S6266 Percutaneous Endoscopic Gastrostomy to Treat Large Hiatal Hernia and Gastric Volvulus After Failed Surgical Gastropexy

Introduction: A hiatal hernia (HH) occurs when the upper portion of the stomach traverses through the diaphragm into the chest cavity. Gastropexy, surgical fixation of the stomach to the abdominal wall, is a surgical option for elderly patients with multiple co-morbidities. However, gastropexy can fail leading to recurrence of symptomatic HH. A percutaneous endoscopic gastrostomy (PEG) can provide a permanent fixation between the stomach and the abdominal wall to prevent recurrence of HH. We report the first case of PEG successfully utilized to treat a large HH after failed surgical gastropexy. Case Description/Methods: The patient is an 88-year-old man with a history of atrial flutter, atrial fibrillation, complete heart block status post pacemaker placement, coronary artery disease, chronic obstructive pulmonary disease, hypertension, hyperlipidemia, and gout. He presented with 2 days of severe nausea, vomiting, epigastric pain and inability to tolerate any oral intake. Computed tomography (CT) scan showed a large HH and gastric volvulus. The stomach and esophagus were distended with fluid consistent with a gastric obstruction. Given the patient’s advanced age and multiple co-morbidities, surgery performed a laparoscopic gastropexy which is less invasive compared to fundoplication. Laparoscopic gastropexy using an absorbable suture was successful, and all symptoms resolved. Seven months later, the patient presented with a similar presentation. CT scan showed recurrence of the large HH and gastric volvulus. The patient was deemed not a candidate for another surgical intervention. He underwent an esophagogastroduodenoscopy with endoscopic alpha reduction of the gastric volvulus and PEG placement with a 20 French feeding tube to fixate the stomach to the anterior abdominal wall. The PEG tube was not used for tube feeding, as the patient was able to tolerate oral intake right after endoscopy. He was discharged in stable condition with close monitoring in the GI clinic. Two months later, the PEG tube was removed without complications. The patient has been symptom-free 1 year after PEG placement. Discussion: This case report demonstrates the first utilization of PEG placement for gastric fixation to the anterior abdominal wall after failed surgical gastropexy. When surgical interventions are not recommended or there has been a failure after surgical gastropexy, PEG placement can be considered for mechanical fixation. PEG placement is a safe and effective option and can be utilized as a practical intervention for HH and gastric volvulus in elderly patients with multiple comorbidities.