**5. Principle of techniques for introducer percutaneous endoscopic gastrostomy**

The introducer PEG is performed with the patient in the supine position under local anesthesia, intravenous sedation, or general anesthesia. EGD is necessary for visualization of the stomach during the procedure. For the patients with advanced local disease and dysphagia, the standard diameter endoscope (8–12 mm) [58] might not pass through the narrowed esophageal lumen, necessitating the use of the pediatric endoscope, which has a smaller diameter (4.9–6 mm) [59].

Gastropexy is a technique that anchors the stomach wall to the abdominal wall before the feeding tube is inserted; one method is the double needle gastropexy (**Figure 1**). The double-needle gastropexy is a device with two parallel, 20-gauge needles, and a suture-holding loop. The suture-holding loop inserts through the first needle and the suture inserts through the second needle which is grasped with

**55**

injury [18, 65].

**Figure 1.**

*Sumitomo Bakelite Co. Ltd., Akita, Japan).*

**6. Complications**

comorbidities [69].

*Introducer Percutaneous Endoscopic Gastrostomy in Palliative Care of Patients with Esophageal…*

the snare. The needles are withdrawn, and the suture is tied to the left upper quadrant of the anterior abdominal wall. A second gastropexy is performed 2–3 cm apart in the same way. The gastric wall is then punctured and the dilator inserted over the

*Percutaneous Endoscopic Gastrostomy (PEG); Endoscopic view of introducer technique. (A) Double-needle gastropexy. (B) Puncture of the double-needle gastropexy and forming the loop to hold the suture. (C) The suture from one of the needles passes through the loop wire from the other needle and tightens the loop. The doubleneedle device is removed. (D) Puncture and insertion the dilating catheter over the guidewire. (E) The dilating catheter and guidewire are removed. (F) The gastrostomy tube is inserted through the sheath, and then the sheath is peeled away. (G) The bumper of a 24 Fr bumper-type gastrostomy tube (IDEAL PEG Kit; MD-43430; Akita* 

Previous abdominal surgery of the upper abdomen is a relative contraindication because of altered intra-abdominal anatomy [9, 60]. However, there are reports that safe PEG introduction can be achieved safely with the use of transillumination (using an endoscope passed through the abdominal wall with clear endoscopic intra-gastric visualization by external palpation) [61], a plain abdominal film with air insufflation technique, and computed tomography guided PEG [62–64], and laparoscopic-assisted PEG. These techniques aim to avoid intra-abdominal organ

Although the introducer PEG is a proven effective and safe procedure, it suffers the limitation of requiring endoscopy. Passing the endoscope beyond the tumor may be difficult and there is a risk of esophageal perforation in severe esophageal luminal occlusion. In advanced cases, surgical gastrostomy and laparoscopicassisted PEG are the alternative procedures [17, 18]. A recent study published the comparison of both techniques, and the laparoscopic-assisted PEG had advantages in the procedural duration, blood loss, postoperative pain, and hospitalization [18].

Although the push/introducer PEG is a minimally invasive technique that demonstrates a method in enteral nutrition [10, 17, 18, 66, 67], it is associated with several complications [9, 17, 68], including death in patients with underlying

Bleeding is the most common complication and is usually minor and manifest as oozing around the feeding tube. Apply the simple compression should stop the bleeding. If the bleeding more severe, it might be due to injury to e.g. gastric and

guidewire, followed by the gastrostomy tube (**Figure 1**) [16, 17].

*DOI: http://dx.doi.org/10.5772/intechopen.95409*

*Introducer Percutaneous Endoscopic Gastrostomy in Palliative Care of Patients with Esophageal… DOI: http://dx.doi.org/10.5772/intechopen.95409*

#### **Figure 1.**

*Suggestions for Addressing Clinical and Non-Clinical Issues in Palliative Care*

Although surgery plays a long history of enteral nutrition, the various procedures have developed to reduce complications, pain, and additional cosmetic results. Pull-type or introducer PEG is a favored method for a minimally invasive procedure, avoiding the risk of cancer seeding compared to surgical gastrostomy [17, 18]. In addition to patients with esophageal cancer, the introducer PEG could also use in patients who indicated enteral nutrition support with pre-pyloric feeding, demand for long-term enteral feeding, the patients with head and neck cancer that could diminish the risk of cancer seeding from PEG procedure, and apply for

The contraindications for a PEG include: patients with unstable vital signs, sepsis, uncorrected coagulopathy, gastric outlet obstruction or intestinal obstruction as well as patients who have endoscopic contraindications such as a viscus perforation, gastric pathology or severe abdominal wall infection especially at the site for the feeding tube, massive ascites, pregnancy, caustic esophageal or gastric injuries,

