If an endoscope is passed through a stenosis it is not always sure that a peg tube can be passed as well. Case report

Background: Tube feeding for patients with oro-pharyngeal dysphagia, caused by head and neck cancer, via percutaneous endoscopic gastrostomy (PEG) is worldwide the preferred method of choice. PEG tubes might be placed by using the pull-through or push-wire, the so called oral techniques or by a Seldinger method according to Russell. The original pull-through technique is most often used. Endoscopiests are at the opinion that a stenosis where a gastroscope might be passed a PEG tube is easily pulled trough.

Case report: A 56 years old male patient was operated on because of cancer of the hypopharynx 13 years ago. Total larynx and partial pharynx resection was carried out. In the postoperative period, because of bleeding, he was re-operated twice. Later pharyngo-cutenous fistula developed which was closed with a latissimus dorsi myocutan flap reconstruction. Half a year ago loco-regional recidive tumour was diagnosed. The patient got 70Gy photon irradiation. Because of severe dysphagia and malnutrition PEG feeding was advised. At endoscopy rigid narrowing of the oesophageal inlet was found. Only a gastroscope with 9.6mm in diameter could be passed. While pulling through the 18CH tube it stopped at the level of the stenosis and it could not be forced trough by means of several techniques. Therefore the button of the tube was grasped with a snare and pulled back. We had no possibilities for using the Russell's introducer method therefore a laparoscopic surgical gastrostoma was decided and carried out.

Conclusions: Not the diameter of the feeding tube but the diameter of the compressed button is important. Using the oral PEG procedures and facing a stenosis an endoscope should be used which diameter is wider than that of the compressed button. It should be caped in mind that the diameter of the compressed button is about twice that of the feeding tube.