Pneumatosis Intestinalis Following Surgical Gastrostomy Tube Placement in a Patient With Glottic Squamous Cell Carcinoma: A Case Report.

Pneumatosis intestinalis (PI) is a rare medical and post-surgical sequela of multiple different etiologies which can be either benign or life-threatening. Various mechanisms have been proposed to explain the occurrence of PI; however, the pathophysiology is dependent on the suspected cause. The condition is largely categorized into two broad groups: idiopathic PI, which remains relatively uncommon, and secondary PI. The latter often surfaces as a result of a wide array of both gastrointestinal and non-gastrointestinal illnesses. These encompass vascular compromise, bowel mucosal disruption, gastrointestinal dysmotility, as well as infectious and immunological etiologies. Management ranges from conservative medical strategies to emergent surgical intervention. We present the first case to our knowledge of spontaneous PI developing within five days of a surgical gastrostomy tube (SGT) placement in a 79-year-old female with glottic squamous cell carcinoma which unfortunately proved fatal. The purpose of this case report is to highlight a rare fatal complication of a common surgical procedure and the necessity of initiating interdisciplinary management quickly to determine the best treatment course.

Percutaneous Endoscopic Gastrostomy: A Possible Trigger for Dieulafoy's Lesion.

Introduction: Upper gastrointestinal (GI) bleeding is a medical condition commonly seen in clinical practice due to variable etiologies and a multitude of presentations. The patients can present with hematemesis, melena, or hematochezia in case of severe bleeding. The initial evaluation should involve assessing the hemodynamic status with adequate resuscitation followed by diagnostic tests to identify the source and potentially treat it. Dieulafoy's lesion, sometimes referred to as Dieulafoy's disease, is a rare cause of upper GI bleeding with no clear risk factors, which makes it a diagnostic conundrum. Here we describe an unusual case of Dieulafoy's lesion developing following percutaneous endoscopic gastrostomy (PEG) placement. Case Presentation: We describe a case of a 70-year-old female patient with a past medical history of hyperlipidemia, well-controlled hypertension, and an ischemic cerebrovascular accident, which caused neurologic dysphagia and placement of a PEG tube 3 weeks prior. She presented to the emergency department due to melena, with hypotension of 90/50 mmHg, tachycardia of 126 beats/minute, and hemoglobin of 5.6 g/dl. An endoscopy revealed a Dieulafoy's lesion on the lesser curvature of the stomach just across the PEG tube, which was managed with epinephrine and hemoclips. Conclusion: This is a rare case of Dieulafoy's lesion on the lesser curvature of the stomach, potentially developing due to PEG placement.

Factors Associated With Short-Term Complications After Percutaneous Endoscopic Gastrostomy Tube Insertion: A Retrospective Cohort Study.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) tube placement is generally safe but is associated with a range of complications. Minor complications include infections, granuloma formation, leakage, and blockages, while major complications encompass aspiration pneumonia, hemorrhage, and more serious conditions such as necrotizing fasciitis and colonic fistula. AIM: This study aimed to assess the rate of short-term complications within one month of endoscopic PEG insertion, focusing on their correlation with patient characteristics. METHODOLOGY: This retrospective cohort study analyzed data from patients who underwent PEG insertion between January 2020 and December 2022. It evaluated the incidence of complications in relation to variables such as the indication for the procedure, the patient's immune status, albumin and CRP levels, and the setting of the procedure (inpatient vs. outpatient). RESULTS: The study included 121 patients, with a mean age of 69.73 years, comprising 71 males (58.7%) and 50 females (41.3%). Neurological indications accounted for 64.5% of the cases. Notably, 67.8% of the patients were immunocompromised. Within 30 days of PEG insertion, 16.5% experienced complications, including GI bleeding (4.1%), infection at the PEG site (11.6%), and peritonitis (0.8%). Complications were significantly higher in immunocompromised patients and those with non-neurological indications. Higher serum albumin and lower CRP levels were associated with fewer complications, though the association was not statistically significant. CONCLUSION: The study highlights that gastrostomy site infection is the most common short-term complication following PEG insertion. Immune status and the reason for PEG insertion emerged as key factors influencing the likelihood of complications.

Endoscopic Complications Are More Frequent in Levodopa-Carbidopa Intestinal Gel Treatment via JET-PEG in Parkinson's Disease Patients Compared to Nutritional PEG in Non-Parkinson's Disease Patients.