**5. Principle of techniques for introducer percutaneous endoscopic** 

The introducer PEG is performed with the patient in the supine position under local anesthesia, intravenous sedation, or general anesthesia. EGD is necessary for visualization of the stomach during the procedure. For the patients with advanced local disease and dysphagia, the standard diameter endoscope (8–12 mm) [58] might not pass through the narrowed esophageal lumen, necessitating the use of the

Gastropexy is a technique that anchors the stomach wall to the abdominal wall before the feeding tube is inserted; one method is the double needle gastropexy (**Figure 1**). The double-needle gastropexy is a device with two parallel, 20-gauge needles, and a suture-holding loop. The suture-holding loop inserts through the first needle and the suture inserts through the second needle which is grasped with

and previous gastric or intra-abdominal surgery (**Table 2**) [9, 57].

pediatric endoscope, which has a smaller diameter (4.9–6 mm) [59].

gastric decompression [9, 25, 55, 56].

**gastrostomy**

**Indications**

**For esophageal cance**r

**Contraindications Patient factor** Unstable vital signs

**Endoscopic factor** Viscus perforation Gastric pathology

Massive ascites Pregnancy

**Table 2.**

Uncorrected coagulopathy

*Indications and contraindications.*

Caustic esophageal or gastric injuries Previous intra-abdominal surgery

Sepsis

Apply for gastric decompression

Enteral nutrition support with pre-pyloric feeding Minimize the risk of cancer seeding from PEG procedure

Gastric outlet obstruction or intestinal obstruction

Severe abdominal wall infection (especially at the site for the feeding tube)

**54**

*Percutaneous Endoscopic Gastrostomy (PEG); Endoscopic view of introducer technique. (A) Double-needle gastropexy. (B) Puncture of the double-needle gastropexy and forming the loop to hold the suture. (C) The suture from one of the needles passes through the loop wire from the other needle and tightens the loop. The doubleneedle device is removed. (D) Puncture and insertion the dilating catheter over the guidewire. (E) The dilating catheter and guidewire are removed. (F) The gastrostomy tube is inserted through the sheath, and then the sheath is peeled away. (G) The bumper of a 24 Fr bumper-type gastrostomy tube (IDEAL PEG Kit; MD-43430; Akita Sumitomo Bakelite Co. Ltd., Akita, Japan).*

the snare. The needles are withdrawn, and the suture is tied to the left upper quadrant of the anterior abdominal wall. A second gastropexy is performed 2–3 cm apart in the same way. The gastric wall is then punctured and the dilator inserted over the guidewire, followed by the gastrostomy tube (**Figure 1**) [16, 17].

Previous abdominal surgery of the upper abdomen is a relative contraindication because of altered intra-abdominal anatomy [9, 60]. However, there are reports that safe PEG introduction can be achieved safely with the use of transillumination (using an endoscope passed through the abdominal wall with clear endoscopic intra-gastric visualization by external palpation) [61], a plain abdominal film with air insufflation technique, and computed tomography guided PEG [62–64], and laparoscopic-assisted PEG. These techniques aim to avoid intra-abdominal organ injury [18, 65].

Although the introducer PEG is a proven effective and safe procedure, it suffers the limitation of requiring endoscopy. Passing the endoscope beyond the tumor may be difficult and there is a risk of esophageal perforation in severe esophageal luminal occlusion. In advanced cases, surgical gastrostomy and laparoscopicassisted PEG are the alternative procedures [17, 18]. A recent study published the comparison of both techniques, and the laparoscopic-assisted PEG had advantages in the procedural duration, blood loss, postoperative pain, and hospitalization [18].

#### **6. Complications**

Although the push/introducer PEG is a minimally invasive technique that demonstrates a method in enteral nutrition [10, 17, 18, 66, 67], it is associated with several complications [9, 17, 68], including death in patients with underlying comorbidities [69].

Bleeding is the most common complication and is usually minor and manifest as oozing around the feeding tube. Apply the simple compression should stop the bleeding. If the bleeding more severe, it might be due to injury to e.g. gastric and

gastroepiploic arteries. A pressure dressing is often effective but if bleeding continues, it can be treated by endoscopy, embolization, or surgery [9, 17, 57]. Selecting carefully the correct anatomical site and correcting a coagulopathy, if present, should prevent or minimize the risk of bleeding complications.

Abdominal organ injuries to the small bowel, colon, liver, and spleen may occur caused by the interposition of these organs between the gastric wall and the abdominal wall [9, 57, 70–73]. EGD should always be performed using transillumination, for clear intra-gastric visualization, and external palpation to identify and interposition of the internal organs [61]. If there is doubt, then laparoscopy can be performed to assure direct visualization of the intra-abdominal cavity [18].

