Managing a Mis-deployed Over-The-Scope Clip
Managing Gastrocutaneous Tract Closure Post-PEG: A Case of OTSC Failure and Design Improvement Proposal
Percutaneous endoscopic gastrostomy (PEG) is a commonly used procedure for patients needing long-term enteral nutrition. However, a persistent challenge following PEG removal is the formation of a gastrocutaneous tract that fails to close, leading to leakage of gastric contents through the abdominal wall. This post details a complex case where a large gastrocutaneous tract developed after PEG removal, resulting in a need for closure before a new PEG site could be established. The case involved deploying an over-the-scope clip (OTSC) to close the tract, followed by complications with its removal when the clip failed to close the defect fully. This case highlights a suggestion for improving future procedural efficiency by color-coding critical portions of OTSC clips to aid in their easier identification during removal.
Case Overview: Gastrocutaneous Tract Closure Following PEG
In this case, a patient developed a large gastrocutaneous tract following the removal of a PEG tube. The enlarged lumen of the tract caused persistent leakage of gastric contents, posing risks of infection, dehydration, and local skin irritation. Given the significant size of the defect, spontaneous closure was unlikely, and the decision was made to close the tract using endoscopic techniques before establishing a new PEG site.
An OTSC, a standard tool for tissue approximation and closure of leaks and fistulas, was deployed to close the tract. However, due to the size of the lumen, the clip failed to seal the defect completely, resulting in continued leakage. This necessitated the removal of the OTSC for further management.
Gastrocutaneous Tracts: Pathophysiology and Complications
Gastrocutaneous tracts can develop after the removal of PEG tubes when the pathway between the stomach and the skin fails to close. In normal circumstances, the tract heals through secondary intention, but larger lumens or chronic inflammation can delay or prevent closure. As the tract remains open, gastric contents can leak through the skin, leading to local irritation, pain, and potential infection.
Using an OTSC for Gastrocutaneous Tract Closure
Over-the-scope clips (OTSCs) are advanced endoscopic devices designed to close gastrointestinal defects, including leaks, perforations, and fistulas. The clips are placed over the defect and compressed, approximating the tissue edges to promote healing. Given the size of this patient’s gastrocutaneous tract and the persistent leakage, an OTSC was chosen as the method of closure.
During the procedure, the clip was successfully deployed over the tract; however, the large lumen of the tract exceeded the clip’s ability to fully approximate the tissue. As a result, the defect remained partially open, necessitating further intervention. The plan to pursue a new PEG site had to be delayed until the existing tract could be effectively closed.
Challenges in OTSC Removal with the reMOVE System
With the OTSC failing to close the tract, the next step was to remove the clip using the reMOVE system, a specialized device for OTSC removal. The reMOVE system includes a DC Cutter tool, which is designed to sever the OTSC at its thin sections, allowing the clip to be retrieved safely.
However, the removal process encountered significant difficulties. OTSC clips feature thick and thin sections, with the thin portions serving as targets for the DC Cutter. Identifying these thin sections proved challenging, particularly given the complex anatomy of the tract and the limited visibility in the endoscopic field. After multiple attempts to locate and cut the correct section, the thin portion was finally identified, and the clip was successfully removed.
The procedural delay and difficulty in identifying the correct target area increased the patient’s discomfort and prolonged the overall procedure. These challenges raised questions about how future OTSC removals could be streamlined to avoid similar complications.
A Proposed Improvement: Color-Coding Thin Sections of OTSC Clips
One clear lesson from this case is the need to enhance the ease and accuracy of OTSC removal, particularly in challenging scenarios like large gastrocutaneous tracts. A simple, yet effective solution would be to color-code the thin sections of OTSC clips, making them easier to identify during removal procedures.
Currently, OTSC clips rely on visual cues and endoscopic navigation to locate the thin sections that must be cut by the DC Cutter. By adding color-coded markers to these areas, proceduralists would have a clearer visual target, reducing the time spent trying to identify the correct cutting point. This modification could drastically improve the efficiency of clip removal, minimizing the risk of tissue injury and reducing procedural time.
The Impact of Design Improvements on Patient Outcomes and Procedural Efficiency
The benefits of color-coded OTSC clips are multifaceted. For proceduralists, the visual aid would allow faster and more accurate identification of critical sections, decreasing the number of failed attempts to cut the clip. This improvement would reduce frustration during complex procedures and shorten the time spent in endoscopic navigation.
For patients, reducing the overall procedural time would enhance comfort and decrease the risks associated with prolonged procedures, such as infection or tissue trauma. In cases like the one presented, where a new PEG site was contingent on the successful closure of the gastrocutaneous tract, efficient clip removal is critical for timely and effective patient management.
Conclusion: Optimizing Endoscopic Tools for Enhanced Clinical Practice
The management of large gastrocutaneous tracts following PEG placement presents a significant challenge for gastroenterologists, especially when traditional closure methods, like OTSC clips, fail to fully resolve the defect. As this case illustrates, the need for OTSC removal can introduce additional procedural complexity, particularly when the clip’s thin sections are difficult to identify and target.
By introducing color-coded markers on the thin portions of OTSC clips, proceduralists could more easily locate the correct areas for the DC Cutter to target, improving the overall efficiency of clip removal. This seemingly simple modification has the potential to significantly enhance both the proceduralist’s experience and the patient’s outcome, reducing the time and effort required to successfully complete the procedure.
Key Takeaways:
- Large gastrocutaneous tracts after PEG removal are difficult to manage due to persistent leakage and the risk of infection.
- OTSC clips are valuable tools for closing these defects but may fail in cases with larger lumens, necessitating removal.
- The reMOVE system is designed for OTSC removal but can be challenging when thin clip sections are difficult to locate.
- A simple design improvement, such as color-coding the thin sections of OTSC clips, could improve procedural efficiency and patient safety by aiding in faster and more accurate clip removal.
The continued refinement of endoscopic tools is critical to advancing patient care, and small modifications, like color-coding, can have a significant impact on the ease and success of complex procedures.
