Endoscopic percutaneous drainage in a COVID-19 patient with iatrogenic gastric perforation

 

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A 60-year-old male under mechanical ventilation through endotracheal intubation due to severe COVID-19 pneumonia was treated at our intensive care unit (ICU) with extracorporeal membrane oxygenation for several weeks. Computed tomography (CT) revealed bilateral lung involvement and a left pulmonary abscess drained by a percutaneous catheter ([Fig. 1]). Percutaneous endoscopic gastrostomy (PEG) was performed, but the patient developed an early buried bumper syndrome [1] [2] [3] [4] after one month, so the tube was removed and gastroscopy showed an unexpected gastric perforation of the fundus ([Fig. 2], [Video 1]), defined as de novo perforation.

Video 1 Video shows how the percutaneous intra-abdominal drainage was inserted through the patient’s abdominal wall defect under direct endoscopic and radiologic visualization. Later, a full-thickness continuous suture was successfully performed using the OverStitch suturing device.

A CT scan showed a fluid collection in the left upper abdominal region, so the multi-disciplinary decision was to perform a peritoneoscopy (with a 6-mm scope), which was safely performed thanks to the insufflation of carbon dioxide [5]. The ultra-slim scope allowed us to cross the gastric leak and directly visualize the diaphragm ( [Fig. 3 a]), spleen ([Fig. 3 b]), and the inner abdominal wall defect from PEG insertion ([Fig. 3 c]).

The patient was critically ill and unfit for surgery, so we placed a percutaneous drainage and closed the leak with an endoscopic suturing system. The isolated COVID-ICU room was organized as an endoscopic theater, allowing us to perform the procedure at bedside. The percutaneous drainage was inserted through the abdominal wall defect (previous PEG fistula) under direct endoscopic and radiologic visualization ([Fig. 4 a, b]). Continuous sutures were performed using the OverStitch suturing device (Apollo Endosurgery, Inc., Austin, Texas, USA) ([Video 1]), and closure was confirmed by the absence of intra-abdominal contrast diffusion after intra-gastric contrast injection ([Fig. 5]).

Meanwhile, the SARS-CoV-2 infection resolved, allowing his transfer to the ICU, where a second gastroscopy was necessary due to lack of clinical improvement. It showed another leak next to the sutured area, so another suture was performed and strengthened with a whipstitch over it ([Video 1]). The absence of intra-abdominal contrast diffusion confirmed the complete closure, but he died one month later from his terminal pulmonary condition.

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Publication History

Article published online:
18 February 2022

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• References

• 1 Arvanitakis M, Gkolfakis P, Despott EJ. et al. Endoscopic management of enteral tubes in adult patients – Part 1: Definitions and indications. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53: 81-92 DOI: 10.1055/a-1303-7449.
  Article in Thieme ConnectPubMedGoogle Scholar
• 2 Gkolfakis P, Arvanitakis M, Despott EJ. et al. Endoscopic management of enteral tubes in adult patients – Part 2: Peri- and post-procedural management. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53: 178-195 DOI: 10.1055/a-1331-8080.
  Article in Thieme ConnectPubMedGoogle Scholar
• 3 Anderloni A, Di Leo M, Barzaghi F. et al. Complications and early mortality in percutaneous endoscopic gastrostomy placement in Lombardy: a multicenter prospective cohort study. Dig Liver Dis 2019; 51: 1380-1387
  CrossrefPubMedGoogle Scholar
• 4 Pih GY, Na HK, Ahn JY. et al. Risk factors for complications and mortality of percutaneous endoscopic gastrostomy insertion. BMC Gastroenterol 2018; 18: 101
  CrossrefPubMedGoogle Scholar
• 5 Lo SK, Fujii-Lau LL, Enestvedt BK. et al. The use of carbon dioxide in gastrointestinal endoscopy. Gastrointest Endosc 2016; 83: 857-865
  CrossrefPubMedGoogle Scholar