1. The basic principle of achalasia dilatation
2. The common devices used
3. How to actually do it
4. Aftercare

Choosing the correct patient

1. If you cannot pass the endoscope beyond the narrowing at GOJ , reconsider your diagnosis and consider pseudo-achalasia
2. A thorough endoscopic examination is important, with particular attention given to the GOJ, where malignancy can simulate achalasia (pseudoachalasia).
3. It is very important that your diagnosis of achalasia is quite firm  ideally with endoscopic, Barium swallow and manometry findings.
4. Quite high risk procedure (5% chance of perforation)- so discussion in the clinic with the patient is important while discussing the alternatives (Laparoscopic cardiomyotomy)
5. These patients are prone to aspirate particularly when regurgitation of old food is the predominant symptom.
6. The patient is advised to fast for at least 12 hours prior to the procedure +/- liquid diet for one or two days preceding the dilation
   

Procedure

Choice of balloon

1. A 30 mm balloon is used for a first dilatation. Subsequent dilatation may involve larger balloon- 35 and 40cm.
   This are quite big sized balloon compared to standard stricture dilatation balloons- the idea being to rupture the muscle fibres.
2. Inflate the  balloon before use to check for any leaks
3. We  describe the  OTW ( over the wire) achalasia balloon from Rigiflex™ II ( Boston Scientific)


Picture1: RigiflexII achalasia dilatation balloon: Courtesy Boston Scientific

4. Another frequently used balloon is Wilson-Cook


Picture2 and 3: Wilson-Cook achalasia dilatation balloon and the inflation and luminal port

5. Another alternative is reusable balloon (shown below)


Picture4 and 5: Reusable achalasia dilatation balloon with the pressure gauge: the endoscope goes through the top end of the yellow tube and comes out below the balloon

Positioning the balloon across the LOS

1. A guidewire is passed through the biopsy channel of the endoscope into the stomach and the scope is withdrawn to the GOJ.
2. Note the distance between the incisors and the GOJ along the length of the scope.
3. The endoscope is then removed (taking care to maintain the position of the guidewire in the stomach- push/pull technique).
4. As an aid in initial placement, a marker (such as a paper tape/ tippex) can be placed on the shaft of the dilating catheter to correspond to the previously noted distance from the incisors to the GOJ.
5. This distance should be measured from the middle of the balloon on the dilating catheter.
6. The balloon and tip of the shaft is lubricated and passed over the previously placed guide wire until the marker is in place at the incisors- that means the midpoint  of the balloon is now at GOJ.
   

Actual dilatation

1. Using fluoroscopy, the balloon is then gradually inflated with air, noting the position of the developing waist.
2. Inflation is achieved with a 50ml syringe attached to the balloon port with a 3 way stopcock ( one end to catheter, second to syringe and third port to the pressure gauge)
3. The balloon is inflated with air
4. Small adjustments usually have to be made in the position (deflating the balloon each time) to ensure that the waist occupies the centre of the balloon- balloon will slip downwards if you are too down and then you will have to exert a pull upwards and vice versa- called the cone effect
5. After a satisfactory position is obtained, the balloon is fully inflated (usually requiring about 120 mL of air).
6. The required pressure will be specified on the moulded junction- average 7-15 PSI
7. The balloon is kept inflated for 60 seconds, during which patients may be very  uncomfortable- give pethidine or fentanyl 2 minutes before the dilatation
8. After the 60 seconds are over, the balloon is rapidly deflated.
9. Sudden disappearance of the waist is very suspicious of rupture
10. Thereafter, perform another full inflation for 60 seconds and again note the pressure required to obliterate the waist. This is usually less than the initial pressure
11. Another alternative is reusable balloon-
    • The scope here is passed through the balloon and then the scope is introduced beyond GOJ- a J manoeuvre confirms part of the balloon beyond the GOJ ( see picture)
    • The side catheter containing the inflation port is attached straight to a inflation device with a pressure gauge ( see picture)
    • Pressure of 200mm kept for 2minutes and then release

Aftercare:

1. The patient is observed for the next five to six hours during which serious complications, such as perforation would be obvious
2. Routine post procedure CXR is advisable
3. Follow up in clinic to assess response

Here is the link for achalasia dilatation video

Acknowledgement/Bibliography:

1. Khan AA et al. Pneumatic balloon dilatation in achalasia: a prospective comparison of balloon distention time. Am J Gastroenterol 1998; 93:1064-1067
2. Kadakia SC et al.Graded pneumatic dilation using Rigiflex achalasia dilators in patients with primary achalasia. Am J Gastroenterol 1993; 88:34-38
3. Barkin JS et al.Forceful balloon dilation: an outpatient procedure for achalasia. Gastrointest Endosc 1990; 36: 123-125
4. Product guide of the respective companies- Wilson-Cook and Boston Scientific

