Ryan M Juza, MD, Joshua S Winder, MD, Eric M Pauli. Penn State Hershey Medical Center
Introduction: Percutaneous endoscopic gastrostomy (PEG) tube placement has become the mainstay for durable enteral access, eliminating the need for surgical gastrostomy. Placement requires a safe tract through the abdominal wall directly into the stomach. Colon interposition between the stomach and abdominal wall is uncommon, but precludes PEG tube placement. In cases where the colon directly interferes with PEG tube placement we have employed multi-modality therapy by performing simultaneous colonoscopy, fluoroscopy and upper endoscopy to permit PEG technique placement.
Methods: A prospectively maintained database was retrospectively evaluated for patients undergoing simultaneous PEG and colonoscopy; two patients were identified. Both operations were performed at a single academic institution by a trained surgical endoscopist. Patients were positioned supine and frog-leg on a fluoroscopy-compatible operative bed. Endoscopic towers were positioned at the head and foot of the bed. A standard gastroscope was introduced per os and upper endoscopy performed. When transillumination was poor despite gastric insufflation, a colonoscope was used to decompress and/or distract the colon. Contrast enhanced fluoroscopy was used to observe the simultaneous positioning of the two endoscopes and delineate the colonic border. When an appropriate window was visualized, PEG tube placement was carried out in standard fashion using the safe tract technique and a Ponsky pull method.
Results: Both patients tolerated the procedure well. Using the safe tract technique, the needle was visualized entering the stomach at the same time as air was aspirated in the barrel of the syringe and there was no evidence of enteric contents to suggest colonic injury. Colonoscopy during wire placement confirmed no colon injury. There were no postoperative complications.
Discussion: Colonoscopy is performed by many surgeons and most endoscopists. Colonoscopic-assistance for PEG tube placement may be an enabling technique to avoid colonic injury in challenging cases and to avoid the need for an open gastrostomy. While the rate of gastrocolocutaneous fistula creation during PEG placement is low, the consequences of colonic injury are significant. By pairing upper and lower endoscopy, patient morbidity may be reduced in an otherwise challenging situation where enteral access is needed.