Okay, last session, and I've already been told to speed up, and I think it's because I'm talking about feeding tubes, but we'll get, I'll hit the highlights for sure. So indications, pretty much what you would think, give fluid and nutrition if you can't get enough PO. We still use it some for decompression in patients who have sort of end-stage cancer, peritoneal carcinomatosis and no motility, or malignant obstruction, sometimes they're too sick. And then we hate to talk about gastroparesis at the ASGE, but sometimes for decompression of those patients as well. So pre-PEG assessment, pretty similar to anyone you're going to scope. Don't forget the antibiotics. We used weight-based dosing, so at least a gram of ANSAP, but sometimes one and a half or two. Antithrombotics, again, it is classified as a high-risk procedure in terms of bleeding risk. It's really kind of the lowest-risk, high-risk procedure, if that makes any sense. So I'll talk a little bit about that. Prior surgery, it's funny, you can do it, even in patients who have had partial gastrectomies, you can do it in most of the time. In people who've had a gastric sleeve, it can be tough because you need that sort of greater curvature of fundus. That's usually what you're kind of hitting. bypass, you'll obviously have to do a direct J. But we get consulted a lot for this, and they say, do you think you can do it, and you go look at the CT, and you're not sure. But when you insufflate air and move the bowel around a little bit, it's amazing how many patients that you think you might not be able to do it that you can. Comorbidities, obviously these guys have higher comorbidities, and because of their comorbidities they're often more difficult to get consent. So you want to obviously, as a fellow, it's on you to make sure that goes smoothly. So according to the ASGE guidelines, again, it's high risk, but again, the bleeding risk around 2%. In general, if you can hold the antithrombotics, hold them. In high-risk patients, as with all of GI, where more and more, hey, just continue if you can. We still sometimes bridge with a low molecular weight heparin, but it's really, the data for that is not very good, and if they're really high risk, put them on IV heparin and hold it, or else don't hold it. And you can always put in a Dobhoff and wait it out. So Warfarin, five days, that's pretty standard. I don't recheck the INR beforehand, I just do it. Thyopyridines, there's some data now that you can hold as low as three. You'll see there's an ASGE statement coming out that may say that you don't need to hold them at all. I think you're going to have a hard time convincing most of your attendings for that, but the problem is we see the risk of them bleeding. We don't see when they have another stroke or a heart attack. But overall, better for the patients to, again, be aggressive about not holding their antithrombotics when able. Start Warfarin in the evening of. Doax, usually I'll start it the next day, but if I think that the procedure hasn't gone well and they had a little more bleeding during it, I'll hold that up to two days. And I always, always, always just continue their aspirin. So pre-PEG assess—oh, I'm going the wrong direction. Okay, contraindications. The medical futility is super important. We're lucky now that I think primary care docs, hospitalists, palliative care medicine are sort of having this discussion with patients beforehand, but if it's not been discussed and it's really not indicated for the reasons that we all know, it's up to us to do it. Internal issues. You don't know when you can't oppose the anterior abdominal wall to the gastric wall until you try. But if you can't get a good indention, especially with doing a direct J, which we're not going to talk about, that's when I don't do it. If you can't get the scope down there, although you can use an ultrathin scope in people with stenosis, you can put the ultrathin scope through the nose and the bumpers are deformable enough that I've put it—used ultrathin scopes in all the situations and just pulled the bumper through. And then ethical, you know, there's a lot of religious and cultural issues depending on where your patient's from and all that, so obviously got to pay attention. Relative contraindications. As you can see, there's a whole long list of these. I would say that, honestly, I probably put a peg in every single one of these contraindications. That's why they're relative. Again, you want to manage these. I guess if they had multiple ones, but in many cases, you know, give it a try. You can always fail, and that's okay. Peg tray components. Nothing too important to say here other than they're pretty complete, the peg kits that are out there, not missing anything. I will say just a logistical thing. This is a procedure you do in the dark and in the light, so you got to have someone turning on and off the light, sort of the lowest-ranked person in the room, I would say, because