of the endoscopist is critical to the success of initiating and maintaining aggressive enteral nutritional support and providing a port of delivery for nutrients, fluids, and medications. Level 1 prospective randomized controlled trials indicate that achieving gut access and providing enteral feeding favorably impacts patient outcome. Compared with perennial feeding and gut disuse, achieving enteral access and feeding through the enteral route reduces the incidence of nosocomial infection, multiple organ failure, length of hospital stay, and even mortality in a variety of disease processes ranging from pancreatitis and burns to trauma and critical illness. Hi, I'm Steve McClay. We're excited to bring you this comprehensive videotape entitled Endoscopic Techniques and Enteral Access. And I'm Mark DeLegge. The objective of this videotape is to provide a brief discussion in the basic techniques of endoscopic enteral access device placement and also modifications of these techniques which may be individualized to particular patient situations. Along the way, helpful hints will be provided as to specific features of the endoscope or feeding tube as well as subtleties of technique which enhance success. The techniques described in this videotape are not simple and may necessitate skills no less difficult than those required for ERCP or endoscopic ultrasound. Endoscopic nasoenteric tubes, or ENET, are required for short-term feeding in which nutritional support is anticipated to be less than four weeks in duration prior to advancement to oral diet and resumption of the patient's own volitional intake. Using endoscopy to place a nasoenteric tube can be a surprisingly complex and difficult procedure. The choice of endoscope is critical to the success of ENET. The optimum instrument may be the pediatric colonoscope which is a length that allows penetration one to two loops below the ligament of trites and a degree of stiffness which helps prevent coiling in the stomach. The adult colonoscope has a larger diameter which makes negotiation of the oropharynx and pylorus difficult. A gastroscope may be too short to reach much past the third portion of the dodeum. An acceptable alternative is the small bowel endoscope. The endoscope should be passed through the stomach along the lesser curve, carefully avoiding air insufflation which may help prevent later looping of the scope in the stomach. There are several helpful techniques which may promote successful ENET placement. As the endoscope passes into the proximal small bowel, the endoscopist must pay attention to landmarks in order to identify the point at which he passes beyond the ligament of trites. Just beyond the pylorus in the duodenal bulb is the gentle curve of the duodenal C-loop. The longitudinal view seen just past the duodenal C-loop corresponds to the third and fourth portion of the duodenum leading up to the proximal jejunum and the ligament of trites. Negotiation of the curve following this longitudinal segment indicates passage below the ligament of trites. The over the guide wire technique is the most common method of ENET passage. It is important to successfully pull the scope off the wire without dislodging the distal tip. While an assistant may help support the weight of the scope, the endoscopist places one hand on the scope exiting the patient's mouth and the other hand on the valves where the wire exits the endoscope. Discoordinate rates of transfer between the endoscope and the wire or separate individuals handling the scope versus the wire all may lead to proximal displacement of the wire tip. Once the scope has been withdrawn, an oral nasal transfer tube is passed through one area and out the mouth. Care must be taken passing the wire through the oral nasal transfer tube to avoid inadvertent perforation. The oral nasal transfer of the wire is facilitated by pinning the wire against the posterior pharynx as the proximal end of the wire is passed through the transfer tube and pulled out through the nose. The nasal enteric tube is then passed over the wire again using the technique in which a single endoscopist has one hand at the patient's mouth passing the tube while the opposite hand is placed on the wire exiting the tube at the other end. Carefully matching the rates of tube being passed over the wire with wire exiting at the other end helps maintain position at the wire tip. Initially, these techniques may be practiced under fluoroscopic guidance, but eventually after only a handful of cases, this procedure may be mastered and ENET placed in a blinded fashion. Several alternatives to this procedure may be adapted according to personal preferences. One alternative is the through the scope technique. Using a larger therapeutic gastroscope, an 8-10 French feeding tube is passed through the operating channel and out into the lumen of the small bowel. The scope is withdrawn off the feeding tube prior to an oral nasal transfer. Another alternative is the transnasal technique. A neonatal gastroscope may be passed through the nares down through the stomach into the small bowel. A wire is placed through the operating channel out into the lumen of the gut and the scope is removed off the wire. The feeding tube is then placed directly over the wire into the