Percutaneous endoscopic gastrostomy tube placement after sleeve gastrectomy: a case report

Percutaneous endoscopic gastrostomy (PEG) provides long-term enteral nutrition in patients who cannot maintain adequate oral intake. However, altered gastric anatomy after sleeve gastrectomy can make PEG technically challenging because the stomach becomes narrow and tubular, limiting its distensibility. Although several reports describe PEG placement in patients with reduced stomach size, there is very limited data available for patients with a history of sleeve gastrectomy. This makes such cases unique and important to report, as they add to the limited experience and help guide clinicians in managing similar situations in the future.

We report a 64-year-old woman with a prior history of sleeve gastrectomy who was referred for PEG tube placement before starting radiotherapy for squamous cell carcinoma of the right buccal mucosa. The patient had previously undergone sleeve gastrectomy in 2010 without any adverse events and later had an incisional hernia repair. During the procedure, identification of the insertion site was initially difficult due to post-surgical changes and obesity. Using careful insufflation, transillumination, and the finger indentation method, a safe site was located and a 24-Fr PEG tube was placed using the pull (Ponsky-Gauderer) technique. The procedure was uneventful, and the patient remained stable post-procedure. She began PEG feeding 12 hours later and was followed up after 24 hours, 5 days, and 1 month, with no complications or tube-related issues.

This case highlights that PEG placement after sleeve gastrectomy is feasible when performed cautiously. With proper patient selection and technique, PEG can be safely achieved in surgically altered anatomy and can serve as an alternative to interventional radiology-guided methods.