you don't want to stab yourself with those needles and scalpels and so forth. Okay, so the technique itself. This is like an upper endoscopy you do on a patient's back, and they're almost by definition high-risk of aspirating, so I'm even more paranoid about aspirating than usual, so I'll put them up at minimum 30 degrees. If I can get them up 45 degrees, even better, and I'll often, if we have enough hands, I'll often stick somebody at the head of the bed just to do continuous suction. If there's a medical student, you got an extra tech, whatever, I don't think you can do that too much, and don't forget the antibiotics. If you're using Probe, they're out enough that they're not going to move their hands. Okay, so where are you going to look for? Usually the easiest place to see it is right along the left costal border, but you don't want to put it too close to the left costal border, because when they breathe, if you put it within a couple of finger breaths or a couple of centimeters, it can sort of bang up against there, so I try to go below that, and then I try to go just left of midline or midline. I kind of like going through the linea alba because it's tougher tissue, but there's less blood vessels, so again, midline, that's pretty easy to see, right, you start sort of at the xiphoid and go down, and that's a sweet spot right there. You can go through the liver, usually it's no problem, but you don't want to. Colon, that's why you insufflate, because you want to get that stomach up against the anterior abdominal wall and shove down that transverse colon. Okay, translumination, hugely important. Again, like I said, especially if you're doing direct J's, you don't want the whole stomach wall to shove down, you want to see that discreet indention of your finger, and you want to get a really good light. And even if they're obese, if you get a good spot, you'll see that at the tip of your finger. I don't transilluminate very much because usually if it's a good spot, you won't need to transilluminate. Transilluminate can sort of help you get closer to that good spot, but then I turn it off and make sure I can see it with regular light. So here's what it is. The finger's on the costa border, then they're going below it, and again, see how discreet that indention is? That's what you want. Oftentimes, you're along that greater curve, as you can see there, junction of the greater curve of the anterior abdominal wall. And even in obese people, you'll see that light if you look for it. Safe track technique. This is so you don't hit something before you hit the stomach. Most commonly, that's going to be transverse colon. So as you advance that needle, you've got your fingers on the plunger, and when you feel that plunger give, or if you have air with lidocaine, feel the bubbles, you'll see the needle in the stomach lumen. If you don't see it, you probably put it through the transverse colon, which is no big deal. Just don't put your peg through there, just find a different spot. But don't worry about... I can't tell you how many times when I've been doing a J-tube that I've stuck a needle, I don't know where, but it's never a problem. Okay, so here's the safe track technique. Again, you see the bubbles there, and you see it right when you get in. You see it in the lumen. For incision, the key here is just to make it deep enough along the length. I do it about a centimeter. You can do it smaller, but it makes it a little bit harder to pull through. I try to really match it to the size of the peg. So like a 20 French, you'll do like eight, nine millimeters, a 24 French, you'll do more like a centimeter. But you don't want it much bigger than your peg, because it's just more likely to bleed. I often use a sawing motion, because you want to get through the skin. The subcutaneous tissue, you don't worry about. It's really the skin that gives you the difficulty pulling it through. And then when I put the trocar or the angiocatheter in, I use safe track on that too. You can put a syringe on most of them. The other thing is, when you switch needles from your finder needle to your trocar, I stress again, make sure you're in the same spot. Make sure that who's ever doing the endoscopy is continuing to give air, because you want to, again, float that stomach up against that anterior abdominal wall. And most of us use CO2 now, and that resorbs faster. So they've got to give a lot of air. This is the one time in endoscopy that you want to give air. And sometimes you can see that the stomach wall will deform like that. So sometimes you've got to really give it a stab. And that's why you want to really insufflate a lot of air, so it makes it easier to get through the gastric wall there. And then we, in this one, they don't do that. But what we'll do is we'll snare the trocar with the hard needle in it, and then pull it out. Here they pull it out, the needle out, and put the blue wire through and snare that. I've had the instance where