Percutaneous endoscopic gastrostomy (PEG) tube perforation through colon

Case contributed by Dr Michael P Hartung

Presentation

1 day following PEG tube placement. Worsening abdominal pain.

Patient Data

Age: 80
Gender: Male

Pneumoperitoneum. Percutaneous gastrostomy tube flange is normally located within the stomach. However, there is soft tissue interposed between the gastric wall and anterior abdominal wall which is continuous with the transverse colon.

The examination was repeated due to motion on the original portal venous phase imaging (included for comparison). 

Operation Exploratory laparotomy with repair of colon perforation.

Description

The patient was taken back to the operating suite, placed in the supine position, sterilely prepped and draped in the usual fashion. Half percent Marcaine with Epinephrine was used at the incision site. An incision was made from the umbilicus up to the xyphoid process. The incision was carried down to the rectus fascia. The rectus fascia was incised. The peritoneum is elevated and the abdomen is opened. There are no adhesions to the abdomen. There is no soiling of stool in the abdomen. Visualization of the PEG tube showed the PEG tube going through a small portion of transverse colon. The amount of colon had a 0.5 cm bridge of tissue on 1 side with the majority of the colon without any injury. This was in between the abdominal wall and the stomach. There was no soiling of stool. There was no abscess here. I thought best to incise the bridge of colon and release the colon from the PEG tube. Once this was accomplished, I elevate the lumen of the colon created by the PEG tube and me cauterizing/releasing the transverse colon. The defect was 4 cm long. Good hemostasis is noted which is on the antimesenteric border. I thought secondary to the patient's cardiac history and the pristine surgical site that it would be best to take a laparoscopic GI stapling device 60 cm in length and fire this across the opening. I then invert the staple line with a 3-0 silk. Palpation of the lumen found it adequate. I dropped this back into the abdomen. Again there was no soiling. There was no abscess cavity noted. There was no active bleeding. I then left the PEG tube in place again as this looked pristine. I then closed the peritoneum with 0 Vicryl. I then reapproximate the rectus fascia with interrupted 1 Vicryl. I then closed the subcutaneous tissue with 3-0 Vicryl. I then reapproximate the skin using stainless steel clips. Xeroform and sterile dressing was applied. The patient tolerated the procedure well and went on to the recovery room in satisfactory condition. All sponge, needle and instrument counts were correct.

Case Discussion

The original, motion degraded portal venous phase images makes this case more difficult, and might be worth reviewing to determine how confidently you think might be able to make the correct diagnosis. The delayed phase images help to clarify the diagnosis. The presence of free intraperitoneal air following percutaneous endoscopic gastrostomy tube placement indicates that there is either a leak from the stomach or perforation of bowel. In this case, a thin portion of transverse colon has been perforated and interposed between the gastric and anterior abdominal wall. This was confirmed at the time of surgery.
PlayAdd to Share

Case information

rID: 59953
Published: 2nd May 2018
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included

Updating… Please wait.

 Unable to process the form. Check for errors and try again.

 Thank you for updating your details.