Crystal J Yi, DO1, Eric Seitelman, MD2, Rajiv Datta Rajiv, MD2, Joel Lowenstein, MD2, Robert Amajoyi, MD2. 1St. John’s Episcopal Hospital, 2South Nassau Communities Hospital
Percutaneous endoscopic gastrostomy (PEG) is an alternative to laparotomy for open gastrostomy tube placement to provide enteral nutrition for those who are unable to pass nutrition orally. Despite being less invasive, the procedure is not without its complications, one of which includes the formation of a gastrocolocutaneous fistula.
The case describes a 90 year old female who presented with a PEG placed 6 months prior with reports of leakage of tube feeds from the gastrostomy site. As there was concern for possible ileus or obstruction, an upper GI series was completed which seemed to indicate dislodgement of the g-tube. The g-tube was replaced and a follow-up gastrograffin study was repeated which now indicated that the g-tube was within the lumen of the colon. Soon thereafter fecal matter was noted to be draining around the g-tube site; however, patient was without clinical signs of peritonitis.
The patient was managed non-surgically as she was a poor surgical candidate with multiple prohibitive co-morbidities. The g-tube was removed bedside by cutting it flush at the skin level with the anticipation that the remainder of the tube would be excreted with bowel movements. The decision was then made to attempt closure of the gastric fistula endoscopically which was accomplished with hemoclips. A follow up upper GI study 72 hours later showed no extravasation of contrast through the gastric fistula. The colocutaneous fistula had self-resolved over the next couple days as well.
Placement of the PEG tube through the transverse colon can present with varying ill effects including diarrhea, pneumoperitoneum, peritonitis, gram negative pulmonary infection or feculent vomiting with the formation of a gastrocutaneous fistula. Treatment historically for a gastrocolocutaneous fistula has been exploration and excision of the fistula tract with resection of the involved colonic segment. However, there currently is no gold standard for the management of, and really ranges from conservative management to surgical and is dependent on the presenting symptoms. If the PEG becomes dislodged with resultant spillage from the colon with resultant peritonitis, surgical exploration is needed with removal of the g-tube and repair of the stomach and colon. On the other hand, non-surgical management has been suggested in management of a well-established fistula. Fistula closure may be spontaneous; however, can be inhibited due to delayed gastric emptying or leakage of gastric secretions through the fistula. Endoscopic clipping of the fistula tract employing the hemoclips is a treatment option.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 85296
Program Number: P186
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster