How to rescue a percutaneous gastrostomy tube perforating the jejunum

Percutaneous gastrostomy (PEG) tubes are widely used for long-term enteral nutrition. Major adverse events are rare but often necessitate surgical repair. We detail an endoscopic approach to repairing a PEG tube perforation involving the jejunum.

A 75-year-old man with short bowel syndrome and a recent combined intestinal-kidney transplant (duodenojejunostomy) presented with persistent abdominal pain and delirium 5 days after PEG tube placement. Computed tomography imaging showed the PEG bumper in the stomach, but the tube was perforating the overlying small bowel. Endoscopy confirmed correct bumper placement in the gastric body with tube protrusion into the jejunum.

Using an upper endoscope, we introduced a snare and opened it to grasp the wire, which was then extracted through the mouth and secured. The scope was reinserted, and the PEG bumper was grasped and removed carefully. The guidewire was seen traversing the jejunum, and transillumination confirmed scope position. A lumen-apposing metal stent was deployed at the site of the gastrojejunal fistula under endoscopic guidance. A direct jejunostomy tube was then inserted via the existing PEG tract. Tube feeding was restarted without any adverse events.

Endoscopic techniques offer effective, minimally invasive alternatives to surgery in managing PEG-related adverse events.