Enteral Access Techniques


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Enteral Access Techniques: Percutaneous Endoscopic Gastrostomy and Jejunostomy


Lauren K. Schwartz1 and James A. DiSario2


1 New York University Grossman School of Medicine, New York, NY, USA


2 University of Utah Health Sciences Center, Salt Lake City, UT, USA


Introduction


Endoscopic procedures for percutaneous enteral access include percutaneous endoscopic gastrostomy (PEG), percutaneous endoscopic gastrostomy with jejunal extension (PEG‐J), and direct percutaneous endoscopic jejunostomy (DPEJ) [1]. These procedures have specific indications, and many common and unique techniques that must be imparted to the trainee. Fundamental principles are those of standard esophagogastroduodenoscopy (EGD), guide wire techniques, push enteroscopy, and fluoroscopy. PEGs are the mainstay for long‐term provision of enteral nutrition. Jejunal access is required for persons with intolerance to gastric feeds, gastric dysmotilty, upper intestinal obstruction, and can be considered in patients with severe pancreatitis [2]. The instruction process involves a stepwise progression in procedural training from PEG to PEG‐J, and ultimately to DPEJ. The trainee should be taught both the endoscopic and abdominal wall maneuvers required for these procedures. Additionally, the beginner must be taught about replacement and removal of these tubes, stoma care, and management of complications [3–5].


Prerequisite expertise and skill


Most enteral nutritional access procedures are Level 1, which means that they are appropriate for the routine practice of gastroenterology [3–7]. The trainee should understand that these procedures are a mainstream part of the practice of gastroenterology, can be performed in a safe and efficient manner with proper techniques, and are effective in the short and long terms. Trainees must understand the principles of gut anatomy and physiology. They should be skilled in EGD prior to attempting PEG, and guide wire manipulation, push enteroscopy, and basic fluoroscopy as prerequisites for jejunal access procedures. The trainee must also understand the principles of sterile surgical technique, and wound and stoma care. Because of the difficulty in maneuvering the endoscope in the jejunum, and the need for an assertive trocar puncture into the jejunum, DPEJ is most appropriately taught only after the trainee has developed significant PEG and enteroscopy skills [5–7].


Success in DPEJ placement depends in part on the patient’s body habitus as abdominal wall and omental fat may limit the ability to transilluminate adequately. Jejunostomy placement is generally easier in patients with previous abdominal surgery because of adhesions that may cause small bowel adherence to the abdominal wall and limit motion. This type of patient is good for initial training for the novice [2–5].


Setting


Training should be done in accredited training programs with trainers who are experts in endoscopy and teaching [3, 6, 7]. Training in most enteral access procedures can be done in appropriately accredited standard ambulatory or inpatient units. Jejunal access procedures may require fluoroscopy and the requisite facilities. Requirements for trainees are generally those of EGD; however, jejunal access procedures may require more experience with the technique being performed [8].


Equipment


There are numerous commercially available products for enteral nutritional access. It is not necessary for the trainees to know all about the numerous products but they must be made familiar with one or two types of devices for each technique. PEG, PEG‐J, and DPEJ gastrostomy devices are often made of silicone or polyurethane, are 12–24 Fr, contain an internal fixation apparatus that may have a balloon or molded mushroom shape, and have an external bolster and a coupling device. Generally, they come in kits that contain all necessary supplies including: topical disinfectants, syringes and needles, injectable anesthetics, a scalpel, an endoscopic snare, a guide wire, antibiotic ointment, dressing materials, and instruction booklets for the providers and patient. PEG‐J jejunal extension tubes range from 9 to 12 Fr, are about 60 cm long, and may come with or without a central lumen for passage over a wire. Other systems may also contain T‐fasteners, a sequential dilation apparatus for the track, and a peel‐away sheath. PEG‐J kits may have a separate jejunal tube that passes through the PEG with a coupling device. DPEJ insertion may be done with a standard PEG kit. Replacement tubes are available in various diameters with an adjustable external fixation bolster and an inflatable internal fixation balloon. There are also tubes with a mushroom‐shaped internal fixation tip that can be stretched straight with the enclosed stylet. The mushroom shape will return when the stylet is removed. These tubes come in preset lengths for the stoma track and require a measuring device. Endoscopic clips may be useful for J‐tube fixation [8].


