Placement of an esophageal self-expandable metal stent through a percutaneous endoscopic gastrostomy tract, for endoscopic therapy of upper gastrointestinal bleeding.

Slim endoscopes can be passed through gastrostomy tracts, but dilation is required for the passage of standard endoscopes, which may result in tract disruption. Large-diameter covered self-expandable metal stents (CSEMS) have been placed through percutaneous tracts to enable endotherapy. A 20-year-old man underwent complex thoraco-abdominal surgery following traumatic injury, resulting in a cervical esophagus that was disconnected from the remaining gut. Intermittent bleeding from a gastrojejunal anastomotic ulcer was diagnosed using slim (5.9-mm) endoscopes passed through a 20-Fr mature percutaneous endoscopic gastrostomy (PEG) tract, but the small working channel precluded passage of hemostatic accessories. Attempts at angiographic embolization were unsuccessful. An innovative endoscopic approach was undertaken to manage recurrent massive bleeding (●" Figs.1–6, ●" Videos1–3). With the patient under general anesthesia, the gastrostomy tube was removed and an ultrathin endoscope (Olympus GIF-XP160; Olympus, Tokyo, Japan) was advanced through the gastrostomy tract toward a 2-cm marginal ulcer with a visible vessel. After guide wire placement into the jejunum, and endoscope withdrawal, a 7-cm long, 18-mm diameter CSEMS (Alimaxx; Merit Endotek, Jordan, Utah, USA) was deployed across the PEG tract, with one end exiting the skin and the other intragastrically. Balloon dilation (18-mm ATLAS PTA Dilatation Catheter; BARD Peripheral Vascular Inc., Tempe, Fig.2 Dilation of transgastric self-expandable metal stent (SEMS) to 18mm using a peripheral vascular dilating balloon with high burst pressure. Fig.1 Esophageal self-expandablemetal stent (SEMS) deployed across percutaneous endoscopic gastrostomy (PEG) site.