Endoscopic rescue of early percutaneous endoscopy gastrostomy tube dislodgement.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) tube placement is one of the most common methods for establishing durable enteral access. Early PEG dislodgement occurs in < 5% of cases but typically prompts urgent surgical intervention to reestablish the gastrocutaneous tract and prevent intra-abdominal sepsis. To date, there is a single case report in the literature where successful endoscopic "rescue" of an early dislodged PEG tube negated the need for operative intervention. Here, we report our experience with a series of endoscopic PEG rescues for early dislodged PEG tubes. METHODS: A retrospective analysis of cases was reviewed from two institutions. Patients with early PEG dislodgements underwent PEG rescue using a gastroscope and standard Ponsky "Pull" PEG techniques through the original tract. RESULTS: Eleven patients were identified from the database and underwent PEG rescue after early PEG dislodgement. Mean operative time was 68 min, and there were no complications related to PEG rescue. PEG rescue permitted safe re-establishment of the gastrostomy tract while avoiding laparoscopic or open surgical intervention in hemodynamically stable patients. All patients tolerated the procedure well and were able to resume use of the PEG tubes shortly after intervention. CONCLUSION: Endoscopic rescue represents a feasible noninvasive option for PEG tube replacement following early inadvertent PEG tube dislodgement in appropriate clinical settings.

Posterior component separation with transversus abdominis release successfully addresses recurrent ventral hernias following anterior component separation.

PURPOSE: Anterior component separation (ACS) with external oblique release for ventral hernia repair has a recurrence rate up to 32%. Hernia recurrence after prior ACS represents a complex surgical challenge. In this context, we report our experience utilizing posterior component separation with transversus abdominis muscle release (PCS/TAR) and retromuscular mesh reinforcement. METHODS: Patients with a history of recurrent hernia following ACS repaired with PCS/TAR were retrospectively identified from prospective databases collected at two large academic institutions. Patient demographics, hernia characteristics (using CT scan) and outcomes were evaluated. RESULTS: Twenty-nine patients with a history of ACS developed 22 (76%) midline, 3 (10%) lateral and 4 (14%) concomitant recurrences. Contamination was present in 11 (38%) of cases. All were repaired utilizing a PCS/TAR with retromuscular mesh placement (83% synthetic, 17% biologic) and fascial closure. Wound morbidity consisted of 13 (45%) surgical site occurrences including 8 (28%) surgical site infections. Five (17%) patients required 90-day readmission, and two (7%) were related to wound morbidity. One organ space infection with frank spillage of stool resulted in the only instance of mesh excision. This case also represents the only instance of recurrence (3%) with a mean follow-up of 11 (range 3-36) months. CONCLUSION: Patients with a history of an ACS who develop a recurrence represent a challenging clinical scenario with limited options for surgical repair. A PCS/TAR hernia repair achieves acceptable outcomes and may in fact be the best approach available.