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doi:10.1111/jgh.12300
NUTRITIONAL MANAGEMENT
Safety of percutaneous endoscopic gastrostomy in high-risk patients Wei-Kuo Chang and Tsai-Yuan Hsieh Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
Keywords enteral access, enteral nutrition, percutaneous endoscopic gastrostomy. Accepted for publication 22 May 2013. Correspondence Dr Wei-Kuo Chang, Division of Gastroenterology, Tri-Service General Hospital, Number 325, Chengong Road, Section 2, Neihu, Taipei 114, Taiwan. Email: [email protected]
Abstract Percutaneous endoscopic gastrostomy (PEG) is a minimally invasive procedure. However, failure to transilluminate the anterior wall of the stomach or visualize the indentation of the physician’s finger represents the most frequent obstacles encountered by the endoscopist in safely completing PEG tube placement. We described several methods to safely assess PEG placement in high-risk patients. An abdominal plain film after gastric insufflated with 500 mL of air is obtained before PEG in patients. The body of the stomach near the angularis, equidistant from the greater and lesser curves, was defined as the optimal gastric puncture point. The location of the puncture points varied greatly, being situated over the right upper quadrant in 31% of patients, left upper in 59%, left lower in 5%, and right lower quadrant in 5% of patients. If there is any question of safe puncture site selection, safe track technique can be used to provide the information of depth and angle of the puncture tract. Computed tomography can provide detailed anatomy and orientation along the PEG tube and show detailed anatomical images along the PEG tract. Computed tomography-guided PEG tube placement is used when there is difficulty either insufflating the stomach, or the patients had previous surgery, or anatomical problems. Full assessment of the position of the stomach and adjacent organs prior to gastric puncture may help minimize the risk for potential complications and provide safety for the high-risk patients.
Introduction Percutaneous endoscopic gastrostomy (PEG), introduced into clinical practice by Gauderer and Ponsky et al. in 1980, is the procedure of choice for long-term tube feeding.1 The number of PEG tube placements increased from 61 000 to 216 000 cases in the USA from 1989 to 2000.2 Although PEG is a minimally invasive procedure, major complications occurred at a rate of 1.0–2.4% with 0.8% mortality.3–5 PEG procedure-related major complications include aspiration, hemorrhage, peritonitis, wound infections, and injury to adjacent organs.5 Iatrogenic perforation of the esophagus, small bowel, and colon, and laceration of the liver have been reported.5–8 Safety of PEG is generally enhanced by good transillumination through the abdominal wall, as well as clear visualization of indentation of the stomach by external palpation.9 However, PEG is difficult to perform in patients with obesity, previous gastric operation, or aberrant anatomy. The exact position of the colon or small bowel loop, which frequently lies superficial to the distal body of the stomach, is often not known, and thus, it can be inadvertently punctured.10–14 Several methods had been reported for overcoming this problem by verifying the anatomical relationship between the stomach and adjacent organs prior to gastric puncture.15–18 Chang 118
et al. reported that an abdominal plain film utilized a gastric insufflation technique prior to PEG tube placement.9 Ultrasound images and fluoroscopic guidance may help to define the anatomical relationship between stomach and adjacent organs.15–17 Computed tomography (CT) guidance could also offer a safe alternative method for patients with obesity or previous gastrectomy.11,14 We describe the methods to safely assess PEG tube placement in high-risk patients, with the aim to minimize the risk for potential complications and to provide assurance to the endoscopists.
PEG performed by the Ponsky “pull” technique1 With the patient placed in the supine position, the fasting stomach was insufflated with air by nasogastric tube or endoscope.9 The optimal puncture position was also confirmed endoscopically by transillumination and by clear visualization of the indentation of the stomach by external palpation on the marked point. A small incision was made with a surgical blade, and a 14-G needle with a cannula was inserted through the abdominal wall. A guide wire was passed through the cannula. A snare was passed through the endoscope to catch the guide wire, which was brought out through the mouth. The PEG tube was then pulled through the marked
Journal of Gastroenterology and Hepatology 2013; 28 (Suppl. 4): 118–122 © 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd
W-K Chang and T-Y Hsieh
Safety of endoscopic gastrotomy
(a)
(a)
(b)
(b)
(c)
Figure 2 Positioning a safe gastric puncture point by abdominal plain film before (a) and after air insufflation (b). Marked puncture points (¥) lie under the costal margin (white line).
Figure 1 Sample of small 25-G puncture needle and large 19-G trocar needle (a). Small puncture needle (white arrows, b) and trocar needle (black arrows; c) inserted through the abdominal wall to the stomach.
point on the abdominal wall. The PEG tube was secured with the outer flange. Patients received tube feeding 24 h later.
