Endoscopic Feeding Techniques

Fig.7.1

Localization of feeding tubes at the upper GI tract (Jet-PEG PEG with jejunal port)

Tubes’ nomenclature:

Tubes to be inserted manually:

Nasogastric tubes:

– Nasogastric

Tubes to be inserted endoscopically:

Nasal tubes:

– Jejunal tubes

– Combination tubes (tubes with multiple ports)

Percutaneous tubes – gastric/jejunal:

1. Primary techniques:

– PEG: percutaneous endoscopic gastrostomy

– PEG with jejunal port: «jejunal tube through PEG» = PEG + internal catheter

– PEJ: percutaneous endoscopic jejunostomy (also «EPJ»)

2. Secondary techniques:

– Button

– Gastrotube

Percutaneous tubes – colon:

– PEC: percutaneous endoscopic colostomy/caecostomy

Tubes to be inserted surgically:

– FNCJ: fine-needle catheter jejunostomy

Ethical-Legal Aspects Regarding Tube Feeding

The primary objective of nutritional therapy is to maintain the patient’s nutritional state or to improve it, thus positively influencing the patient’s prognosis regarding his illness. Nutrition used to be an instrument of basic care, but in the meantime, it has developed into a highly efficient instrument for medical therapy and prevention and has become part of a modern and multimodal therapy concept (e.g. intensive therapy, oncological therapy, paediatrics, etc.). In addition to tube-specific indications, which are explained in the individual sections, it is now part of the physician’s skills to develop a patient-dependent and targeted strategy under medical and ethical aspects, together with the care personal, the relatives and others involved. The type of patients treated ranges from a child in intensive care to the geriatric patient suffering from dementia at the end of his life.

Generally valid procedures cannot be determined. The legal provisions (living will, guardianship, possibly associated with the involvement of court, if needed) as well as the basics of palliative care and the involvement of an ethics consultation at the hospital (Oehmichen et al. 2013) should be taken into consideration.

7.2 Transnasal Tubes

Transnasal tubes are used when tube feeding is only performed for a short period of time (<4 weeks) or when the duration of feeding remains unclear and the definitive decision about the further procedure is still waited on (e.g. after a stroke with dysphagia and tendency of improving quickly or in intensive care patients) (Bernhardt 2007). The area of use varies significantly, and there are a number of tube sizes available for children and adults (► Sect. 2.1). Currently, only tubes made of polyurethane or silicone are used (Bernhardt 2007).

Nasogastric or nasojejunal tubes are used for brief (up to 4 weeks) enteral feeding.

Nowadays, we differentiate between three types of tubes (◘ Fig. 7.1).

Nasogastric Tube

Various types of tubes are available; they differ in their outside diameter, length and the number of ports. They can be placed without the assistance of instruments, endoscopically or radiologically and/or a combination of both procedures.

Nasointestinal Tube

This tube has one port only and is the simplest type of jejunal tube. Usually, the tube can be inserted under radiological or endoscopic control down into the upper jejunum. For the latter technique, diameters of 8.5 CH are available, through which only nutritional solution containing no fibre can be applied.

Combined Tube (Gastric and Jejunal Port)

Usually, two-port tubes are used. The second port ends in the stomach, as is the case in the gastric tube, and serves for decompression of the stomach. Three-port tubes are also available, which are a combination of the two-port tube with an additional possibility for ventilating the stomach and an intestinal port.

Indications and Contraindications

Gastric tubes are usually used for the isolated and temporary deviation of secretion from the upper gastrointestinal tract, especially of the stomach. Here, peri- and postinterventional motility disorders, e.g. after interventions at the upper abdomen, must be named. In the case of a st. p. (partial) removal of the stomach, jejunal feeding via one-port tube is preferred; it is, e.g. necessary, when an early enteral feeding is planned, but the stomach’s motility has not yet returned. One-port tubes are used for short-term enteral feeding (up to a max. of 4 weeks) or when a PEG is contraindicated (► Sect. 3). One benefit of two-port gastric tubes is that the stomach can be actively decompressed through the port inserted into the stomach, while the other port is available for the administration of nutrition or for removing secretions. This prevents the mucous membranes from adhering.