small bowel. One final method which should be avoided is the drag and pull technique. A nasoenteric tube is passed into the stomach and biopsy forceps are used to grab the string on the end and drag the tube into the duodenum. This particular technique is one of the most common causes of frustration for the endoscopist as the withdrawal of the scope frequently dislodges the tube which has just been placed. The average longevity of a nasoenteric tube is approximately 9 days. The most common cause of nasoenteric tube dysfunction is inadvertent displacement by the patient or healthcare worker. Securing nasoenteric access devices and preventing inadvertent dislodgement by the patient may be achieved by one of several methods. Commercial bandage clipping devices are available which help secure the tube to the patient's skin. In those patients at greatest risk for inadvertent tube displacement, the nasoenteric tube may also be secured by using a bridle. In this technique, a 5 French neonatal feeding tube is passed through one nary, out the mouth, clamped and placed to the side of the patient. A second similar tube is passed through the opposite nary, again out the mouth, clamped and placed to the side of the patient. The two ends of the bridling tubes protruding from the mouth are sutured together with a single silk suture. Although a variety of tubes or surgical tape have been used for the bridling technique, an optimal device is the 5 French neonatal feeding tube. The small diameter of this tube minimizes patient discomfort and also potential complications. To position the bridle, traction is placed on the end of one of the bridling tubes protruding from the nose. This pulls the other bridling tube into position through one nary, around the nasal septum, and out the other nary. An oral-nasal transfer tube should be placed at this point to minimize patient's discomfort as they are still sedated. The endoscopist then proceeds with any of the aforementioned techniques to place the feeding tube. Following placement of the feeding tube, the tube is taped to the bridle beginning approximately one to two centimeters below the nose. Taping the tube to the bridle avoids direct suturing or taping of the nasal anterior tube to the patient's nose with its associated potential complications. More permanent internal access may be achieved by placement of a PEG or percutaneous endoscopic gastrostomy. This procedure may be required if advancement to oral diet and resumption of the patient's own volitional intake is delayed and the duration of nutrition support is expected to be in excess of four weeks' duration. Because the procedure is slightly more invasive, requiring a skin incision and passage of the tube through the anterior abdominal wall, prophylactic antibiotics may be warranted to prevent infection or cellulitis at the PEG site. In patients not already on antibiotics, a single dose of a third generation cephalosporin should provide adequate protection. It is helpful to outline the relationships of the left costal margin and the midline of the abdomen with an indelible marker. The PEG site should be localized two centimeters or more below the left costal margin to avoid excessive pain to the patient and inadvertent laceration of the liver, as well as two to three centimeters from the midline to avoid the tough linea alba. The optimal site may be localized by seeing obvious endoscopic evidence of finger palpation and good translumination of the endoscope light through the anterior abdominal wall. These signs of reassurance may not be present in patients who are obese or have altered surgical anatomy. Superficial injection to create the appearance of an orange peel is used to obtain optimal skin anesthesia. The FOUCH safe track technique helps ensure that no intervening loop of colon is positioned between the anterior abdominal wall and the stomach. Aspirating as a small 10cc syringe is pushed inward toward the stomach, bubbles should appear as the needle is seen to enter the stomach. If bubbles appear before the needle appears in the stomach, position of the site should be reevaluated to avoid passage through a loop of colon. A vertical incision may cause less bleeding and discomfort for the patient than a horizontal incision and a length of only 4 to 5 millimeters is required. All three types of PEG placement require insufflation and distention of the stomach with air, the same procedure for localizing the PEG site as described above, and the passage of a wire through an initial trocar into the stomach. The pull-type technique utilizes the basic principles of the original PEG procedure described by Jeff Ponsky back in 1981. Following placement of the initial trocar, a wire loop is placed into the stomach. The wire loop is grabbed with a snare and withdrawn out through the mouth. A smaller wire loop attached to the proximal end of the feeding tube is used to tether the tube to the larger wire loop protruding from the patient's mouth. Not connecting the two loops should be examined closely to avoid slippage or separation and should be tightened down and lubricated to avoid excessive trauma to the mucosa of the oropharynx and esophagus. The rest of the tube system should be further lubricated to facilitate passage through the