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18115 Stomas Via Percutaneous Endoscopy
Fig. 15.2 The SafeTack technique is used to place the fi nder needle.
The second operator inserts a syringe containing fl uid through the
abdominal wall from the outside. Traction is applied to the syringe.
Bubbles should be observed by the second operator at the same time
that the fi rst operator sees the needle enter the stomach. If bubbles are
noted before this, the needle is withdrawn and a new site selected as the
needle may have entered the colon. Illustration © CCF
dissection procedure and was used successfully for many
years in a simplifi ed fashion for patients with neurologic
disease and those with extensive facial trauma. Bucklin and
Gilsdorf developed a feeding pharyngostomy tube that could
be performed at the bedside with the patient awake [ 49 ] . The
main indication for this approach was for patients who constantly removed nasogastric tubes or who had aphagopraxia
(Table 15.3 ). It is a technique that can be used successfully
for head and neck patients who require prolonged tube feeding. This type of tube is also appropriate for patients with
advanced intra-abdominal malignancy who would benefi t
from palliative decompression but who are not candidates for
conventional PEG tube placement [ 50, 51 ] . This technique
was used at the Cleveland Clinic by Mackey and Ponsky and
found to be safe and effective for decompression in malignant
gastrointestinal obstruction [
The tube can be hidden under a high collar and the patients
can care for this tube themselves at home by using a mirror
to look at the site. It is better then using an NG tube as it
52 ] .
avoids sinusitis and interference with speech or swallowing
for this very select group of patients.
Direct Percutaneous Jejunostomy (DPEJ)
Direct percutaneous jejunostomy (DPEJ) is a modifi cation of
PEG placement. The original description of a PEG/PEJ was
a one-piece apparatus that consisted of a gastrostomy tube
and a smaller jejunostomy tube that was drawn through the
pylorus into the duodenum (JET/PEG). This technique was
complicated by the jejunostomy tube falling back into the
stomach as the endoscope was withdrawn. It also did not prevent aspiration as the pylorus was made incompetent with
the placement of the jejunostomy tube. The fi rst PEJ tube
was placed by Ponsky and Aszodi in 1984 [ 53 ] . Shike (1987)
later placed PEJ tubes in cancer patients with prior gastric
resection [ 54 ] .
DPEJ tubes should be placed beyond the ligament of
Treitz, or at least in the third or fourth portion of the
duodenum. These tubes may be more diffi cult to replace if
dislodged and they may need more nursing care. PEJ tubes
that are anchored by balloon are more likely to have
long-term problems with balloon rupture and diffi culty
with replacement of the balloon. Mushroom catheter
placement is preferred. Jejunostomy tubes may be placed
over a wire or a pediatric endoscope may be used instead
of a gastroscope. The lumen of the jejunum is much smaller
than the lumen of the stomach so that placement has to be
more precise. The most important part of the procedure is
using the impression made by a fi nger applying pressure to
the abdomen from the outside to mark the point of insertion
of the PEJ tube because the light from a forward viewing
endoscope places the point of insertion a little further
forward than the actual end of the instrument. Using the
light as a reference point can therefore result in placement
of the tube in a nonoptimal position. Peristalsis can also
change the location of the loop in relation to the abdominal
wall. It is therefore important to ascertain the appropriate
puncture point very close to the time of actual puncture of
the skin [ 55 ] .
A safetrack is verifi ed by using a 19–21 gauge needle.
The needle is secured with an endoscopic snare to stabilize
the segment of jejunum. The larger trochar needle can then
be inserted adjacent to the fi nder needle. It is important to
maintain fi xation of the fi nder needle so that the jejunum
does not fall away from the abdominal wall. After the stylet
is removed from the trochar, a guidewire is inserted and the
procedure completed as for a standard pull-type PEG. It is
not known what length of time is required for this track to
mature. It is prudent to allow 6 weeks before removing the
DPEJ and perhaps longer in malnourished patients. Feeding
can begin within 24 h.
