Introduction

Single‐stage PEG is a novel adaptation of the preexisting technique. The standard procedure for gastrostomy is performed in two steps, with a change from a PEG tube to a PEG button 6–8 weeks after PEG tube placement, a necessary time frame for the stoma to mature.

The new alternative to classic PEG is coming forward as a superior method in selected cases: one‐step endoscopic procedure for inserting a low‐profile tube button that permits initial placement of a balloon‐retained device.

Indications

Single‐stage PEG is used in patients who are at high anesthetic risk and experience chronic problems with feeding, requiring long‐term or lifetime enteral nutritional support, such as neurologically impaired children.

Contraindications

These are the same as for standard PEG placement (see Chapter 33). Relative contraindication: small child (10 kg) due to potential reduced surface area for triangulation around the stoma site with gastropexy needles.

Advantages of single‐stage PEG

A single‐stage PEG button allows the button to be placed without requiring a second procedure. There are several advantages for the patient: no additional anesthetic session or hospitalization, cosmetically better than a long tube (facilitating social integration), durable device with a significantly longer interval between device changes [1]. The procedure is of particular advantage to patients with a high anesthetic risk as it incorporates just one session of anesthesia and one interventional endoscopy and associated health costs are thus reduced [2].

Studies have shown that single‐stage PEG and classic PEG share a similar safety profile and complication rate [1–5], with more benefits derived from a single‐stage PEG button: a lower rate of peristomal infection [2], as the PEG catheter is not passed through the oropharynx, less common postoperative feeding intolerance [1], and fewer concerns for dislodgment [3] (Table 34.1).

The single‐stage PEG can also be performed in instances where gastro‐jejunal feeding is needed [4].

Drawbacks

Although the recent ESPGHAN position paper on management of PEG in children welcomes the advantages of single‐stage PEG, it acknowledges that published experience in children is limited [6].

Technique

Procedure

1. Site identification

The patient is in the supine position. The endoscopist introduces the endoscope in the stomach and insufflates the stomach with air. Transillumination and indentation are used to identify the site of PEG placement which should be one‐third of the distance from the umbilicus to the left costal margin at the midclavicular midline. The endoscopist should see the depression caused by indentation on the anterior surface of the gastric wall (Figure 34.1) and the physician performing the intervention should clearly see the transillumination on the same spot (Figure 34.2).

2. Marking the site

Three marks should be made in a triangular shape that surrounds the PEG site, being equidistant – approximately 2 cm from each mark to the site of PEG (Figure 34.3).

3. Placing of gastropexy

1. Attach a syringe with saline to the preloaded gastropexy needle (Figure 34.4) and insert the needle in one of the corners of the triangle (Figure 34.5). Correct position is confirmed by air noted only while entering the stomach.
   
2. Remove the suture thread (Figure 34.6). Detach the syringe.
   
3. Bend the strip on the needle (Figure 34.7). Dislodge the T‐bar by pushing the inner hub into the outer hub.
   
4. Withdraw the needle and pull the T‐bar until it is positioned on the gastric mucosa (Figure 34.8).
   
5. Slide and close the suture lock on the abdominal surface (Figure 34.9).
   
6. Repeat the procedure for the other two marked sites. At the end of it, the anchor set should be placed on the corners of the triangle (Figures 34.10 and 34.11). The gastric wall is now fixed to the anterior abdominal wall.

4. Creating the stoma tract

1. Identify the PEG placement site at the center of the gastropexy triangle.
   
2. Anesthetize the site of PEG placement (Figure 34.12).
   
3. Make a small (<0.5 cm) but deep incision (Figure 34.13).
   
4. Insert the safety introducer needle (Figure 34.14).
   
5. Advance the guidewire and remove the safety introducer needle, keeping the safety collar (Figures 34.15–Figure 34.17 ).

5. Dilation of the stoma tract and measuring the stoma length

1. Advance the dilator over the guidewire in order to dilate the stoma tract to the desired size using clockwise and anticlockwise movements while endoscopically maintaining visualization of its inner part throughout the entire procedure (Figures 34.18 and 34.19).
   
2. With the guidewire in place, remove the dilator and advance the measuring device over the guidewire (Figure 34.20).
   
3. Inflate the balloon of the measuring device and slide the disc to the abdominal wall while pulling. Measure the length. Deflate the balloon and remove the measuring device but keep the guidewire (Figure 34.21).
   
4. Continue dilation by advancing the dilator over the guidewire again and using the same movements as above until the appropriate diameter is reached (12–16 French) (Figures 34.22 and 34.23).
   
5. Rotate the dilator central part to release the peel‐away sheath from the dilator (Figures 34.24 and 34.25).
   
6. Remove the dilator and the guidewire, leaving the peel‐away sheath in the stoma tract (Figure 34.26).

6. Button placement

1. Advance the appropriate‐sized button through the peel‐away sheath while peeling the sheath down to the skin level (Figures 34.27–34.29).
   
2. When the button is in the stomach, peel the sheath completely and remove it (Figure 34.30–34.35).
   
3. Inflate the balloon as per its own kit instructions.

After completion of all steps, the balloon should be placed in the center of the triangle delimited by the three gastropexy T‐bars (from the gastric view) and the button in the center of the triangle delimited by the three suture locks (from abdominal view) (Figures 34.36 and 34.37).

Postprocedure management

• Both the stoma and gastropexy areas should be inspected daily for signs of infection.
  
• Enteral feeding can be started as per classic PEG insertion protocols.
  
• The sutures may be left to be absorbed or may be cut but no earlier than two weeks post procedure.

Complications

Complications are the same as the standard PEG although pneumoperitoneum has a slightly higher incidence (see Chapter 33).

Once enteral access is no longer required, the button can be removed in an outpatient setting or at home and the gastrostomy site can be allowed to close by itself.

Useful tips

• Pick the location that is best based on individual anatomy.
  
• Ensure at least 1 cm distance between triangulation sites and in addition 1 cm distance from the gastrostomy site to the gastropexy needle site.
  
• Ensure the position of the gastrostomy site is correct with the aid of a local anesthetic needle. The risk of colonic interposition between the abdominal wall and stomach can be minimized by using the local anesthetic syringe. Whilst introducing this syringe into the stomach, if air bubbles are noticed in the syringe only before visualization of needle in stomach, then this raises the possibility of colonic interposition.
  
• “Pull” the gastropexy sutures up (i.e., pull the stomach against the abdominal wall) gently and only when the dilator is being introduced into the stomach. Excess pulling force may risk snapping of the suture or eroding of the T‐bars into the gastric mucosal wall.
  
• Use CO₂ instead of air as it is absorbed more easily following escape into the peritoneal cavity after stomal opening in the stomach.
  
• Secure the gastrostomy button using Tegaderm® or similar sheaths in the first 72 hours of inpatient stay to minimize movement of the gastrocutaneous fistula and reduce the risk of leak by the formation of a “Y” tract.

Materials

The procedure described in this chapter was performed using a Halyard® introducer kit for gastrostomy feeding tube.

Consent

The mother of the patient shown in the images consented for the procedure to be performed and for photos to be taken and used for educational purposes.