An unpredictable complication during percutaneous endoscopic tube placement: esophageal perforation

A percutaneous endoscopic gastrostomy (PEG) was performed to provide an enteral feeding route. Major and minor complications related to this procedure include, aspiration, wound infections, necrotizing fasciitis, peritonitis, abscess, peristomal leakage, pneumoperitoneum, ileus, portomesenteric venous gas, colon injury, gastrocolocutaneous fistulae, abdominal wall bleeding, intra-abdominal bleeding, gastric outlet obstruction, inadvertent gastrostomy tube removal, spleen trauma, clogged PEG tube, tumor implantation at PEG site, and buried bumper syndrome [1] [2].

An 88-year-old woman with Alzheimer’s disease required PEG tube placement as an alternative feeding route. The procedure was performed using the pull-through technique (Flexiflo kit; Abbott, Sligo, Ireland). On endoscopy, tertiary contractions occurred in the esophagus. The procedure was uneventful until moments before the insertion of the tube into the esophagus through the mouth. A moderate resistance was felt while pulling the tube wire. Inspection of the tube after removal revealed deformation of its tip ([Fig. 1]). A new tube was inserted and then the upper esophagus was checked endoscopically. Severe lacerations and minimal bleeding were observed in the upper part of the esophagus ([Fig. 2]).

Fig. 1 The deformation of the tube tip.

Fig. 2 Minimal bleeding and laceration in the esophagus.

Shortly thereafter, the patient presented dyspnea, followed by edema and crepitation in the neck. Thoracic computed tomography indicated the presence of air in the mediastinum ([Fig. 3]). The patient presented mild peripheral cyanosis, tachycardia, tachypnea, and a subfebrile rise in body temperature. She was cared for in the intensive care facility.

Fig. 3 Axial noncontrast-enhanced computed tomography images after the procedure showed free air bubbles in the left cervical region (a, b), and the periesophageal (c) and right paracardiac (d) spaces.

A few hours later, she reported feeling better. Vital signs returned to normal. Feeding via the PEG tube was initiated 2 days later, and the tube functioned properly. The patient was hospitalized for 32 days after the procedure.

This report describes the occurrence of an esophageal perforation during the insertion of a PEG tube. As this complication was detected early, conservative treatment was sufficient for its successful resolution, and the patient healed satisfactorily.

Endoscopy_UCTN_Code_CPL_1AH_2AI

• References

• 1 Jarnagin WR, Duh QY, Mulvihill SJ et al. The efficacy and limitations of percutaneous endoscopic gastrostomy. Arch Surg 1992; 127: 261-264
• 2 Rimon E. The safety and feasibility of percutaneous endoscopic gastrostomy placement by a single physician. Endoscopy 2001; 33: 241-244