upper gastrointestinal tract. Traction is then applied to the wire protruding from the skin, pulling the feeding tube down through the mouth and out through the anterior abdominal wall into final position. The push-type technique, originally described by Sax Bein, involves passing a single-stranded wire through the trocar into the stomach, grabbed again by biopsy forceps, and then brought out the mouth. The procedure is similar in most aspects to the pull-type method and the skills required for the two techniques are virtually identical. Choice between the two procedures should be based more on availability of materials and personal preferences. The biggest difference relates to the long, hard plastic dilator attached to the proximal end of the feeding tube, which allows the tube to be actually pushed over the guide wire down through the esophagus and stomach and then out through the anterior abdominal wall into final position. The third introducer type, or Russell technique, differs substantially from the first two methods and is utilized more often by radiologists than endoscopists. Similar to the push technique, a single-stranded wire is placed through the initial trocar into the stomach. However, throughout this technique, the wire is held in place in the stomach by the grasping snare. A degree of tension is applied to anchor the wire and provide as straight a tract as possible into the gastric lumen. The tract is then dilated with two or three Seldinger type dilators of increasing size. Each time, the dilator is pushed carefully over the wire into the stomach and then passed back and forth to establish tract patency. After the tract has been sufficiently dilated, the peel-away introducer sheath and cannula are passed over the wire into the stomach. Once the hub of the outer sheath appears in the gastric lumen, the inner cannula is removed. The feeding tube itself is now finally passed over the guide wire into the stomach. The outer introducer sheath is then simply peeled away and discarded. A stitch placed through the skin and tied around the shaft of the tube secures it in place and obviates the need for an external bolster. A variation of the Sachs-Vine push-type technique involves the placement of a button skin-level device in a virgin abdomen. After initially passing the wire through the trocar, the wire is held in place in the stomach by a snare. A device passed over the guide wire is used to measure the length of the tract across the gastric and interior abdominal wall and then determines the stem length of the button peg ultimately required. Skin-level gastrostomy tubes have become a more commonly used enteral access device amongst gastroenterologists. These systems provide access to the stomach but have the advantages of improved cosmetic appearance and elimination of a dangling gastrostomy tube from the abdominal wall. In this particular patient, the button skin-level device is being placed via a Ponsky pull technique. Once the peg has been pulled out through the anterior abdominal wall, the plastic sheath will be removed to separate the dilator from the skin-level device. This plastic sheath is removed by simply pulling up on an attached suture to the plastic sheath. The skin-level device can be accessed within an extension tube for either feeding or for gastric decompression. While a second pass of the endoscope to confirm final position of the peg is certainly not required, a fairly simple technique facilitates this procedure and provides valuable information to the endoscopist. A snare passed through the endoscope is attached to the internal bolster. The scope is pulled up closely to about the face of the bolster. As the tube is pushed or pulled down into final position, the scope is pulled with it down into the stomach. Once in the stomach, the snare is opened and then displaced off the internal bolster. The endoscope can now be used to visualize final placement of the tube and to help set the appropriate position and tension of the external bolster. A variety of techniques for securing peg tubes exist and help either to reduce the risk of inadvertent displacement or to avoid excessive tension leading to the development of buried bumper syndrome. This commercial device is ideal for peg tubes of larger diameter as it can be clamped or fixed fairly tightly to the tube while maintaining the appropriate angle perpendicular to the skin. A variety of similar devices and strategies exist, any of which may be tailored to meet the needs of the individual patient or be adapted to specific characteristics of the access device. In patients at high risk for inadvertent tube displacement or in patients undergoing the Russell introducer peg placement, it may be important to secure the stomach up against the anterior abdominal wall. This may be facilitated by placement of T-fasteners. Several commercial devices of differing design are available, but each utilize the same principle by which a T-bar attached to a long suture is delivered into the stomach. A scalpel is used to make a small nick in the patient's skin. This particular device involves the introduction of an initial trocar which houses the sutured T-bar into the gastric lumen. A cannula passed through the trocar dispenses the T-bar and the trocar is