182 M.D. Inkster and J.J. Vargo II
Fig. 15.3 The endoscope has
been removed from the stomach,
the snare has been pulled through
the patient’s mouth, and the PEG
tube has been attached. The
endoscope is then reinserted into
the stomach, and force applied to
pull the snare attached to the
bumper through the abdominal
wall. Illustration © CCF
Fig. 15.4 The mushroom
catheter in place on the inside of
the stomach while the external
bumper is placed loosely against
the abdominal wall. The external
bumper will be adjusted the day
after the procedure. Illustration ©
CCF
The question of successful PEG placement in obese
patients was addressed by Kirby as detailed previously. The
question of successful DPEJ placement in obese patients
was addressed by Mackenzie and colleagues [ 56 ] who found
that, of 80 DPEJ placed in 75 patients, DPEJ placement was
feasible whether the patients were obese or not but that
adverse events were more common in patients with a body
mass index (BMI) greater than 25. These were jejunal
18315 Stomas Via Percutaneous Endoscopy
Table 15.2 Complications of PEG tube placement
Major Minor
Aspiration pneumonia
Buried bumper syndrome Peristomal infection
Dehiscence of the wound Tube blockage
Gastrocolic fi stula Tube dislodgement
Gastric perforation
Perforation of the transverse colon
Peritonitis
Seeding of the abdominal skin with
metastases
Subcutaneous abscess
External leakage
obstruction, jejunal volvulus, necrotizing fasciitis/death,
and sepsis in a total of fi ve patients. Success rate was 96%
for underweight, 81% for normal weight, and 73% for overweight patients. Maple used computed tomography (CT)
scans to try to predict the success of DPEJ placement [ 57 ] .
There was poor sensitivity and specifi city in this study, but
an abdominal wall thickness of greater that 3 cm was associated with a greater likelihood of placement failure. See
Table 15.4 for common complications of DPEJ placement
and Fig. 15.5a–g .
Radiological Placement of Gastrostomy Tubes
When a feeding tube cannot be placed by an endoscopist, the
procedure may be deferred to a radiologist. One method that
has been used by radiologists is to place an NG tube the night
before the procedure and to administer a dilute barium
solution into the gut so that on the day of the procedure the
contrast should be in the colon and the operator can avoid
puncturing the colon. The NG tube is then placed to suction
2–3 h prior to the procedure. Fluoroscopy is used to evaluate
the abdomen before selecting a skin site. Glucagon may be
given to decrease gastric peristalsis and emptying. Air is then
insuffl ated through the nasogastric tube and distention monitored by fl uoroscopy. In selecting an appropriate puncture
site, some radiologists also use ultrasound examination of
the abdomen so that the liver can be visualized as well as the
superior epigastric artery, thereby minimizing the risk of
bleeding. When the initial catheter is placed, a peel-away
sheath is often necessary. The feeding tube is pushed through
the abdominal wall into the stomach and secured after the
location in the lumen of the stomach has been confi rmed.
The use of gastropexy anchors may or may not be used; both
methods have been described. Proper tube placement can be
confi rmed with water-soluble contrast injection if desired.
Placement of direct gastrostomy tubes is technically less diffi cult than placement of direct jejunostomy tubes. Because
there can be more complications with primary DPEJ placement, some radiologists will only replace them [
58 ] .
Percutaneous Cecostomy (PEC) and Percutaneous Sigmoid Colostomy
Tube cecostomy had been used successfully in the 1960s for
patients who had colorectal cancer and in emergencies such
as post-traumatic fractures or for patients with ileus [ 59 ] . In
1985, Ponksy introduced the percutaneous cecostomy (PEC)
for colonic decompression for two patients who had Ogilve’s
syndrome [
60 ] . The mushroom catheter was placed in the
cecum with immediate decompression. The fi rst patient died
a week later from progressive respiratory and renal failure
but the second patient was discharged a week later without
surgical intervention and with resolution of his sepsis. More
recently, Holm and Baron used cecostomy tubes for palliation for patients who had decreased colonic transit time secondary to narcotic use, tumor obstruction, or progressive
neuromuscular disease [
61 ] . PEC tubes are not used to meet
nutritional needs in adults, rather they are used for decompression and to prevent pain from abdominal bloating, antegrade washout for chronic constipation, and to alleviate
obstruction for patients with neoplasms.