Safe track technique with a fine guiding needle Palpation the stomach and obtaining transillumination through the abdominal wall is a valuable assurance for proper PEG site selection. Should there be any difficulty, safe puncture site is selected, especially in patient with part of the small intestine or colon located in front of the stomach. Using a 25-G needle and a syringe with 1–2 mL of saline, the needle is passing through the abdominal wall at the proposed PEG site (Fig. 1).19 If bubbles appear in the syringe while aspirating immediately at the needle pass into the stomach indicates that the puncture track is appropriate. If bubbles appear before the needle pass into the stomach, there may be an intervening loop of bowel present. Using the 25-G spinal puncture needle has two advantages. First, the caliber of the spinal puncture needle is thin enough. For high-risk patients, the suitable safe puncture area on the abdominal plain film is small. In case of penetration to the bowel, a 25-G spinal puncture needle is much safer than a large 14-G large trocar needle. Second, the spinal puncture needle (9 cm) is long enough. Before the 14-G trocar needle is inserted through the abdominal wall to the stomach, it can be used as a guiding needle and provide the information of depth and angle of the puncture tract.
Positioning a safe gastric puncture point by abdominal plain film An abdominal plain film with air insufflation technique was performed 1 day before the PEG tube placement.9 With the patient placed in the supine position, a nasogastric tube was placed, and the fasting stomach was insufflated with 500 mL of air. An abdominal plain film obtained immediately afterward was used to demonstrate the air-filled stomach and position of adjacent organs
and structures including the liver, colon, small bowel, and ribs. The shape, size, and position of the stomach are clearly demonstrated on abdominal plain film after 500 mL of air insufflation as shown in Figure 2. The body of the stomach near the angularis, equidistant from the greater and lesser curves (not obscured by an overlying adjacent organ), was defined as the optimal gastric puncture point on the abdominal plain film. It is now routine to place feeding tubes through a PEG in the anterior abdominal wall. The area of lower body of stomach provides the greatest interface between the stomach and the anterior abdominal wall.20 It provides the shortest, most direct passage into the stomach. The lower position within the stomach places the PEG near the antrum, which facilitates conversion of the PEG to a percutaneous endoscopic gastrojejunostomy. Percutaneous endoscopic gastrojejunostomy is the method of choice if patient had delayed gastric emptying associated with PEG feeding intolerance.21 After insufflation with 500 mL of air, we used the abdominal plain film before PEG in 84 patients. PEG was unsuccessful in one (1.2%) patient because the stomach was positioned high behind the ribs. One patient developed an acute abdomen and required explorative laparostomy 7 days after the procedure.9
Pitfalls of the air insufflation technique The amount of air volume. An underinflated stomach may fail to displace the colon, or paradoxically, overinflation may lead to gas entering and distending the small bowel, hence lifting the colon upward.9 Insufflation of the stomach with air has been routinely practiced in patients suspected of having perforated peptic ulcer or to verify the correct PEG tube replacement.22,23 Using 300–400 mL of air along with plain film radiography is sufficient to outline most adult stomachs.22–24 After reviewing the results of studies, we have increased the amount of air injected to 500 mL because this will make it more likely to obtain a fully distended stomach on the abdominal plain film.9 The timing of air insufflations technique. During the traditional Ponsky “pull” technique, 500 mL of air is administered through a nasogastric tube or endoscope to obtain adequate
Journal of Gastroenterology and Hepatology 2013; 28 (Suppl. 4): 118–122 © 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd
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distention of the stomach. Large amounts of air in the stomach may leak through the pyloric sphincter into the small intestine. Theoretically, a longer PEG procedure time may led to more air volume passing into the small intestines, decrease the tension and volume in the air-distended stomach, increase the amount of air in the proximal small intestine, lift the colon upward, and cause additional risk of complications. An abdominal plain film with 500 mL air insufflation was performed 1 day before the PEG tube placement. A nasogastric tube was used to decompress the stomach filled with excessive air. After an overnight fasting just before PEG, the patient was placed on supine position, and 500 mL of air was administered through a nasogastric tube into the stomach.9 Abdominal plain film with air insufflations was obtained the day before PEG. The position