Key steps for proper technique


Percutaneous endoscopic gastrostomy (PEG) insertion, replacement and removal


Pull‐ or push‐type PEG insertion


c30i001 Pull‐type PEGs are systems where the PEG tube is attached to a loop in the wire passed through the abdominal wall and out through the mouth. The wire is pulled from outside the abdomen to retract the PEG tube through the mouth, esophagus, and out the stoma. A pull‐PEG apparatus is shown in Figure 30.1, a commercial kit in Figure 30.2, and the procedure is demonstrated in Figure 30.3 (Video 30.1). The push‐type employs a guide wire pulled through the abdominal wall and out through the mouth. The PEG tube is inserted over the guide wire and pushed through the mouth, esophagus, stomach, and abdominal wall where it is grasped and pulled through [2, 9]. The push‐PEG procedure is shown in Figure 30.4. The following steps should be taught to the trainee:

Photo depicts the pull-PEG apparatus. The image shows a 24-Fr polyurethane PEG tube with a mushroom-type internal fixation design and a moveable external bolster over the tube.

Figure 30.1 The pull‐PEG apparatus. The image shows a 24‐Fr polyurethane PEG tube with a mushroom‐type internal fixation design and a moveable external bolster over the tube.



  1. Prophylactic antibiotics: Antibiotics should be administered 1 hour prior to incision time. In select patients who require vancomycin prophylaxis, the infusion should be within 2 hours of the procedure since a slower infusion rate is required [10]. If patients are receiving antibiotics for other indications, care should be taken to ensure appropriate microbial coverage and that the infusion occurs within the designated timeframe. Additional antibiotics should be administered if necessary.
    Schematic illustration of a commercial pull-PEG kit. The kit contains a silicone PEG tube, guide wire, local anesthetic, scalpel, syringe, and trocar.

    Figure 30.2 A commercial pull‐PEG kit. The kit contains a silicone PEG tube, guide wire, local anesthetic, scalpel, syringe, and trocar.

    Schematic illustration of the pull-PEG.

    Figure 30.3 The pull‐PEG. (a) The endoscope is positioned in the stomach, a loop‐tipped guide wire is passed through the transabdominal trocar sheath and ensnared in an endoscopic snare, and the endoscope is retracted. (b) The endoscope is pulled out through the mouth and the transabdominal wire is released. (c) The pull‐PEG feeding tube is coupled with the transendoscopic wire, which is retracted from the abdominal side. (d) The transendoscopic wire and pull‐PEG feeding tube are pulled through the abdominal wall, the trocar sheath is removed, and retraction is continued until the internal retention bumper is felt to abut the gastric and abdominal walls.

    Schematic illustration of the push-PEG.

    Figure 30.4 The push‐PEG. (a) The endoscope is positioned in the stomach, a straight‐tipped guide wire is inserted through the transabdominal trocar sheath and ensnared in the endoscopic snare, and the endoscope is retracted out through the mouth. (b) The transabdominal wire is released from the snare and inserted through the push‐PEG feeding tube. (c) The wire is held firm from both ends and the push‐PEG is pushed over the wire. (d) The trocar sheath is removed, the tip of the feeding tube is grasped when it passes through the abdominal wall, and the feeding tube is then pulled until the internal retention bumper is felt to abut against the gastric and abdominal walls.


  2. Position the patient supine.
  3. Sedation and analgesia: Administer standard mild to moderate sedation and analgesia.
  4. Perform EGD: Esophageal intubation in the supine position is facilitated by flexing the neck. Carefully observe and suction the oropharynx to prevent aspiration. A complete endoscopic exam should be performed prior to PEG placement. Endoscopists frequently find lesions that change clinical management.
  5. Abdominal site selection: The optimal site for PEG placement is in the left upper quadrant at least 2 cm inferior to the costal margin. This distance minimizes the potential for the ribs to touch the PEG tube and cause pain when the patient sits upright. Other sites can also be used, including a prior PEG site or existing scar site. Ultimately, site selection depends on identifying an area along the abdominal wall with proper transillumination and digital palpation. This is an area where the light of the endoscope can be seen on the surface of the abdominal wall and an acute indentation from digital palpation can be seen internally along the stomach wall. This area is identified as follows:

