Delayed Perforation of Gastrocolocutaneous Fistula after Percutaneous Gastrostomy
Anthony M. Villano, MD, Ariana Metchik, MD, Ravinder Bamba, MD, Parag Bhanot, MD
Department of General Surgery, MedStar Georgetown University Hospital, Washington, DC, USA (Drs Villano, Metchik, Bamba, and Bhanot)
Introduction: Percutaneous endoscopic gastrostomy (PEG) tube placement is generally a safe and effective method for establishing long-term enteral access in a minimally invasive fashion. Placement through an intervening loop of colon is a surgical pitfall that ultimately requires operative exploration to correct. Delayed perforation remote from the initial PEG placement is not yet described in the literature and represents an unusual but serious form of this complication.
Case Description: A 62-year-old male with history of Down syndrome and severe intellectual disability, chronic PEG, and tracheostomy developed free air during his admission. Subsequent exploratory laparotomy demonstrated that the PEG traversed the sigmoid colon and entered the gastric lumen, with a small perforation along the exit site of the sigmoid colon. Segmental colonic resection with end colostomy was performed without complication, and the gastrostomy was revised in a Stamm fashion. He was able to resume tube feeds prior to hospital discharge.
Conclusion: Intestinal perforation secondary to a misplaced PEG tube with gastrocolocutaneous fistula can occur in a delayed fashion, even long after the tube was placed and feeding was initiated. Utilization of the “safe tract” method must carefully be employed to minimize the risk of placement through an intervening hollow viscous such as colon or small bowel. Perforation or coloenteric fistulae require surgical intervention to correct.
Key Words: Gastrostomy, Cutaneous Fistula, Endoscopy.