and volume of colon gas are changeable, and the appropriate site of PEG might differ from day to day. For patients with potentially bowel loop lying in front of the stomach, safe track technique and fine guiding needle to locate an appropriate puncture track are used (Fig. 1). The part of the liver that is in front of the stomach occasionally cannot be seen in the abdominal plain film. Furthermore, the stomach is pushed downward by an endoscope; therefore, the site of the stomach might be changed from that of the abdominal plain film. For the sake of patient safety considerations, puncture position could be confirmed endoscopically by transillumination and clear visualization of the indentation prior to puncture needle insertion. Stomach anatomy and relevance to PEG. The relation of stomach anatomy to the other abdominal organs is of clinical significance to endoscopists, particularly with the advent of PEG. The stomach is commonly described as a “J-shaped” object that sits in the left upper quadrant of the abdomen. The stomach connects the esophagus at the lower esophageal sphincter, which is fixed in the retroperitoneum region. The duodenum is fixed in position by suspension ligaments, including hepatoduodenal ligament and ligament of Treitz. The stomach is suspended from the dorsal wall of the abdominal cavity. The stomach volume normally ranges from 1.5 to 2 L in adulthood. After overnight fasting, shortly before PEG, the stomach was insufflated with 500–1000 mL of air administered through a nasogastric tube or endoscope to obtain adequate distention of the stomach. The PEG feeding tubes were routinely placed through the abdominal wall to the anterior surface of the stomach. The anterior surface of stomach contacts with adjacent organs varies greatly, depending on the gastric sizes, shapes, and patient’s position. When the stomach is empty, the transverse colon may lie on the front part of stomach. As the stomach fills, it tends to expand forward and downward in the direction of least resistance. The lowest part of the stomach may reach or be below the region of the umbilicus. Our results showed that the shape, size, and position of the stomach on plain abdominal film should replicate the actual anatomy during PEG.9 This anatomy shares similar reference of marked puncture points, including: (i) the identical volume of air insufflated into the stomach, (ii) similar gastric muscular tone of the same patient, (iii) similar supine posture during PEG procedure, and (iv) similar surrounding viscera of the same patient.9 Using the air insufflation technique 120
(a)
(b)
(c)
Figure 3 Marked puncture points (¥) located high under the left costal margin (white line) (a), left lower (b), and right lower quadrants (c) on the abdominal plain film.
may help to guide the site selection prior to the PEG and shorten the PEG procedural time. Unusual puncture point on the abdominal plain film. The traditional location for PEG has been in the left upper quadrant of the abdomen in the vortex formed by the midline and the left costal margin, regardless of variation in the position of the stomach within the peritoneal cavity.25 The shape and position can be greatly modified by normal anatomic variation and by extrinsic compression from the surrounding viscera. The actual puncture sites of PEG may be hidden in the thoracic cavity,9,11,13 descend near the umbilicus, or reach the pelvic cavity.9,26 The location of the puncture points marked on abdominal films varied greatly. The marked puncture points on the abdominal plain films may lie high under the costal margin (Fig. 3a). Choosing the site for PEG tube placement in such patients would otherwise be quite a challenge because part of the low body is situated directly beneath the left costal margin. The location of the puncture points varied greatly, being situated over the right upper quadrant in 31% of patients, left upper in 59%, left lower in 5% (Fig. 3b), and right lower quadrant in 5% of patients (Fig. 3c).9 Dangerous puncture point of patients receiving PEG. The marked puncture points on the abdominal plain film allows physicians to check the air-filled stomach. This technique is also useful for clearly delineating the left lobe of the liver, a dilated loop of small intestine, or a high-lying transverse colon, thus avoiding inadvertent puncture of these adjacent organs. Our study showed that in the case of one patient with a tracheoesophageal fistula, only the proximal stomach could be visualized on the abdominal plain film because of air leakage through the tracheooesophageal fistula.9 The mucosal surface was closely apposed, and the luminal position for the needle puncture was
Journal of Gastroenterology and Hepatology 2013; 28 (Suppl. 4): 118–122 © 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd
W-K Chang and T-Y Hsieh
Safety of endoscopic gastrotomy
Figure 5 Computed tomography demonstrated a safe puncture point and the shorter distance (white arrow) between the gastric remnant and the abdominal wall.
