How to rescue a percutaneous gastrostomy tube perforating the jejunum. Percutaneous endoscopic gastrostomy or PEG tube is commonly used to provide long-term nutritional support for patients. PEG insertion is a safe procedure with lower rates of complications compared to total parental nutrition. However, PEG tube insertion may be associated with a wide range of mechanical complications. Minor mechanical complications such as tube dislodgement occurs in up to 15% of the cases. However, major complications such as intestinal perforation is rare and occurs in up to 3% of the cases and typically require surgical repair. Here we present a case of endoscopic repair of a PEG tube perforation involving the jejunum. A 75 years old male with complex past medical history of short bowel syndrome due to total small bowel resection with total abdominal colectomy secondary to fistulizing Crohn's disease and ulcerative colitis presented with failure to thrive. One month prior to presentation he underwent a combined intestinal and kidney transplant with duodenal jejunostomy where his native duodenum d2 d3 was attached to the donor jejunum. Due to persistent nausea and abdominal pain a PEG tube was placed to assist in meeting his nutritional needs. A standard pull 20 French PEG tube was placed with transillumination and endoscopic view. Within five days of PEG tube insertion the patient had persistent abdominal pain, elevated white cell count, and mental status changes with worsening delirium. In order to assess the position of the PEG tube an upper endoscopy and ileoscopy was performed which showed that the tube was present in the lumen of the jejunum. This was located 20 centimeters distal to the duodenal jejunal anastomosis. CT abdomen showed that the bumper of the PEG tube was present within the stomach however the tube was traversing the jejunum before entering the stomach. There were also concerning findings of hematoma and a possible bile leak. Abdominal examination revealed a functioning PEG tube. This is an illustration of PEG tube placement in our patient. Due to his altered gastrointestinal anatomy a jejunal loop was present between the skin and the stomach resulting in perforation of the jejunum during placement of the PEG tube. On upper endoscopy the bumper of the PEG tube was seen to be located appropriately within the gastric body. An upper endoscopy was performed in which a snare was introduced through the upper endoscope. The snare was then opened to grasp the wire. The wire was then extracted to the mouth and secured. The upper endoscope was then re-inserted into the stomach through the mouth. The snare was used this time to grasp the bumper of the PEG tube in order to help with the removal of the PEG tube. The PEG tube was carefully cut to avoid damaging the wire and the surrounding tissue. The PEG tube was then carefully removed over the wire. The bumper of the PEG tube was grasped and removed. The PEG tube was then carefully removed over the wire. The bumper of the PEG tube was grasped and removed successfully. This shows the removed PEG tube and the bumper. The upper endoscope was then used to perform a detailed examination to find the exact site of small bowel perforation. The wire was seen transecting the jejunal lumen. However, the surrounding small bowel mucosa appeared completely healthy. Crohn's illumination of the jejunum confirmed the scope's positioning and suggested the cause of the PEG perforation. An abnormally high placement of a jejunal loop in the left upper quadrant appeared to contribute to the perforation. After the exact site of jejunal perforation was confirmed, a lumen opposing metal stent was used to close off the site of the jejunal fistula. In order to have adequate visualization of where the lumen opposing metal stent was being deployed, an upper endoscope was inserted alongside the wire containing the metal stent. This figure illustrates the side-by-side insertion of the wire containing the metal stent and the upper endoscope in order to have adequate visualization of where the metal stent was being deployed. This shows the metal stent over the wire while the upper endoscope is overlooking the exact site of metal stent deployment at the site of jejunal fistula. A 10 mm by 1 cm lumen opposing metal stent was deployed at the site of jejunal fistula without any immediate complications. This shows another luminal view of successful deployment of the lumen opposing metal stent while still under endoscopic guidance. After successful deployment of the lumen opposing metal stent, an 18 French direct jejunostomy was inserted percutaneously over the wire directly into the jejunum utilizing the same skin incision from the previously placed back tube. This was performed under endoscopic guidance for adequate visualization. This figure illustrates the two endoscopic procedures performed in our patient. In order to close off the GJ fistula and stop the leakage, a lumen opposing metal stent was placed. In order to provide nutritional support to our patient, a J tube was directly inserted into the jejunum through the incision of previously placed back tube. There were no immediate complications. Tube feeding was restarted and the patient was discharged. Through this case, we aim to highlight successful management of jejunal transaction during back tube placement. There should be a low threshold for imaging and less invasive endoscopic interventions before opting for surgical procedures to prevent delays in addressing tube related complications. Suspicion for tube related complications should be high in patients with surgically altered gastrointestinal anatomies. Therefore, less invasive, safe, and cost effective endoscopic methods can be employed for mechanical complications of back tubes.

PEG tube complications

endoscopic intervention

jejunal perforation

lumen opposing stent

direct jejunostomy