Tubes with multiple ports, with a gastric port and a jejunal port, can be used for decompression of the stomach as well as of the upper jejunum, as you would be able to with a one-port gastric tube. At the same time, jejunal feeding is possible or liquid medication can be administered. This is particularly indicated after surgery at disrupted increase of feeding or during long-term intensive therapy.

Further indications include the bridging of oesophagogastric, oesophagojejunal or gastrojejunal anastomoses and insufficiencies of anastomoses or patients with motility disorders of the stomach caused by diabetes mellitus, neurosurgical interventions or peritoneal carcinomatosis. In these cases, tubes with multiple ports can serve to relieve pressure in the area of the anastomosis but predominantly serve early enteral postoperative feeding.

For tube insertion, the same indications and contraindications apply as for gastroscopy. Passing through anastomoses must be discussed with the surgeon prior to the intervention, since it might lead to increased stress on the anastomosis. Usually, tubes are inserted without problems; the risk of an endoscopic passage is often overestimated.

In cases of injuries to the face or skull, the therapeutic options have to be checked from case to case, since particularly in the case of tubes with multiple ports, a nasal access should be used.

Preparation of Patient

The patient’s preparation also mostly corresponds to that of a routine gastroscopy. Prior to placing the tube, the patient and/or the relatives should be informed about the measure, which should also include subsequent nutritional therapy. In case of a nasal tube, the upper gastrointestinal tract must be freely passable.

For jejunal tubes, the patient must be prepared as he would be for an endoscopy. Intensive care patients are usually already sedated and ventilated. For a patient who is awake, analgosedation is essential for the endoscopic insertion of a tube.

Personnel-Related Requirements

Nasogastric tubes are usually inserted by trained nursing staff. The tube is often also inserted during surgery, during anaesthesia.

During an endoscopy, at least one endoscopy nurse and one physician must be present. The physicians must be experienced in endoscopy and in the use of the application technique required, since, depending on the site, a modification might be necessary. The measure should be planned in advance by the treating physician.

Instrument-Related Requirements

Usually, little is required of instruments. Tube-grasping forceps are practicable for grabbing the tubes. Ideally, devices with larger working canals (greater than 3 mm) are used. An endoscopy unit (possibly with mobile use in intensive care) must be present; additionally, the possibility of monitoring must also be available, if it is not an intensive care patient.

The preparation of the respective types of tubes will be depicted in the following sections.

7.2.1 Nasogastric Tubes

Instrument-Related Requirements

The following items are required: tube; lubricant for the mandrin, if needed; a stethoscope; irrigation syringe; bandage set; local anaesthetic; and a collection bag.

Practical Course

A number of tube sizes are available for children and adults (diameter 6.5–15 CH, length 40–60 cm for children, 100–130 cm for adults). PVC tubes should not be used anymore. Due to their high biocompatibility, the decreased feeling of foreign body and the good long-term stability, newer tubes made of polyurethane plastics and silicone rubber are also used for long-term nasal and percutaneous use.

The selection of tubes depends on various parameters. The tube’s diameter should be as small as possible to allow for the highest possible comfort of the patient. At the same time, however, if the diameter is too small, application of nutrition and/or medication might become more difficult and can lead to an occlusion of the tube. For children, usually tubes with a diameter of 8 CH are used, whereas for adults, tubes with a diameter of 15 CH are usually used. For children, the tube should be 50–60 cm long, and for adults, however, it should be between 100 and 120 cm.

Sometimes, it can be of use to determine the respective length of the tube required ahead of time. For this, the distance from the earlobe to the tip of the nose (usually 10 cm) must be added to the distance of the nose to the epigastrium (usually 40–50 cm). This distance can then be marked on the tube to avoid a curling of the tube once it is placed in the stomach.

After having cleaned the nasal passages and selected the larger nostril, the nasal entry is anaesthetized with a local anaesthetic gel or spray. The patient is positioned in an upright or semi-upright position. Initially, the tube is advanced for about 10 cm at the bottom of the inferior nasal meatus. Then, the head is tilted forwards and the patient is asked to actively swallow while, at the same time, advancing the tube. If the patient is coughing or if there is resistance, the tube must be retracted, and another attempt must be made. In case of a good passage, advance the tube in gastric direction, and after having determined the position, usually by blowing in air through auscultation (alternative methods include determination of pH or x-rays), the tube is then secured to the nose.

