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[Tube dislocation following percutaneous, endoscopically-controlled gastrostomy--a case report]
G Hardegg1, T Heller, P Frühmorgen
1Medizinische Klinik I, Krankenanstalten des Landkreises Ludwigsburg, Bundesrepublik Deutschland.
Zeitschrift Fur Gastroenterologie
|December 1, 1991
Summary
A new Memosond system for percutaneous endoscopic gastrostomy (PEG) offers easier placement but carries risks. A case study showed tube dislocation into the abdominal cavity, leading to patient death.
Area of Science:
- Gastroenterology
- Surgical Innovation
Background:
- Percutaneous endoscopic gastrostomy (PEG) is a common method for enteral nutrition.
- The Memosond system offers potential advantages over traditional thread-guided tubes, including simplified placement and replacement without repeat endoscopy.
Observation:
- A 65-year-old female patient with advanced throat cancer underwent a PEG procedure using the Memosond system.
- Two days post-procedure, the distal portion of the Memosond tube dislocated into the abdominal cavity.
Findings:
- The Memosond system, while simplifying PEG placement, was associated with a rare but serious complication of distal tube dislocation.
- This complication occurred despite the purported advantages of the Memosond system.
Implications:
- This case highlights the critical importance of secure tube placement and monitoring following PEG procedures, regardless of the system used.
- Further investigation into the biomechanical integrity and fixation mechanisms of novel PEG systems like Memosond is warranted to prevent such adverse events.