I'm a gastroenterologist at the University of Utah. And today we're gonna talk about something that you guys will all see this year, so I think it's very relevant. So we're gonna talk about PEG tubes. I'm just curious, have you guys come across this yet? Have you helped out with one or seen anybody do one yet? Maybe a little, some people have, some haven't. Okay. So we're just gonna kind of go through them a little bit about the PEG technique and complications and all that good stuff. So. Why does it not work? There we go, okay. So I have no disclosures. Okay, so just starting off, we're gonna talk a little bit about indications for PEG placement. So why might you wanna think about placing a PEG? So the first one is kind of obvious. If your patient has inability to tolerate adequate PO intake, so be that, because maybe they've had a stroke or they may have a neurologic disorder, so something like ALS. And so there's all sorts of reasons that somebody may not tolerate adequate PO intake. So you may place a PEG for nutrition, giving them hydration, ability to administer medications. And of note, this is usually expected to last more than 30 days. So if the length of time that they may not be able to tolerate nutrition is less than 30 days, that may be a reason just to place like a nasoenteric tube, something a little bit less permanent and a little bit less invasive. And then another reason that you may place a PEG, which is less common, I would say, is for gastric decompression in the setting of like malignancy or a bowel obstruction or even a motility disorder. But that's a little bit less common. Mostly we're focusing kind of on that first indication. So you have been consulted on a patient for a possible PEG. What are some things that you wanna think about before you go ahead and put the PEG in? So first off, like what are the patient's active medications specifically? Are they getting any antibiotics? Because you will be administering prophylactic antibiotics prior to the procedure, as well as antithrombotic agents. It's obviously important. Knowing what their anatomy is and if they've had prior abdominal surgeries, as you can imagine, if maybe they've had a gastric bypass that may impact your PEG planning. So knowing their prior abdominal surgeries, having a sense as to what their current nutritional status is, what are their medical comorbidities, which I think is also important for planning your anesthesia with your anesthesia colleagues. A lot of the times these patients have a lot of medical comorbidities that put them at high risk for sedation, so things like ALS. So just kind of knowing those things going into it. And also obtaining a really good informed consent is very important for PEGs, especially because a lot of the times our patients may not be able to do that themselves. So making sure you have a good family member present to talk about that with. So this is something that we actually went over yesterday, but it's also in this talk. So we'll go over it again so you guys really get it hammered home. But those ASG guidelines about managing antithrombotics peri-procedurally definitely come into play here because PEG is considered a high-risk procedure, meaning that it has a bit of a higher bleeding rate, so up to 2.5%. And just like we talked about yesterday, you want to identify if your patient's clotting disorder is a low-risk or a high-risk situation. For example, high-risk being like a mechanical heart valve or somebody who maybe just had a pulmonary embolism, although should that patient be getting a PEG, I guess, is another question. So kind of trying to decide how risky it is to hold their antithrombotics and if it's high-risk bridging them with low-molecular weight heparin. And then importantly, again, if your patient just had a PE yesterday and you're getting a consult for a PEG, like maybe this isn't a great time to be placing a PEG. They're not usually like emergency procedures and maybe this would be a good time to delay PEG placement and just use a nasoenteric tube in the meantime. And so just give them some more time when it's safer to hold their anticoagulation. Holding antithrombotics, so for Warfarin, you want to hold it for five days. Of note, you can give either Plavix or aspirin alone is fine, but together that increases your risk of bleeding. So just Plavix, you don't have to hold it. DOACs, they are kind of quick on, quick off. So you want to hold those for about two days. And then low-molecular weight heparin for 24 hours. Restarting antithrombotics. So pretty much with every procedure you're going to do, you can usually restart Warfarin that same day just because it takes time for it to become therapeutic in the blood. And then you're probably going to want to wait to restart somebody's DOAC just because it comes on so quickly. So waiting 24 to 48 hours. And just as has been mentioned several times, continuing aspirin throughout this procedure is safe and you should be doing that. So what might be some contraindications to PEG? So always trying to think about why shouldn't I do this? There's a couple things. So the first thing is just like, is this a futile procedure? Does your patient have a really limited life expectancy? And like, what are the goals of the patient? You know, if their goal is to live longer, maybe PEG's not going to do that. And that's important to talk about before the procedure. Advanced dementia. PEGs have not shown to improve mortality in patients with advanced dementia or terminal cancer. So these are, again, important things to think about. Technical issues we'll go into a little