1. How to determine the location of the foreign body
2. How urgently the endoscopy needs to be done
3. How to use an overtube
4. How to grab the FB
5. When can you wait and watch
6. Food bolus obstruction

Location of the foreign body:

1. Two important questions-What is it and Where  is it ( Pharynx/Larynx/trachea/oesophagus etc)
2. Take history and get an x-ray of neck/CXR /AXR depending on the history and clinical suspicion
3. Remember -Bones may not show on x-ray
4. Get both coronal and sagittal views- if in doubt
5. Beware of airway compromise

How urgent is the need for an endoscopy?

1. Immediate if
   • Complete obstruction
   • Sharp – up to 35% perforate
   • Battery – burn within 2 hours and can perforate within 6 hours
2. Everything else within 24hours


Picture1: An overtube
How to use and overtube

3. Use overtube- prevents repeated intubation and protect airway and mucosa
4. Thoroughly lubricate the inside and the outside of the overtube
5. Pass the endoscope through the overtube- the thicker and corrugated end remains outside the oral cavity – then intubate and advance the gastroscope
6. Keep the tip of the overtube in the lower oesophagus while you find the foreign body as it immediately deflates the stomach and view will be compromised
7. Once FB is viewed and position located – do a J manoeuvre and advance the overtube – note the tip protruding through the GOJ- both overtube and the scope is black but scope has got white ring marking
8. Next withdraw the overtube just within the GOJ and inflate the stomach again
9. Find the foreign body and grasp it – use Roth net for battery, for razor blade use stent grabber- anything sharp – you need to grab it along its axis and not across
10. Pull the scope very close to GOJ
11. Advance the overtube OVER the scope to cover the sharp object – we find it more convenient than to pull the scope into the overtube
12. Immediately the whole field will look black
13. Withdraw the endoscope and FB together keeping the overtube in place
14. Can go back again if more FB is to be picked
15. Remove the overtube at the end

How to grab the FB

1. Tool kit- snare/triprongs/Roth net/Suction cap/biliary basket/Rat toothed forceps


Picture2: Capuchon hood

2. Capuchon hood is another device which can be used instead of overtube in selected cases- it is fitted at the tip of the endoscope and looks like a rubber skirt which invaginates itself once the scope is withdrawn into the GOJ and then covers the FB
3. Dry run outside the patient with similar objects- ensure the size of the FB is compatible with the holding size of your device
4. Move with pointed end trailing
5. If both ends pointed cover one with forceps
6. For razor blades rat toothed forceps ( stent grabbers) are probably best as with other devices you can catch it across which is problematic
7. If perforation- conservative management only in highly selected cases (endoclips or covered stents)- most require operation

When can you wait and watch

1. If the patient is
   • Asymptomatic
   • Blunt FB
   • Inert FB
   • Not>5cm
   • Healthy gut
2. Warn to report symptoms
3. Check X-Ray

Food bolus obstruction:

1. If complete obstruction with saliva drooling urgent OGD
2. Once visualised one can either
   • Pull- Forceps/snare/net/grasper
   • Push it down in to the stomach by using
     • Air insufflations
     • Gentle pressure
     • Fragment and gentle pressure
3. Success 97%
4. Remember to take oesophageal biopsy particularly if young male to exclude Eosinophilic oesophagitis
5. If narrowing is seen once the bolus is gone- e.g. benign stricture, web, schatzki’s ring or malignant stricture – that needs to be addressed then or later depending on the pathology.

Here is the link for foreign body extraction video:

1. Video 1
2. Video 2

Acknowledgement/Bibliography:

1. Alhaji M et al. Razor blade removal from the stomach utilizing a novel modification of the overtube. Endoscopy. 2009;41 Suppl 2:E166. Epub 2009 Jul 23.
2. Webb WA et al.Management of foreign bodies of the upper gastrointestinal tract. Gastroenterology. 1988 Jan;94(1):204-16.
3. Stack LB et al. Foreign bodies in the gastrointestinal tract. Emerg Med Clin North Am. 1996 Aug;14(3):493-521.

