Clinical Case Summary

Percutaneous endoscopic gastrostomy (PEG) tube has been frequently placed for various indications in order to provide long term enteral nutrition support[i],[ii],[iii]. Approximately 160,000 to 200,000 PEG tubes are placed each year in United States[iv]. Advancements in surgical interventions of gastrointestinal tract has resulted in increased number of anatomically altered stomachs, and so anatomically changed on endoscopic examination as well; which makes endoscopic interventions a little different[v]. Multiple case series have been reported for PEG tube placement in patients with subtotal gastrectomy [vi], however, there is scarce data available for PEG tube placement in patients with history of sleeve gastrectomy. The case that is presented here is regarding 64 years old lady with history of sleeve gastrectomy and now referred for PEG tube placement as she was advised for radiotherapy for squamous cell carcinoma of right buccal mucosa. PEG tube was successfully placed and follow up to a month showed effectively functional PEG tube with no major complications.

References

[i] Powell-Tuck J, Van Someren N. Enterostomy feeding for patients with stroke and bulbar palsy. Journal of the Royal Society of Medicine. 1992 Dec;85(12):717-9.
[ii] Richards DM, Tanikella R, Arora G, Guha S, Dekovich AA. Percutaneous endoscopic gastrostomy in cancer patients: predictors of 30-day complications, 30-day mortality, and overall mortality. Dig Dis Sci. 2013;58:768–776. doi: 10.1007/s10620-012-2397-8.
[iii] Orphanidou C, Biggs K, Johnston ME, Wright JR, Bowman A, Hotte SJ, Esau A, Myers C, Blunt V, Lafleur M, Sheehan B. Prophylactic feeding tubes for patients with locally advanced head-and-neck cancer undergoing combined chemotherapy and radiotherapy—systematic review and recommendations for clinical practice. Current oncology. 2011 Aug;18(4):e191.
[iv] Wei M, Ho E, Hegde P. An overview of percutaneous endoscopic gastrostomy tube placement in the intensive care unit. J Thorac Dis. 2021 Aug;13(8):5277-5296. doi: 10.21037/jtd-19-3728. PMID: 34527366; PMCID: PMC8411178.
[v] Morrell D, Pauli E, Juza R. Endoscopy in surgically altered anatomy. Annals of Laparoscopic and Endoscopic Surgery. 2019 Apr 24;4.
[vi] Singh P, Kahn D, Greenberg R, Indaram A, Pooran N, Bank S. Feasibility and safety of percutaneous endoscopic gastrostomy in patients with subtotal gastrectomy. Endoscopy. 2003 Apr;35(4):311-4. doi: 10.1055/s-2003-38156. PMID: 12664387.

Introduction

Gallbladder cancer (GBC) has a poor prognosis due to its aggressive nature and limited treatment options. Although early diagnosis through imaging is critical, it remains difficult—particularly in cases of focal gallbladder wall thickening (FGWT), which can mimic benign conditions such as adenomyomatosis or chronic cholecystitis.

Aims & Methods

This study aimed to identify lesions that progressed to GBC (precancerous lesions of GBC; PLGBC) by evaluating prior imaging and to describe their clinical characteristics and outcomes. Patients diagnosed with GBC at Iwata City Hospital between 2014 and 2024 were retrospectively reviewed. Those who had prior imaging—defined as abdominal ultrasound (US), computed tomography (CT), or magnetic resonance imaging (MRI) performed more than three months before GBC diagnosis—were included for analysis. PLGBC was defined as a lesion identifiable on prior imaging but not diagnosed as GBC, and corresponding to the site of subsequently diagnosed GBC. Imaging features and clinical outcomes were compared between patients with and without PLGBCs.

Results

Among 140 patients diagnosed with GBC, 66 (47%) had prior imaging available for review and were included in the analysis. The median age at GBC diagnosis was 80 years (interquartile range [IQR]: 71–86), with 33 male patients (50%). The median interval between prior imaging and GBC diagnosis was 753 days (IQR: 404–1796). The modalities of prior imaging included CT only in 42 patients, US only in 7, MRI only in 1, US and CT in 6, CT and MRI in 6, US and MRI in 3, and all three modalities in 1 patient.
PLGBCs were identified in 32 patients (48%). Regarding lesion morphology, 28 patients presented with FGWT, 2 patients with diffuse gallbladder wall thickening (DGWT), and 2 patients with gallbladder polyps. Lesion locations were the neck in 5 patients, the body/fundus in 25 patients, and the entire gallbladder in 2 patients. Features such as intramural stones or Rokitansky–Aschoff sinuses (RAS) were observed in 15 patients, and gallstones in 7 patients.
No significant differences were found between patients with and without PLGBCs regarding resectability (36% vs. 35%, P = 1.00), radical resection rates (13% vs. 13%, P = 1.00), or survival from diagnosis (median: 640 vs. 791 days, P = 0.96). Six patients with PLGBC were diagnosed with GBC during observation of gallbladder lesions (median follow-up: 406 days, range: 350–552 days), and all underwent successful radical resection of GBC.

Conclusion

PLGBCs were identified in approximately half of the patients who had undergone imaging before their GBC diagnosis, with FGWT being the predominant imaging feature. Recognizing PLGBCs and ensuring appropriate follow-up may enable timely surgical intervention, offering a potential opportunity to improve outcomes in patients with GBC.