bit more, but if you can't oppose the anterior gastric wall to the abdominal wall, you're not going to be able to place the PEG. So we'll go over reasons why that might be. But then also like, if you can't advance the endoscope through the esophagus, then you also cannot place a PEG. So where people have seen them before, you know this is like a two-person job, right? So you have your person on the outside who's doing the poke, and then you have your person that's doing the scope. During your first year, I'd say probably you're going to be doing more scopies than pokies, but it'll change over time. But if you have like a really bad esophageal stricture or like a cancer there that's blocking the way, then you can't, you know, do the procedure because you need to have the scope in the stomach to insufflate and all those things. So it's really important. And then ethical issues. So can surround this procedure quite a bit. And I think I won't get into it too much, but I just encourage you to like, think about these things. So oftentimes you get a referral, like that shows up on your outpatient endoscopy and you end up having this discussion with the patient you don't know. And I think it's okay to like be a doctor here and you know, not just a technician and kind of provide your own ethical feelings about somebody having a PEG or not having a PEG. So I just encourage you to think about that as you go through these cases during fellowship. So these are some relative contraindications to PEG placement, but they are relative. So oftentimes patients with most of these things can actually have PEG placed depending on the proceduralist level of, you know, risk acceptance and technical skill, I would say. But these are some relative contraindications to think about. So like anything that's gonna make that wall size bigger is gonna make it harder. So things like ascites, gastric varices, I think is like a pretty obviously scary thing to place a PEG through. Hepatomegaly, so the liver, you know, if it goes too much over the stomach, that could be something you'd be at risk of puncturing. Morbid obesity, kind of similar to ascites can make it hard to get through the wall and all these other things. But truthfully, like as you'll see, like if you can get a good translumination, really find a good window, it can still be possible. So this video is gonna go over all of the contents of a PEG trade kit. So everybody's PEG kit is different and I'd encourage you to get familiar with the one that you use at your institution. But this is a scalpel, so that was the scalpel. This is the angio catheter, so that you'll insert the wire through. This is the finder needle, very important. Those are scissors, so we got scissors there. That's a Kelly clamp that I don't know if comes in all PEG kits, but can be needed sometimes. Kelly clamp. And then this is a drape, so a sterile drape. You know, this is a sterile procedure. You'll be wearing like sterile gloves and doing your best to maintain a sterile field and the drape definitely can help with that. So there's our drape, very well shown. And then this is like chlorhexidine or whatever antiseptic you have to sterilize the patient's skin with beforehand. That's the clamp that goes on the tube. That's that Y-port adapter. That's the external bumper. And then that's probably like some antibacterial ointment, those kinds of things, a different type of bumper. And then down in the bottom, these are actually things that you're gonna be handing to your tech. So that's the actual PEG itself, finally, that you're seeing there. You can see it has like a loop of wire at the end. That'll come into play a little bit later. And then there's also gonna be a snare in the kit. You're also gonna hand that to the tech. That'll be for the scope person to use. Opening and closing. And then the final piece of equipment there is your wire that's gonna go through the angio catheter. So there's like a lot of things in the PEG kit and it can be pretty overwhelming to like be in a procedure and your attending's like, okay, open up the kit and like, let's go. And then you're like open and there's all this stuff. So I think it's just nice to like kind of know where everything is and what everything does. So, okay, now we're gonna talk a little bit about PEG technique. So just starting out, you want your patient to be in the semi-recumbent position, meaning like having the head of their bed elevated about 30 to 45 degrees, which I think can be helpful for a few things. So one is to decrease their aspiration risk. Just keeping in mind, again, the patient's medical comorbidities, they may not be very good at protecting their airway. So you wanna be careful about that. I think it can also kind of help displace that transverse colon a little bit more coddle. So maybe not getting your way as much. So always starting it that way. And then gently restraining hands. That's meaning that the hands of the patient, you obviously need your hands, but the patient, you know, you don't want them to like mess up your sterile field. So making sure they're out of the way. And then antibiotics, very important. And we're gonna talk about that again a little bit later. So giving pre-procedure antibiotics. So where do you wanna place the peg? So this is like probably the biggest, most important thing, right? Because like where we place it helps us make sure we don't have complications. So ideally you're gonna place it in the stomach. And how do we find the stomach? So it's basically to the left of the midline. And then you want it to be at least two finger widths below