Background: To date, no studies comparing complication rates between patients with nutritional percutaneous endoscopic gastrostomy (N-PEG) and Parkinson's disease (PD) patients with percutaneous endoscopic gastro-jejunostomy (JET-PEG) for treatment administration have been published. Our study aimed to compare complication rates and the number of re-endoscopies between N-PEG and JET-PEG patients. Methods: Individuals requiring N-PEG or JET-PEG insertion between 2014 and 2021 were included in this single-center retrospective observational study. Complications were divided into time-related medical and technical complications. Reasons for post-insertion re-endoscopies and their number were also analyzed. Results: Eighty-seven subjects, 47 (54.02%) in JET-PEG group and 40 (45.98%) in the N-PEG group, were included. Early and technical complications were more frequent in JET-PEG vs. N-PEG subjects (70% vs. 10% [p < 0.001], and 54.5% vs. 5.1% [p < 0.001], respectively). The presence of psychiatric disease was associated with a higher number of early complications (p < 0.002). All three types of complications were significantly more frequent in subjects where a healthcare professional did not handle PEG (p < 0.001). Subjects with JET-PEG required a higher number of re-endoscopies compared to the N-PEG group (57.1% vs. 35%, p = 0.05). Conclusions: Complications are significantly more common in individuals with JET-PEG than those with N-PEG, which can be attributed to higher mobility in PD patients.

The "cut and push" method of removing percutaneous endoscopic gastrostomy tube is not safe in paediatric patients.

PURPOSE: A "cut and push" (CP) approach has been described in the literature for removal of percutaneous endoscopic gastrostomy (PEG) tubes. The aim of this study is to investigate the safety profile of this method in children. METHOD: Our study included all children who underwent CP procedure for either removal or replacement of Freka PEG tube at our centre between January 2016 and August 2021. Parents contacted to establish if the internal component had been seen in the stools post-procedure. If not seen, a plain film of chest, abdomen and pelvis was arranged followed by computerised tomography (CT) scan. The presence of the internal component as a retained foreign body on imaging was evaluated along with any complication. RESULTS: Of the 27 patients included, six (22.2%) patients had the internal component seen in the stool. Five (18.5%) patients in total had a retained internal component with three (11.1%) patients had major complications requiring complex surgical interventions, and two (7.4%) patients required endoscopic retrieval. CONCLUSION: Our study reports more severe complications that required complex surgical interventions compared to the previous studies. We believe that this method of removal is not safe in children and should be abandoned. Also, patients with Down syndrome might be at higher risk of retention and complications.

Incidence of Pneumoperitoneum After Gastrostomy Tube Removal.

We present the case of an 88-year-old man with a previous medical history of severe colitis and colonic strictures who presented with hematemesis. The patient was found to have a lower esophageal ulcer without any signs of perforation. Esophagogastroduodenoscopy (EGD) revealed a scar in the greater curvature of the stomach from a previously removed gastrostomy tube two months prior. On CT imaging, an incidental finding of pneumoperitoneum was also found alongside stomach perforation near the healing scar. Due to the lack of evidence of any other colonic perforation, the patient was believed to have developed this pneumoperitoneum status post-gastrectomy tube removal two months prior to presentation. Pneumoperitoneum has a wide range of presenting symptoms that vary in severity and nature, and our patient failed to present with any physical or laboratory signs of infection. Over the course of the next four months, the patient was monitored with serial CT scans, during which the pneumoperitoneum resolved. In this report, we present a case of a patient who was found to develop pneumoperitoneum post-gastric tube removal and its complete resolution without surgical or procedural intervention.

Effect of percutaneous endoscopic gastrostomy prior to oesophageal cancer surgery on postoperative wound complications in patients: A meta-analysis.

