Case Presentation: A 79-year-old female with a history of metastatic cholangiocarcinoma treated with chemotherapy and a Whipple procedure 17 years before admission presents with deconditioning and weakness secondary to peri-prandial abdominal pain and poor oral intake. This problem existed since her Whipple but progressed over the last year, complicated by cachexia, weakness, and inability to ambulate. Upon presentation, she was malnourished, with a body mass index of 13.4 kg/m. Serum albumin was 2.2 g/dL. Ascites was present and ascitic analysis suggested hypoalbuminemia as the causative etiology. Workup including esophagogastroduodenoscopy, colonoscopy, abdominal computerized tomography, autoimmune and malignancy serology, and psychiatry consultation were unrevealing for the cause of peri-prandial pain. The patient tolerated tube feeds via NG with improvement in serum albumin. She was not a candidate for PEG given her ascites however her NG tube precluded her from placement in a subacute rehabilitation facility (SAR). On hospital day (HD) 27 she underwent placement of a PTEG. The procedure was well tolerated and the patient resumed tube feeding the next day. Due to unfamiliarity with daily maintenance of a PTEG, delays in placement occurred with eventual discharge on HD 38 to a SAR.
Discussion: PTEG was first described by Oishi in 1994 as a minimally-invasive technique for gastrointestinal decompression in patients with malignant obstruction and contraindications for PEG (1). It has been broadly adopted in countries like Japan as a safe alternative to NG. In one prospective, randomized study, 40 patients with terminal malignant bowel obstruction were randomized to PTEG or NG for palliative management of their bowel obstruction. Patients who underwent PTEG had significantly improved symptom scores, higher quality of life scores, and no increased adverse events or mortality (1). An article reviewing the use of PTEG for malignancy that included 14 studies found that nearly all 340 patients described in the studies experience relief of their symptoms from PTEG placement. Among these patients, 65 (19.1%) had minor complications and 5 (2.1%) had significant complications which included bleeding and aspiration pneumonia (2). Other complications described in the literature include tube dislodgement, tube malfunctions, catheter site leaks, and superficial infections (2,3). Another retrospective study evaluated patients with aspiration risk or prior gastrectomy who received PTEG and found this method to have acceptable relative safety and efficacy (4). Despite promising data, this procedure is under-described in medical literature. A PubMed search for “percutaneous transesophageal gastrostomy” yields only 15 results over the last ten years, none of which appear in general medicine or hospital literature.
Conclusions: This case describes successful utilization of PTEG in a patient with contraindications to PEG and underscores the limitations presented by unfamiliarity with the procedure. More publication is necessary to increase awareness of the efficacy of this procedure for both providers and long-term care facilities.