Aspiration pneumonia is a severe complication and is associated with a mortality of PEG [9, 57]. Esophageal cancer patients, especially in elderly, heavy smokers with or without chronic obstructive pulmonary disease (COPD), have a higher risk of aspiration pneumonia compared to other patients and is related to residual liquid or food in the esophagus proximal to the obstruction. By technical for advanced esophageal cancer patients, the pediatric endoscope often chosen for the PEG procedure. The endoscope's small diameter is followed by the small endoscopic channel, resulting in less suction performance than the standard endoscope. Measures to reduce the risk of aspiration include the use of topical pharyngeal anesthesia rather than sedation, frequent mouth suction, and the reverse Trendelenburg position [74, 75].

The buried bumper syndrome (BBS) occurs when the internal bumper erodes into the wall of the stomach and sometimes becomes entirely buried within the gastric wall. It might cause by a disproportionate size and length of the feeding tube with the thickness of the abdominal wall. The main causative factor is excessive tightening of the external bumper, leading to increased pressure of the internal bumper on the wall of the stomach, local ischemia and gastric wall erosion (**Figure 2**). Additional risk factors include obesity, weight gain, malnutrition, corticosteroid therapy, and poor wound healing. BBS is a late complication and usually occurs > one year post PEG but it may be seen within several weeks of PEG placement. It may be asymptomatic or cause pain. Malfunction of the PEG is common, leading to leakage around the entry site, difficulty administering the feeds, fluids or drugs, infection, abscess or peritonitis [76, 77]. If BBS occurs, the tube should be removed by endoscopy, surgical intervention, or external traction, depending on the type of feeding tube and the patient's situation [9, 77, 78].

Necrotizing fasciitis is the rare and severe PEG complication and is associated with a high mortality. Local ischemia leads to bacterial infection with a mix of anaerobic and aerobic organisms from gastrointestinal tract and skin. The infection progresses rapidly along with fascial plane and causes extensive abdominal fascia necrosis [79]. Treatment includes urgent aggressive and wide surgical debridement, intravenous broad-spectrum antibiotics and close clinical monitoring in the intensive care unit [9, 80–82]. The prognosis is very poor.

Granuloma formation is a minor but common complication that results from peristomal hyper-granulation due to friction of the PEG tube and humidity due to tube leakage [83, 84]. Patients are prone to local infection and contact bleeding. Treatment includes topical antibiotics, topical steroids, electrocauterization, or cauterizing by silver nitrate. Surgical debridement may be required for sizeable peristomal granulomas [9, 83, 85].

Peristomal leakage and local infection are also minor complications that causing discomfort, pain and annoyance for patients and their families. Good peristomal hygiene and dressings combined with reducing the volume of feeds and minimizing PEG tube movements are treatment options. If these failed, removing the PEG tube and placing it in another area can be done or abandoning PEG enteral feeding for another form [9, 57, 68].

**57**

this chapter.

**7. Conclusion**

**Figure 2.**

**Acknowledgements**

**Conflict of interest**

The author declares no conflict of interest.

**Notes/thanks/other declarations**

*Introducer Percutaneous Endoscopic Gastrostomy in Palliative Care of Patients with Esophageal…*

Percutaneous endoscopic gastrostomy is a minimally invasive procedure for the patients who need enteral nutrition support, hydration, and medications. For esophageal cancer patients and palliative care, the introducer technique is the optimal technique and prevents cancer seeding from the operative procedure.

*Buried bumper syndrome. (A, B) The external and internal bumper held correctly in position (A) but with pressure and ischemic necrosis, the internal migrates through the gastric wall into the abdominal wall (B).* 

*(C) Endoscopic examination of a patient with the Buried Bumper syndrome.*

The author would like to thank Assistant Professor Jirawat Swangsri M.D., Ph.D. (Department of Surgery, Siriraj Hospital, Mahidol University) for the first case technical assistance with the introducer PEG procedure in Thammasat University Hospital.