Figure 4 Marked puncture points (¥) covered by dilated bowel gas on the abdominal plain film.
difficult. The marked puncture point on the abdominal plain film seems to be partially obscured by a dilated loop of small bowel and by diffuse dilation of the small bowel due to severe ileus (Fig. 4). The suitable area for insertion of the trocar to permit safe gastric puncture may be very small. Such information can be obtained before PEG and used to determine the site of exit in PEG placement that closely correlates with the actual placement site in the patients. Application of this air insufflation technique in clinical practice should complement the traditional method of palpating the stomach and obtaining transillumination through the abdominal wall, and may provide further assurance to the endoscopist. Abdominal CT examination. Abdominal CT was used to evaluate the PEG tract and access device.27,28 Prior to the abdominal CT, the patient received 300–500 mL of air by a nasogastric tube. This amount of air can help the radiologist identify the gastrointestinal tract (stomach, and small and large bowel) and also help assess the position of the stomach remnant in relation to the ribs, liver, small intestine, colon, and other hollow organs.29,30 CT guidance PEG has been described when there has been difficulty either in insufflating the stomach, previous surgery, or anatomical problems.29,30 CT before PEG tube placement was able to localize an optimal puncture site and the shorter distance between the gastric remnant and the abdominal wall (Fig. 5). We have performed PEG in 12 patients with previous gastrectomy. Two patients did not receive the PEG because CT demonstrated that the bowel loop lies superficial to the remnant stomach. Two patients failed PEG because the small guiding needle could
not identify a safe puncture track to the remnant stomach. Eventually, we successfully placed a PEG tube in eight (75%) patients.29
Conclusions Positioning a safe gastric puncture point by abdominal plain film with air insufflation technique is recommended before PEG in high-risk patients. Carrying out nasogastric tube air insufflation is safe and easily performed in most clinical settings without the need for supervision by experts. If there is any question of safe puncture site selection, we recommend that physicians apply the safe track technique with a fine guiding needle prior to the PEG. CT guidance PEG can be used when there has been difficulty either in insufflating the stomach, previous surgery, or anatomical problems. Full assessment of the position of the stomach and adjacent organs prior to gastric puncture may help minimize the risk for potential complications, thus providing further assurance to the endoscopist and safety of the patients.
References 1 Gauderer MW, Ponsky JL, Izant RJ. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J. Pediatr. Surg. 1980; 15: 872–5. 2 Owens DA. Percutaneous endoscopic gastrostomy and palliative care. J. Hosp. Palliat. Nurs. 2006; 8: 257–8. 3 Skelly RH, Kupfer RM, Metcalfe ME et al. Percutaneous endoscopic gastrostomy: change in practice since 1988. Clin. Nutr. 2002; 21: 389–94. 4 Rimon E. The safety and feasibility of percutaneous endoscopic gastrostomy placement by a single physician. Endoscopy 2001; 33: 241–4. 5 McClave SA, Chang WK. Complications of enteral access. Gastrointest. Endosc. 2003; 58: 739–51.
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6 Kenigsberg K, Levenbrown J. Esophageal perforation secondary to gastrostomy tube replacement. J. Pediatr. Surg. 1986; 21: 946–7. 7 Amann W, Mischinger HJ, Berger A et al. Percutaneous endoscopic gastrostomy: 8 years of clinical experience in 232 patients. Surg. Endosc. 1997; 11: 741–4. 8 Evans PM, Serpell JW. Small bowel fistula: a complication of percutaneous endoscopic gastrostomy insertion. Aust. N. Z. J. Surg. 1994; 64: 518–20. 9 Chang WK, Yu CY, Chao YC. Positioning a safe gastric puncture point before percutaneous endoscopic gastrostomy. Int. J. Clin. Pract. 2007; 61: 1121–5. 10 Kobak GE, McClenathan DT, Schurman SJ. Complications of removing percutaneous endoscopic gastrostomy tubes in children. J. Pediatr. Gastroenterol. Nutr. 2000; 30: 404–7. 11 Vogt W, Messmann H, Lock G et al. CT-guided PEG in patients with unsuccessful endoscopic transillumination. Gastrointest. Endosc. 1996; 43 (2 Pt 1): 138–40. 12 Simeon-Gelu M, Guimber D, Michaud L et al. Intercostal positioning of a percutaneous endoscopic gastrostomy. Endoscopy 2003; 35: 546. 13 Singh P, Kahn D, Greenberg R et al. Feasibility and safety of percutaneous endoscopic gastrostomy in patients with subtotal gastrectomy. Endoscopy 2003; 35: 311–14. 14 Thornton FJ, Varghese JC, Haslam PJ et al. Percutaneous gastrostomy in patients who fail or are unsuitable for endoscopic gastrostomy. Cardiovasc. Intervent. Radiol. 2000; 23: 279–84. 15 Bleck JS, Reiss B, Gebel M et al. Percutaneous sonographic gastrostomy: method, indications, and problems. Am. J. Gastroenterol. 1998; 93: 941–5. 16 Thornton FJ, Fotheringham T, Alexander M et al. Amyotrophic lateral sclerosis: enteral nutrition provision-endoscopic or radiologic gastrostomy? Radiology 2002; 224: 713–17. 17 Varney RA, van Sonnenberg E, Casola G et al. Ballon techniques for percutaneous gastrostomy in a patient with partial gastrectomy. Radiology 1988; 167: 69–70.
