0016-5107/111/2701-0009$02.00/0 GASTROINTESTINAl ENDOSCOPY Copyrighl © 19111 by lhe American Sociely tor Gaslroinlestinal Endmcopy
Percutaneous endoscopic gastrostomy: a nonoperative technique for feeding gastrostomy Jeffrey L. Ponsky, MO Michael W. L. Gauderer, MO Cleveland, Ohio
Feeding gastrostomy is a useful means of providing nutrition in patients unable to swallow. Percutaneous endoscopic gastrostomy provides a means for creating a feeding gastrostomy without the necessity for laparotomy. It adds a new tool to the armamentarium of the therapeutic endoscopist.
Patients unable to take oral alimentation often require the establishment of a feeding gastrostomy. Such patients include those with severe neurological impairment, retarded infants, and individuals with tumors of the oral cavity. Conventional techniques for performance of a feeding gastrostomy require formal abdominal laparotomy. These patients are frequently poor anesthetic and operative risks. We have developed an endoscopic technique for creation of a gastrostomy which can be accomplished with local anesthesia and without the necessity for laparotomy. Percutaneous endoscopic gastrostomy (PEG) is a nonoperative, endoscopic technique for placement of a transabdominal gastric feeding tube. This method is rapid, safe, and effective in providing an adequate avenue for enteral alimentation in selected patients.
MATERIALS AND METHOD Patients were selected for PEG after careful determination that no other long term method of alimentation was superior. A total of 30 patients have undergone the procedure at the time of this writing. These patients ranged in age from 4 months to 83 years. Eleven children had severe neurological impairment or mental retardation which made oral alimentation impossible or dangerous because of the risk of aspiration. Twelve adult patients had neurological impairment following stroke or extensive neurosurgical procedures, two had severe respiratory failure, and five procedures were done in patients with carcinoma of the oral cavity. The patient is placed on the endoscopy table in the supine position. The posterior pharynx is sprayed with From th~ Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio 44706. Reprint requests and correspondence: leffrey L. Ponsky, MD, Direclor of Surgery, Mt. Sinai Hospital of Cleveland. 1800 f. 105 Street, Cleveland, Ohio 44706. VOLUME 27, NO. 7, 7987
topical anesthesia and intravenous sedation is administered. The abdomen is prepared with antiseptic solution and sterile drapes are applied. The gastroscope is introduced through the patient's mouth and the stomach is fully inflated. Distention of the stomach displaces the liver upward and the colon downward. With the room lights dimmed the light of the endoscope is seen to transilluminate the abdominal wall, indicating the gastric and abdominal walls are in direct contact. A point is chosen on the abdominal wall approximately one third the distance from the midpoint of the left costal margin to the umbilicus (Fig. 1 a). The skin and fascia at this point are infiltrated with local anesthetic, and a 5-mm skin incision is made using a no. 11 scalpel blade. A 16-gauge Medicut catheter is thrust through the abdominal wall and into the inflated stomach under direct vision of the gastroscope, and the metal stylet is removed (Fig. 1 b). A polypectomy snare is passed through the gastroscope and opened to surround the catheter. A 6O-inch silk suture is then passed through the catheter from the outside of the abdomen to the inside of the stomach. Because the snare surrounds the catheter, it also surrounds the silk suture (Fig. 1 c). When the suture is well into the stomach, the plastic catheter is pulled back and the snare is tightened around the silk suture. The suture and the gastroscope are then withdrawn from the patient's mouth (Fig. 1 d). A standard no. 16 mushroom tip catheter is modified for the gastrostomy tube. The flared end opposite the mushroom tip is cut off and a stitch is placed through this end. This stitch is then threaded through another Medicut catheter and the rubber mushroom catheter is put on stretch to allow it to slip into the Medicut. The tapered Medicut will act as a dilator and lead the way for the rubber catheter which follows. Holes are cut in a 2-inch piece of soft rubber tubing, and this is threaded down behind the mushroom tip to act as a bumper (Fig. 1 e). 9
Figure 1. a, Site chosen for percutaneous gastrostomy placement. b, A Medicut catheter is inserted through the abdominal wall into the stomach and the stylet is removed. c, A silk suture is passed through the Medicut catheter into the stomach. d, The suture is withdrawn with the gastroscope through the patient's mouth. e, A no. 16 mushroom catheter is prepared to serve as the gastrostomy tube. f, The mushroom catheter is pulled downward in a retrograde fashion through the esophagus and stomach and out through the abdominal wall. g, The gastroscope is re-inserted and under direct vision tension is applied to the catheter until the mushroom and bumper are firmly seated against the gastric wall. h, A second rubber bumper is positioned on the gastrostomy tube as it emerges from the abdominal wall. i, A flared adapter is placed into the end of the gastrostomy tube to adapt it to syringe or intravenous tubing. 10
The suture on the end of the mushroom catheter is tied to the silk emerging from the patient's mouth. Lubricant is then applied to the entire rubber catheter. Traction is applied to the silk suture which enters the patient's abdomen. This pulls the mushroom catheter downward, in a retrograde fashion, through the mouth, esophagus, stomach, and out through the abdominal wall. Only the mushroom tip and the rubber bumper behind it remain in the stomach (Fig. 1 f). The gastroscope is reinserted and under direct vision tension is applied to the catheter until the mushroom and bumper are firmly seated against the gastric wall (Fig. 1 g). Another rubber bumper is prepared and is positioned on the catheter as it emerges from the abdominal wall (Fig. 1 h). This is sutured in place and tied to the catheter to secure it. The stomach is thus held in apposition to the abdominal wall by the two bumpers, one in the stomach, and one on the abdominal wall. A flared adapter is placed into the end of the catheter to adapt it to a syringe or IV tubing (Fig. 1 i). Tube feedings may begin in 24 hours.
RESULTS To date, this procedure has been performed in 30 patients: 11 children and 19 adults. One patient, a severely malnourished elderly man in respiratory failure, developed a leak into his peritoneal cavity. This occurred three weeks after the procedure and was identified by the presence of free air on his abdominal film. Surgery was performed and a standard gastrostomy was fashioned using the original tube. A second patient, who had prevously undergone multiple abdominal laparotomies, developed a tiny gastrocolic fistula one month following the PEG due to adhesions pulling his colon up over his stomach. The colon had been pinched between the stomach and the abdominal wall. The fistula closed spontaneously a few days
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after the gastrostomy tube was removed. Several patients early in the series developed a superficial infection of the skin around the catheter. This has been obviated in all later patients by administration of a single preoperative dose of an intravenous cephalosporin. There were no other major complications and no deaths. At the time of this writing our first patients continue to use their catheters 10 months after their insertion.
DISCUSSION Feeding gastrostomy is an accepted means of providing enteral alimentation in patients unable to swallow. Such patients include children and adults with severe psychomotor retardation, those with advanced neurological disease, and patients with oropharyngeal neoplasms. 1 • 2 Standard techniques for placement of a feeding gastrostomy require formal abdominal laparotomy and, often, general anesthesia. PEG provides a means of establishing a feeding gastrostomy without the necessity for laparotomy or general anesthesia. Standard feeding gastrostomy is associated with occasional complications. 2 . 3 Such complications may occur with PEG, but those associated with anesthesia and laparotomy are avoided. PEG provides a safe, rapid, and effective method for establishing a feeding gastrostomy. It may become an important tool in the armamentarium of the therapeutic endoscopist. REFERENCES Gastrostomy, its inception and evolution. Am J Surg 72:610, 1946 2. CAMPBElL R, SASKI M: Gastrostomy in infants and children: an analysis of complications and techniques. Am Surg 40:505,1974 3. CONNAR G, SEALY We: Gastrostomy and its complications. Ann Surg 143:245, 1956 1. CUHNA F: