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Inicio Gastroenterología y Hepatología (English Edition) External digital pressure to enable a deeper tulip-bundle technique for endoscop...
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Vol. 40. Núm. 4.
Páginas 290-291 (abril 2017)
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Vol. 40. Núm. 4.
Páginas 290-291 (abril 2017)
Scientific letter
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External digital pressure to enable a deeper tulip-bundle technique for endoscopic closure of a refractory chronic gastrocutaneous fistula
Presión digital externa para permitir una técnica de «tulip-bundle» más profunda para el cierre endoscópico de una fístula gastrocutánea crónica refractaria
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Ana Ponte
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ana.ilponte@gmail.com

Corresponding author.
, Rolando Pinho, Teresa Pinto-Pais, Adélia Rodrigues, Iolanda Ribeiro, Luísa Proença, Joana Silva, Jaime Rodrigues, João Carvalho
Department of Gastroenterology, Centro Hospitalar Vila Nova de Gaia, Espinho, Portugal
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Dear Editor,

The authors present a case of a 68-year-old woman with end-stage metastatic breast cancer and biphosphonate-related osteonecrosis of the jaw with a chronic gastrocutaneous fistula which persisted a month after removal of a 24 Fr percutaneous endoscopic gastrostomy (PEG) tube. Conservative management with intravenous antibiotics, regular wound cleaning, high-dose proton pump inhibitor and a nasojejunal tube for enteral feeding was instituted. After two unsuccessful attempts to close the gastric defect with endoclips, a third endoscopy was performed revealing extravasion of methylene blue through the gastric orifice with the previously placed endoclips (Fig. 1). After closure of the gastric orifice with additional endoclips, a tulip-bundle technique was performed. In this technique an endoloop snare (MAJ-254; Olympus, Japan) was placed over the endoclips resulting in closure of fistulous tract (Video). External digital pressure of the stoma enabled proper positioning of the endoloop deeper below the endoclips, which was then tightened around the endoclips (Fig. 2) closing the gastric orifice (Fig. 3). A follow-up endoscopy performed half a month later revealed complete closure of the gastric defect with no extravasion of methylene blue (Fig. 4A) to the skin (Fig. 4B).

Figure 1.

Endoscopic image revealing the gastric orifice partially closed with endoclips.

(0.14MB).
Figure 2.

Endoscopic image showing proper placement and tightening of the endoloop around the endoclips.

(0.15MB).
Figure 3.

Endoscopic image showing complete closure of the gastric orifice, after releasing the endoloop.

(0.16MB).
Figure 4.

(A) Endoscopic image showing methylene blue instillation over the previous gastric defect. (B) No extravasion of methylene blue through the cutaneous orifice occurred.

(0.26MB).

Although PEG is a safe and efficient procedure for enteral nutrition, some complications may occur, including peristomal infection, leakage and chronic gastrocutaneous fistula.1–3

The tulip-bundle technique has a range of applications including hemostasis and closure of perforations and fistulae.3–6 The tulip-bundle technique may represent a good alternative for closure of chronic gastrocutaneous fistula,3 which is particularly useful in patients with multiple comorbidities as our patient.

Appendix A
Supplementary data

The following are the supplementary data to this article:

(10.59MB)

References
[1]
A. Ponte, R. Pinho, J. Carvalho.
Thinking outside the box of the gastrostomy kit: stylet-assisted technique for challenging gastrostomy tube replacements.
Clin Gastroenterol Hepatol, 13 (2015), pp. e137-e138
[2]
D. Westaby, A. Young, P. O’Toole, G. Smith, D.S. Sanders.
The provision of a percutaneously placed enteral tube feeding service.
Gut, 59 (2010), pp. 1592-1605
[3]
F. Perri, M. Gentile, D. Scimeca, F. Terracciano, A. Merla, F. Spirito, et al.
Closure of a gastrocutaneous fistula by a tulip-bundle technique.
Endoscopy, 43 (2011), pp. E419
[4]
R. Pinho, J. Silva, A. Ponte, J. Rodrigues, I. Ribeiro, M.C. Lucas, et al.
Grasp-to-retract modification of the tulip-bundle technique in forward and retroflexed position in the sigmoid colon for difficult hemostasis.
Endoscopy, 47 (2015), pp. E554-E555
[5]
F. Mocciaro, G. Curcio, I. Tarantino, L. Barresi, M. Spada, S.L. Petri, et al.
Tulip bundle technique and fibrin glue injection: unusual treatment of colonic perforation.
World J Gastroenterol, 17 (2011), pp. 1088-1090
[6]
G. Curcio, R. Badas, R. Miraglia, L. Barresi, I. Tarantino, M. Traina.
Duodenal stump fistula following Roux-en-Y gastrectomy, treated with single-balloon enteroscopy using the tulip bundle technique and fibrin glue injection.
Endoscopy, 44 (2012), pp. E364-E365
Copyright © 2016. Elsevier España, S.L.U., AEEH and AEG
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