Special thanks to Dr. Bob Taylor for assistance in editing the English version of

*DOI: http://dx.doi.org/10.5772/intechopen.95409*

*Introducer Percutaneous Endoscopic Gastrostomy in Palliative Care of Patients with Esophageal… DOI: http://dx.doi.org/10.5772/intechopen.95409*

#### **Figure 2.**

*Suggestions for Addressing Clinical and Non-Clinical Issues in Palliative Care*

should prevent or minimize the risk of bleeding complications.

gastroepiploic arteries. A pressure dressing is often effective but if bleeding continues, it can be treated by endoscopy, embolization, or surgery [9, 17, 57]. Selecting carefully the correct anatomical site and correcting a coagulopathy, if present,

Abdominal organ injuries to the small bowel, colon, liver, and spleen may occur caused by the interposition of these organs between the gastric wall and the abdominal wall [9, 57, 70–73]. EGD should always be performed using transillumination, for clear intra-gastric visualization, and external palpation to identify and interposition of the internal organs [61]. If there is doubt, then laparoscopy can be

performed to assure direct visualization of the intra-abdominal cavity [18].

Aspiration pneumonia is a severe complication and is associated with a mortality of PEG [9, 57]. Esophageal cancer patients, especially in elderly, heavy smokers with or without chronic obstructive pulmonary disease (COPD), have a higher risk of aspiration pneumonia compared to other patients and is related to residual liquid or food in the esophagus proximal to the obstruction. By technical for advanced esophageal cancer patients, the pediatric endoscope often chosen for the PEG procedure. The endoscope's small diameter is followed by the small endoscopic channel, resulting in less suction performance than the standard endoscope. Measures to reduce the risk of aspiration include the use of topical pharyngeal anesthesia rather than sedation, frequent mouth suction, and the reverse Trendelenburg position [74, 75]. The buried bumper syndrome (BBS) occurs when the internal bumper erodes into the wall of the stomach and sometimes becomes entirely buried within the gastric wall. It might cause by a disproportionate size and length of the feeding tube with the thickness of the abdominal wall. The main causative factor is excessive tightening of the external bumper, leading to increased pressure of the internal bumper on the wall of the stomach, local ischemia and gastric wall erosion (**Figure 2**). Additional risk factors include obesity, weight gain, malnutrition, corticosteroid therapy, and poor wound healing. BBS is a late complication and usually occurs > one year post PEG but it may be seen within several weeks of PEG placement. It may be asymptomatic or cause pain. Malfunction of the PEG is common, leading to leakage around the entry site, difficulty administering the feeds, fluids or drugs, infection, abscess or peritonitis [76, 77]. If BBS occurs, the tube should be removed by endoscopy, surgical intervention, or external traction, depending on the type of feeding tube and the

Necrotizing fasciitis is the rare and severe PEG complication and is associated with a high mortality. Local ischemia leads to bacterial infection with a mix of anaerobic and aerobic organisms from gastrointestinal tract and skin. The infection progresses rapidly along with fascial plane and causes extensive abdominal fascia necrosis [79]. Treatment includes urgent aggressive and wide surgical debridement, intravenous broad-spectrum antibiotics and close clinical monitoring in the inten-

Granuloma formation is a minor but common complication that results from peristomal hyper-granulation due to friction of the PEG tube and humidity due to tube leakage [83, 84]. Patients are prone to local infection and contact bleeding. Treatment includes topical antibiotics, topical steroids, electrocauterization, or cauterizing by silver nitrate. Surgical debridement may be required for sizeable

Peristomal leakage and local infection are also minor complications that causing discomfort, pain and annoyance for patients and their families. Good peristomal hygiene and dressings combined with reducing the volume of feeds and minimizing PEG tube movements are treatment options. If these failed, removing the PEG tube and placing it in another area can be done or abandoning PEG enteral feeding for

**56**

patient's situation [9, 77, 78].

peristomal granulomas [9, 83, 85].

another form [9, 57, 68].

sive care unit [9, 80–82]. The prognosis is very poor.

*Buried bumper syndrome. (A, B) The external and internal bumper held correctly in position (A) but with pressure and ischemic necrosis, the internal migrates through the gastric wall into the abdominal wall (B). (C) Endoscopic examination of a patient with the Buried Bumper syndrome.*

## **7. Conclusion**

Percutaneous endoscopic gastrostomy is a minimally invasive procedure for the patients who need enteral nutrition support, hydration, and medications. For esophageal cancer patients and palliative care, the introducer technique is the optimal technique and prevents cancer seeding from the operative procedure.

#### **Acknowledgements**

The author would like to thank Assistant Professor Jirawat Swangsri M.D., Ph.D. (Department of Surgery, Siriraj Hospital, Mahidol University) for the first case technical assistance with the introducer PEG procedure in Thammasat University Hospital.

#### **Conflict of interest**

The author declares no conflict of interest.

#### **Notes/thanks/other declarations**

Special thanks to Dr. Bob Taylor for assistance in editing the English version of this chapter.

*Suggestions for Addressing Clinical and Non-Clinical Issues in Palliative Care*
