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Persistent Peristomal Leakage from Percutaneous Endoscopic Gastrostomy Successfully Treated with Argon Plasma
Cláudia Macedo1, Nuno Almeida1,2, Ana Rita Alves3
1Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
Insights
Pulsed argon plasma coagulation (APC) effectively treats persistent peristomal leakage from mature gastrostomy tracts, offering a safe and low-cost endoscopic solution when conservative measures fail.
Area of Science:
- Gastroenterology
- Endoscopic procedures
- Surgical complications
Background:
- Percutaneous endoscopic gastrostomy (PEG) is a common procedure.
- Peristomal leakage can occur early or late after PEG placement.
- Conservative management is the initial approach for leakage, but may fail.
Observation:
- Four cases of late peristomal leakage unresponsive to medical treatment were treated.
- Endoscopic intervention involved circumferential fulguration with pulsed argon plasma coagulation (APC).
- Additional endoscopic clips were used in two cases for enlarged stoma orifices.
Findings:
- Complete resolution of leakage and skin changes occurred within 2–6 weeks post-procedure.
- No recurrence of leakage was observed during a mean follow-up of 19 months.
- The APC technique, alone or with clips, was successful in all four patients.
Implications:
- APC offers an effective and safe endoscopic treatment for persistent peristomal leakage.
- This technique is a relatively low-cost alternative to surgical revision or creating new fistulas.
- Endoscopic management with APC can prevent complications and maintain enteral nutrition.
Introduction:
Percutaneous endoscopic gastrostomy is a safe and effective technique and its use is widely spread. Peristomal leakage may occur within the first few days after gastrostomy tube placement and also in the mature gastrostomy tract. The initial treatment involves conservative measures. If the leakage does not resolve, different endoscopic interventions could be necessary with consequent impairing of enteral nutrition and, in some cases, the need of creating a new gastro-cutaneous fistula.
Case Report:
We present 4 consecutive cases complicated with late peristomal leakage and medical treatment failure. These patients underwent upper digestive endoscopy, and circumferential fulguration of the mucosa surrounding the tube with pulsed argon plasma coagulation (APC) at 50 W and 1 L/min flow rate was performed. Additional long through-the-scope clips were applied in 2 cases, since the inner orifice remained enlarged, in order to obtain a better closure. Complete leakage and skin changes resolution occurred between 2 and 6 weeks after the procedure (mean 3.5 weeks). The overall mean follow-up was 19 months after the endoscopic procedure (maximum 30 months, minimum 10 months). There was no recurrence of leakage.
Conclusion:
The use of APC alone or combined with long through-the-scope clips in large internal stoma orifice resolved persistent leakage from percutaneous endoscopic gastrostomy in all 4 presented cases without complications. In our case series, this technique appeared to be an effective, safe, and relatively low-cost alternative to the treatment of persistent peristomal leakage of the mature gastrostomy tract.
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