Complications and Management of the Same

Great advantages of the nasogastric tube placement include the bedside placement and simple technique, which is noninvasive and available everywhere. Compared to the percutaneous techniques, no parallel techniques are required (Bernhardt 2007).

Despite all precautions, the placement of a nasogastric tube is also associated with acute and chronic risks. The placement of tubes can lead to nosebleed and injuries to the afferent ways as well as to a refractory bradycardia up to asystole. In the long run, repeated tube dislocations and lesions of the afferent paths (nose, oropharynx, oesophagus, stomach) limit the use of these types of tube systems. In addition, swallowing rehabilitation is also more difficult when a tube is inserted. Clinically relevant factors include the reduced application of enteral nutrition compared to percutaneous tubes, caused by dislocation, as well as the latent danger of aspiration. This can lead to a vital threat to patients.

Standardized Aftercare After the Placement of Tubes

Aftercare generally corresponds to the general care guidelines; food can be introduced immediately.

7.2.2 Nasojejunal Tubes

Instrument-Related Requirements

The following are required: prepared tube, possibly lubricant for the mandrin, a bandage set, a gastroscope (with a large lumen) and grasping forceps. In the case of many manufacturers, preparation of the tube includes filling the lumen with silicone oil or water, which significantly facilitates the later removal of the mandrin.

◘ Figs. 7.2, 7.3 and 7.4 show tubes with one, two and three ports.

Fig.7.2

One-port tube (Courtesy of company Fresenius)

Fig.7.3

Two-port tube (Easy In) (Courtesy of company Fresenius)

Fig.7.4

Three-port tube Trelumina (Courtesy of company Fresenius)

A deciding factor for the successful clinical use of nasointestinal tubes is the application technique that must guarantee the secure and permanent position of the tube in the area distal of the duodenojejunal flexure or, in rare cases, in the distal duodenum (Külling et al. 2000).

Techniques of jejunal tube placement:

TTS («through the scope»)
OTW («over the wire»)
BTS («beneath the scope»)

The simplest method is the «through the scope» technique (TTS), which includes the direct insertion of a thin tube directly into the jejunum through a widely guided endoscope, which is then left in place when removing the device. During the final naso-oral deviation, it must be ensured that the tube is placed straight in the hypopharynx. A disadvantage of this method is that even when a device with a maximum-sized working canal is used, only tubes with one port and a small diameter can be used.

In the case of the «over-the-wire» (OTW) technique, a guidewire (e.g. 0.035″ Jagwire Boston Scientific) is endoscopically inserted into the small intestine and remains in place when removing the endoscope. Through this inserted wire, which had been deviated nasally, a tube is placed (◘ Fig. 7.5) (see technique of nasobiliary tube, ► Chap. 4).

Fig.7.5

Insertion of a Trelumina tube over a guidewire (OTW technique)

This technique can be used for one-port (nasojejunal) as well as for tubes with several ports, but usually requires a radiological checking of the position prior to applying nutrition.

Especially in the case of tubes with several ports, a radiological control or having marked the tube with a colour code is helpful.

Very often, the insertion technique «beneath the scope» (BTS) is used. It includes grabbing the distal end of the nasally inserted tube with special forceps endoscopic-gastrically, which is then guided in intestinal direction using the device. If further endoscopy is not possible anymore, the forceps with the affixed tube are advanced as much as possible and then remain in situ while the device is retracted. Once the (diagnostic) endoscope is positioned in the stomach, the forceps are loosened and then slowly moved back into the device. This technique is generally helpful when inserting intestinal tubes, such as a jejunal tube via PEG.

If the tube is dislocated in proximal direction, the tube can then be advanced again using the grasping forceps. When placing tubes with several ports, it must be ensured that the gastric tube opening is not placed transpylorically. Sometimes, this endoscopic procedure is work intense and also requires special skills of the person performing the procedure. An advantage includes the good control of the tube’s position through direct visual control.

