Percutaneous endoscopic gastrostomy . Courtesy of Dr. Jeffrey Ponsky.
Transillumination and finger indentation in PEG placement. Courtesy of Dr. Jeffrey Ponsky.
An alternative to this conventional PEG placement is the endoscopically guided primary button placement or “push technique” (Fig. 24.3): after endoscopic visualization and gastric insufflation, transillumination and one-to-one finger indentation is used to identify the future gastrostomy site. The stomach wall is then secured to the anterior abdominal wall by the use of T-fasteners or a lasso U-stitches . A needle is introduced into the gastric lumen percutaneously, through which a guidewire is advanced. The track is serially dilated for primary gastrostomy button placement as described for laparoscopic placement (“push” technique ).
PEG using the direct “push” method. Courtesy of Dr. Jeffrey Ponsky.
Pitfalls: Laparoscopic Gastrostomy Placement
The guidewire can dissect the gastric wall instead of entering the gastric lumen, resulting in the placement of an intramural button. Endoscopy at the completion of button placement can confirm intraluminal button placement. The feeding tube should flush without resistance. The use of methylene blue aspirated via nasogastric tube to flush the tube also confirms intraluminal placement and rules out both intraperitoneal leak as well as a through-and-through gastrotomy.
The transcutaneous stitches should not be placed more than 1.5 cm apart to avoid laxity of the anterior gastric wall, making it difficult to dilate the puncture site without appropriate tension.
U-sutures should be tied loosely to prevent ulceration of the gastric mucosa and inflammation, which may progress to infection.
Holding stitches should be removed ideally within the first 72 h and, at the latest, after 1 week to prevent discomfort, inflammation, and infection.
Gastrostomy access at the costal margin causes chronic peritoneal irritation and pain.
Pearls: Laparoscopic Gastrostomy Placement
A gastrostomy site should be carefully selected to avoid anatomical distortion of the stomach which may result in gastric outlet obstruction or disruption of the gastroesophageal junction, both of which can worsen gastroesophageal reflux postoperatively.
Insufflation of air into the stomach via nasogastric tube by the anesthesiologist helps to identify an ideal gastrostomy site; facilitates grasping the wall of the stomach; reduces tension on the gastrostomy button and transfascial stitches by bringing the stomach closer to the abdominal wall; and provides tension to help advance the needle into the gastric lumen.
Pitfalls: Endoscopic Gastrostomy Placement
Transhepatic or transcolonic PEG placement can occur if adequate transillumination, finger indentation, and safe-track technique are not utilized.
Remember the smaller volume of the pediatric stomach. Care should be taken not to overinflate the gastric lumen as air quickly tracks into the small bowel and cannot be evacuated. This can lead to postoperative pain and prolonged ileus.
While pulling the PEG through the oropharynx and esophagus, care should be taken to avoid injuries due to excess retraction.
The bumper should not be placed too snugly against the skin. We place the bumper 1 cm from the skin to accommodate postoperative swelling and facilitate drain sponge placement. A tight bumper may result in skin and tissue necrosis, increasing the risk of skin infection while enlarging the stoma, thus causing drainage around the feeding tube.
Pearls: Endoscopic Gastrostomy Placement
The use of a smaller pediatric endoscope reduces the risk for endotracheal tube dislodgement.
When selecting the appropriate gastrostomy site, we recommend starting subxiphoid and then palpating in 1-cm increments along the left subcostal margin to select an area with appropriate transillumination and finger indentation.
Apply pulsatile air insufflation of the stomach and evacuate gastric air between surgical steps if insufflation is not required to limit postoperative pain.
Turning off overhead lights during transillumination allows easier visualization, especially in the larger patient.
The safe-track technique has been shown to decreased risk of placement PEG through other organs.
Depending on the technique, feeds via the new gastrostomy tube can be restarted a few hours after placement.
The gastrostomy site is dressed with slit gauze to absorb expected minor leakage. In younger children or noncompliant patients, we find that abdominal binders (or Kerlix in the smaller patient) wrapped loosely around the abdomen helps decrease the incidence of inadvertent tube displacement in the immediate postoperative period.