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18 Lin XZ, Yang SH, Chen CY et al. Percutaneous endoscopic gastrostomy in a patient with subtotal gastrectomy. Hepatogastroenterology 1999; 46: 180–1. 19 McClave SA, Chang WK. Techniques in enteral access. In: Ginsberg GG, ed. Clinical Gastrointestinal Endoscopy. Philadelphia, PA: Elsevier Saunders, 2005; 349–66. 20 Levine CD, Handler B, Baker SR et al. Imaging of percutaneous tube gastrostomies: spectrum of normal and abnormal findings. AJR Am. J. Roentgenol. 1995; 164: 347–51. 21 Bosco JJ, Barkun AN, Isenberg GA et al. Endoscopic enteral nutritional access devices. Gastrointest. Endosc. 2002; 56: 796–802. 22 Upadhye AS, Dalvi AN, Nair HT. Nasogastric air insufflation in early diagnosis of perforated peptic ulcer. J. Postgrad. Med. 1986; 32: 82–4. 23 Miller RE. The air-contrast stomach examination: an overview. Radiology 1975; 117: 743–4. 24 Burke DT, Hoberman CJ, Morse LR et al. A new procedure for gastrostomy tube replacement verification: a case report. Arch. Phys. Med. Rehabil. 2005; 86: 1484–6. 25 Dulabon GR, Abrams JE, Rutherford EJ. The incidence and significance of free air after percutaneous endoscopic gastrostomy. Am. Surg. 2002; 68: 590–3. 26 Lotan G, Broide E, Efrati Y et al. Laparoscopically monitored percutaneous endoscopic gastrostomy in children: a safer procedure. Surg. Endosc. 2004; 18: 1280–2. 27 Chang WK, Huang WC, Yu CY et al. Long-term percutaneous endoscopic gastrostomy: characteristic computed tomographic findings. Abdom. Imaging 2011; 36: 684–8. 28 Wojtowycz MM, Arata JA Jr, Micklos TJ et al. CT findings after uncomplicated percutaneous gastrostomy. AJR Am. J. Roentgenol. 1988; 151: 307–9. 29 Lin IS, Chang W-K, Wang CC, Chou CC, Loh CH. CT guidance for percutaneous endocscopic gastrostomy in patients with previous gastrectomy. Gastroenterol. J. Taiwan 2010; 27: 12–17. 30 Sanchez RB, van Sonnenberg E, D’Agostino HB et al. CT guidance for percutaneous gastrostomy and gastroenterostomy. Radiology 1992; 184: 201–5.
Journal of Gastroenterology and Hepatology 2013; 28 (Suppl. 4): 118–122 © 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd
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doi:10.1111/jgh.12300
NUTRITIONAL MANAGEMENT
Safety of percutaneous endoscopic gastrostomy in high-risk patients Wei-Kuo Chang and Tsai-Yuan Hsieh Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
Keywords enteral access, enteral nutrition, percutaneous endoscopic gastrostomy. Accepted for publication 22 May 2013. Correspondence Dr Wei-Kuo Chang, Division of Gastroenterology, Tri-Service General Hospital, Number 325, Chengong Road, Section 2, Neihu, Taipei 114, Taiwan. Email: [email protected]
Abstract Percutaneous endoscopic gastrostomy (PEG) is a minimally invasive procedure. However, failure to transilluminate the anterior wall of the stomach or visualize the indentation of the physician’s finger represents the most frequent obstacles encountered by the endoscopist in safely completing PEG tube placement. We described several methods to safely assess PEG placement in high-risk patients. An abdominal plain film after gastric insufflated with 500 mL of air is obtained before PEG in patients. The body of the stomach near the angularis, equidistant from the greater and lesser curves, was defined as the optimal gastric puncture point. The location of the puncture points varied greatly, being situated over the right upper quadrant in 31% of patients, left upper in 59%, left lower in 5%, and right lower quadrant in 5% of patients. If there is any question of safe puncture site selection, safe track technique can be used to provide the information of depth and angle of the puncture tract. Computed tomography can provide detailed anatomy and orientation along the PEG tube and show detailed anatomical images along the PEG tract. Computed tomography-guided PEG tube placement is used when there is difficulty either insufflating the stomach, or the patients had previous surgery, or anatomical problems. Full assessment of the position of the stomach and adjacent organs prior to gastric puncture may help minimize the risk for potential complications and provide safety for the high-risk patients.
