clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

Percutaneous Endoscopic Gastrostomy

Capecomorin S. Pitchumoni

Indications and Contraindications

Preoperative Investigations/Preparation for the Procedure

■Consent/written advanced directives

■Cardiorespiratory status assessment

■Baseline laboratory parameters

Transillumination is attained through the anterior abdominal wall after darkening the room.

The assistant makes a finger impression over the point of transillumination (A). Failure to transilluminate implies presence of intervening bowel loops, making the

procedure unsafe.

This indentation must be clearly visible through the endoscope, which is already positioned facing the anterior abdominal wall (B).

After marking this point on the skin using a blunt tip or marker, the assistant injects a local anesthetic into the skin and makes a shallow 5-mm cut using a scalpel.

An 18G hollow needle is passed through this incision, piercing the gastric wall, thus entering the endoscopic field.

The tapering end of the lubricated PEG tube is threaded over the wire and pushed through the mouth into the esophagus and the stomach, while the assistant pulls the wire back through the incision. This is called a “pull” PEG as the assistant pulls the PEG out through the anterior abdominal wall by pulling on the wire. As more wire is pulled out, the tapered tip of the PEG tube becomes visible and the process is continued until only about 3–4cm of the PEG tube remains deep to the skin. The markings on the tube help determine the length.

Procedure:“Push PEG”

This procedure is currently less popular.

Alternatively, after withdrawing the needle, a trochar can be passed with a plastic removable catheter around it.

The trochar is then withdrawn, and the feeding tube is passed through the catheter into the stomach.

The catheter is removed, leaving the feeding tube in place, which is then fixed to the abdominal wall. This is called “Push PEG,” as it involves pushing the feeding tube into the stomach through the abdominal wall incision.

The stopper now approximates the anterior wall of the stomach to the abdominal wall.

Feeding is generally commenced on the following day, after the patient is examined.

240 SECTION 2 Esophagus, Stomach and Duodenum

PEG Removal

This is only advisable for cases where a well-defined tract has been formed.

Indications and Contraindications

The tube is cut from the outside using a pair of scissors or scalpel.

The snared end is pulled out along with the endoscope.

Reinsertion

A new balloon-type PEG tube is inserted through the existing stoma and inflated with water. The balloon end is pulled up to the stomach wall and a rubber stopper is applied on the outside to position it snugly against the anterior abdominal wall.

Standard Postoperative Investigations

■Daily check for an adequate approximation of the gastric wall to the abdominal wall to prevent dislocation and peritonitis

Postoperative Complications

■Perforation of esophagus, stomach, transverse colon

■Hemorrhage

■Sepsis: usually detected in 2–3days

■Clogging of the tube

■Gastrocutaneous fistula

■Gastric ulcer

■Peritonitis

■“Buried bumper syndrome” when the bumper gets buried in the stomach wall

■Distal migration of the tube resulting in gastric outlet obstruction

■An agitated patient may pull the tube out

Tricks of the Senior Surgeon

■Care has to be taken for a necrosis of the gastric wall in case of a too strong approximation by the “mushroom.”

Laparoscopic-Assisted Gastrostomy

Tim Strate, Oliver Mann

Introduction

Laparoscopic gastrostomy is an excellent minimally invasive procedure for patients who are unable to swallow and unable to undergo percutaneous endoscopic

gastrostomy. The original open method was devised as a feeding tube by Bronislaw Kader in 1896 and modified for minimally invasive technique in the 1990s.

Indications and Contraindications

Preoperative Investigation/Preparation for the Procedure

See chapter “Surgical Gastrostomy: Temporary or Permanent Gastric Fistula.”

Procedure

Access

■3-Trocar technique (2¥10-mm and 1¥5-mm trocars)

■10-mm subumbilical trocar

■Pneumoperitoneum of 12mmHg

■10-mm trocar in left lower quadrant

■5-mm trocar in right upper quadrant

Using a straight needle which is brought into the abdomen through the skin at the left hypogastric region, a triangle is created by three full-thickness stitches which allow the catheter system to be introduced under laparoscopic control (stitches: skin-abdominal wall-stomach-abdominal wall-skin).