the rib margin. So that's like your golden ticket right there. Places you don't wanna place the peg include the liver, that's off to the right, as well as the colon. That's obviously down lower. And then, you know, you're always thinking about that transverse colon, which can kind of like run sort of in your way. But ideally you're sort of on the middle left side and then two finger widths below the rib margin. And when you're picking a peg spot, there's two important steps that you wanna do to make sure you have a good place. And that's translumination and finger indentation. So translumination, meaning the scope person, right, has the scope in the stomach and you're like insufflating. So like your big job is to keep that stomach as insufflated as possible to approximate the stomach anteriorly as close to the abdominal wall as you can. And then meanwhile, the poke person is gonna be kind of like poking around and like trying to find like a very like discrete finger indentation. And if you have those two things, like you can really see the light kind of shining through the stomach from the outside and then you can see this like really nice discrete poke. You can be pretty sure that this is a safe place to go, that there's nothing in the way and that you're gonna be successful. So this is a good example. You can see the poke person has their two fingers there below the ribs and now they're poking around. And then you can see endoscopically there, the scope person seeing this like really nice like discrete indentation. This is a good sign. You can even kind of see, so that's an example of how translumination might look. So you can have your techs like turn the lights on and off so you can like make sure you really see the light. I think in the absence of those things, you need to kind of worry like, okay, is like the liver in the way or the colon or something, like something's not quite right. So when I see those two things and I feel comfortable about proceeding. So what's the next step? So the next step is something called the safe track technique. And what you're gonna do is take that finder needle that we showed you in the kit. You're gonna draw some lidocaine into that. It's not included in here, but usually you'll make like a little wheel and under the skin. So you've already identified the place you're going. You're gonna make a little wheel. And then what you're gonna do is you're gonna insert the needle. And as you do that, you're actually gonna draw back on the syringe for two reasons. So one reason would be like, obviously you're looking for blood. So like, did I hit a vessel or something like that? The other reason would be so when the scope person, you know, has a scope in there, you wanna see the needle come through into the stomach at the same time as you first see air come into the needle. Because if you see air before that, you may worry that you've entered the transverse colon. So it's kind of an important step to make sure you have a good track. So you're kind of slowly advancing this needle in and then watching for air, which we'll show you here. So they're slowly advancing and suctioning back. And then you can see the bubbles that start to form there as the needle enters into the stomach. And then you're like, okay, like, this is a good spot. So your next step is to make a skin incision in that exact same location. And that's exactly what it sounds like. So you just make a little incision with your scalpel. This really doesn't need to be any bigger than the diameter of your peg. So take a look at the peg. There's different size pegs. I think 20 French is what we usually use. And so just take a look at that and make sure your incision is that big to make your life a little easier down the road. And then the next step is, you know, now you've identified this safe track, you're feeling good. So we're gonna go for it. So we're gonna insert our angiocatheter. And as you can see, you kind of want it to be just like perpendicular there to the skin to kind of minimize the length of the tract that you're making. And then this video up here is sort of showing you a little bit more detail about the angiocatheter. So it usually has a sheath over it and you take it off. And then there's like this kind of like floppy, plastic sheath that covers over this needle. It's like bigger needle. And so once you've inserted it, then you can use that as a channel for your wire. So they're gonna, oh, it's also very floppy. And now they're gonna show you the wire gets inserted in there. And then this is what the scope person is gonna grab with their snare on the inside and pull through. So we're gonna show you that again here. You can see the push person is pushing the needle through. It's gone through very nicely. The needle's still in place, which can be helpful when you open up the snare. If it's like flopping around, it's harder to grab it. So you're gonna put the needle on here. You're gonna open up your snare and then you're gonna move your snare over just like that. And at this point now you can kind of safely remove the needle, so you're probably doing that. Now the needle's gone and the outside person, you can imagine then they're inserting the wire and now you see that blue wire come out and then you grab it with a snare and close on it. Beautiful. And then what you're gonna do next is you're gonna hold on really tight and then you're just gonna pull the whole wire out. And so now there's wire hanging outside the body, going into the stomach and then coming out of the esophagus. And so now, just imagine that this wire is kind of like