Introduction Percutaneous endoscopic gastrostomy (PEG), introduced into clinical practice by Gauderer and Ponsky et al. in 1980, is the procedure of choice for long-term tube feeding.1 The number of PEG tube placements increased from 61 000 to 216 000 cases in the USA from 1989 to 2000.2 Although PEG is a minimally invasive procedure, major complications occurred at a rate of 1.0–2.4% with 0.8% mortality.3–5 PEG procedure-related major complications include aspiration, hemorrhage, peritonitis, wound infections, and injury to adjacent organs.5 Iatrogenic perforation of the esophagus, small bowel, and colon, and laceration of the liver have been reported.5–8 Safety of PEG is generally enhanced by good transillumination through the abdominal wall, as well as clear visualization of indentation of the stomach by external palpation.9 However, PEG is difficult to perform in patients with obesity, previous gastric operation, or aberrant anatomy. The exact position of the colon or small bowel loop, which frequently lies superficial to the distal body of the stomach, is often not known, and thus, it can be inadvertently punctured.10–14 Several methods had been reported for overcoming this problem by verifying the anatomical relationship between the stomach and adjacent organs prior to gastric puncture.15–18 Chang 118
et al. reported that an abdominal plain film utilized a gastric insufflation technique prior to PEG tube placement.9 Ultrasound images and fluoroscopic guidance may help to define the anatomical relationship between stomach and adjacent organs.15–17 Computed tomography (CT) guidance could also offer a safe alternative method for patients with obesity or previous gastrectomy.11,14 We describe the methods to safely assess PEG tube placement in high-risk patients, with the aim to minimize the risk for potential complications and to provide assurance to the endoscopists.
PEG performed by the Ponsky “pull” technique1 With the patient placed in the supine position, the fasting stomach was insufflated with air by nasogastric tube or endoscope.9 The optimal puncture position was also confirmed endoscopically by transillumination and by clear visualization of the indentation of the stomach by external palpation on the marked point. A small incision was made with a surgical blade, and a 14-G needle with a cannula was inserted through the abdominal wall. A guide wire was passed through the cannula. A snare was passed through the endoscope to catch the guide wire, which was brought out through the mouth. The PEG tube was then pulled through the marked
Journal of Gastroenterology and Hepatology 2013; 28 (Suppl. 4): 118–122 © 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd
W-K Chang and T-Y Hsieh
Safety of endoscopic gastrotomy
(a)
(a)
(b)
(b)
(c)
Figure 2 Positioning a safe gastric puncture point by abdominal plain film before (a) and after air insufflation (b). Marked puncture points (¥) lie under the costal margin (white line).
Figure 1 Sample of small 25-G puncture needle and large 19-G trocar needle (a). Small puncture needle (white arrows, b) and trocar needle (black arrows; c) inserted through the abdominal wall to the stomach.
point on the abdominal wall. The PEG tube was secured with the outer flange. Patients received tube feeding 24 h later.
Safe track technique with a fine guiding needle Palpation the stomach and obtaining transillumination through the abdominal wall is a valuable assurance for proper PEG site selection. Should there be any difficulty, safe puncture site is selected, especially in patient with part of the small intestine or colon located in front of the stomach. Using a 25-G needle and a syringe with 1–2 mL of saline, the needle is passing through the abdominal wall at the proposed PEG site (Fig. 1).19 If bubbles appear in the syringe while aspirating immediately at the needle pass into the stomach indicates that the puncture track is appropriate. If bubbles appear before the needle pass into the stomach, there may be an intervening loop of bowel present. Using the 25-G spinal puncture needle has two advantages. First, the caliber of the spinal puncture needle is thin enough. For high-risk patients, the suitable safe puncture area on the abdominal plain film is small. In case of penetration to the bowel, a 25-G spinal puncture needle is much safer than a large 14-G large trocar needle. Second, the spinal puncture needle (9 cm) is long enough. Before the 14-G trocar needle is inserted through the abdominal wall to the stomach, it can be used as a guiding needle and provide the information of depth and angle of the puncture tract.
