Discussion

Patients with esophageal strictures often develop significant weight loss, primarily due to mechanical impairment of bolus transit [9], with the extent of dysphagia being associated with the nutritional deficit [10]. In the present case, a cumulative weight loss of nearly 40 kg necessitated urgent nutritional stabilization. This was of central importance both independently of the underlying disease and with regard to any potential subsequent surgical treatment. At the time the indication was established, the condition was still considered benign, which is why the decision was made to place a PEG tube. This case particularly illustrates the diagnostic challenge of differentiating benign peptic lesions from occult malignancy in the context of severe esophageal stenosis accompanied by extensive inflammation, which additionally complicated representative tissue sampling. Repeated histopathological analyses consistently demonstrated severe chronic inflammation and granulation tissue without evidence of dysplasia or malignancy. In this context, it should be considered that biopsies obtained during esophagogastroduodenoscopy (EGD) are superficial and do not allow conclusions regarding possible malignant cells in the deeper layers of the tissue. In retrospect, the combination of progressive dysphagia, marked weight loss, and refractoriness to therapy represented important clinical red flags that should have sustained a high index of suspicion for an underlying malignancy despite initially negative histopathological findings. Furthermore, the diagnostic workup might have benefited from endoscopic ultrasound evaluation to assess mural invasion and locoregional lymphadenopathy. However, this technique is frequently technically unfeasible in cases of high‐grade stenosis.

Had a malignant origin been suspected at that time, an alternative form of nutritional support, such as percutaneous endoscopic jejunostomy (PEJ) or parenteral nutrition, would have been preferentially considered [11]. However, these approaches are also associated with specific limitations and challenges. Placement of a PEJ tube, for instance, may initially appear to be a suitable alternative, but the procedure is technically more demanding, and its success depends on the physician's expertise [12]. Parenteral nutrition, on the other hand, can also serve as a temporary bridging strategy in patients in whom enteral access is not possible or where diagnostic clarification is still pending. Nevertheless, its long‐term use is limited by the risk of infectious and metabolic complications [13]. Regardless of the method, the timely restoration of adequate nutritional status was the primary focus, as this is an essential prerequisite for further therapeutic planning and also, concerning the later surgery, for reducing postoperative complications, shortening the recovery phase, and improving overall surgical resilience [14]. The importance of nutritional support is also stated in the guideline: Patients with high metabolic risk should receive nutritional therapy before surgery, even if the surgery must be postponed [15].

PEG tube placement is generally considered a relative contraindication in patients with suspected or confirmed malignancy requiring esophagectomy with gastric pull‐up, due to potential implications for subsequent reconstruction [16]. However, several studies have demonstrated that a preexisting PEG tube does not adversely affect Ivor Lewis esophagectomy, and gastric conduit formation can usually be performed without relevant limitations or increased postoperative morbidity [17, 18, 19, 20]. Nevertheless, PEG‐related fibrosis or scarring of the anterior gastric wall may theoretically impair gastric conduit preparation and perfusion, particularly when the PEG is placed at the caudal stomach near the right gastroepiploic vessels (see Figure 2B). As these vessels represent the primary vascular supply for reconstruction, injury or compromise may result in impaired gastric perfusion [21, 22]. Adequate perfusion is critical, as hypoperfusion increases the risk of serious complications such as ischemia, anastomotic leakage, and gastric conduit necrosis [23]. In severe cases, alternative reconstruction using jejunal or colonic interposition may be required. To minimize those risks, the alternative nutritional strategies mentioned above could be considered, particularly if an esophageal resection is anticipated.

Another relevant aspect concerns the oncological implications of PEG tube placement in cases of undiagnosed malignancy. Though rare, tumor seeding along the gastrostomy tract has been described in some case reports and should therefore be taken into account before the intervention [24, 25, 26]. To minimize the spread of tumor cells by avoiding passage through the cancerous area, the PEG tube placement should be performed in direct percutaneous introducer technique (push method) [27, 28], as it was done in our case. A meta‐analysis by Siu et al. demonstrated that this approach significantly reduced the event rate of gastrostomy site metastasis (0.56% with pull method vs. 0.29% with push method) [29]. However, due to concerns regarding data quality, as well as reports describing tumor cell dissemination via hematogenous spread even with the push method, the American Society for Gastrointestinal Endoscopy (ASGE) refrained from exclusively recommending the push over the pull method in its latest guideline. While advisable, it should not be mandatory. Furthermore, higher‐quality studies on implantation metastasis will be necessary to more accurately assess the risk [30].