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Novel hybrid technique for closure of refractory gastrocutaneous fistula: endoscopically guided percutaneous suturing

      A 40-year-old woman had a history of epilepsy and global developmental delay after placement of a percutaneous endoscopic gastrostomy (PEG) tube 25 years earlier. She had an 18F gastrostomy tube exchanged every 2 months. During the past year, the stoma had increased in size progressively, and the patient presented with PEG site leakage. An initial attempt at gastrocutaneous fistula (GCF) closure with both an over-the-scope clip and endoscopic suturing was not possible because of a narrow mouth aperture. Endoscopic closure with hemoclips failed. We describe the use of a novel and simple hybrid technique for closure of this refractory GCF using an endoscopically guided percutaneous suturing approach (Fig. 1; Video 1, available online at www.giejournal.org). A nonabsorbable suture (silk 0) was used for this procedure. The procedure was performed with the patient under deep sedation, and she received 2 grams of cefoxitin as antibiotic prophylaxis. Continuous CO2 insufflation was maintained to reach a close position of the distended stomach to the abdominal wall. This technique could be considered a primary approach for closure of GCF or as a rescue therapy in case other treatment modalities fail or are not possible.
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      Figure 1Endoscopically guided percutaneous suturing technique. A, An 18-gauge trocar was advanced to the gastric lumen under direct and endoscopic guidance. A 1-0 silk suture was advanced across the trocar into the gastric lumen. B, The suture was then externalized through the fistula tract with a biopsy forceps. C, The trocar was inserted again into the gastric lumen on the opposite side, and the suture was advanced from the external area into the gastric lumen. D, With a biopsy forceps traversed across the fistula tract, the suture was externalized. E, The suture was cut to remove the trocar. F, The suture was knotted together. G-H, The knot was pulled to get an external position. I-J, The suture lines were tied with the knot pulled along the long axis of the defect, allowing the knot to slide to the gastric side.
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