# Acute Subcutaneous Gastric Perforation at a Previous Percutaneous Endoscopic Gastrostomy (PEG) Site

## TL;DR

A rare case of delayed gastric perforation six years after PEG removal is reported, emphasizing the need for early surgical intervention in such life-threatening complications.

## Contribution

This is the first reported case of spontaneous subcutaneous gastric perforation six years after PEG removal without intervening procedures.

## Key findings

- Delayed subcutaneous gastric perforation can occur years after PEG removal, mimicking necrotizing soft-tissue infection.
- Surgical excision and gastric repair are essential for managing this complication when sepsis or contamination is present.
- Early recognition and intervention are critical for favorable outcomes in such rare but severe cases.

## Abstract

Percutaneous endoscopic gastrostomy (PEG) is commonly used to provide long-term enteral nutrition and is generally associated with a low rate of major complications. Persistent gastrocutaneous fistula after PEG removal occurs in approximately 0.5-3.9% of cases. We report an unusual case of delayed subcutaneous gastric perforation into the subcutaneous space presenting as abdominal wall sepsis six years after PEG removal without prior history of PEG-related complications.

A 24-year-old man with a history of repaired congenital tracheoesophageal fistula and long-term PEG dependence presented with fever, abdominal pain, and rapidly progressive swelling of the left lower abdominal wall. Computed tomography demonstrated extensive subcutaneous emphysema and fluid collections concerning for necrotizing soft-tissue infection. Emergency surgical exploration revealed gastric contents tracking through the abdominal wall fascia into the subcutaneous plane at the site of the previous PEG with intact skin. A defect in the anterior gastric wall was repaired primarily with omental patching, and the fascial tract was excised and repaired. The subcutaneous collection was managed with extensive washout and drainage. The patient required intensive care for septic shock but made a good recovery following definitive surgical source control and antimicrobial therapy.

PEG site healing is usually uncomplicated, with most of the tracts closing spontaneously. True delayed reactivation after years of apparent healing is exceedingly rare. Isolated reports describe delayed enterocutaneous and gastrocolocutaneous fistulae presenting after prolonged asymptomatic periods. A previous case report described delayed subcutaneous leakage occurring two years after division of a gastrostomy tract; however, to our knowledge, spontaneous subcutaneous gastric perforation occurring six years after PEG removal, in the absence of any intervening procedure, has not previously been reported. Proposed mechanisms include persistent epithelialization of the gastrostomy tract, dense adhesions between the stomach and abdominal wall, localized ischemia, and micro-perforation related to infection. These changes may allow delayed breakdown and direct subcutaneous leakage. Radiologically, this presentation may mimic necrotizing soft-tissue infection, making early surgical exploration essential for diagnosis and source control.

Management depends on clinical severity. Endoscopic techniques such as argon plasma coagulation, clip placement, and suturing may be used in stable patients with gastrocutaneous fistulae, but in the presence of perforation, sepsis, or extensive soft-tissue contamination, surgical excision of the fistulous tract with primary gastric repair and wide drainage remains definitive. As no formal guidelines exist for this rare complication, treatment should follow general surgical principles of prompt source control, antimicrobial therapy, and supportive care, as demonstrated in this case.

This case highlights a rare but life-threatening delayed complication of PEG removal. Clinicians should maintain a high index of suspicion for late PEG-related fistulae in patients presenting with unexplained abdominal wall sepsis, even many years after gastrostomy removal, as early recognition and prompt surgical management are essential for favourable outcomes.