Endoscopic Management of PEG Tube Perforation

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Purpose: Background: Percutaneous endoscopical gastrostomy (PEG) tubes are a common means of providing enteral nutrition. Annually over 100,000 PEG tubes are placed with low complication rates. Minor events, such as tube dislodgement, peristomal wound infection, and bleeding occur in 10-15% of cases. Major complications, including intestinal perforation, are infrequent (1-3%) and often require open surgical repair. We describe an endoscopic repair of a PEG tube perforation through the transverse colon. Case: An 88 year old man with a history of refractory COPD and respiratory failure required tracheostomy and PEG placement. He had no previous history of abdominal surgeries or gastrointestinal disease, and was not receiving systemic steroids or anticoagulation. A PEG was placed without complications with initiation of tube feeds without event and he was discharged to a skilled nursing facility. Two weeks later, he was readmitted to another institution for worsening ventilatory failure. He was noted to have heme-positive brown stool with a decrease in hemoglobin. He had a benign abdominal exam that was notable for a functioning PEG tube. Colonoscopy demonstrated the PEG tube passing through the transverse colon causing a partial luminal obstruction. CT scan did not reveal pneumoperitoneum. Intervention: Upon repeat colonoscopy, a portion of PEG tubing was seen obliquely traversing the wall of the colon, without extending into the lumen. The surrounding colonic mucosa was completely normal without evidence of ischemia, ulceration, or necrosis. Boston Scientific Resolution® clips were used to close the defect. Sequentially, 4 clips were placed to completely oppose the mucosa around the PEG tube. The PEG itself was not visible at the completion of the procedure. Follow-up radiography again did not demonstrate any free air. A tube study confirmed the position of the PEG and failed to demonstrate extravasation of contrast. Resumption of tube feeds was well tolerated with no evidence of peritonitis. The patient's abdominal exam remained benign and he was discharged without further incident. Conclusion: While PEG placement is a common procedure with relatively low morbidity, complications can occur. Patients undergoing PEG placement are often poor surgical candidates, and visceral perforation often necessitates laparotomy for surgical repair. We describe the first report of a fully endoscopic approach to the closure of a colonic mucosal defect caused by PEG placement.