dangling out of their esophagus. You insert the blue wire through that loop of wire in the peg. And then you attach the peg, make a little knot. Your tech might be doing this. And then you pull it nice and tight, give her a nice tug, tuggy, tuggy, tuggy. Beautiful. Attached. All right, so the next step, I think, is like where everybody gets a little scared, right? Because like you got to really yank on this thing to get it through the stomach. But, oh, sorry, never mind. They're going to show you this again. So that's the same thing. So they're attaching the peg to the outside. All right, so here's where you're wrapping it all up in your hand. You really got to give it some strength and pull, pull, pull, pull, pull. Keep on pulling, keep on pulling. It's getting threaded through their mouth. Sometimes, like you may have to make your incision a little bit bigger, but with enough like tension, you can usually pull it through. And then when you put the scope back down, you should see your nice internal bumper there just kind of hanging out and being in a good spot and you feel happy with your success. Okay. And so the next step is you're going to secure the bumper. So that end of the peg has this like nice taper on it. So don't cut that off until you've put the bumper on. Otherwise, it'll be like impossible. So you slide the bumper over and down. There's different types of bumpers to usually come with the peg. And where you leave it is kind of important. So you want it to be like a little bit loose, having like maybe a centimeter-ish between the bumper and like having it taut there can help prevent buried bumper syndrome that way. So kind of like loose, like touching the skin a little bit if you release it, not tight. It can be a little hard to pull it back if you make it too tight. So just being a little careful with that. And always take note of where you, how many centimeters are in there so you know how long your stoma track is. And then you put the last couple of little things on and the port on the end and then you're done. And should you look again to make sure the bumper is where it should be, like technically you don't really have to. I always do just because it makes me feel good and it's easy to do. It's really not necessary unless you feel like something didn't go well. It should be there. When can you use your peg after it's placed? So there's really no data that suggests you need to wait a really long time to use it. You can start beginning feeds within about four hours of placement, which is nice. And you can use it for medications immediately. Okay, so we've placed the peg. Unfortunately there can be adverse events associated with pegs just like anything else. So we're going to talk about those now. There's actually not a lot of periprocedural mortality. But things to note are aspiration, infection, bleeding, and pneumoperitoneum, and then post-procedure, all these things that we're going to go through. There's a high mortality post-procedure, but that's really probably associated with the patient's medical comorbidities than actual complications from the procedure itself. So it's actually a pretty safe procedure. Aspiration, that tends to occur during the procedure. That's why we talk about elevating the head of the bed and doing aggressive suctioning. But of note, that can happen later once you initiate feeds. Placing a peg does not decrease risk of aspiration. However, you could potentially decrease the risk of aspiration if you place a feeding tube more distally, so like doing a peg with a jejunal extension, or doing a direct peg into somebody's genome called a D-pedge. So you could do those things. But a peg itself does not decrease the risk of aspiration. So infection, super important, usually caused by skin flora. Antibiotics have been shown to prevent this from happening. So giving an antibiotic about 30 minutes prior to procedure can decrease somebody's risk of infection. In fact, they did a meta-analysis where they looked at 10 studies, and it decreased from 26% to 8%, so pretty significant, with a number you need to treat of 8. So we usually give a gram or two of ANSEF, kind of depending on the patient's body weight. And you can give that, again, before the procedure. Post-procedurally, if somebody calls in with an infection, you can give oral antibiotics, or obviously if they have an abscess or something, you may need to treat that with incision and drainage. So pneumoperitoneum, obviously here you can see some free air there under the diaphragm. This happens very commonly after peg placement, and it's really nothing to be concerned about. So we kind of expect it to some degree. It doesn't happen as much if you use CO2, which as you know dissipates a lot faster than O2. And we don't typically get x-rays after procedures anyway, but if you did, you would probably see this. So unless your patient's coming in with raging abdominal pain and concern for peritonitis, if you were to see this incidentally in the ER, you would kind of ignore it. So it's not clinically significant. And I believe this shows up on board, so just of note. And then leakage, another problem that's pretty common, usually gastric contents and related to excessive tension or torsion. Obviously if somebody's calling in with leaking, you want to make sure they don't have an infection or buried bumper syndrome or something like that. I think the important thing here is that the treatment of a leaking tube is not to place a bigger French tube, so don't increase the size of your tube, because then you're just going to have a bigger fistula with more leaking. So