Chapter 41 ■ Gastrostomy 287

E. Percutaneous Endoscopic

Gastrostomy (PEG)

Developed in 1980 by Drs. Gauderer and Ponsky, percutaneous endoscopic gastrostomy (PEG) has become the

primary method of gastrostomy in children (1,4,10). Infants

and children require general anesthesia for PEG placement.

1. The gastrostomy site preparation and antibiotic prophylaxis are similar to the open technique.

Standard PEG kits include a drape for the abdomen.

2. A flexible endoscope is inserted through the oropharynx and guided down to the stomach.

3. The stomach is insufflated to approximate the stomach

to the abdominal wall.

4. An introducer needle is placed percutaneously into the

insufflated stomach under direct endoscopic visualization.

a. Transillumination of the stomach along the greater

curvature through the abdominal wall with the

endoscope can aid in introducer placement.

b. Proper gastrostomy site is about 2 cm inferior to the

left costal margin along the paramedian plane,

which can also be palpated and visualized by the

endoscope.

c. A looped guidewire is inserted through the introducer into the stomach and the proximal end is

captured with an endoscopic snare. The snared

guidewire is then pulled through the mouth with

the endoscope, with the distal end remaining externally on the abdomen.

5. A gastrostomy tube is attached to the proximal end of

the guidewire.

Simultaneously, a small nick (~8 mm) is made

with a scalpel at the site of the introducer to allow for

the gastrostomy placement.

6. The guidewire is gently pulled back from the abdominal end, guiding the gastrostomy tube through the oropharynx, esophagus, and into the stomach.

7. The tapered end of the gastrostomy is pulled through the

abdominal wall until the intragastric mushroom-type

flange fits snugly up against the abdominal wall (1).

8. An external bolster/immobilizing ring is slid over the

tube down to the abdominal wall to secure the gastrostomy in place.

9. The gastrostomy tube is cut to the desired external

length and a feeding adaptor is placed on the end of the

tube.

F. Laparoscopic Gastrostomy

Laparoscopic placement of gastrostomy tubes, one of the

most popular methods, has been described as safe and efficacious (11). Some believe that the laparoscopic gastrostomy technique has a lower complication rate than the

PEG technique in neonates and small children (12).

1. The gastrostomy site preparation and antibiotic prophylaxis are similar to the open technique.

a. Mark the costal margin and proposed gastrostomy

site.

b. Oro- or nasogastric tube decompression of the stomach.

2. A 3- to 5-mm 30-degree laparoscope is inserted through

an umbilical incision.

The abdomen is insufflated to 8 to 10 torr with carbon dioxide.

3. A small subcostal incision is made at the aforementioned proposed site.

A 5-mm trocar and then a laparoscopic grasper are

inserted.

4. Under direct visualization, the stomach is grasped

along the greater curvature and pulled toward the

abdominal wall.

The abdomen is desufflated, the trocar is removed,

and the stomach is pulled through the abdominal

wall.

5. A traction suture is placed and the stomach is secured

to the abdominal fascia in four quadrants.

Inner purse-string is placed.

6. A gastrostomy is created by stab incision or with cautery

and a gastrostomy tube is inserted. The gastrostomy

tube can either be a Pezzer-type tube, or more

Fig. 41.3. After the tube is secured inside the stomach and

passed through a stab wound in the abdominal wall, the anterior

wall of the stomach is sutured to the inner wall of the abdomen.