Herniation through gastrostomy site: Case report.

INTRODUCTION: Herniation through gastrostomy site is an extremely rare complication of percutaneous endoscopic gastrostomy (PEG). We present two unusual cases of gastrostomy site herniation, the surgical management thereof, and a corresponding review of the literature. CASE
PRESENTATION: The first patient is a 65year old Caucasian male who complained of epigastric pain and a bulge at his previous gastrostomy tube incision site three weeks after its removal. Initial exam revealed a hernia measuring approximately 10cm which was later repaired by laparoscopic surgery with a composite mesh. The second case is 66year old obese Caucasian male who complained of continued pain in the midepigastric region around his gastrostomy site scar five months after removal of his PEG tube. On physical exam he was found to have a hernia of 6cm in the midepigastrium. His hernia was later repaired by open surgery with a composite mesh. Both patients recovered uneventfully postoperatively.
CONCLUSION: Herniation through gastrostomy site is a possible complication of PEG tube and clinicians should consider this possibility in patients with ongoing leakage, bulge or pain at the gastrostomy site. This entity can be safely corrected via laparoscopic or open techniques.

Introduction

Percutaneous Endoscopic Gastrostomy (PEG) tube placement has been the minimally invasive procedure of choice for enteral access, or decompression, since the early 1980s [1]. An array of complications has been described in association with this procedure. Herniation through gastrostomy site is considered an extremely rare complication with only four cases reported. We present two unusual cases of gastrostomy site herniation, the surgical management thereof, and a corresponding review of the literature.

Case presentation

The first patient is a 65 year old Caucasian male who presented to the surgery clinic after a prolonged hospitalization for congestive heart failure exacerbation resulting in the need for gastrostomy tube placement. The patient had the PEG tube in place for approximately a month and then it was removed by traction technique after no longer in use. The patient noticed an enlarging defect about 3 weeks after removal. At time of presentation he complained of epigastric pain and a bulge at his previous gastrostomy tube incision site. Initial exam revealed a hernia measuring approximately 10 cm. After appropriate preoperative evaluation the patient was scheduled for laparoscopic surgical repair. The hernia was easily reduced with gentle traction, and a gastro-cutaneous attachment resected (Fig. 1). A polyester composite mesh was then used to repair the gastrostomy site ventral wall defect (Fig. 2). The second patient is a 66 year old obese Caucasian male who was hospitalized in the intensive care unit for lithium overdose. He required prolonged enteral feeding, and for that purpose he received a percutaneous endoscopic gastrostomy. Subsequently he recovered well and had the tube removed by simple traction in the office. Five months later he complained of continued pain in the midepigastric region around his gastrostomy site scar. On physical exam he was found to have a hernia of 6 cm in the midepigastrium. He was taken to the operating room and his hernia was repaired by open surgery with a composite mesh.

Fig. 1

Herniation through Gastrostomy site.

Fig 2

Laparoscopic repair with prosthetic mesh.

Both patients had non-complicated reducible hernias at presentation and no extra imaging or specific diagnostic modalities were required. Postoperatively both patients recovered uneventfully.

Methods

A PubMed search of the literature of gastrostomy site herniation was conducted. Only four results were found.

Results

Discussion

PEG site herniation has been described previously but without description of operative intervention received. With the increasing numbers of PEG tubes being placed every year, it is expected that complications like these will gradually increase. Discussion of preventing this complication was presented by Boldo-Roda et al. [2] and included avoidance of placement of PEG tube through linea alba, as this is an area of potential weakness; and possibly using cut and push technique rather than traction. It is possible that vigorous traction during removal may create a more permanent cavity than expected. However cut and push technique carries its own innate risks and clinicians should keep this in mind when deciding on the removal technique of choice.

Conclusion

While gastrostomy site hernia is an exceedingly rare complication with only four other cases reported in the literature, it is likely, given the number of gastrostomy tubes placed per year, that it is simply underreported. Clinicians should stay vigilant when performing physical exams or additional workup in patients with ongoing leakage, bulge or pain at the gastrostomy site; as this is potentially a surgically correctable entity, and can be safely managed via laparoscopic or open techniques.

Conflicts of interest

None.

Source of funding

None.

Ethical approval

There was no ethical approval required for this case.

Consent

Written informed consent was obtained from the patients for publication of these two case reports and accompanying images. A copy of the written consents is available for review by the Editor-in-Chief of this journal on request.

Author contribution

Fernando Navarro: study concept and design.

Catherine Loflin: writing the paper, data collection and data analysis.

Paul Diegidio: writing the paper, data collection and data analysis.

Abdelaziz Atwez: writing the paper and proofreading.

Jeremy Reeves: data collection.

Guarantor

Fernando Navarro.

Author	Date	Diagnosis	Removal Method	Intervention	Outcome
Chuang [1]	2003	Leakage from around PEG tube, bulge with coughing	Traction	Removal of PEG tube via traction method, plan for surgical intervention	Pneumonia, Respiratory Failure, and Death before surgery
Boldo-Roda [2]	2005	Leakage from around PEG tube, bulge with physical activity	Traction	N/A	Unk
Kaplan [3]	2006	Leakage from around PEG tube, bulge with physical activity	Traction	Referral for surgical intervention	Unk
Ozutemiz [4]	2007	Bulging	Traction	N/A	Unk