Mediastinitis complicating a percutaneous endoscopic gastrostomy: a case report

Abstract

BackgroundSince its introduction in the early 1980s, percutaneous endoscopic gastrostomy has become the most popular method for performing a gastrostomy for long-term enteral feeding. It has been associated, however, with a lot of minor and major complications.Case presentationA case of mediastinitis with concominant sepsis caused by a masked esophageal perforation after percutaneous endoscopic gastrostomy in a multi-traumatized, brain-injured patient is presented. Ten – fourteen days after the procedure, the patient became febrile and gradually septic with tenderness of the sternum and upper abdomen. Computerized tomography of the thorax revealed mediastinitis. An urgent left thoracotomy and laparotomy were performed for drainage of the mediastinum, removal of the gastrostomy and insertion of a jejunostomy tube. The patient improved soon after the surgery. He was successfully weaned off the ventilator and was discharged from the Intensive Care Unit.ConclusionPerforating mediastinitis is a rare but potentially lethal complication of percutaneous endoscopic gastrostomy. When diagnosed and properly treated it may have a favourable outcome.

How far is the endoscopist to blame for a percutaneous endoscopic gastrostomy complication?

“…In a 3-mo-old boy weighing 3.7 kg, the pulling of a 18CH gastrostomy tube immediately led to esophageal intussusception towards the stomach and thus complete esophageal transection[ 49 ]. The other case was an obese, multi-trauma patient, on whom PEG procedure was difficult[ 50 ]. Without the help of transillumination, and only using finger pressure, 3 attempts, at a 45° angle, were made to insert the needle into the stomach.…”

“…The second case is a gastric volvulus, following insertion of the PEG into the posterior gastric wall, due to stomach over-inflation, finally causing compromised gastric emptying[ 51 ]. The third is the case of an obese, multi-trauma patient; without trans-illumination, 3 puncture attempts at a 45° angle, resulted in a gastrostomy placement but also an esophageal perforation which were fortunately recognized after 14 d of suffering mediastinitis[ 50 ].…”

Pneumoperitoneum with Subcutaneous Emphysema after Percutaneous Endoscopic Gastrostomy

“…Morbidity rates of the procedure range from 9% to 17% but major complications are under 5% and mortality is lower than 1% [ 6 , 7 ]. Papakonstantinou et al divided the complications into three subgroups [ 8 ] ( Table 1 ).…”

Percutaneous Endoscopic and Radiologic Gastrostomy

“…Advantages of this technique include use of a smaller endoscope (e.g. in case of stenosis), or even transnasal endoscopy with an ultra-thin caliber endoscope (UTCE) (77,78). With UTCE, sedation is not necessary, which makes it feasible for patients with severe (pulmonary) comorbidities.…”