It is still a matter of controversy whether percutaneous endoscopic gastrostomy(PEG) should be used prior to the operation for the purpose of feeding the patient with resectable oesophageal carcinoma (EC). Comparison was made between EC and preoperatively treated PEG and non-preoperative PEG. An extensive literature review has been conducted to determine the results about PEG and No-PEG trials. In this paper, we chose 4 papers out of 407 of them through a strict selection process. In this trial, there were 1027 surgical cases of oesophagus carcinoma, 152 with PEG pre-surgery and 875 without PEG. The total sample size ranged from 14 to 657. Two studies showed that there was no statistically significant difference in the occurrence of postoperative wound infection among PEG and No-PEG(OR, 1.03; 95% CI, 0.38, 2.80 p = 0.96), there was no statistical significance in the likelihood of anastomotic leak among PEG after surgery compared to No-PEG in 4 trials (OR, 1.13; 95% CI, 0.62-2.07 p = 0.69), and there were no statistical differences between PEG and No-PEG before operation on anastomotic stricture for esophagectomy(OR, 0.70; 95% CI, 0.31-1.56 p = 0.38). No wound or anastomosis complications were observed in the PEG group. Thus, PEG preoperatively is an effective and safe procedure without any harmful influence on gastrointestinal structure or anastomosing. It can be applied to patients with oesophagus carcinoma who have a high risk of undernutrition. Nevertheless, because of the limited number of randomized controlled trials in this meta-analysis, caution should be exercised in their treatment. More high-quality research involving a large sample is required to confirm the findings.

12Fr-Pigtail Versus 14Fr-Balloon Percutaneous Radiologic Gastrostomy (PRG), Retrospective Evaluation of Outcomes and Complications; A Maastricht University Medical Centre Study.

PURPOSE: To retrospectively compare tube and placement related results of a 12Fr-pigtail and a 14Fr-balloon gastrostomy tube. MATERIALS AND METHODS: All consecutive patients who underwent percutaneous radiologic gastrostomy (PRG) between January 2016 and June 2020 were enrolled in this retrospective single-center analysis. Follow-up for all patients was 180 days. Mortality after 30 days, technical success, days to first complication within 180 days, reason of unexpected visit (tube, anchor or pain related), and tube specific complications (obstruction, pain, luxation, leakage) were taken as outcome measures. Data were obtained from both PACS software and electronic health records. RESULTS: A total of 247 patients were enrolled (12Fr-pigtail: n = 139 patients and 14Fr-balloon: n = 108 patients). 30-day mortality was very low in both groups and never procedure related. Technical success was 99% in both groups. The average number of complications within 180 days after initial PRG placement was significantly higher in the 12Fr-pigtail group (12Fr-pigtail: 0.93 vs. 14Fr-balloon: 0.64, p = 0.028). Time to first complication within 180 days was significantly longer in the 14Fr-balloon group (12Fr-pigtail: 29 days vs. 14Fr-balloon: 53 days, p = 0.005). In the 14Fr-balloon group, the rate of tube-related complications (luxation and obstruction) was significantly lower compared to 12Fr-pigtail (29% vs. 45%, p = 0.011). CONCLUSION: 14Fr-balloon gastrostomy tubes have significantly lower (tube-related) complications rates and longer time to first complication compared to 12Fr-pigtail tubes. No procedure-related mortality was observed in either group. Technical success was very high in both groups. Level of Evidence Level 3, non-controlled retrospective cohort study.

Uretero-Jejunal Fistula: A Rare Cause of Acute Pyelonephritis.

Penetrating peptic ulcers often lead to severe complications. The development of uretero-enteric fistulas is rare and can be challenging to diagnose and treat. Here, we present the case of a 41-year-old patient who previously underwent gastrojejunostomy for superior mesenteric artery syndrome and developed a peptic jejunal ulcer, leading to a uretero-jejunal fistula and finally causing acute pyelonephritis. The patient was managed with a multidisciplinary approach including medical therapy and endoscopic and radiologic interventions.

Diarrhea Caused by the Displacement of Percutaneous Endoscopic Gastrostomy Tube Tip Into the Duodenum: A Rare Case.

Percutaneous endoscopic gastrostomy (PEG) is a widely used procedure for patients with dysphagia and inadequate oral intake. Although PEG offers numerous benefits, complications can occur. Here, we present an unusual case of a 68-year-old woman who developed persistent diarrhea following a routine PEG tube exchange. Despite treatment attempts, her symptoms persisted, prompting further investigation. Abdominal computed tomography (CT) revealed the unexpected displacement of the PEG tube tip into the duodenum. Repositioning of the tube tip into the stomach resolved the diarrhea, and the patient was discharged without recurrence. Diarrhea is a common gastrointestinal side effect in patients receiving enteral nutrition through a PEG tube, typically attributed to multiple factors. However, to our knowledge, this is the first reported case of diarrhea resulting from a PEG tube tip straying into the duodenum. The patient did not undergo any changes in enteral preparation or receive medications known to cause diarrhea. The identification of the tube misplacement was incidental during the CT scan, underscoring the importance of imaging studies in refractory cases. While previous reports indicate no significant difference in diarrhea occurrence between duodenal and gastric feeding, our findings suggest that the presence of the PEG tube tip in the duodenum may contribute to diarrhea in some patients. This case highlights the potential role of CT imaging in diagnosing the cause of persistent diarrhea in PEG-fed individuals. Further accumulation of cases is necessary to establish the significance of duodenal tube placement as a cause of diarrhea during PEG procedures. In conclusion, this case report emphasizes the importance of considering tube misplacement as a potential cause of refractory diarrhea in patients receiving enteral nutrition through a PEG tube. The use of abdominal CT imaging can be valuable in identifying such misplacements and guiding appropriate interventions. Further research is needed to validate these findings and explore the clinical implications for the management of PEG-related diarrhea.

