Percutaneous endoscopic gastrostomy (PEG) is the preferred method for achieving enteral
access for patients requiring long-term nutritional support [1]. The popular PEG pull-through technique is not adequate for patients with obstructive
head and neck or esophageal cancer because of the higher morbidity associated with
the technique, including the risk of malignant implantation at the stoma. The introducer
technique is then indicated as described by Russell et al. [2]. This involves direct puncture of an inflated stomach through the anterior abdominal
wall, followed by the introduction of a guide wire and dilation of the newly created
tract. The introduction system is removed by peeling it off.
It is believed that gastropexy provides safer conditions for direct puncture of the
stomach, in particular for the insertion of larger gastrostomy feeding tubes [3]
[4]
[5]
[6]. We believe that there is a simple and cheaper alternative to the use of a guide
wire, dilator, and “peeling off” devices. This is a development of a trocar system,
consisting of an external sheath with a lateral cleft. The usual three-sided, sharply
pointed end of the internal shaft of the trocar system is replaced by a cone-shaped
end, in order to reduce the cutting trauma to the abdominal and gastric walls ([Fig. 1]).
Fig. 1 Schematic representation of the trocar system with a cone-shaped internal shaft and
a lateral cleft for the insertion of the feeding tube.
Two gastropexy stitches are placed under endoscopic guidance using a double-needle
puncturing device [3]
[4]. The trocar system is then advanced through a 10-mm skin incision between the fixation
sutures and into the transilluminated and inflated stomach under endoscopic guidance.
The internal shaft is removed and a 20-Fr ballooned tube is introduced through the
lateral cleft. Once the tube is in place the balloon is inflated and the external
sheath of the trocar is pulled out as the feeding tube is slid out through the lateral
cleft ([Fig. 2], [3]).
Fig. 2 External and endoscopic (inset) views just after the puncture of the inflated and
transilluminated gastric cavity by the trocar system. Note that a gastropexy has been
performed previously.
Fig. 3 As the balloon is inflated the tube can be kept in the stomach by sliding it through
the lateral cleft while the external shaft of the trocar is pulled out.
Another advantage of this technique is the potential availability of the device in
different diameters, allowing insertion gastrostomy tubes of various sizes.
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