removed. Traction on the suture then pulls the stomach up against the anterior abdominal wall. A needle affixed to the opposite end of the suture is used to secure the device to a one centimeter segment of tubing on the skin. Usually, the placement of two or more T-fasteners are required to adequately secure the stomach to the anterior wall. Placement of a jejunal tube through an existing peg is called a percutaneous endoscopic gastrojejunostomy or PEGJ and may be required when the patient's hospital course is complicated by the development of ileus, gastroparesis, partial gastric outlet obstruction, or tube feeding aspiration. The placement of the initial peg is as described above with a couple of modifications. Greater effort should be made to position the peg low in the antrum pointed towards the pylorus to facilitate easier jejunal tube placement. Also, the peg should be cut down to a length of approximately 10 to 12 centimeters to allow placement of the jejunal tube as deep as possible. The main technique for PEGJ involves passing a biopsy forceps out from the stomach and through the peg in order to grasp a guide wire. The biopsy forceps then pulls the wire into the stomach and proceeds to drag it down into the small bowel, hopefully below the ligament of trites. A vent plug placed over the wire and into the proximal end of the peg is very important to maintain air insufflation in the stomach and allow optimal endoscopic visualization. Similar to the ENET technique, the choice of the endoscope is critical. The pediatric colonoscope, again, has the appropriate stiffness to avoid looping in the stomach and the length required to achieve deep enough penetration below the ligament of trites. A biopsy forceps, alligator forceps, or coin grabber is superior to a snare for transporting the wire, as the snare may be difficult to extract once the wire has been properly placed in position. Passing the endoscope and thus dragging the wire lower in the small bowel, down to or below the ligament of trites, allows passage of the full length of the jejunal tube and avoids looping in the stomach. The wire is held in place in the small bowel by advancing the biopsy forceps as the scope is backed out in an aureate direction. Initially, the procedure may be learned under fluoroscopic guidance, but very quickly the technique may be adapted to be performed in blinded fashion. The scope is withdrawn back to the proximal stomach. The feeding tube is first lubricated and then, under direct endoscopic visualization, is placed over the wire, through the peg, down into position in the small bowel. The wire may be then withdrawn and removed, the biopsy forceps are retracted back into the scope, and the procedure is completed. The final endoscopic view before releasing the wire should be direct passage of the feeding tube down through the pylorus without a loop formed in the stomach. In many centers, there is poor understanding of PEGJ placement techniques and frustration with obtaining successful placement results. Many physicians have developed personal techniques to improve their placement results. In a modification of the previously described PEGJ placement technique, a retrieval snare is passed through the peg into the stomach and the pediatric colonoscope is passed through the snare, then down beyond the pylorus, deep into the small bowel. The position of the endoscope can be confirmed with fluoroscopic guidance, although this is not necessary and, after learning this technique, can be performed without fluoroscopic assistance. A guide wire is placed through the endoscope into the small bowel. This also can be confirmed with fluoroscopic guidance, although, again, after learning the technique, it can be performed without fluoroscopic assistance. The colonoscope is slowly withdrawn from the small bowel, leaving the guide wire intact. Care must be taken to slowly remove the colonoscope to prevent displacement of the distal end of the guide wire. The snare is then enclosed on the wire and it is pulled back through the peg to the outside of the patient. Care must be taken to make sure that the oral end of the guide wire is being retracted through the peg to prevent displacement of the distal end of the guide wire. With the scope still positioned in the proximal stomach, the jejunal tube is then passed over the wire in position into the small bowel. The jejunal tube should be well lubricated to aid in passage through the peg without placing significant tension on the gyro, which would also result in its displacement. Another modification of this technique, following placement of the initial peg, involves the use of a neonatal gastroscope. Next to the pediatric colonoscope, this instrument may be one of the most important for the endoscopist routinely involved in placing enteral access. The outer diameter, at 5.5 millimeters, is much smaller than the standard or 2T therapeutic gastroscope and allows passage through a 28 French peg. To perform this same procedure in peg tubes of smaller diameter, a bronchoscope or ureteroscope may be needed. The neonatal gastroscope is passed through the peg into the stomach and then down beyond the pylorus into position as deep as possible into the small bowel. The increased flexibility of this