1862 Novel Endoscopic Repair of a Percutaneous Endoscopic Gastrostomy Tube Malpositioned Through the Transverse Colon

Abstract

INTRODUCTION: Malpositioning of a PEG tube on placement has been well documented in the medical literature. This case outlines a novel approach to repairing a malpositioned PEG tube in a patient that was not a surgical candidate. CASE DESCRIPTION/METHODS: This is a 60-year-old male with a past medical history of gastroparesis, end-stage renal disease, and diabetes mellitus who was admitted for influenza and severe acidosis. Soon after admission he underwent cardiac arrest and had return of spontaneous circulation after 20 minutes of resuscitation. Following a prolonged hospital course, tracheostomy and PEG tube placement with Soldinger technique were performed. Over the subsequent days, he experienced melenic stools and declining hematocrit. Colonoscopy showed a foreign body suspicious for a feeding tube crossing the transverse colon. He was found to not be a surgical candidate due to his comorbidities, and a contrast enema showed no extravasation of contrast. Repeat endoscopy was therefore performed to attempt correction. Our novel approach began with colonoscopy. Once the foreign body was visualized, the tubing was cut from the outside and pulled by forceps into the lumen of the transverse colon. Hemostatic clips were applied to the colonic mucosa to close the first perforation. The team then transitioned to gastroscopy. The PEG tube hub was visualized in the stomach and removed. Additional clips were used to close this gastric perforation. The team then turned attention to the second colonic perforation. Once located, clips were used to close this final perforation. Subsequent plain films did not show free air, and abdominal exam remained generally benign. Upper GI series was without evidence of extra-luminal contrast material. CT showed no abscess or fluid collection. He was soon able to be fed through a nasoduodenal tube. Later, he was weaned from the ventilator and able to resume a solid diet without complication. DISCUSSION: This case was unique in its endoscopic approach to repairing a malpositioned PEG tube in a patient that could not be taken to surgery. Without this novel endoscopic approach, this patient would have likely experienced significantly increased morbidity. Although these methods have not been extensively documented in the literature, this approach may be warranted in some patients who could not proceed to traditional surgery. We hope to start discussion about future research into the area of endoscopic repair of a malpositioned PEG tube.