CT-Guided Percutaneous Endoscopic Gastrostomy (PEG) Tube Replacement in a Post-Partial Gastrectomy Patient: A Pioneering Experience

Abstract

Background:
Percutaneous endoscopic gastrostomy (PEG) provides effective long-term access for enteral feeding. One indication for PEG is inadequate enteral intake due to dysphagia secondary to a neoplasia or neurologic disorder. However, history of previous partial gastrectomy is considered a relative contraindication for PEG due to limited gastric remnant. Computed tomography (CT)-guided PEG is an alternative technique in cases where endoscopic placement is not ideal.

Objective: To demonstrate the feasibility of PEG tube placement in post-gastrectomy patients.

Case Presentation:
An 84-year-old female who previously had partial gastrectomy with Billroth 2 anastomosis and who has had multiple hospitalizations due to recurrent pneumonia is presented. Initial endoscopic evaluation showed unremarkable esophageal and remaining proximal gastric mucosa with intact gastrojejunostomy anastomosis. Prior to puncture, identification by CT scan of the left pleura, diaphragm in the superior aspect of the stomach, and the anastomotic site between the stomach and jejunum was done. Guided by CT scan, PEG tube was inserted by pull-through technique under intravenous sedation and local anesthesia at the puncture site. Initiation of enteral feeding was tolerated without untoward event within 24 hours after the procedure. Full intermittent feeding was achieved on the fourth postoperative day.

Conclusion:

With this first-hand experience, we have shown the greater advantage of CT-guided PEG over endoscopy alone in a previous gastric surgery patient. Radiologic guidance provides better anatomic orientation, preventing accidental puncture of adjacent organs and reduces the risk of tube misplacement. CT-guided PEG is a safe alternative procedure prior to surgical tube placement.