The BTS procedure is of the same value as the OTW procedure described before; the method being used is up to the person performing the procedure.

Due to the comfortable technique, two procedures of inserting a tube are usually combined. In the case of the two-port tube Easy In, the jejunal tube is initially placed using the TTS technique. The jejunal part of the tube is then deviated with a deviation tube as would be the case when inserting a nasobiliary tube (► Chap. 4). Afterwards, the inserted tube is used as a splint for the gastric port, which is inserted through the same into the stomach, nasally. An alternative procedure would include the nasal insertion of the three-port tube into the stomach, as would be the case with a gastric tube, and then placed into the jejunum using the BTS technique.

Complications and Management of the Same

Acute complications during the insertion procedure are rare. An inexperienced endoscopic physician might have difficulties with the placement, which may sometimes be technically even impossible for him. Time requirements vary significantly, but usually it takes an experienced physician 15 min.

The following applies to all intestinal procedures: The small diameter of the tube promotes occlusion, especially when applying medication. In addition to the problems associated with nasal tubes, which are identified above, intestinal tubes carry the potential risk of dislocation with the consecutive risk of aspiration. This is particularly the case when there is no deep intestinal placement.

Changing from the mouth into the nose also carries the risk of dislocation.

Tubes inserted for a longer period of time carry the risk of erosions and ulcerations at the distal oesophagus and stomach. For these reasons, these should not be inserted for more than 2 weeks; then instead, a PEG is placed. In the end, nasointestinal tubes with one or more ports should only be used for short periods of time, in selected patients. Deciding factors are experience and success of primary placement (Dormann and Deppe 2002).

7.3 Percutaneous Endoscopic Gastroscopy

Since the initial description through Gauderer and Ponsky in 1980, the percutaneous endoscopic gastrostomy (PEG) is now widely spread worldwide due to the technically simple and secure placement options and due to the high acceptance by patients. In the United States, about 216,000 PEG tubes are now newly inserted annually (210,000 adults, 6000 children). The annual growth rate is in the double digits. There are no reliable numbers for Germany, but based on epidemiology, we assume that in Germany, there must be about 130,000 PEGS newly inserted annually.

Indications

Please view ◘ Table 7.1 regarding the indications for a percutaneous tube. As is the case in every medicamentous therapy, each case must be assessed carefully to ensure that this type of feeding procedure is a reasonable therapeutic option. This especially applies to patients suffering from dementia.

Table 7.1

Significant indications for the insertion of a PEG

Neurological illnesses	Swallowing disorders, e.g. due to insult, cerebral trauma or surgery, atrophic lateral sclerosis (ALS), brain tumours, multiple sclerosis, dementia (?)
Oncological illnesses	Swallowing disorders, e.g. in cases of stenosing tumours in the oropharynx and oesophagus Tumour cachexia due to inadequate oral food intake Mucositis, diarrhoea
Other indications	Traumas of the facial skull or surgery Chronic obstructive pulmonary illnesses with severe cachexia Severe absorption disorders, also short bowel syndrome Mucoviscidosis Systemic illnesses (collagenoses, etc.) Palliative decompression, retention stomach Longer enteral feeding at intensive care

Contraindications

The absolute contraindications are clinically significant.

Absolute contraindications for insertion of a PEG:

Endoscopy cannot be performed, e.g. in the case of absolute passage obstruction
Severe coagulation disorders (Quick <50%, PTT >45 s, platelets <50,000/μl)
Pylorus stenosis, e.g. endoscopic local findings (large ulcers, severe erosive gastritis, extensive tumour infiltration of the stomach)
General contraindications for enteral feeding, e.g. peritonitis, ileus
Acute abdominal illnesses, e.g. intraabdominal infections, pancreatitis, peritonitis
Anorexia nervosa
Severe psychosis

The relative contraindications are predominantly dependent on the examiner’s experience and should be checked strictly by the beginner.