Effectiveness of betadine-coating gastrostomy tube to reduce peristomal infection after percutaneous endoscopic gastrostomy: a randomized controlled trial.

BACKGROUND: Peristomal wound infection is a common complication in patients receiving percutaneous endoscopic gastrostomy (PEG). The main reason for peristomal infection might be the oral microbes coating the gastrostomy tube during implantation. Povidone-iodine solution can be applied for skin and oral decontamination. We designed a randomized controlled trial to test the effectiveness of a Betadine® (povidone-iodine) coated gastrostomy tube to reduce peristomal infection after percutaneous endoscopic gastrostomy. METHODS: A total of 50 patients were randomized to Betadine and control groups (25 patients in each group) from April 2014 to August 2021 at a tertiary medical center. All patients received the pull method for PEG implantation using a 24-french gastrostomy tube. The primary endpoint was peristomal wound infection rate 2 weeks after the procedure. RESULTS: Changes in Neutrophil/Lymphocyte ratio (N/L ratio) and C-Reative protein (Delta CRP) at 24 h after PEG were higher in the control group than in the Betadine group (N/L ratio, 3.1 vs. 1.2, p = 0.047; CRP, 2.68 vs.1.16, p = 0.009). The two groups did not differ in post-PEG fever, peristomal infection, pneumonia, or all-cause infection. Delta CRP could predict peristomal infection and all-cause infection within 2 weeks (AUROC 0.712 vs. 0.748; p = 0.039 vs. 0.008). The best cut-off-point of Delta CRP for the diagnosis of peristomal wound infection was 3 mg/dl. CONCLUSION: The betadine coating gastrostomy tube method could not reduce peristomal infection after percutaneous endoscopic gastrostomy. CRP elevation of less than 3 mg/dl may be used to exclude the potential peristomal wound infection. TRIAL REGISTRATION: NCT04249570 ( https://clinicaltrials.gov/ct2/show/NCT04249570 ).

Risk Factors and Role of Antibiotic Prophylaxis for Wound Infections after Percutaneous Endoscopic Gastrostomy.

BACKGROUND AND STUDY AIM: The incidence of wound infections after percutaneous endoscopic gastrostomy (PEG) varies widely in recent studies. The present study systematically investigates the underlying risk factors for the development of wound infections in a large cohort of patients over a long-term follow-up period. PATIENTS AND METHODS: A retrospective cohort study of patients undergoing PEG insertion using either the pull or push technique was conducted and patients followed up for 3 years. Tube-related wound infections were identified, and pathogens regularly cultured from wound swabs. Adjusted analysis was performed via univariate and multivariate logistic regression analysis. RESULTS: 616 patients were included in this study. A total of 25% percent of patients developed wound infections upon PEG tube insertion and 6.5% showed recurrent infections. Nicotine abuse (p = 0.01), previous ischemic stroke (p = 0.01) and head and neck cancer (p < 0.001) showed an increased risk for wound infection after PEG placement. Moreover, radio-chemotherapy was associated with the occurrence of wound infections (p < 0.001). Infection rates were similar between pull and push cohorts. The most common bacterial pathogen detected was Enterobacterales (19.2%). Staphylococcus aureus, Pseudomonas aeruginosa and enterococci were frequently detected in recurrent infection (14.2%, 11.4% and 9.6%, respectively). Antibiotic prophylaxis showed no effect on infection rates. CONCLUSIONS: Wound infections after PEG placement are common and occasionally occur as recurrent infections. There is potential for improvement in everyday clinical practice, particularly regarding antibiotic prophylaxis in accordance with guidelines.