In 1996, Chait in Canada published his series of PEC
tubes in children [
62 ] . Between June 1995 and September
1996 he placed 42 PEC tubes in children who had fecal
incontinence and troublesome soiling, unresponsiveness to
rectal enemas, requirement for diapers, and anorectal malformations. Twenty-nine patients had spina bifi da, nine had
imperforate anus, three had cloacal anomalies, and one had
Hirschprung’s disease. Ten patients were ambulatory and the
rest used wheelchairs. The development of the Trapdoor
device (Cook Medical, Bloomington, Indiana) allowed all
patients to have a low-profi le device, irrespective of their size
or weight. These are now known as the Chait Trapdoor
TM
Cecostomy Catheters and are used for antegrade irrigation of
the bowel. They appear to be a standard of care both in
Canada and in the United Kingdom. For indications and
contraindications for this procedure in children see Table 15.5
and in adults, Table
in Table
15.7 .
15.6 . Common complications are detailed
Technique
Placement of the Chait Trapdoor Cecostomy™ tube is a twostep procedure. These patients are given a bowel preparation,
if possible, via nasogastric tube until rectal drainage is clear.
Fluoroscopy is used for visualization and glucagon is used to
paralyze the bowel. A balloon catheter is placed into the
rectum and air instilled until the cecum is suffi ciently insuffl ated. Then the rectal balloon is infl ated to keep the balloon
in place and to keep the air in the colon. Insuffl ation is monitored by ultrasound. A temporary loop retention drainage
catheter (for example, a Dawson-Mueller drainage catheter)
184 M.D. Inkster and J.J. Vargo II
a
c
b
Fig. 15.5 Complications that can occur with placement of PEG and
DPEJ tubes. ( a ) Torsion of the stomach around the insertion site. ( b )
Leakage around the insertion site. ( c ) Gastrocolic fi stula. ( d ) Migration
of the tube within the stomach and insertion into the opposing wall.
A balloon catheter was used and an external bumper was not used.
( e ) Migration of the tube within the stomach so that it is coiled and
not fl ush with the abdominal wall. ( f ) Buried bumper syndrome.
( g ) Intussusception of the catheter within the small bowel lumen.
Illustrations © CCF
18515 Stomas Via Percutaneous Endoscopy
d
e
f
Fig. 15.5 (continued)
186 M.D. Inkster and J.J. Vargo II
Table 15.5 Indications and contraindications for pediatric cecostomy
tube placement
Indications Contraindications
Cloacal anomalies
Imperforate anus Coagulopathies
Klippell Fell Syndrome Known medical problems that put
Myelomeningocele
Paraplegia
Sacral agenesis
Spina bifi da
Previous abdominal surgical
procedures
them at risk
Fig. 15.5 (continued)
Table 15.3 Complications of pharyngostomy tube placement
Accidental removal
Exuberant granulation tissue around the exit wound
Hemorrhage
Hyperemia around the stoma
Kinking of the tube
Persistent cervical fi stula
Table 15.4 Complications of DPEJ placement
Abdominal cramping
Abdominal distention
Constipation
Displacement of the tube
Focally thickened jejunal folds
Jejunal hematomas
Jejunal volvulus
Migration of the tube
Nausea
Occlusion of the tube
Retrograde fl ow of feeding material
Small bowel intussusceptions
Small bowel obstruction
Table 15.6 Indications for adults for percutaneous cecostomy [
I. Antegrade irrigation
II. Decompression
A. Malignant colonic obstruction
Colon cancer
Pelvic malignancies
B. Benign colonic obstruction
Colonic pseudo-obstruction (Ogilvie syndrome)
Neurogenic bowel
C. Fecal incontinence
Table 15.7 Complications of percutaneous cecostomy
Peristomal infection
Peritonitis – leakage of fecal contents during placement of device
Granulation tissue around insertion site
Placement into the terminal ileum
Self-removal of catheter
60 ]
is placed percutaneously into the cecum and the track allowed
to mature. Suture anchors are recommended to assist the
introduction of the temporary drainage catheter. The patient
fl ushes the temporary catheter twice every day with 10 mL of
water. This is continued for 1 week in conjunction with a
normal rectal enema regimen. Then antegrade enemas can
begin. After maturation (approximately 6 weeks) the temporary catheter is removed and the Chait Trapdoor catheter is
placed (Fig. 15.6a–d ). A metal stiffener is inserted into the
catheter to straighten the coils and to push the catheter
through the tract over a prepositioned wire guide. Once the
catheter is inserted, the guide wire is removed until the
Trapdoor is fl ush against the access site. The catheter coils
reform in the cecum once the guidewire has been removed.
