Читать книгу Successful Training in Gastrointestinal Endoscopy - Группа авторов - Страница 100

PEG tubes can provide enteral nutrition to patients with chronic feeding problems stemming from neurologic conditions, malignancies, or other associated medical disorders. The trainee should learn that there are contraindications to placement of PEG tubes, which include the presence of bowel distension or obstruction, ascites, obstructing esophageal or gastric malignancies, and the presence of portal hypertension or other hypercoagulable states. The pull technique is illustrated in Chapter 30 of this book (Figure 30.1) and remains the most popular method of placement. This technique commonly requires two physicians, one performing the endoscopy and one responsible for the cutting portion. With the patient in the supine position, the endoscope is advanced into the stomach. The stomach should be fully insufflated and a point of maximum transillumination should be identified along the anterior wall of the stomach. Using a single finger, one‐to‐one indentation of the abdominal wall should be seen by the endoscopist. If this is unable to be achieved, there may be overlying bowel loops or fluid, and PEG placement should not occur via endoscopic means.

Once the insertion site is identified, local anesthesia with 1% lidocaine should be injected at the site. The second physician should make a small skin incision at the site measuring approximately 1.0 cm. The trocar with the introducer needle should then be advanced through the incision, maintaining the trocar at a 90° angle. The needle should then be removed, and a guidewire introduced through the trocar. The endoscopist should grasp the guidewire with a snare and remove the endoscope along with the guidewire through the mouth. The suture loop attached to the PEG tube should then be tied to the guidewire. The opposite end of the guidewire should be gently pulled away from the abdominal wall so that the PEG tube can be pulled into the stomach until the bumper is along the anterior gastric wall. It is recommended to reintroduce the endoscope to confirm proper placement of the PEG bumper. Once confirmed, the external portion of the PEG tube can be cut to the desired length and secured. There are variable data regarding when tube feeds following PEG tube placement can be initiated. Traditionally, tube feedings have been delayed until the next day or up to 24 hours after PEG placement if the PEG site is intact and the abdominal exam is benign. However, some data suggest that early feeding (less than 4 hours after placement) is a safe alternative to delayed feeding with no overall differences in complication rates [23].