Surg Endosc (1992) 6:261-262
Surgical Endoscopy 9 Springer-Verlag New York Inc. 1992
A simplified technique for percutaneous endoscopic gastrostomy Robert D. Fanelli l and Jeffrey L. Ponsky 2 Department of Surgery, Mount Sinai Medical Center, Cleveland, OH 44106; 2 Case Western Reserve University School of Medicine, and Department of Surgery, Mount Sinai Medical Center, Cleveland, OH 44106
Summary. Percutaneous endoscopic gastrostomy (PEG) is the preferred method of establishing long-term enteral access for feeding. Many patients requiring PEG are elderly and at risk for complications. Expeditious placement of the gastrostomy tube will minimize complications, but distorted esophageal anatomy can significantly lengthen the procedure. Some endoscopists abandon conventional repeat gastroscopy in difficult cases to accelerate the procedure. The authors describe a reliable method for quick reinsertion of the endoscope which shortens time required for PEG, and may reduce complications. Key words: Percutaneous endoscopic gastrostomy P E G - Gastrostomy tube - Enteral f e e d i n g - Percutaneous gastrostomy
Percutaneous endoscopic gastrostomy (PEG) has become the procedure of choice for providing access in patients requiring long-term enteral feeding [1]. The majority of these patients are elderly and suffer from multiple medical illnesses, placing them at high risk for complications such as oversedation, aspiration, and respiratory and cardiac arrest [3]. PEG is a desirable means of obtaining enteral access in the infirm elderly because of both its minimally invasive nature and its expedience compared with standard gastrostomy. In addition to multiple medical illnesses which may increase the risk of PEG, many patients referred for this procedure present distorted esophageal anatomy. Severe kyphoscoliosis, dilated tortuous esophagi, esophageal diverticula, strictures, and large-hiatus hernias may lengthen the time required for PEG placement because of difficulty in passing the endoscope.
Each PEG begins with careful esophagogastroduodenoscopy (EGD) to define the anatomy and identify the anticipated site for placement of the gastrostomy tube. Once the PEG has been established, repeat EGD is needed to view the gastric portion of the device to confirm proper placement. Reinsertion of the endoscope through a difficult esophagus can be time consuming, significantly prolonging the procedure and increasing patient risk. With the advent of new types of PEG catheters, some endoscopists favor abandoning repeat EGD. H o w e v e r , if accomplished safely and rapidly, repeat EGD provides added security in confirming proper PEG positioning. We describe a reliable method for rapid reinsertion of the endoscope during P E G placement, allowing the gastroscope to be returned to the stomach within seconds even in the most difficult cases. By significantly reducing the time required for the procedure, this technique may reduce patient risk and complications.
Method After performing diagnostic EGD, the site for PEG placement is identified and the procedure is conducted in the standard manner [2]. Once the feeding-tube assembly is ready to be drawn down the esophagus into the stomach and through the anterior abdominal wall using the pull technique [1], a rat tooth forceps is passed through the biopsy channel of the gastroscope and used to grasp the center hub of the PEG mushroom (Fig. 1). The gastroscope is then advanced over the forceps until its tip is shrouded by the PEG mushroom (Fig. 2). As the gastrostomy tube is drawn through the hypopharynx and esophagus, the endoscope is gently guided behind it. Once the gastroscope has been carried 40 cm past the teeth, the rat tooth forceps is released and withdrawn from the biopsy channel. The endoscope is well positioned to follow the gastrostomy tube into the stomach to assure proper placement. The esophagus is inspected during withdrawal of the endoscope and the feeding tube is anchored as usual.
Results Offprint requests to: Jeffrey L. Ponsky, M.D., FACS, Director, Department of Surgery, Mount Sinai Medical Center, One Mount Sinai Drive, Cleveland, OH 44106
We have used this technique in eight consecutive cases with excellent results. By combining reinsertion of the gastroscope with placement of the P E G tube, the procedure time has been reduced by several minutes. In
262
Fig. 1. A rat tooth forceps is inserted through the biopsy channel of the endoscope and used to grasp the inner hub of the PEG mushroom
all cases, reinsertion time was decreased to 15 s or less, and no complications have been encountered using this method. Conclusion
We recommend this effective technique for rapid reintroduction of the gastroscope during PEG placement. It significantly shortens the procedure by reducing the time required for repeat EGD. Since this technique entails passive towing of the shrouded gastroscope through the esophagus, there are no contraindications in patients otherwise suitable for percutaneous endoscopic gastrostomy. Decreased periods of sedation,
Fig. 2. The endoscope is advanced over the rat tooth forceps until its tip is shrouded by the PEG mushroom. The mushroom provides a protective, flexible cover for the gastroscope as it is guided through the hypopharynx and esophagus
manipulation, and supine positioning reduce patient risk and complications. References 1. Ponsky JL (1989) Percutaneous endoscopic gastrostomy for enteral alimentation and decompression. In: Cameron JL (ed) Current surgical therapy - - 3. B.C. Decker, Philadelphia, pp 366-70 2. Ponsky JL, Gauderer MW (1981) Percutaneous endoscopic gastrostomy: A nonoperative technique for feeding gastrostomy. Gastrointest Endosc 27:9-11 3. Strodel WE, Ponsky JL (1988) Complications of percutaneous gastrostomy. In: Ponsky JL (ed) Techniques of percutaneous gastrostomy. Igako-Shoin, New York, pp 63-78