instrument tends to lead to inadvertent looping in the stomach. Once the scope has been passed deep enough, a guide wire is placed through the operating channel out into the lumen of the gut and advanced even further. The scope is then withdrawn off the wire out through the peg. Again, while fluoroscopic guidance may facilitate learning this procedure early on, it quickly may be adapted to be performed in blinded fashion. The jejunal feeding tube now may be passed over the guide wire into final position in the small bowel and the wire is withdrawn. The procedure is completed by capping the jejunal portion of the tube. Several helpful hints improve success with PEGJ placement. A vegetable cooking spray may be used to lubricate the endoscope, the outside of the tube, or the guide wire to facilitate jejunal tube passage. The view at completion of the procedure as seen from the proximal stomach is critical. Poor placement is indicated by formation of a loop which arches towards the fundus of the stomach. If the tube is not withdrawn and the procedure repeated, the natural tendency of this loop is to promote proximal displacement of the tube back into the stomach. Successful tube placement can be visually confirmed with passage of the jejunal feeding tube directly from the peg to the pylorus. Patients who experience recurrent displacement of a PEGJ tube and yet require continued long-term jejunal feeds may be better facilitated by placement of a DPEJ or direct percutaneous endoscopic jejunostomy tube. A slightly larger area of the abdomen from the costal margin down almost to the iliac crest should be sterilized. Both physicians involved in this technique should expect to spend more time to achieve adequate translumination. The skin man should palpate over a larger surface area while the scope man passes the instrument back and forth through various segments of the small bowel. The skin man must be ready to apply quick skin anesthesia and then pass a 25-gauge sounding needle. Upon visualization of the sounding needle within the lumen of the small bowel, the needle is grasped by a snare which serves to anchor the small bowel in place. The trocar is passed alongside the sounding needle, attempting to duplicate the exact angle of penetration. Once the trocar is visualized in the lumen of the small bowel, the scope man must transfer the snare from the wire to the trocar while removing the sounding needle. The guide wire is then passed through the trocar and snared by the scope man within the lumen of the bowel. The wire is withdrawn out through the mouth. Only then is more complete skin anesthesia performed at the site and a small 4-5mm vertical incision made over the wire. At that point, the peg is placed using standard Ponsky pull-through or Sachs vine push technique with the endoscope being pulled down by snare attachment to the internal bolster into the stomach and small bowel. In comparison to routine pegs, it is much more important to visually confirm final position. Because the internal bolster tends to pop down from one segment of the small bowel to the next as the tube is pulled down through the upper GI tract, it may be difficult to tell blindly when the bolster is seated appropriately. Clearly, a low-profile internal bolster is important to prevent obstruction of the small bowel that might occur with larger balloon-type bolsters. It is important to remember in the patient with an intact GI tract that passage of the scope below the ligament of trites is required to properly localize the deep-hedged site as this is the point at which the bowel exits the retroperitoneal space and enters the peritoneal cavity. Most peg tubes are designed to be manually retracted to bedside with approximately 10-15 pounds of pull pressure. Differences in the collapsibility of the internal bolster determines the ease and comfort with which this procedure may be performed. Other peg tubes have a distendable internal bolster. Utilization of an obturator allows the peg tube tip to be extended. Extension of the peg tube tip with an obturator allows the peg tube to be removed by simple traction. For patients maintained on chronic peg feeds with a mature tract, a wide variety of options exist should the tube need to be replaced. Many commercial brands of replacement pegs are available, with subtle differences in design. Balloon replacement pegs utilize an inflatable balloon to create the internal bolster. Low-profile, skin-level, or button replacement pegs are often desirable in active, high-functioning patients. One design utilizes an inflatable balloon for an internal bolster, while another uses a distensible bolster requiring an obturator. A holding clamp facilitates placement of this particular device at the bedside. The obturator reversibly distends the internal bolster for placement through the tract. It is very important to determine the appropriate stem length for these replacement peg devices. While subtle differences in design exist, the basic principle involves simple measurement of the tract length from the gastric lumen to the anterior abdominal wall. This may be performed at the bedside in blinded fashion by these simple devices. The first version utilizes a collapsible internal bolster. The device is pulled out against the gastric