Contrast injection is used to confi rm placement and patency
in the cecum. The patient inserts a metal cannula tip into the
opening of the Trapdoor and administers a phosphate enema,
followed 15 min later by a saline enema via gravity until
drainage is clear – usual volume is 200–500 mL.
This technique is now an accepted method for the previously mentioned conditions in a number of countries. In the
United Kingdom it is also approved for sigmoid colostomy
18715 Stomas Via Percutaneous Endoscopy
a
c
b
Fig. 15.6 Placement of the Chait Trapdoor Cecostomy tube™. ( a ) The
Dawson Mueller tube in place in the cecum. ( b ) Placement of the Chait
Trapdoor with a metal stiffener. ( c ) The stiffener has been removed
d
allowing the distal end to coil in the cecum. ( d ) The Chait Trapdoor in
place. Illustrations © CCF
in patients who have sigmoid volvulus, fecal impaction,
constipation, incontinence, and for the delivery of
anti-infl ammatory agents for patients with colitis. Baraza
confi rmed the utility of this technique in adults with colonic
pseudo-obstruction, and slow transit constipation [
63 ] .
Van den Berg in the United States, however, performed
colonic manometry in children with defecation disorders
prior to insertion and determined that, for patients without
high amplitude propagating contractions, the placement of a
cecostomy tube was less likely to be benefi cial [ 64 ] .
188 M.D. Inkster and J.J. Vargo II
Outcomes
Anis reported that of 191 patients 76% would have a PEG
tube placed again, 84% felt that feeding was easier, 63% that
the tube was cosmetically acceptable, and 60% that the tube
increased survival [
65 ] . Data from the Scottish MND Register
was evaluated for 142 patients who had PEG tubes placed
between 1989 and 1998 [
66 ] . Mean age at insertion was
66.8 years with a mean disease duration of 24 months.
Median survival after placement was 146 days. The 30-day
mortality was 25%. Placement did not confer a survival
advantage compared with no tube placement, but it was felt
that the unexpectedly high mortality rate was secondary to
lack of selection bias.
Rabeneck published a study of long-term outcomes in
1996 in which 7,369 patients who received a PEG tube
between 1990 and 1992 were evaluated [
67 ] . The mean age
was 68.1 years and 23.5% died during the hospitalization in
which the PEG tube was placed. The median survival was
7.5 months (approximately 240 days). Most of the patients
had PEG tube placement in the terminal phase of their illness. Other studies reported a 30-day mortality of 22% at
30 days [
68 ] , and 67% at 30 days [ 69 ] . Several studies have
looked at poor prognostic factors for PEG placement. These
include hypoalbuminemia (albumin <2.8 g/dL) in which
6-month mortality was 44% [ 70 ] , dementia with a 6-month
mortality of 81%, and in patients with multiple comorbid illness a 6-month mortality of 50% [ 65 ] . Kirby concluded that
it is important to concentrate on patient selection and reducing complications [ 71 ] . The role of jejunostomy tube feeding
in long-term enteral feeding has not yet been clearly
established.
Outcomes for the Chait Trapdoor PEC tube are detailed in
Refs. [ 62, 63 ] . Ninety-four percent of patients were satisfi ed
with the effectiveness of the device, rating it better than the
irrigation/bowel cleansing routine that they had previously
used. Ninety-seven percent of the 124 patients said they
would recommend the device to others.
Conclusion
Gauderer refl ected on the development of endoscopic placement of gastrostomy tubes in 1999 [ 72 ] . His original inten-
tions were to provide a technique to simplify catheter
placement and he and his colleagues clearly accomplished
that goal. There are now multiple kits available to insert these
tubes and multiple indications for the use of the procedure.
Most of the problems associated with actual tube placement
are minor and can be treated fairly easily. The major complications, however, such as transverse colon through-andthrough perforation can lead to death. Most of the patients
are debilitated medically and malnourished and care must be
exercised in selection of patients who undergo this procedure. The person who performs the procedure needs to critically assess each patient for suitability prior to performing
the procedure.
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