Pull-PEG placement using cholangioscopy, ultrasound and fluoroscopic guidance in a patient with pharyngo-laryngo-eosophagectomy: a case report

Percutaneous endoscopic gastrostomy (PEG) remains the first-line modality for long-term enteral feeding in patients not meeting their nutritional requirements. This particularly applies to oncological patients with obstructive tumors, such as head-and-neck cancers. PEG is generally preferred over surgical gastrostomy, with recent ESGE guidelines recommending push-PEG access in patients with obstructive tumors. However, both push-PEG and percutaneous radiological gastrostomy (RIG) could be technically challenging with higher complication rates in patients with altered anatomy. A 60-year-old patient with a former pharyngo-laryngo-esophagectomy with gastric pull up 1 year ago for locally advanced hypopharyngeal cancer, and recent progression with metastatic disease, presented with total dysphagia. Endoscopic examination revealed significant narrowing at the pharyngo-gastric anastomosis due to cervical recurrence, preventing the passage of a pediatric gastroscope. A cholangioscope (SpyGlass™ Discover) was successfully advanced through the thoracic tubular section of the stomach into its smallest subdiaphragmatic part, applying adequate endoscopic air insufflation. Under ultrasound and fluoroscopic guidance, puncture of the subdiaphragmatic part of the stomach was performed and a string was introduced. This was grasped with SpyGlass™ retrieval snare and was finally pulled out through the mouth. A small pull-gastrostomy was successfully placed. The patient had no complication, with immediate significant nutritional improvement. Consequently, endoscopic pull-PEG placement using a cholangioscope appears to be an effective and safe technique in oncological patients with obstructive tumors and no access to RIG.

Publication History

Article published online:
27 March 2025