    1. 5a Gastric insufflation: Insufflating the stomach with air causes the anterior gastric wall to abut the abdominal wall and allows for transillumination.
    2. 5b Transillumination: Position the tip of the endoscope close to the anterior gastric wall to direct the light through the abdominal wall. Darken the endoscopy room and use the transillumination mode on the endoscopic processing unit for a brighter light to facilitate this maneuver if necessary.
    3. c30i0015c Digital abdominal pressure (Video 30.2): Apply digital abdominal wall pressure at the brightest transillumination site. Assure that there is direct indentation on the gastric view, which is commonly termed “good one‐to‐one apposition.” Digital abdominal pressure may be used to help locate the transillumination site when it is not clearly seen in the standard fashion that often occurs in obese patients.

    Of note: The anterior aspect of the gastric body is a preferred location for PEG placement since positioning the tube in the proximal body directs the axis of the PEG tube toward the pylorus. This is useful if the PEG is ever converted to a PEG‐J since a jejunal extension tube can be fed into the PEG tube through the pylorus and into the small intestine. In contrast, distally placed PEG tubes are angled superiorly making it difficult to direct a J‐tube extension toward the pylorus and into a stable position that will not dislodge.


  6. Mark the spot: Mark the site of maximal transillumination and digital indentation with a sterile marker or other device.
  7. Abdominal preparation and draping: Using sterile technique, cleanse the intended PEG site with betadine and extend outward in a spiral fashion. The person doing the abdominal maneuvers should now dress in a sterile gown and gloves. Once in sterile garb, cover the entire abdomen with sterile drapes.
  8. Anesthetize the site: Use a small caliber (25 G) needle for injection of the local anesthetic, creating a bleb in the skin.
  9. c30i001 The safe track (Video 30.3) [11]: Attach a fluid‐filled syringe with a medium gauge needle of adequate length to enter the stomach through the selected site. Aspirate back on the plunger as it is inserted. The needle should be endoscopically seen to enter the stomach at the same time that air is seen to enter the syringe. This helps to assure that there is not a loop of bowel interposed between the stomach and the abdominal wall. If air is seen in the syringe before the needle enters the stomach, there is likely to be interposed bowel. In this circumstance, the entire PEG process must be redone at a different site or the procedure aborted. For efficiency, use the syringe with the local anesthetic for the safe track and anesthetize the peritoneum and abdominal wall as the needle is withdrawn.
  10. Position the endoscopic snare: Pass a snare through the endoscope and position it near the safe track site in the gastric mucosa.
  11. Incision: Make a 1 cm‐long incision at the puncture site. Orient the incision on the horizontal axis for a better cosmetic outcome in the event that the PEG is removed.
  12. c30i001 Trocar insertion (Video 30.4): Insert the trocar through the safe track and endoscopically visualize it in the stomach. Gently ensnare the trocar and remove the obturator. Put a finger on the open trocar sheath to minimize air (and insufflation) loss, which could change the position of the stomach.
  13. c30i001 Insert the guide wire (Video 30.5): Pass the guide wire through the trocar sheath and grasp it with a snare a few centimeters from the tip. Pull the tip of the snare with ensnared guide wire slightly inside the working channel of the endoscope.
  14. Retract the endoscope and guide wire: Unlock the knobs on the endoscope and gently retract it through the mouth while the person doing the abdominal maneuvers advances the wire to avoid tension. Leave the trocar sheath in place to prevent trauma to the puncture site. Clamp a hemostat on the abdominal end of the wire to avoid inadvertent retraction into the stomach or out through the mouth.
  15. c30i001 Pass the gastrostomy tube (Video 30.6): Secure the PEG tube to the oral end of the wire (or pass it over the wire for push‐type kits), liberally apply sterile lubrication, and pull (or push) it through the mouth and out through the abdominal incision site.
  16. c30i001 Secure and dress the PEG tube (Video 30.7):

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Jul 31, 2022 | Posted by in GASTOINESTINAL SURGERY | Comments Off on Enteral Access Techniques

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