Alexander Gonzalez-Jacobo, DO, Faith Buchanan, Hubby Buehler, Jacob Eisdorfer, DO, Javier Andrade, MD. St. John’s Episcopal Hospital
Introduction: Percutaneous endoscopic gastrostomy (PEG) is a common procedure frequently performed to provide nutrition via enteral access for patients that are unable to feed orally. PEG tube insertion has fallen into favor due to its minimally invasive technique in addition to its cost-effectiveness compared to open gastrostomy. Although it boasts an impressive safety profile and is a reasonably straightforward procedure, PEG tube placement does entail risks. We present a rare case of an elderly female patient who experienced prolapse of the gastric wall from the PEG site and a novel laparoscopic/endoscopic approach to the subsequent repair.
Case Description: A 90-year-old female, with extensive comorbidities was admitted to our institution for hypotension and electrolyte abnormalities. During her workup, it was discovered that the patient had developed gastric prolapse and herniation surrounding the PEG tube due to increased abdominal pressure caused by pulmonary fibrosis and chronic ventilator support. The PEG tube was removed and a gastrograffin study was performed which showed no extravasation. Attempts were made to externally reduce the prolapse but were unsuccessful. Due to concerns of ischemia to the prolapsed gastric wall the decision was made to attempt the reduction surgically. The abdomen was accessed laparoscopically and the prolapsed stomach was identified. Adhesions were lysed and small incisions were made on either side of the PEG tract to mobilize the stomach through the abdominal wall. A partial gastrectomy was then performed from the exterior with an Endo-GIA stapler. The stomach was returned into the abdomen and the integrity of the repair was confirmed via endoscopy. Due to the continued requirement for enteral feeding, a laparoscopic-assisted endoscopic gastrostomy tube was then placed along with multiple T-fasteners to secure the anterior gastric wall to the abdominal wall preventing future gastric prolapse. The patient experienced an uneventful post-operative course and was discharged.
Discussion: Exploratory laparotomy has been previously described for repair of gastric prolapse, however a review of current literature has yielded no reports of laparoscopic-endoscopic assisted repair of the aforementioned condition in the adult population. Studies have shown PEG has a major complication rate of up to 11%. Due to the infrequency of our patients’ complication, no standard has been identified in adults for repair of gastric prolapse through gastrostomy. The advancements of laparoscopic technique as well as the decreased recovery time accompanying laparoscopic repairs, suggest laparoscopic-endoscopic assisted repair of gastric prolapse is a superior method of repair in clinically stable patients.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 93611
Program Number: P502
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster