Laparoscopically Assisted Endoscopic PEG tube insertion Adrian Fox

Laparoscopically Assisted Endoscopic PEG tube insertion Adrian Fox Upper GI Registrar

Indications

Indications n Failed endoscopic PEG n n n Unable to easily access stomach with seeker needle Failure transillumination of abdo wall Obesity Intrathoracic stomach Post gastrectomy

Requirements

Laparoscopic access ¡ May be difficult n n Extensive upper abdominal surgery GA required

Endoscopist n three person procedure n n Endoscopist 2 people scrubbed

Procedure

Preparing and positioning stomach n Endoscopically brilliant transmural light from the laparoscope

Locating puncture site n Indentation of abdo wall under vision ¡ ¡ ‘poke’ method Avoiding obvious vessels Away from costal margin In relation to your accessible stomach

Locating puncture site n n n First seeker needle Benefit of 30 degree scope Then larger percutaneous PEG cannula

Stomach Puncture n Under direct vision ¡ ¡ ¡ Laparoscopically Endoscopically Choose ideal position on the ant stomach wall

Rendezvous n Blue retrieval wire loop inserted through cannula, grasped with endoscopic snare and withdrawn through the mouth

n Peg tube looped on and pulled through

Final placement n n Actual PEG segment is pulled through Positioned under vision n Laparoscopically Endoscopically Positioned as pneumoperitoneum released

Future

Lap assisited PEJ tube placement n Enteroscope – otherwise same technique just described or n Enteroscope and push needle technique

n Kyle P et al A new technique for jejunal tube placement: a marriage of enteroscope and laparoscope Gastrointestinal Endoscopy June 1996

Mini / Micro Laparoscopy

Mini Laparoscopy n n Can be performed with sedation and Local anaesthesia 1. 75 -3 mm instruments

Mini Laparoscopy n As technology improves n n ? In endo suite with the difficult PEG Alone – direct gastric or small bowel puncture ? liver Biopsy under vision ? Office procedures

Mini Laparoscopy n n Emergency room diagnostic laparoscopy Intensive care bedside diagnostic laparoscopy Pecoraro et al The routine use of diagnostic laparoscopy in the intensive care unit. Surg Endosc. 2001

Mini Laparoscopy n Emerging / experimental technique

PEG problems n Mortality ¡ ¡ While the PEG placement is considered low risk still has 1% mortality 30 day mortality is around 22% Fewer than half of patients survive for a year or more very few return to living in their own homes n American Gastroenterological Association Technical Review on Tube Feeding for Enteral Nutrition. Gastroenterol 1995

PEG problems n Complications ¡ ¡ ¡ reported in up to 70% of patients. lead to hospitalization or death in 3% to 11% of cases. Aspiration is one of the most common problems ¡ ¡ n reflux of gastric contents or continued aspiration of saliva Aspiration pneumonia is reported in about 20% to 30% of PEG-fed patients and is a frequent terminal event

Best Technique n ? mini-Lap assisted enteroscopic PEJ ¡ ¡ Cost Future

The End