Relative contraindications for PEG insertion:

Chemotherapy, acute infections, sepsis
No diaphanoscopy
Ascites, peritoneal carcinomatosis
Ulcer in the area of the puncture
(Partial) stomach removal (select jejunal tube technique)
Anatomical particularities (e.g. hernias of the abdominal wall)
Portal hypertension, abdominal wall varices
Peritoneal carcinomatosis
Ventriculoperitoneal shunt
Peritoneal dialysis
Ileus/intestinal obstruction
Gastrointestinal fistulas
Infaust prognosis (survival time <4 weeks)

If the patient is suffering from an acute infection or sepsis, enteral feeding should be guaranteed by a nasal tube until the infection has consolidated. In the case of an acute infection and prior to and/or after chemotherapy with leucocyte nadir, the elective insertion of a PEG should be postponed and performed at a more beneficial time. If that is not possible, a periinterventional antibiotic prophylaxis should be performed for a few days, and/or ongoing antibiotic therapy should be continued.

Nowadays, a missing diaphanoscopy is not considered a contraindication anymore. If an impression of the abdominal wall leads to a good protrusion of the stomach’s wall and if a good passage into the stomach can be achieved with a thin needle during the trial puncture, a PEG can also be inserted into these patients, provided the physician has some experience (Ponsky 1996). Patients proven to be suffering from disorders affecting the emptying of the stomach should primarily receive a jejunal tube. If that is not possible, a PEG can be initially inserted, which can then, over time, be increased in length in jejunal direction (► Sect. 4). Larger amounts of ascites or a peritoneal carcinomatosis can prevent the adhering of the stomach to the abdominal wall and pose a contraindication. If, periinterventionally, insertion of a long-term ascites drain is guaranteed, a PEG can also be inserted in these patients using a direct puncture procedure and gastropexy (► Sect. 3.2). In this case, however, the tube remains taught for a prolonged period of time, so as to ensure adherence of the anterior wall of the stomach to the anterior abdominal wall.

An active ulcer is only a problem if the ulcer is located directly in the area of the puncture site at the anterior wall of the stomach or at the pyloric orifice. In these cases, ulcer therapy should take place first, and the tube should be inserted later on. An alternative would be using the jejunal tube technique. Placement of a PEG may also be impossible due to st. p. surgeries, especially when stomach-removing procedures were selected and when the remaining residual stomach is too small or not present (◘ Fig. 7.6).

Fig.7.6

Postoperative insertion of a PEG

If placement is not possible, a jejunal tube insertion is usually possible without problems in these cases. Sporadically, larger hernias in the upper abdomen can make placing a tube more difficult. In cases of portal hypertension leading to oesophageal varices and hypertensive gastropathy, placement of a PEG can sometimes be impossible due to large vessel convolutes or severe coagulation disorders. In patients with a ventriculoperitoneal shunt or peritoneal dialysis catheters, making a decision is more difficult. For both cases, there are reports of successful placements of PEGs. This intervention should then, however, be performed in experienced centres to avoid damaging the catheter and infectious complications. A simultaneous implantation of a ventriculoperitoneal shunt must be avoided.

Anorexia nervosa and psychoses are still generally clear contraindications. In cases of a terminal illness, indication is only given under the palliative aspect of draining the stomach.

Preparation of the Patient

Preparation of the patient should be a standardized procedure at every hospital. Upon arriving at endoscopy, a checklist should be used to ensure the presence of everything required, before the patient is brought to the exam room. Patients receiving a PEG should be scheduled early to allow for discovering possible complications during the course of the day.

Preparing a patient for insertion of a PEG:

Information: >24 h prior to intervention, signed legally valid informed consent, give out copy to the patient/guardian (please note: a guardian is required in cases where patient is not able to provide consent).
Patient needs to remain fasting (at least 8 h), in case of a retention stomach up to 24 h.
Stable venous access.
Regular administration of antibiotic prophylaxis (e.g. cephalosporin first generation) 30 min prior to the intervention.
Facultative: disinfection of the mouth/pharynx.
If there is hair, shorten hair with hair cutter, if needed.
Rule out contraindications.
Current coagulation status: Quick >50%, PTT <40 s, platelets >50,000/mm³).
During endoscopy, positioning of the patient in supine position with the head sideways.
Fixation of the hands using Velcro strips, if needed.

Personnel-Related Requirements

The following must be present during the examination: at least one person for sedation (usually a nurse experienced with sedation), an endoscopy nurse and two physicians for endoscopy and puncture. The physicians must be experienced in endoscopy and in the use of the various tube techniques, since, occasionally, depending on the site, changing of the application technique might be required.

Instrument-Related Requirements

As is the case in every interventional endoscopy, continuous measuring of O₂ saturation (pulse oximetry), taking of the blood pressure with documentation and, in patients starting at ASA III, an EKG deviation are required.
Additionally, a sterile table must be prepared especially for this examination, containing the following:
- PEG set (PEG tube, scalpel, puncture cannula made of steel with a plastic sheath, external fixation plate, tubing clamp, application adapter (◘ Fig. 7.7))
- Incise drape
- Gauze pads
- Dressing set with y-gauze pad
- Syringe 10 ml with local anaesthetic and puncture needle size 1
Fig.7.7

PEG set CH 15 Freka (Courtesy of company Fresenius)
For sedation, prepare midazolam (5 mg syringe) and propofol (200 mg syringe).
Prepare standard gastroscope.
Surgical standard with sterile gloves, clamp or tweezers for washing off and solution for skin disinfection.

Practical Development

After disinfection of the abdomen, intubation of the endoscope and ruling out of relevant illnesses of the proximal gastrointestinal tract (such as ulcer, pylorus stenosis, etc.). In a darkened room, after extensive insufflation of air in the area of the anterior wall of the stomach, in oral direction of the angulus fold, searching for a diaphanoscopy. Required is the following: a circumscribed, clear and clearly identifiable diaphany with clearly positive fingerprint and no problems with reproduction (◘ Fig. 7.8). It might be helpful to position the patient flat or with exposition of the lower thoracic aperture, so as to allow a secure puncture of the stomach. The examiner must be aware of the insufflation changing the stomach’s topography and that the most secure puncture site is slightly left to the epigastrium, yet at least 2 cm from the left coastal arch.

Fig.7.8

Diaphanoscopy prior to insertion of PEG

7.3.1 Thread Pull-Through Method

After local anaesthesia of the abdominal wall, puncture of the stomach’s lumen. The puncture site is located in the middle area of the left upper abdominal quadrant. Especially in the case of insecurities regarding the puncture, aspiration is possible while advancing the local anaesthesia needle. If blood or air is aspirated without the tip of the needle being visible in the stomach’s lumen, the puncture site must be changed (negative needle aspiration test) (◘ Fig. 7.9a). The puncture needle is then directed into the stomach to determine the length and direction of the future stoma canal. Afterwards, deep puncture incision is done, about 1 cm in width, and puncture cannula of the regular set is introduced (◘ Fig. 7.9b). After retreating the puncture needle, the introductory sheath remains in the stomach. Through the same then, introduction of the pulling thread is done, which is grabbed using forceps and then pulled in oral direction (◘ Fig. 7.9c, d). The PEG tube is attached to the end of this thread and pulled through the oropharynx into the stomach (◘ Fig. 7.9e). The base of the tongue is protected by inserting one finger between the thread and the actual tongue. The thread is pulled with caution and continuously. At the end of the intervention, the internal fixation plate must be located at the anterior wall of the stomach. An endoscopic control is usually not required. In case of stenoses of the passage way, the internal fixation plate can be cut crosswise so as to facilitate the passage. Afterwards, application of the external fixation plate and application of a standardized dressing to the wound are done. The tube must be affixed using light pressure to ensure adhesion between the stomach and the abdominal wall. After 48 hours, loosening of the tube, turning of the same in the stoma canal and slight pulling prior to applying another dressing.

Fig.7.9

Placement of a PEG via pull-through method of thread: a prepuncture, b cannula in place, c cannula with introduced forceps, d grasping forceps with thread grabbed, e temporary internal fixation plate through the oesophagus

7.3.2 Direct Puncture Technique mod. According to Dormann

Indications/Contraindications

From technical standpoint, the procedure deviating from the direct puncture technique (insertion of the tube from outside to inside) is better suited for the patients, since the fixation plate is not passing through the oropharynx (Russel et al. 1984). It is primarily indicated for the patient groups described below who benefit from this percutaneous access.