I've pulled out the metal needle. And because of the way it was angled and the patient was breathing, that that plastic trocar slipped into the perineal space, and that was a real pain. So anyway, that's how I do it. This is a simple thing, but we mess it up all the time. And we say blue through, right? We put the blue loop guide wire through the metal loop on the tip of the peg, blue through. And that's how it makes your slip knot the easiest. Same thing, blue through. I think almost everyone does the pull technique. And so now you've got your peg attached, and you see how we're wrapping it? I think that might be my hand, actually. Wrap it around the fat part of your hand, the strong hand, whether you're left-handed or right-handed, because you're going to pull hard. And then you put your fingers on the side of where you made your track. And when that thing pops through the tapered part, you really got to give it a good yank. And then putting on the bumper. Do you have to look and check position if everything went well? The answer is no. I said this last time, someone said, I asked about why we should look again. They're saying, well, where else is the peg going to be? So if it goes smoothly, we don't recheck. One can use it, meds immediately, I'll often decompress them right after you're done. Take all the air out of their tummy, so they feel better right away. But again, meds right away, feeding three to four hours. Adverse events, separated into ones that are around the procedure versus post-procedure. Again, around the procedure, very, very low adverse event rate, and very low mortality. Should be close to zero. Post-procedure, high mortality, but that's because of their comorbidities, not because of what we did. So we'll go over some of these. Aspiration, I talked about that. Get the head of the bed, have someone on suction the whole time. You know, pegs, we're often putting pegs because someone's failed their swallow test. But if you actually look at the data, it's not that good that pegs actually prevent aspiration. Now it's hard not to put in a peg on somebody who fails a swallow test and is aspirating pretty badly. But I tend to just put in a peg, and then if they aspirate on that, then switch them to a GJ or put in a direct J. I don't usually put in a J-tube initially. Infection, don't forget to give it. Post-procedure, it still happens, even with prophylactic antibiotics. And I think this is one of the things that I think it's easy for them to take a picture and send it to you through their EMR, and you can diagnose it fairly easily and treat it. It's easily treatable with oral antibiotics, but I have had a couple of patients, one that died of necrotizing fasciitis, where they have to take him to the—it's like gangrene of your abdominal wall, where they take him to the OR and debride it widely. And that's just because it's a foreign body, and it's something that if you jump on and treat the infection early, you can prevent that. Pneumoperitoneum, you almost always have pneumoperitoneum after you do a procedure, whether you use air or CO2. I think in this study—this is our study, actually—and I think we had 50% of them still had—40% or 50% still had pneumoperitoneum, even using CO2. So the reason to talk about this is, like, they go home, they have pain because you just put a peg in there. They show up at some ER, and they do a CT or a plain film, and they say they got air and they got pain, and someone wants to take them to the OR. And they're probably not leaking now. They leaked a little air during the procedure, and they have pain because of the procedure. So you really want to have a contrast study showing that they're leaking now, not that they leaked before and it just hasn't resorbed yet. Leakage, if you do a lot of this, this is kind of a really common nuisance-type problem. Obviously, it's usually gastric content. We think it's a little bit from the post-hole phenomenon. You know, that initial peg that you place kind of sticks out far, and it's got to lie on one side to the other. There are patients that are rolling around, they're taping it on one side or the other, and so it's just like making the hole bigger and bigger, and they have poor wound healing. You want to rule out these things that are listed here. Infection and buried bumper are the most common, and you try to stabilize the tube. Most commonly, you can just—there are these different clamps and right-angle bumpers, but you can also just switch them to a low-profile tube that doesn't have that post-hole thing and try to stabilize it. But it doesn't—honestly, it doesn't always work. Wound and skincare are super important. Stoma nurses that are in most hospitals are really good at skincare. I did put in there, don't overly tighten the bumper, because that can lead to infection, buried bumper, pressure necrosis, and putting in a larger tube will usually help for the first few days, and then when the same thing—the same sort of