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feeding through a gastrostomy has become the most accepted method for patient support , in any case of long- or medium long - term need for enteral nutrition . from the time of the first percutaneous endoscopic gastrostomy ( peg ) ,
as early as 1985 , endoscopic gastrostomy placement has almost totally replaced surgical , due to its simplicity and the avoidance of general anaesthesia .
however , in some cases , such as neck or esophageal malignancies , where a severe stricture does not allow the passage of the gastroscope , laparotomy is needed .
alternatively , a gastric feeding tube can be introduced by means of a laparoscopy , or by radiology , the main criterion for the election of the procedure being the experience of the operator.1 we present herein the case of a woman who underwent a peg , after the endoscope being inserted through the sinus tract of a previously performed surgical gastrostomy for advanced , supraglottic obstructing malignancy .
a 70-year old female was re - admitted to our ward for a second peristomal leakage episode , leading to severe necrotizing fasciitis and extended dermatitis and inflammation around a gastrostomy tube over a 3-month period .
five years earlier , the patient had been subjected to a surgical gastrostomy for feeding after the diagnosis of a neck malignancy causing a supraglottic stenosis ; thereafter , she received both water and enteral nutrition by this route with no problem .
three months earlier , she had been admitted for severe peristomal inflammation due to excessive leakage around the gastrostomy tube .
she was treated by parenteral nutrition , somatostatin and proton pump inhibitors to inhibit the secretions and control the acidity , while the tube was initially put into external drainage .
barrier creams ( conveen critical barrier ; coloplast a / s , thessaloniki , greece ) and skin protectants containing silver ( biatain ag ; coloplast ) were applied to the surrounding skin , and 6-days later the 22 fr gastrostomy tube was removed to allow the tract to partially close . after a total of 10-days of treatment , a new 18 fr gastrostomy tube of smaller caliber ( tri - funnel , replacement gastrostomy tube ; bard , salt lake city , ut , usa ) was inserted percutaneously through the same site , now considerably shrunk .
the peristomal skin was also well healed and so the patient was switched to enteral nutrition through the new tube , and 2 days later was discharged from the hospital , after being advised to use skin barriers around the stoma .
three months thereafter , she was again admitted to be treated as previously , as she again presented suffering a more pronounced irritation with signs of focal skin necrosis . however , the recurrence of the same severe complication with no prominent cause ( diabetes , immunosupression , malnutrition , and adjuvant chemo / radiotherapy ) after a short time and long after gastrostomy construction was a cause for discussion and it was decided to perform a new gastrostomy at a different site . since the patient has a severe supraglottic stenosis due to malignancy ( dysphagia 4 ) ,
the peroral endoscopic route was totally restricted , and we thus , decided to try endoscopically through the sinus of the current stoma . under light midazolam sedation ,
dilatation of the sinus tract was initially performed with a controlled radial expansion balloon ( cre , boston scientific international s.a .
, nanterre cedex , france ) and thereafter the olympus gif q165 gastroscope ( olympus , tokyo , japan)-with a distal and outer diameter of 9.2 mm - was inserted into the stomach through the enlarged opening of the existing gastrostomy tract .
after identification of the stomach anatomical signs , transillumination was performed and a new point was selected - as far away as possible from the existing stoma - for needle puncture .
a thread was then carried forward by needle lumen into the stomach , delivered by means of grasping forceps through the working channel of the endoscope and exteriorized from the former gastrostomy stoma .
the new gastrostomy tube was then attached to this thread , and the thread pulled through the new puncture site ( figs . 1 , 2 ) .
the procedure terminated successfully and the patient returned to the surgical ward with a new peg .
three days later , the old tract was totally closed and the skin irritation was healed .
one of the most common complications after a tube placement into hollow viscera is that of peristomal leakage , reported in 3% to 36% of the procedures performed .
this complication might lead from simple skin irritation , to severe inflammation , infection and tissue necrosis , the severity depending on the patient 's accompanying pathology ; individuals with diabetes , malnutrition or immunosuppression are more likely to suffer sinus tract mishealing and thus peristomal leakage , and its consequences.2,3,4,5 the rareness of the present case based on the fact that this complication occurred 5 years after a surgically performed gastrostomy , with no prominent causes to affect the already healed sinus tract .
in addition to which , although the patient was treated properly , in order to reduce both the gastric acidity and the gastric contents and the skin was protected by skin barriers , the achieved healing lasted only briefly , and 3 months later a recurrence occurred .
one idea would be to allow the sinus track to be totally closed , with no feeding tube in situ , and a new peg performed .
however , in our case , the peroral endoscopic route was totally restricted , due to a total malignant obstruction .
laparoscopic performance would be another option , but it was rejected because of the history of previous surgical gastrostomy and the adherence of the stomach to the abdominal wall , as well as for the need for general anaesthesia .
bibliographic references to a method of blind - under x - ray control - stomach puncture1 and tube insertion by the " push " technique was also rejected , due to our lack of experience with this technique . since our team has very considerable experience in endoscopy , it was a challenge for us to use the sinus track for the insertion of the endoscope into the stomach to perform an intervention .
moreover , to the best of our knowledge , this would be the first case of the sinus track being used for peg performance .
the first step was to dilate the sinus track by a hydrostatic , controlled radial expansion balloon .
although the gastroscope was inserted and passed without difficulty , this procedure does involve two possible problems : first , that the stomach is so narrow , due to the exact point of the previous stoma in relation to the major or minor curvature , that the endoscope is unable to retroflex in order to " see " the inferior gastric wall ; and second , the area that is actually visible after retrovision , denies transillumination , to secure the point for needle puncture . in our case
a third problem would be the direction of thread with the attached gastrostomy tube . in normal conditions the inserted thread - by means of the needle into the stomach through the inferior wall of the viscera
the traction force applied at the visceral end of the thread - in order to pull the gastrostomy tube from the mouth through the esophagus to the stomach- is thus applied in an almost straight line . in our case
, on the other hand , we had a thread both inserted and coming out through the inferior wall of the viscera , the two points being at a distance of 10 cm , the two ends of the thread being parallel so that the force applied for gastrostomy tube traction involved an angle of no more than 20 degrees , making the traction difficult . in conclusion , apart from the above mentioned problems , the use of the sinus tract of a previous gastrostomy for the insertion of a gastroscope , should it be necessary to perform a further gastrostomy at a new point , seems to be a simple , safe and effective procedure , giving the patient the opportunity to avoid sedation and more complicated procedures .
we present the case of a woman on whom a percutaneous endoscopic gastrostomy ( peg ) was performed through the sinus tract of a previous surgical gastrostomy for supraglottic obstructing malignancy . 
 five years after the induction of the surgical gastrostomy , she experienced a peristomal leakage , leading to severe necrotizing fasciitis , with skin irritation and inflammation . despite extensive treatment to heal the abdominal wall close to the feeding tube 
 , it recurred 3 months later , without any obvious cause . 
 it was thus decided to perform a new gastrostomy in a nearby normal skin area , but , since it was totally impossible for the endoscope to be passed by mouth , due to obstruction , the sinus tract of the gastrostomy was used to facilitate endoscope insertion into the stomach for a new peg .