you can exchange it for a low-profile tube or try to stabilize it in some way. And sometimes what we'll even do is take the tube out and let the tract actually close down a little bit and then replace the tube, so take it out for 24 hours. But you should not be placing a larger tube, and that's not really the answer here. This is buried bumper syndrome, so you can actually see here that that internal bumper has migrated into the gastric wall. And that's caused by excessive tension between the external and the internal bumpers. So you can imagine if you place your external bumper too tight, that might put you at risk for this. Or as your patient gains weight and the width starts to widen there, you can imagine that might place more tension. So this is something to be aware of if your patient is presenting with abdominal pain or sepsis. And then the dreaded gastrocolic fistula, that's probably very uncommon, but always something that we're worried about when we're replacing pegs. Again, this is where you're puncturing the colon when you place the peg. And it's a transverse colon as it runs across there. We've gone over some things to try to avoid that from happening, like when you're using your finder needle, looking for air, and that sort of thing. But it's not always apparent right away either, so your patient could have abdominal pain after the procedure, or they may present with diarrhea during their tube feeds weeks down the road. So just something to have suspicion for. And obviously, if this happens, you need to remove the tube. OK. And so this is, oops, I pulled the peg too early, a case of tubus interruptus. And so the concern here is that the stoma tract takes two to four weeks to mature, and we really should not be pulling the tube before that time. Because essentially, you can cause peritonitis, and basically, you're giving a patient perforation. So we do not want to pull the tube before the stoma tract has matured. If that were to happen, you want to consider either repeating the procedure very quickly to replace the tube, as well as conservative things like antibiotics for peritonitis, and considering a surgical consult. This I think, you think of it more happening in a patient who may be agitated, and may be pulling at the tube, and that sort of thing. So trying to prevent it from happening by using binders, or mittens, or whatever, or placing it in a low-profile tube that's less easy to pull out. OK. But what if the peg falls out, and it's been there for a while, so you haven't pulled a mature stoma tract? Well, if it happens early, you want to just basically put whatever you can there. I mean, obviously, to a certain degree. So if the patient's at a nursing home, oftentimes, they'll put a Foley in there. Or if you have a patient that has a low-profile tube, sometimes we'll give them an extra one to have at home, so they can just kind of put it in themselves. But really, any tube that you can, because this tract closes very, very, very quickly. But if it happens too late, and they come to the ER, and that tract is kind of closed down, you can try to save it by putting a wire through it. But you want to kind of be careful, because you don't want to misplace that wire and it not be going into the stomach. And so you may try to redo the peg in that same tract, or you may have to make a different tract altogether. Or sometimes, we'll even dilate the tract a little bit. OK. So does anybody have any idea what this could be? Keloid? Yes. This is a trick question, because it's actually a peg site metastasis. So this is just getting at that if you had an active cancer in the esophagus, or in basically the upper aerodigestive tract, you can basically seed that to the peg site. So beware of placing pegs in patients like that, because you're spreading their cancer, and that's not good. And then, so in those patients, you may want to think about different methods, like getting IR involved, or something like that, to prevent seeding. I guess compare that to something more common, which would be like just granulation tissue, which happens all the time. They can just get these kind of like little skin tags of extra granulation tissue that you can kind of just like treat with silver nitrate locally. And it just can be a little irritating for patients or bleed sometimes, so it can be nice to treat it. OK. So peg removal. So the peg that we initially placed was kind of like our standard initial peg that has that solid internal bumper. And you leave that long sort of like tail hanging outside the body. Oftentimes patients want to exchange that for a more low profile peg. And so that's where these like balloons kind of come into play. When you pull a peg, the initial peg pull with that solid bumper can actually be kind of painful. So we often do that under sedation, actually, because it's just more pleasant for the patient. But all you're doing is like applying tension and traction and then pulling out the tube. If the patient has a balloon bumper, then you just deflate the balloon first, and you would know because it would say BAL on the port. So you want to like know what kind of peg you're pulling out before you do that. Again, you don't want to do this before four weeks. You can also cut and push. So like cut at the skin level and push the bumper through, but that can like potentially cause obstruction if you don't like retrieve it, and it requires endoscopy. So we don't usually do that very often. These are some peg replacement tubes. So this is like a perfect example of a Mickey button. You've probably heard of those. So it's just these