Lever access technique as salvage when traditional needle access for PEG fails. Authors? We have no relevant disclosures to make. An 82-year-old man with a PEG tube since 2015 following chemo radiation and surgery for head and neck cancer. The patient suffered from months of leakage of old tube feeds around the dilated PEG tract. This has persisted despite wound care, antibiotics and downsizing the PEG tube. Surgical closure of skin not deemed feasible due to erythema and inflammation around site. The plan was to attempt PEG tube placement at a new site and endoscopic closure of previous site. Percutaneous endoscopic gastrostomy is generally accomplished by passing a needle and trocher through a site identified by transillumination and finger indentation. Transillumination and finger indentation is not always achieved. Sometimes needle and trocher cannot enter the stomach even if transillumination and finger indentation are achieved due to scarring. Lever access technique may be used if these situations arise in patients with a pre-existing stoma if a new PEG site is necessary. The PEG tube is seen in place with a dilated tract. This was removed with gentle traction. You can see how dilated the tract is. Gauze was used to cover the existing tract to allow insufflation of the stomach. We attempted to advance the 19 French needle, trocher and a spinal needle without success. We suspect this is likely due to scar tissue from previous gastrostomy. A plastic catheter was inserted through the prior existing tract and acted as a lever to change the orientation of the stomach. This brings the stomach closer to the abdominal wall. An appropriate window for access was identified. The finder needle was used, followed by a trocher and then the PEG tube was placed using the pull technique. To facilitate closure of the existing tract, argon-plasma coagulation was used to create eschar, the fulgurated area was agitated using a cyto-brush and a brush from the outside until granulation tissue was seen. Endoscopy was repeated in one week, and as you can see, the prior-picked tract site is still dilated. Endoscopic suturing device was used to close the defect. An over-the-scope clip was deployed The stoma was still patent, therefore the endoscopic suturing device was used again When this was over, a guide wire could not advance from the skin to the stomach Enclosure was confirmed by injecting methylene blue from the skin at the fistula site confirming lack of entry into the stomach There was no air bubbles at the fistula site while insufflating the stomach To conclude, lever access technique can be used in a patient with pre-existing tract if there is no adequate window for access The technique is safe and easy to use when indicated and needed

lever access technique

traditional needle access

percutaneous endoscopic gastrostomy

PEG tube placement

leakage around the tract