offers superior access to the gastrointestinal system over surgical methods. Considering that nowadays PEG tube placement is one of the most common endoscopic procedures performed worldwide, knowing its indications and contraindications is of paramount importance in current medicine. PEG tubes are sometimes placed inappropriately in patients unable to tolerate adequate oral intake because of incorrect and unrealistic understanding of their indications and what they can accomplish. Broadly, the two main indications of PEG tube placement are enteral feeding and stomach decompression. On the other hand, distal enteral obstruction, severe uncorrectable coagulopathy and hemodynamic instability constitute the main absolute contraindications for PEG tube placement in hospitalized patients. Although generally considered to be a safe procedure, there is the potential for both minor and major complications. Awareness of these potential complications, as well as understanding routine aftercare of the catheter, can improve the quality of care for patients with a PEG tube. These complications can generally be classified into three major categories: endoscopic technical difficulties, PEG procedure-related complications and late complications associated with PEG tube use and wound care. In this review we describe a variety of minor and major tube-related complications as well as strategies for their management and avoidance. Different methods of percutaneous PEG tube placement into the stomach have been described in the literature with the "pull" technique being the most common method. In the last section of this review, the reader is presented with a brief discussion of these procedures, techniques and related issues. Despite the mentioned PEG tube placement complications, this procedure has gained worldwide popularity as a safe enteral access for nutrition in patients with a functional gastrointestinal system.