Positioning a safe gastric puncture point by abdominal plain film An abdominal plain film with air insufflation technique was performed 1 day before the PEG tube placement.9 With the patient placed in the supine position, a nasogastric tube was placed, and the fasting stomach was insufflated with 500 mL of air. An abdominal plain film obtained immediately afterward was used to demonstrate the air-filled stomach and position of adjacent organs
and structures including the liver, colon, small bowel, and ribs. The shape, size, and position of the stomach are clearly demonstrated on abdominal plain film after 500 mL of air insufflation as shown in Figure 2. The body of the stomach near the angularis, equidistant from the greater and lesser curves (not obscured by an overlying adjacent organ), was defined as the optimal gastric puncture point on the abdominal plain film. It is now routine to place feeding tubes through a PEG in the anterior abdominal wall. The area of lower body of stomach provides the greatest interface between the stomach and the anterior abdominal wall.20 It provides the shortest, most direct passage into the stomach. The lower position within the stomach places the PEG near the antrum, which facilitates conversion of the PEG to a percutaneous endoscopic gastrojejunostomy. Percutaneous endoscopic gastrojejunostomy is the method of choice if patient had delayed gastric emptying associated with PEG feeding intolerance.21 After insufflation with 500 mL of air, we used the abdominal plain film before PEG in 84 patients. PEG was unsuccessful in one (1.2%) patient because the stomach was positioned high behind the ribs. One patient developed an acute abdomen and required explorative laparostomy 7 days after the procedure.9
Pitfalls of the air insufflation technique The amount of air volume. An underinflated stomach may fail to displace the colon, or paradoxically, overinflation may lead to gas entering and distending the small bowel, hence lifting the colon upward.9 Insufflation of the stomach with air has been routinely practiced in patients suspected of having perforated peptic ulcer or to verify the correct PEG tube replacement.22,23 Using 300–400 mL of air along with plain film radiography is sufficient to outline most adult stomachs.22–24 After reviewing the results of studies, we have increased the amount of air injected to 500 mL because this will make it more likely to obtain a fully distended stomach on the abdominal plain film.9 The timing of air insufflations technique. During the traditional Ponsky “pull” technique, 500 mL of air is administered through a nasogastric tube or endoscope to obtain adequate
Journal of Gastroenterology and Hepatology 2013; 28 (Suppl. 4): 118–122 © 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd
119
Safety of endoscopic gastrotomy
W-K Chang and T-Y Hsieh
distention of the stomach. Large amounts of air in the stomach may leak through the pyloric sphincter into the small intestine. Theoretically, a longer PEG procedure time may led to more air volume passing into the small intestines, decrease the tension and volume in the air-distended stomach, increase the amount of air in the proximal small intestine, lift the colon upward, and cause additional risk of complications. An abdominal plain film with 500 mL air insufflation was performed 1 day before the PEG tube placement. A nasogastric tube was used to decompress the stomach filled with excessive air. After an overnight fasting just before PEG, the patient was placed on supine position, and 500 mL of air was administered through a nasogastric tube into the stomach.9 Abdominal plain film with air insufflations was obtained the day before PEG. The position and volume of colon gas are changeable, and the appropriate site of PEG might differ from day to day. For patients with potentially bowel loop lying in front of the stomach, safe track technique and fine guiding needle to locate an appropriate puncture track are used (Fig. 1). The part of the liver that is in front of the stomach occasionally cannot be seen in the abdominal plain film. Furthermore, the stomach is pushed downward by an endoscope; therefore, the site of the stomach might be changed from that of the abdominal plain film. For the sake of patient safety considerations, puncture position could be confirmed endoscopically by transillumination and clear visualization of the indentation prior to puncture needle insertion. Stomach anatomy and relevance to PEG. The relation of stomach anatomy to the other abdominal organs is of clinical significance to endoscopists, particularly with the advent of PEG. The stomach is commonly described as a “J-shaped” object that sits in the left upper quadrant of the abdomen. The stomach connects the esophagus at the lower esophageal sphincter, which is fixed in the retroperitoneum region. The duodenum is fixed in position by suspension ligaments, including hepatoduodenal ligament and ligament of Treitz. The stomach is suspended from the dorsal wall of the abdominal cavity. The stomach volume normally ranges from 1.5 to 2 L in adulthood. After overnight fasting, shortly before PEG, the stomach was insufflated with 500–1000 mL of air administered through a nasogastric tube or endoscope to obtain adequate distention of the stomach. The PEG feeding tubes were routinely placed through the abdominal wall to the anterior surface of the stomach. The anterior surface of stomach contacts with adjacent organs varies greatly, depending on the gastric sizes, shapes, and patient’s position. When the stomach is empty, the transverse colon may lie on the front part of stomach. As the stomach fills, it tends to expand forward and downward in the direction of least resistance. The lowest part of the stomach may reach or be below the region of the umbilicus. Our results showed that the shape, size, and position of the stomach on plain abdominal film should replicate the actual anatomy during PEG.9 This anatomy shares similar reference of marked puncture points, including: (i) the identical volume of air insufflated into the stomach, (ii) similar gastric muscular tone of the same patient, (iii) similar supine posture during PEG procedure, and (iv) similar surrounding viscera of the same patient.9 Using the air insufflation technique 120
(a)
(b)
(c)
Figure 3 Marked puncture points (¥) located high under the left costal margin (white line) (a), left lower (b), and right lower quadrants (c) on the abdominal plain film.
