Gastrostomy in a Patient with Situs Inversus Totalis
A 65-year-old woman was transferred to our department for PEG insertion during nasogastric tube feeding because of dysphagia caused by ICH. She was taking medication for hypertension and osteoporosis for the last 7 years. She was diagnosed with SIT during a colonoscopy performed 2 years prior; she has no family history of this condition. At the time of transfer, she was maintaining a blood pressure of 130/80 mm Hg, heart rate of 65 to 80 beats per minute, body temperature of 36.5℃, and respiratory rate of 18 breaths per minute with alert consciousness. Her heart rate was normal without heart murmur. No difference was found from the previous examination of the chest, and no abnormal findings were detected in the abdomen, limbs, and skin. Analysis of peripheral blood showed a white blood cell count, platelet count, and hemoglobin of 5,170/mm3, 9.7 g/dL, and 290,000/mm3, respectively.\nThe liver function test results were as follows: aspartate aminotransferase/alanine aminotransferase, 13/9 IU/L; prothrombin time-international normalized ratio, 1.08; and partial thromboplastin time, 32.4 seconds (reference range, 20 to 38). The renal function tests were within the reference ranges. Dextrocardia was observed on a chest radiograph (), and complete right to left reversal of internal organs was detected on abdominal computed tomography (CT) scan, indicating a finding of SIT (). No abnormal findings were found on the CT scans of the spleen and major blood vessels. Upper gastrointestinal endoscopy was conducted identical to a general endoscopic procedure, with the patient in a left lateral decubitus position. Along with preoperative monitoring of pulse rate and oxygen saturation, midazolam (3 mg) and propofol (50 mg) were administered via intravenous injection as a pretreatment. The endoscope was turned counterclockwise when it was passed from the bulb to the descending part of the duodenum. The gastric angle, when observed with a J shaped retroflection at the antrum, was mirrored from its normal position. No specific findings were detected during the endoscopy except for a mild chronic superficial gastritis. A puncture site was chosen with the help of an endoscopic light after manually pressing the stomach wall to find the thinnest site. Subsequently, a gastrostomy feeding tube (PEG-24-Pull; Wilson-Cook Medical GI Endoscopy, Winston-Salem, NC, USA) was inserted into the anterior wall of the lower gastric body, which looks like the posterior wall of the lower gastric body in a normal person (). The nutrition was delivered directly into the stomach the next morning after PEG insertion, and no specific complications were observed.