This procedure exhibits the same contraindications as the pull-through PEG.

Patients with indication for direct puncture PEG:

Primary nasal endoscopy
High-degree stenoses in the oesophagus/oropharynx
Danger of spreading tumour through pull-through PEG, especially in cases of curative therapy intentions
Perioperative PEG insertion for a short period of time
Oropharyngeal contamination with MRSA
PEG insertion with gastropexy necessary in case of development of ascites (malignant or hypoalbuminemia)

Preparation of Patient

Preparations are the same as for the pull-through PEG.

Due to the minimal costs and proven efficiency, antibiotic prophylaxis to reduce local infections is, however, necessary.

Instrument-Related Requirements

As is the case in every interventional endoscopy, continuous measuring of O2 saturation (pulse oximetry), taking of the blood pressure with documentation and, in patients starting at ASA III, an EKG deviation, are required.
Additionally, a sterile table must be prepared especially for this examination and must contain the following:
- PEG set (currently only commercially available set Freka-Pexact with PEG tube, scalpel, puncture cannula made of steel with peel-off plastic sheath, exterior fixation plate, tubing clamp, application adapter, suture set, thread set) (◘ Fig. 7.10)
- Incise drape
- Gauze pads
- Dressing set with y-gauze pad
- Syringe 10 ml with local anaesthetic and puncture needle size 1
- Sterile gloves, clamp or tweezers for washing off and solution for skin disinfection
Fig.7.10

Freka-Pexact set (Courtesy of company Fresenius)
For sedation: prepare midazolam (5 mg syringe) and propofol (200 mg syringe).
Prepare stenosis gastroscope (outer diameter of about 5 mm).
Surgical standard for application with sterile gloves.
Have available a guidewire with hydrophilic tip, e.g. Jagwire (Boston Scientific), in case of high degrees of stenoses.
If needed, fluoroscopy option with C-arch, if the endoscope can only be inserted after wire passage.
Have readily available dilation balloons or bougies with a diameter of about 7 mm.

Practical Course

Insertion of the direct puncture PEG depicted here using an example (Freka-Pexact) is a standardized procedure used in every patient (◘ Fig. 7.11a–j). Gastroscopy is primarily performed through nasal or oral intubation. In cases of high degrees of stenoses, the guidewire (e.g. Jagwire, Boston Scientific, 0.035″) is initially guided through the stenosis, and the endoscope is then advanced under radiological control. After having ruled out a pylorus stenosis endoscopically and if there is evidence of the diaphanoscopy and/or positive needle aspiration test, administration of local anaesthesia will follow (10 ml xylocaine 1%). Under surgical conditions, the stomach is now fixed to the anterior abdominal wall via double-port gastropexy device. Once the gastropexy device is securely positioned intragastrically, the sling is opened, and the gastropexy thread is inserted; after fixation, the gastropexy device is removed, and a U-shaped suture is placed above the skin. A second gastropexy suture is placed 2 cm further. After the stab incision (width of the blade of a standard scalpel) between both gastropexies, the stomach is punctured using a trocar with a peel-off sheath. While doing this, a good endoscopic insufflation of air must be ensured so as to avoid injuries to the posterior wall of the stomach by the trocar. Additionally, the gastropexy threads can be used as retention threads of the abdominal wall, if the puncture turns out to be more difficult. Once a secure intragastric position is ensured, the balloon catheter is inserted through the sheath, blocked with 4 ml of 0.9% physiological saline solution, and finally, the endoscope is removed. Afterwards, the exterior fixation plate is fixed. In the end, the wound is disinfected and applied with a pathogen-free dressing (sterile plate and dressing).

Fig.7.11

Direct puncture technique for insertion of a PEG/PEJ: a gastropexy device in situ with opened sling, b grabbed suture thread, c double gastropexy from inside and outside with suture distance, d stab incision, e puncture with trocar, f trocar from gastric, g trocar with peel-off sheath, h peel-off of the sheath, i blocked balloon from the inside, j end of the procedure

Only gold members can continue reading. Log In or Register to continue