Combined endoscopic and surgical gastrostomy when percutaneous endoscopic gastrostomy is contraindicated

The resurgence of enteral feeding, as both a more physiologic and cost-effective means of alimenting patients, has coincided with the increased popularity of endoscopically placed gastrostomies. Indeed, numerous retrospective studies have shown that percutaneous endoscopic gastrostomy (PEG) is superior to its surgical counterpart. There are, however, both absolute and relative contraindications to percutaneous placement. Reported here are three patients who were poor surgical candidates, yet had contraindications to percutaneous placement. Described is a method of combined endoscopic and surgical placement under local anesthesia used successfully in these patients. General anesthesia and laparotomy were not required. A 2-cm incision with endoscopic guidance was used and the gastrostomy was placed under direct vision and secured with a gastric purse string and sutured to the abdominal wall. There was no morbidity or mortality among the three cases reported. All gastrostomies were considered functional within 48 hrs. The authors feel this method is an excellent alternative when PEG is contraindicated. In addition, it may represent the safest and most effective method of gastrostomy placement in the majority of patients requiring a gastrostomy.