Percutaneous endoscopic gastrostomy (PEG) tubes have allowed for a safe and efficient way to feed patients who cannot tolerate oral feeding, yet have a functioning gastrointestinal tract. Gastrocutaneous fistulas (GCF) after PEG removal are an unusual and rare complication in adults and may be in part due to poor tissue healing, delayed gastric emptying, or increased gastric acid production. Various approaches have been reported to treat PEG-related gastric fistulas; however, their success rate is variable and patients frequently require repeat procedures or >1 technique in combination, including acid suppression therapy, silver nitrate ablation of the PEG tract lining, argon plasma coagulation, fibrin glue, and/or endoclipping. Upon our review, there have been no published case series reporting the use of endoscopic banding to close persistent GCFs after PEG removal.
Four patients with persistent GCFs after PEG removal were taken for esophagogastroduodenoscopy with banding of the fistula site. This procedure was chosen due to its relative ease of application. Patient follow-up was by telephone within 3 days of having the procedure and then again 1 to 2 weeks afterward, to ensure that there was no persistent leakage through the fistula tract.
Of the 4 patients who had persistent GCFs after PEG removal, endoscopic banding resulted in complete closure of the fistula in 3 of our 4 patients. In 1 case, banding was unsuccessful secondary to scarring from prior radiation treatment as well as having a previous PEG tube placed 1 inch from the current fistula site. In this case, a second PEG tube was placed through the original PEG stoma, leading to cessation of the gastric leak. The first case resulted in no recurrence after 3 years. The second and third cases have shown no recurrence after 3 months. The fourth case resulted in a second PEG tube to manage persistent drainage through the tract after unsuccessful banding of the site due to complex endoscopic and anatomic issues.
Endoscopic closure of a GCF, regardless of technique used, can help avoid surgical intervention. Anatomic changes from any previous treatment modalities may decrease the success rate of fistula banding. However, in our patients, endoscopic banding proved to be a safe and relatively simple alternative in closing persistent GCFs due to prior PEG tubes.
Departments of *Clinical Nutrition, Center for Human Nutrition
†Gastroenterology and Hepatology, Digestive Disease Institute
§Center for Human Nutrition, Digestive Disease Institute
∥Intestinal Transplant Program, The Cleveland Clinic, Cleveland, OH
‡Johnston-Willis Hospital (HCA Virginia Health System), Richmond, VA
IRB approval for this research work was obtained at The Cleveland Clinic and written informed consent was obtained before these procedures being performed.
O.J.D.: assisted with endoscopy, research, drafting, and revising of the article; K.R.P.: assisted with endoscopy, involved with conception; C.H.: involved in research and data collection as well as assisting in endoscopy; D.F.K.: involved in conception and design, primary endoscopist, and revising the article.
The authors declare that they have nothing to disclose.
Reprints: Omer J. Deen, MD, Department of Clinical Nutrition, Center for Human Nutrition, Digestive Disease Institute, The Cleveland Clinic, 9500 Euclid Avenue/A51, Cleveland, OH 44195 (e-mail: firstname.lastname@example.org).
Received June 25, 2012
Accepted December 5, 2012