pathophysiology starts, you just have a bigger hole that you leak more out of. This is buried bumper. It's almost always with a solid internal bumper, and it's obviously a solid outer bumper, and either the surgeons have placed it, and they're like, you got to tighten that thing down, or you've been successful in your therapy, and the patient's gained weight, but no one's pulled back the outer bumper. Most of the time, it's easy to treat. The easiest way to treat it is just take out the old one, pull it out the rest of the way. As long as there's a little bit of a tract left, you can just put your loop guide wire, pull down a new peg right into place. There's a lot of sort of MacGyver-like things described in the literature, but the way I told you is by far the easiest. Gastrocolic fistula, usually when you do this, again, transverse colon lying right in front of your stomach, you don't even know it until you go to replace it, because you've put the peg through and through the colon wall, both sides of the colon wall, but when you go to replace it, you can't get it all the way through, so you put it in the colon, and then whenever the patient starts their tube feeding, they get diarrhea. That's pretty straightforward. Usually the way to fix it is just pull it out, and I've had a few of these, and they just heal on their own, usually. Okay, I pulled out, the peg got pulled out too early. That your soma tract, we say, you know, we're not going to change out your tube for a minimum four weeks to like a low profile or something like that, but usually it really heals within the first week or two, the soma tract, so that they won't get peronitis if you pull it out, but if it's early, they can. So usually we say, just bring them in, we'll fix it. The sooner the better, and most of the time you can. Sometimes the worst case scenario, you just put a peg right next to where the other one was and seal everything up, but if you can't, you know, NJ tube antibiotics, rarely surgery. I've listed these ways here to prevent it. T-fasteners, put a binder around it so they can't get to it, put a low profile tube, harder to pull. T-fasteners, if they do pull it, the stomach stays against the anterior abdominal wall, you don't have a free perforation, so just helpful hints. Okay, so this call you guys will get, I'm sure. My peg has fallen out. So after that initial stoma tract maturation time, two to four weeks, at that point you don't want the tract to close because you want to be able to put a peg back in it. It usually closes within a week or so, again, it can vary a lot depending on the patient's status, but if it's going to be a while and you hear about it early, whether the ER calls you, the nursing home, almost put anything in there to help maintain the tract. The most common thing that we hear about is for some reason these places all seem to have those little red rubber, like 14 French catheters, put that in there gently and then just have them tape it and then they're good until the morning, you can bring them in and fix it. If you don't hear about it for a week, two weeks later, oftentimes you can still recreate that tract, that last little bit that you can get a floppy wire through, sometimes will take two, three, four weeks to do and that way you can reuse the same tract many times. Just be careful when you're doing replacements that don't go smoothly, whether the patient's doing it at home themselves or their family is. If there's any question that's not in the right place, either scope them and know it's in the right place or use fluoro to know it's in the right place. Okay, should I, Tom, should I stop there? Yeah. Okay, so this is cancer. Rarely happens in patients who have active aerodigestive cancers that you put do the pull-through technique. And I'll just do removal. All pegs are removable at the bedside that are sold in the U.S., not in Europe, in the U.S., and you just pull them out. If they have a balloon, you deflate it and put it back in. It does hurt pretty good to pull them out, but you can't do it in clinic. I'll often bring them down to the lab and give them a little mild sedation. Okay, so again, those calls that you get, have someone look at the site really good. That's half of it. They can FaceTime you. You can see it. You want to know how long the patient's had it. If it's a balloon or solid internal bolster, if it's a balloon, it always has a port that says balloon or BAL. That's your clue. And then the buried bumpers, if you can't rotate it or push it in or out, that's when to worry that they have a buried bumper. And you see I put the wet centimeters on the tube as close to the skin. That's to get some idea. I always put where the outer bumper is of my peg so I know if someone's overly tightened it or it's been pulled back. Sometimes I'll just take a picture of it with the scope. Okay, thanks.

percutaneous endoscopic gastrostomy

PEG procedures

technique

complications

management

patient concerns