Percutaneous endoscopic gastrostomy tube placement after sleeve gastrectomy: a case report

Introduction

Gastrostomy tube (G-tube) has been frequently placed for various reasons to maintain long-term enteral nutrition, for example, in patients with a history of neurological dysphagia (1), obstructing lesions like in oro-nasal cavity carcinoma (2) and esophageal carcinoma (3), prophylactic for patients scheduled for radiotherapy (4), gastroparesis, etc. Approximately 160,000 to 200,000 G-tubes are placed annually in the United States (5).

There are various techniques of G-tube placement, for example, percutaneous endoscopic gastrostomy (PEG), percutaneous interventional radiology guided gastrostomy (IR-G) tube. A PEG tube is usually placed in patients with an anatomically intact stomach; with the advancing era of therapeutics, the number of surgically altered anatomies of the stomach has increased, and so anatomically changed on endoscopic examination as well, which makes endoscopic interventions a little different and sometimes difficult (6).

Multiple case series have been reported for PEG tube placement in patients with reduced stomach, i.e., post-subtotal gastrectomy; however, there is scarce data available for PEG tube placement in patients with a history of sleeve gastrectomy. The case that is presented here is regarding a 64-year-old lady with a history of sleeve gastrectomy and now referred for PEG tube placement as she was advised for radiotherapy for squamous cell carcinoma (SCC) of the right buccal mucosa. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-145/rc).

Case presentation

A 64-year-old female patient was referred to our endoscopy unit for prophylactic PEG tube placement as she was scheduled for radiotherapy for SCC of the right buccal mucosa. The patient had a history of bariatric surgery, specifically sleeve gastrectomy in 2010, with no adverse events. After the sleeve gastrectomy, she underwent incisional hernia repair in 2011. She also had a history of four C-sections. The patient was diagnosed with moderately differentiated SCC of the buccal mucosa. She was advised to have wide lymph node excision with modified radical neck dissection followed by radiotherapy during a multidisciplinary team meeting. The patient had an esophagogastroduodenoscopy for PEG tube placement at another facility; however, transillumination was not achieved, so PEG placement was deferred, and she was referred to our endoscopy unit. She was scheduled for PEG tube placement at our facility after 1 week.

Ethical statement

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompany images and video. A copy of the written consent is available for review by the editorial office of this journal.

Procedural details

Informed consent was taken before starting the procedure. We spoke openly with the patient about the fact that their anatomy was altered after the sleeve gastrectomy, which could make placing a PEG more challenging than in standard cases. We also made it clear that our team’s direct experience with such situations was limited, and that this might increase the likelihood of complications. The patient was encouraged to ask questions, and we took the time to address each one before they gave their agreement to proceed. Pre-procedure assessment showed body mass index of 32.5 kg/m², vitally stable, complete blood count, and prothrombin time was checked. Patient was positioned supine; a bite lock was used to allow easy passage of the endoscope. Mild sedation with 2 mg of intravenous midazolam was given, the site of the PEG tube was prepared with povidone-iodine solution, and the anterior abdominal wall was draped. Standard gastroscope of Olympus GIF HQ 190 was used; post-surgical changes were visualized as a tubular stomach with a staple line scar of previous surgery as a mucosal ridge Figure 1. Initially, the position of the PEG tube insertion was difficult to locate due to post-operative changes and obesity as well. The stomach was insufflated well (Figure 2), and the illumination mode was used, and the PEG tube insertion site was successfully localized, i.e., the maximum trans illumination site was further confirmed via the finger dipping method, around 2 cm below the xiphoid process. This site was around an inch away from the midline surgical scar of skin, and approximately 1 cm away from the endoscopically visualized mucosal scar. The PEG tube site was infiltrated with 2% xylocaine, and a 14-gauge cannula with a stylet was inserted under endoscopic guidance. The stylet was removed, and the guidewire was advanced, followed by retrieval via snare. A 24-Fr PEG tube was placed via pull technique, commonly known as the Ponsky-Gauderer method (Video 1). The external bumper of the PEG tube was fixed at 3.5 cm. Gastroscope was re-inserted to confirm the position of the PEG tube (Figure 3). No procedural adverse events seen. Post-procedure, the patient remained stable; PEG tube priming was started after 4 hours of procedure, and feeding was started after 12 hours as per the institutional protocol to allow mucosal sealing and reduce aspiration risk. Patient was discharged and was followed up via tele-clinic after 24 hours and 5 days. After 1 week, the patient visited the clinic with no complaints of abdominal pain, fever, or discharge around the PEG tube site. Physical examination of the PEG tube site appeared not significant; her radiotherapy was started 1 week following PEG tube placement. Patient was followed up via tele-clinic after a month, with no significant complaints. The patient was extremely satisfied after starting her feed through the PEG tube.

Figure 1 Tubular stomach with mucosal ridge scar due to previous surgery.

Figure 2 Insufflated stomach.

Figure 3 Internal bolster of PEG tube. PEG, percutaneous endoscopic gastrostomy.

Discussion

This case can be categorized as an IDEAL (Idea, Development, Exploration, Assessment, Long-term follow-up) stage 1 (Idea) innovation, where a novel technical approach is described systematically to inform future practice. Literature is scarce for PEG tube placement in patients with a history of sleeve gastrectomy and sleeve gastroplasty. A literature review showed one case report states about placing a G-tube percutaneously under fluoroscopic guidance by an interventional radiologist (IR-G) (7). IR-G needs an interventional radiologist and fluoroscopic guidance, which increases its cost and exposure of X-rays to the patient, along with it IR-G usually needs a second procedure to dilate the gastrostomy tract to place a wider diameter G-tube whereas a PEG tube is a single procedure, needs endoscopist and no fluoroscopic guidance; hence, it is overall cost-effective and no radiation exposure.

This case report will provide insight to the endoscopists that G-tube placement via endoscopy should not be considered as a contraindication; however, caution is needed in view of altered anatomy, and it can be done safely if guidelines are followed well. Ultimately, it may help to reduce the number of referrals for IR-G in sleeve gastrectomy patients. Further data is needed to establish the long-term effects of PEG tube placement in such patients.

Conclusions

PEG tube placement after sleeve gastrectomy can be feasible when performed with caution. However, conclusions regarding safety and effectiveness cannot be generalized from a single case, and further studies are required.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-145/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-145/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-145/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompany images and video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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