may help to guide the site selection prior to the PEG and shorten the PEG procedural time. Unusual puncture point on the abdominal plain film. The traditional location for PEG has been in the left upper quadrant of the abdomen in the vortex formed by the midline and the left costal margin, regardless of variation in the position of the stomach within the peritoneal cavity.25 The shape and position can be greatly modified by normal anatomic variation and by extrinsic compression from the surrounding viscera. The actual puncture sites of PEG may be hidden in the thoracic cavity,9,11,13 descend near the umbilicus, or reach the pelvic cavity.9,26 The location of the puncture points marked on abdominal films varied greatly. The marked puncture points on the abdominal plain films may lie high under the costal margin (Fig. 3a). Choosing the site for PEG tube placement in such patients would otherwise be quite a challenge because part of the low body is situated directly beneath the left costal margin. The location of the puncture points varied greatly, being situated over the right upper quadrant in 31% of patients, left upper in 59%, left lower in 5% (Fig. 3b), and right lower quadrant in 5% of patients (Fig. 3c).9 Dangerous puncture point of patients receiving PEG. The marked puncture points on the abdominal plain film allows physicians to check the air-filled stomach. This technique is also useful for clearly delineating the left lobe of the liver, a dilated loop of small intestine, or a high-lying transverse colon, thus avoiding inadvertent puncture of these adjacent organs. Our study showed that in the case of one patient with a tracheoesophageal fistula, only the proximal stomach could be visualized on the abdominal plain film because of air leakage through the tracheooesophageal fistula.9 The mucosal surface was closely apposed, and the luminal position for the needle puncture was
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Figure 5 Computed tomography demonstrated a safe puncture point and the shorter distance (white arrow) between the gastric remnant and the abdominal wall.
Figure 4 Marked puncture points (¥) covered by dilated bowel gas on the abdominal plain film.
difficult. The marked puncture point on the abdominal plain film seems to be partially obscured by a dilated loop of small bowel and by diffuse dilation of the small bowel due to severe ileus (Fig. 4). The suitable area for insertion of the trocar to permit safe gastric puncture may be very small. Such information can be obtained before PEG and used to determine the site of exit in PEG placement that closely correlates with the actual placement site in the patients. Application of this air insufflation technique in clinical practice should complement the traditional method of palpating the stomach and obtaining transillumination through the abdominal wall, and may provide further assurance to the endoscopist. Abdominal CT examination. Abdominal CT was used to evaluate the PEG tract and access device.27,28 Prior to the abdominal CT, the patient received 300–500 mL of air by a nasogastric tube. This amount of air can help the radiologist identify the gastrointestinal tract (stomach, and small and large bowel) and also help assess the position of the stomach remnant in relation to the ribs, liver, small intestine, colon, and other hollow organs.29,30 CT guidance PEG has been described when there has been difficulty either in insufflating the stomach, previous surgery, or anatomical problems.29,30 CT before PEG tube placement was able to localize an optimal puncture site and the shorter distance between the gastric remnant and the abdominal wall (Fig. 5). We have performed PEG in 12 patients with previous gastrectomy. Two patients did not receive the PEG because CT demonstrated that the bowel loop lies superficial to the remnant stomach. Two patients failed PEG because the small guiding needle could
not identify a safe puncture track to the remnant stomach. Eventually, we successfully placed a PEG tube in eight (75%) patients.29
Conclusions Positioning a safe gastric puncture point by abdominal plain film with air insufflation technique is recommended before PEG in high-risk patients. Carrying out nasogastric tube air insufflation is safe and easily performed in most clinical settings without the need for supervision by experts. If there is any question of safe puncture site selection, we recommend that physicians apply the safe track technique with a fine guiding needle prior to the PEG. CT guidance PEG can be used when there has been difficulty either in insufflating the stomach, previous surgery, or anatomical problems. Full assessment of the position of the stomach and adjacent organs prior to gastric puncture may help minimize the risk for potential complications, thus providing further assurance to the endoscopist and safety of the patients.
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