like little tubes that, you know, once you've pulled out your initial tube, you have this like nice mature track there. You can actually measure it with one of these measuring devices. So you can tell your tech, okay, like I want a four centimeter button tube, and they'll bring it to you. And then you just kind of like slip it right in with a little bit of lube, and you fill it up with like five to 10 cc's of water, and they just kind of hang out there. These should be replaced every three to six months, whereas those internal bumpers, those solid ones, can be there for about a year. So just knowing like how long they should be in place is important because ideally you're replacing them before they like have a complication, right? You want this to be like a planned event. So just know that. Tube migration, if you didn't have an external bumper, the tube could migrate distally into the small bowel. And that's pretty much it. So in conclusion, you're getting called about a PEG. So some things that you're going to want to ask the ER, look at yourself. So you want to look at the site. Is there evidence of infection? Is there leakage? You definitely want to find out how long the patient's had the PEG in because if you're coming in for, you know, the PEG falling out, then you want to know, okay, was this a mature track or not? Again, you want to know like what the internal bumper is like. Is this a solid internal bumper? If I'm going to remove it, do I have to deflate a balloon? Those sorts of things are important. Can you move the tube? So can you like rotate it around easily or are you worried about buried bumper syndrome, that kind of thing? And then, yeah, what centimeter number on the tube is closest to the skin and does that match with what it was like when they initially placed it? So are you worried about migration? If you kind of know most of these things, you can usually troubleshoot pretty well. And that's it. Does anybody have any questions? Yeah. People put like gauze underneath the external bumper and sometimes I'll hear, that's bad, that'll make the track bigger. Is there a specific way in which we should be advising people if they're having issues with leakage or energy too? Yeah, you can. It's hard. It can be kind of tricky to manage it. My question was just how to manage leakage. I think the biggest important thing is just making sure you're keeping the site clean. So I think it's okay to have gauze there. I've not heard that before, but I'd be interested to know why they think that makes it worse. But I think just making sure that you're keeping it clean and wiping it up so you're not getting infections. And then you can use like zinc oxide and like barrier creams and things like that. Like your stoma nurses can be really helpful in these settings to help keep them clean. But yeah, it's a hard problem. And oftentimes you just end up kind of exchanging the tube. Particularly like, you know, after the procedure, then they restart the DOAC and two days later you have like oozing from the actual track site, like tightening the bumper for 24 hours or surgical cell or kind of what do you reach for first or? Yeah. So the question is like bleeding from sort of like your incision site, which is usually like pretty self-limited. So applying pressure, I mean, like normal things that you would do. And then I think actually silver nitrate can be kind of helpful in those situations as well. I would try to not tighten the bumper because then you're going to put yourself at risk for Barry bumper syndrome down the road. So if it's too loose, I guess like fine, but I'd be a little bit nervous about that. And it's hard to pull it back once you've tightened it. Or can we just remove it from outside as well? Yeah. So we don't have to actually use a scope when we remove any of them. So the initial one that you place with like the solid internal bumper, you can remove it with just like a lot of like kind of like tension and oftentimes not as much, but basically like collapses on itself and just like pools through the tract. It just can be painful. And so we sometimes like we'll bring them into the endosuite and give them some sedation and then pull it out just so they're not in pain. So you don't need a scope for that one. And then for the balloon ones, you just deflate the balloon by like withdrawing water out of it through that specific port. And then you can just pull it out. There is a technique where you can actually like cut it on the outside and then you like push it through. So like the internal bumper like falls into the stomach, which we don't like do very often. So if I was going to do it that way, for some reason, I probably would do a scope so I could retrieve it. So it doesn't like cause an obstruction. But that's why we don't really do that very often, because then you have to do a scope. So it's kind of nice that these are all like externally removable without a scope. Yeah. Yeah. I'm sorry. You might have answered this before. The push versus pull technique, is that a better technique or it doesn't matter? It's as per the physician preference? The push technique? Yeah. My attending does pull because that's the kit available, but he was telling me like there's a push kit too and he actually prefers that. Oh really? I don't do the push kit. So I've never seen that one. So I guess I can't comment on it, unfortunately. I think IR kind of does it that way. Anybody else? Awesome. Thank you guys.

PEG tubes

gastroenterologist

neurological conditions

post-stroke complications

pre-procedure considerations

complications

post-procedure care