Surgical Endoscopy 9 Springer-Verlag New York Inc. 1992
A simplified technique for percutaneous endoscopic gastrostomy Robert D. Fanelli l and Jeffrey L. Ponsky 2 Department of Surgery, Mount Sinai Medical Center, Cleveland, OH 44106; 2 Case Western Reserve University School of Medicine, and Department of Surgery, Mount Sinai Medical Center, Cleveland, OH 44106
Summary. Percutaneous endoscopic gastrostomy (PEG) is the preferred method of establishing long-term enteral access for feeding. Many patients requiring PEG are elderly and at risk for complications. Expeditious placement of the gastrostomy tube will minimize complications, but distorted esophageal anatomy can significantly lengthen the procedure. Some endoscopists abandon conventional repeat gastroscopy in difficult cases to accelerate the procedure. The authors describe a reliable method for quick reinsertion of the endoscope which shortens time required for PEG, and may reduce complications. Key words: Percutaneous endoscopic gastrostomy P E G - Gastrostomy tube - Enteral f e e d i n g - Percutaneous gastrostomy
Percutaneous endoscopic gastrostomy (PEG) has become the procedure of choice for providing access in patients requiring long-term enteral feeding [1]. The majority of these patients are elderly and suffer from multiple medical illnesses, placing them at high risk for complications such as oversedation, aspiration, and respiratory and cardiac arrest [3]. PEG is a desirable means of obtaining enteral access in the infirm elderly because of both its minimally invasive nature and its expedience compared with standard gastrostomy. In addition to multiple medical illnesses which may increase the risk of PEG, many patients referred for this procedure present distorted esophageal anatomy. Severe kyphoscoliosis, dilated tortuous esophagi, esophageal diverticula, strictures, and large-hiatus hernias may lengthen the time required for PEG placement because of difficulty in passing the endoscope.
Each PEG begins with careful esophagogastroduodenoscopy (EGD) to define the anatomy and identify the anticipated site for placement of the gastrostomy tube. Once the PEG has been established, repeat EGD is needed to view the gastric portion of the device to confirm proper placement. Reinsertion of the endoscope through a difficult esophagus can be time consuming, significantly prolonging the procedure and increasing patient risk. With the advent of new types of PEG catheters, some endoscopists favor abandoning repeat EGD. H o w e v e r , if accomplished safely and rapidly, repeat EGD provides added security in confirming proper PEG positioning. We describe a reliable method for rapid reinsertion of the endoscope during P E G placement, allowing the gastroscope to be returned to the stomach within seconds even in the most difficult cases. By significantly reducing the time required for the procedure, this technique may reduce patient risk and complications.
Method After performing diagnostic EGD, the site for PEG placement is identified and the procedure is conducted in the standard manner [2]. Once the feeding-tube assembly is ready to be drawn down the esophagus into the stomach and through the anterior abdominal wall using the pull technique [1], a rat tooth forceps is passed through the biopsy channel of the gastroscope and used to grasp the center hub of the PEG mushroom (Fig. 1). The gastroscope is then advanced over the forceps until its tip is shrouded by the PEG mushroom (Fig. 2). As the gastrostomy tube is drawn through the hypopharynx and esophagus, the endoscope is gently guided behind it. Once the gastroscope has been carried 40 cm past the teeth, the rat tooth forceps is released and withdrawn from the biopsy channel. The endoscope is well positioned to follow the gastrostomy tube into the stomach to assure proper placement. The esophagus is inspected during withdrawal of the endoscope and the feeding tube is anchored as usual.
Results Offprint requests to: Jeffrey L. Ponsky, M.D., FACS, Director, Department of Surgery, Mount Sinai Medical Center, One Mount Sinai Drive, Cleveland, OH 44106
We have used this technique in eight consecutive cases with excellent results. By combining reinsertion of the gastroscope with placement of the P E G tube, the procedure time has been reduced by several minutes. In
262
Fig. 1. A rat tooth forceps is inserted through the biopsy channel of the endoscope and used to grasp the inner hub of the PEG mushroom
all cases, reinsertion time was decreased to 15 s or less, and no complications have been encountered using this method. Conclusion
We recommend this effective technique for rapid reintroduction of the gastroscope during PEG placement. It significantly shortens the procedure by reducing the time required for repeat EGD. Since this technique entails passive towing of the shrouded gastroscope through the esophagus, there are no contraindications in patients otherwise suitable for percutaneous endoscopic gastrostomy. Decreased periods of sedation,
Fig. 2. The endoscope is advanced over the rat tooth forceps until its tip is shrouded by the PEG mushroom. The mushroom provides a protective, flexible cover for the gastroscope as it is guided through the hypopharynx and esophagus
manipulation, and supine positioning reduce patient risk and complications. References 1. Ponsky JL (1989) Percutaneous endoscopic gastrostomy for enteral alimentation and decompression. In: Cameron JL (ed) Current surgical therapy - - 3. B.C. Decker, Philadelphia, pp 366-70 2. Ponsky JL, Gauderer MW (1981) Percutaneous endoscopic gastrostomy: A nonoperative technique for feeding gastrostomy. Gastrointest Endosc 27:9-11 3. Strodel WE, Ponsky JL (1988) Complications of percutaneous gastrostomy. In: Ponsky JL (ed) Techniques of percutaneous gastrostomy. Igako-Shoin, New York, pp 63-78