Trends Regarding Racial Disparities Among Malnourished Patients With Percutaneous Endoscopic Gastrostomy (PEG) Tubes.

INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) is performed in patients who cannot tolerate oral intake and who may require more than 30 days of nutritional support. These patients are at high risk for malnutrition, which itself can contribute to worsening clinical status. Racial disparities regarding access to sources of nutrition have been established. We aim to determine if such racial disparities regarding the diagnosis of malnutrition exist in this high-risk population. METHODS: The National Inpatient Sample (NIS) was queried for patients with International Classification of Diseases, Ninth Revision (ICD-9) diagnoses coding for PEG tube placement with or without a diagnosis of malnutrition. Results were stratified by race. Rates of PEG tube complications were assessed. Categorical and continuous data were assessed via chi-squared and analysis of variance (ANOVA) tests respectively. Binary and multiple logistic regression was used to control for confounders. RESULTS: Black patients had the highest rates of malnutrition diagnoses, mechanical complications from gastrostomy placement, and the lowest rates of palliative care discussions. Asian or Pacific Islander patients had the highest rates of aspiration pneumonia, gastrointestinal bleeding, the greatest mortality rates, and the longest hospital stays. DISCUSSION: Racial minorities had worse outcomes while Caucasians had shorter hospital stays and lower complication rates. Such disparities can be multifactorial in etiology, with lack of nutritional access, poor doctor-patient communication, and differential rates of insurance coverage contributing to poorer outcomes among racial minorities. More change is required to promote equity when managing patients with end-of-life diseases necessitating methods of nutritional support.

Underlying disease for percutaneous endoscopic gastrostomy tube placement predicts short- and long-term mortality.

Background: PEG (percutaneous endoscopic gastrostomy) is a well established endoscopic procedure for enteral feeding. However, patients with a shorter life expectancy will not benefit from PEG tube placement. Furthermore, some specific evolving diseases will never benefit from PEG. The aim of the study focuses on short and long term mortality rates after PEG tube placement in a referral gastroenterology centre (Geneva University Hospital). 219 patients were enrolled in this study. Patients and methods: All patients scheduled for a PEG procedure between January 2011 and December 2014 were included. Nine patient parameters were collected for further analysis as well as the main underlying disease requiring PEG tube placement. Patients were subsequently divided into 4 groups according to underlying disease: Group 1) swallowing disorders of neurologic origin; Group 2) swallowing disorders associated with upper digestive tract neoplasia ; Group 3) nutritional support for a non GI reason ; Group 4) Other. Results: 219 patients had undergone a PEG tube placement. 33 patients died within 60 days after the procedure. After one year, 71 patients died. Global survival was 870 days. The nutritional support group had the better survival rate with 1276 days compared to the swallowing groups and others. The multivariate analysis has highlighted the underlying disease as the only associated parameter with short and long term mortality. Conclusions: PEG tube placement is associated with high short and long term mortality depending on the underlying disease. We outlined the potential role of PEG tube insertion as a supportive transient approach for nutritional support.

Clinician's attitude to enteral nutrition with percutaneous endoscopic gastrostomy: a survey in China.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is recommended for long-term enteral nutrition. However, long-term nasogastric (NGT) feeding is still commonplace in China. We surveyed Chinese clinicians' opinions toward PEG feeding in order to identify the potential barriers to acceptancy of PEG feeding. METHODS: A self-reported questionnaire was developed and distributed to 600 doctors. Five-point Likert scales were used for most responses. RESULTS: Of 525 respondents, the mainly nutritional support method was NGT while PEG was less used. Doctors working in the tertiary class A hospitals and radiotherapy department were more likely to choose PEG feeding (p = 0.000). Overall, 241 (46%) participants did not know PEG and 284 (54%) have different understanding degree of PEG. Age (p = 0.002), working life (p = 0.044) and professionalism (p = 0.005) were significantly related to the understanding of PEG. Levels of agreement was high (score of 3.47) for using PEG in patients with prolonged stroke-associated dysphagia. There was high agreement level in the statement that PEG was unnecessary when NGT could sustain the basic needs of patients, though better outcome can be predicted with PEG feeding. The highest scoring factor (score of 3.91) that influenced clinicians' choice of PEG was resistance from patients and families and the second one was the poor cooperation among departments (score of 3.80). CONCLUSIONS: Doctors' insufficient knowledge of PEG feeding, resistance from patients and families, poor cooperation among departments, all these factors leading physicians to prefer more conservative treatment to avoid disputes rather than better ones.