wall and measurements are obtained at the skin. A second version of the measuring device uses a reversibly inflatable balloon as the internal bolster and has an external slide to obtain final measurements. Mismeasurement can result in long stems on the peg which migrate back and forth, causing patient discomfort and possible breakdown of the tract. Pegs which are too short can lead to buried bumper syndrome in a murasmic patient who gains weight with nutritional therapy. In patients requiring replacement of a peg J, a commercial device exists which can be placed endoscopically over a guide wire. The bolster is created by an inflatable balloon. Multiple ports allow for simultaneous aspiration of the stomach with continued feedings into the jejunum. If commercial devices are not available, a surprisingly effective replacement peg may be fashioned from two Foley catheters. First, the funnel on one catheter is cut to a 5 to 6 centimeter segment. The section is folded over and both corners are cut at an angle. This creates an external bolster. Hemostats are then used to pass the bolster over a second Foley catheter. These steps would be done prior to placing the device in the patient. With the newly created bolster fitted on the second catheter, this homemade peg can now be placed through the mature tract. Inflation of the balloon creates the internal bolster. Surprisingly, this device can work just as effectively as a commercial device. A sequence of steps may be required to alleviate clogged feeding tubes. Studies have shown that the best declogging agent is the pancreatic enzyme Biocase. A 650 milligram sodium bicarbonate tablet is used to raise alkalinity and maximize enzyme activity of the Biocase. The tablets are mixed in a 10 cc syringe of warm water. This is injected and retracted back and forth into the tube by working the plunger of the syringe over a 10 to 15 minute period. If there is failure to relieve the clog, an ERCP catheter may be passed down through the tube to position installation of the declogging solution immediately at the level of the clot. Again, the syringe of declogging solution is attached and infusion aspiration is applied over a 10 to 15 minute period. This combination of agents is twice as good at declogging than commercial soft drinks, all of which are better and safer than papain or meat tenderizer. If this does not work, a wire cytology brush from the endoscopy suite may be obtained and passed gingerly down through the feeding tube. Pushing blindly against resistance must be done carefully and judiciously to avoid inadvertent perforation. Somewhat greater safety may be provided by a commercial corkscrew device, which again is passed down through the feeding tube to the level of obstruction. A gentle screwing clockwise motion allows the device to core through the clot and relieve the obstruction. Varied bumper syndrome involves the partial or complete growth of the gastric mucosa over the internal bumper of the PEG tube. Risk factors which promote the syndrome include excessive tension in which the external bolster is cinched too tightly against the skin, stiffer material and smaller surface area of the internal bolster, malnutrition and poor tissue healing, and weight gain in a previously cacectic patient associated with adequate nutritional support. The most common presentation is immobility of the PEG tube and or excessive drainage around the site. More advanced cases may involve abdominal pain, infection and even necrotizing fasciitis. Several techniques have been developed to relieve varied bumper syndrome. The push-pull T technique involves passage of an endoscope into the stomach, cutting the PEG tube down to two sinometers and then placing a snare through the stomach through the PEG to the outside. A one-centimeter segment of the feeding tube is cut to form a T-shaped anchoring device and then the PEG is slowly pulled into the stomach and out through the esophagus and mouth. In a modification of this technique, a balloon catheter may be passed up through the PEG tube to the outside and the balloon inflated to serve as the anchoring device. If the internal bumper is completely overgrown by gastric mucosa, a needle knife technique may be required to cut down to the dome of the feeding tube prior to removal and replacement. The acquisition of a broad range of skills for endoscopic enteral access device management will maximize the number of options available for physicians in patient care management. Knowing the proper techniques for initial enteral access device placement will minimize complications. Identifying and noting the signs and symptoms of complications early will reduce long-term supply. Surprisingly, often simple endoscopic solutions may be required for appropriate management. The role of the endoscopist in achieving and maintaining enteral access is paramount in providing optimal nutritional support and improving patient outcomes. We hope the skills described in this tape empower the endoscopist to become more involved in clinical nutrition and provide a high level of expertise to clinical nutrition specialists and the overall medical community.

enteral access

endoscopic techniques

nutritional support

PEG tubes

feeding tubes

complications

patient outcomes