Introduction Percutaneous endoscopic gastrostomy (PEG) may be extremely difficult in patients with compound hiatus hernia. In this type of hernia, the stomach may be partly or entirely intrathoracic and is normally associated with organoaxial (figure 1A) or mesenteroaxial (figure 1B) rotation.1 There do not appear to be any widely accepted techniques for placement of a feeding prosthesis in this group of patients if artificial nutrition is required. We describe here a short series of successful PEG placements.
Methods A 6-year retrospective review of PEG tube placements in patients with compound hiatus hernia. All patients had prior failed attempts using the conventional ‘finger indentation’ technique.
The technique involves usage of a 20 cm/5 Fr drainage access needle which is inserted towards the stomach using a transhiatal approach from below the xyphisternum, and with combined endoscopic and fluoroscopic guidance. Once successful gastric puncture has been achieved, the procedure is completed as for a conventional PEG insertion.
Results Six cases were attempted during this period. Indications for PEG were; multiple sclerosis (2); cerebrovascular disease (3); intermittent volvulus (1). In each case, the stomach was punctured in the fundus or body at a point within the thoracic cavity. All cases were completed without complication and with successful PEG feeding.
Conclusion PEG tube placement for enteral nutrition may be completed in patients with compound hiatus hernia and intrathoracic stomach. The authors suggest however that a long drainage access needle and combined endoscopic and fluoroscopic guidance are essential for safe completion.
- compound hiatus hernia
- intrathoracic stomach
- percutaneous endoscopic gastrostomy
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Competing interests None.
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