An overview of percutaneous endoscopic gastrostomy tube placement in the intensive care unit.

Critically ill patients are at increased risk for malnutrition as they often have underlying acute and chronic illness, stress related catabolism, decreased appetite, trauma and ongoing inflammation. Malnutrition is recognized as a leading cause of adverse outcomes, higher mortality, and increased hospital costs. Percutaneous endoscopic gastrostomy (PEG) tubes provide a safe and effective route to provide supplemental enteral nutrition to these patients. PEG placement has essentially replaced surgical gastrostomy as the modality of choice for longer term feeding in patients. This is a highly prevalent procedure with 160,000 to 200,000 PEG procedures performed each year in the United States. The purpose of this review is to provide an overview of current knowledge and practice standards with regards to placement of PEG tube in the Intensive Care Unit (ICU). When a patient is considered for a PEG tube, it is important to evaluate the treatment alternatives and identify the best option for each patient. In this review, we provide the advantages and disadvantages of various feeding modalities and devices. We review the indications and contraindications for PEG tube placement as well as the risks of this procedure. We then describe in detail the per-oral pull, per-oral push, and direct percutaneous techniques for PEG tube placement. Additionally, we review the feasibility of having interventional pulmonologists place PEG tubes in the ICU.

Life-Threatening Malnutrition in Very Severe ME/CFS.

Very severe Myalgic Encephalomyelitis (ME), (also known as Chronic Fatigue Syndrome) can lead to problems with nutrition and hydration. The reasons can be an inability to swallow, severe gastrointestinal problems tolerating food or the patient being too debilitated to eat and drink. Some patients with very severe ME will require tube feeding, either enterally or parenterally. There can often be a significant delay in implementing this, due to professional opinion, allowing the patient to become severely malnourished. Healthcare professionals may fail to recognize that the problems are a direct consequence of very severe ME, preferring to postulate psychological theories rather than addressing the primary clinical need. We present five case reports in which delay in instigating tube feeding led to severe malnutrition of a life-threatening degree. This case study aims to alert healthcare professionals to these realities.

Pancreatitis aguda: una complicación infrecuente de las gastrostomías por migración del balón interno. Reporte de un caso y revisión de literatura / Acute pancreatitis: A rare complication of gastrostomy due to intragastric balloon migration. Case report and literature review

Resumen La pancreatitis aguda secundaria a la obstrucción de la papila mayor causada por la migración del balón interno es uno de los efectos secundarios poco frecuentes, pero potencialmente graves relacionados con el uso de gastrostomías endoscópicas percutáneas (PEG). Hasta ahora solo existen 15 casos reportados en el mundo, presentamos el que para nuestro conocimiento sería el caso número 16 en la literatura internacional.

Abstract Acute pancreatitis secondary to major papilla obstruction caused by intragastric balloon migration is one of the rare but potentially severe side effects associated with the use of percutaneous endoscopic gastrostomy (PEG). To date, there are only 15 cases reported worldwide. This article presents a case that, to the best of our knowledge, is the sixteenth case reported in the international literature.

A Novel Approach to Percutaneous Endoscopic Gastrostomy Tube Replacement: Can You Save the Site?

Inadvertent removal or dislodgement is the most commonly encountered complication in patients with percutaneous endoscopic gastrostomy (PEG) tube. Once the gastrocutaneous fistula is formed, bedside tube replacement can be performed at the same site, within 24 hours of dislodgement. Usually, after this timeframe, the tract closes; hence, it is recommended to perform a replacement at a different site. We report a case of a 52-year-old female who presented after 24 hours of inadvertent PEG tube removal. A replacement was performed successfully via endoscopy at the same site of the erstwhile PEG tube, although it appeared to be closed.

Endoscopy in surgery.

In the last 20 years, there have been important developments in endoscopy. Initially, endoscopy was developed and used as a diagnostic tool. As new technology developed, these devices also became the basis for therapeutic maneuvers. In recent years, flexible endoscopes have been used to per- form procedures replacing traditional surgical approaches. Examples of this field are transanal minimally invasive surgery, natural orifice transluminal endoscopic surgery, endoscopic metabolic surgery and third space endoscopies. Throughout history, surgeons have played a vital role in the design and development of endoscopic techniques, procedures, and equipment. Surgeons continue to lead the advancement of endoscopy, make important contributions, and serve as role models for innovation.