WEO Video: Dr. James DiSario and Dr. Pãulo Sakai
Dr. James DiSario from California, USA and Dr. Pãulo Sakai from Brazil perform a percutaneous endoscopic gastrostomy (PEG)
The video begins with an impression on the gastric contour from a finger pressing on the abdominal wall to locate the precise site where the PEG will be inserted. Dr. Sakai then shows a double needle technique for tethering the stomach to the anterior abdominal wall. This technique is not often used, but is helpful in patients in whom one might suspect the possibility of having the PEG pulled out by the patient prior to formation of a permanent tract through the anterior abdominal wall. A needle for local anesthetic is passed through the abdominal wall and some of the local anesthetic is squirted into the stomach demonstrating the precise location of the peg placement for the gastroscopic view. The double needle is then inserted and a plastic loop maneuvered over the second needle through which a suture is placed. The suture is grasped by the plastic loop and held tightly as both needles are retracted. The suture is then secured by tying the ligature on the anterior abdominal wall. A second double puncture is made adjacent to the first and the suture technique is once again employed. Again, an indentation on the anterior abdominal wall between the two sutures shows the location for precise placement of a sheathed trochar. The skin incision is then made between the two sutures which securely hold the stomach against the anterior abdominal wall. The snare from the gastroscope holds the trochar as the sharp needle is replaced by a suture which is then withdrawn retrograde through the incision and exits with the gastroscope from the mouth. The percutaneous endoscopic gastrostomy (PEG tube) is secured to the loop exiting from the mouth. After lubrication, traction on the suture exiting the abdominal wall pulls the pointed end of the peg tube through the mouth and exits the anterior abdominal wall. When tension is felt, caused by the bumper catching on the stomach wall, further traction is discontinued. It is not mandatory to reassess the peg placement by gastroscopy, but this is frequently accomplished to be sure the peg tube is well.
Live demonstration from the Clinica Alemana, filmed during the Pan American Congress which took place in November 2008.
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