The module covers:

1. Two different types of Balloon PEG- Button PEG (Low profile balloon gastrostomy tube)  and replacement balloon PEG
2. When to use which one and how

Low profile balloon gastrostomy tube (also called button PEG)

1. This is for the individual who is ambulatory and feels the long PEG tube is socially inconvenient (not to be confused with Replacement balloon PEG which also has got a balloon as a retaining device)
2. Once the tract is formed – remove the old PEG
   
   Picture1: The measuring device
3. Use the measuring device to measure the length of the tract
   
   Picture2: 16 French 3cm Corflo cuBBy PEG- low profile gastrostomy tube
4. Choose your balloon PEG – length and the French gauge- and get customized low profile balloon PEG for that particular patient
5. Accurate length is important as there is no sliding outer retaining device (in contrast to the Replacement balloon gastrostomy PEG) – so if the tube is longer than necessary it can bob up and down and  stoma will leak.
6. Introduce the lubricated tip of the Low profile balloon gastrostomy tube  gently into the tract
7. Inflate the balloon with the required amount of water
   
   Picture3: The extension tube to be attached just before feed
8. Before the feed- the attachment tube needs to be fixed – the blue mark on the attachment tube needs to be aligned with the blue mark on the button PEG and turned by 90 degrees
9. Once feed is over the extension tube is turned in the opposite direction and removed
10. Because of the extension tube needs to be repeatedly connected and disconnected -button PEG tends to wear out and needs replacement on a regular basis

Replacement balloon gastrostomy tube

1. This tube is placed if an old PEG has fallen/pulled out and there is a well formed and matured tract
2. Disadvantage over endoscopically inserted PEG is that it’s life is much shorter compared to the former.
3. Once the PEG falls out -the tract may close as early as 4 hours -so quick replacement (with balloon PEG or Foley’s catheter) is needed
4. Clean the stoma
   
   Picture4: The replacement balloon gastrostomy tube (not to be confused with button PEG or low profile device which also has got a balloon as a retaining device)
5. Insert the lubricated balloon PEG into the stoma gently and it should pass freely without much resistance
6. Inflate the balloon with water – 5-6ml
7. Pull the tube out until the balloon stops it- slide the outer fixation bumper snugly to the skin


Picture5: The extension tube with the Y connector

8. Attach the extension tube with the Y connector- one takes bladder wash syringe and the other- Luer lock syringe
9. After care- the patient or the carer to check the water amount in the balloon and top up as and when necessary

Here are the links for button PEG and replacement balloon PEG insertion video’s respectively:

Button PEG

http://www.youtube.com/watch?v=hSv4FOwZ9kQ&feature=related

Acknowledgement/Bibliography:

1. Guidelines for enteral feeding in adult hospital patients : BSG 2003
2. Novotny NM et al. Percutaneous endoscopic gastrostomy buttons in children: superior to tubes. J Pediatr Surg. 2009;44(6):1193-6
3. Heiser M et al. Balloon-type versus non-balloon-type replacement percutaneous endoscopic gastrostomy: which is better? Gastroenterol Nurs. 2001 Mar-Apr;24(2):58-63
4. Product guide of the respective companies- Merck Serono and Flocare

http://www.youtube.com/watch?v=hqsaWOTG2ZQ

1. Different types of NJT
2. How to do it
3. Aftercare

Different types of NJT

1. Freka Endolumina- is 8Fr and it is placed through the biopsy channel of the scope (TTS- through the scope)
2. Corflo- is 10F and is placed over a guide wire and it does not go through the biopsy channel
3. Flocare Bengmark Naso-Intestinal tube- inserted non-endoscopically using normal peristalsis-see the video link below

How to do it

TTS type ( Freka Endolumina)

1. It comes with a length of 270cm and 8Fr (2.6mm outer diameter) and so is compatible with the instrument channel of the endoscope ( >=2.8mm)
   
   Picture1: The Freka NJT
2. Insert the scope orally and advance it as far as possible through the stomach towards the intestine
   
   Picture2-4: Freka NJT going through the biopsy channel and the endoscope being removed subsequently keeping the NJT in
   
3. Once the desired position has been reached, advance the intestinal tube (NJT) through the instrument channel of the scope to reach under observation a position distal to the ligament of Treitz. The distal tip of the tube may be moistened with sterile water to assist insertion.
4. Approx 100-105cm mark should be at the incisor level when the tip is in jejunum.
5. Withdraw the scope with rotating /jiggling motion otherwise the friction between the scope and the NJT will pull the tube out
6. Feed more NJT as the scope comes out
7. Assistant holds the end of the scope as it comes out of the mouth and then holds the NJT at lips while the scope is removed
8. So now the NJT is placed but coming out through the mouth which needs to be re-routed through the nostril.
   
   Picture5 and 6: The NJT is being re-routed through the nose: Courtesy Fresenius Kabi
9. Pass a NG  tube (16 size) / blue re-routing catheter  through the nostril
   
   Picture 7: Re-routing catheter, silicone oil, adhesive dressing and Magill’s forceps
10. Grab it from oropharynx with a Magill’s forceps ( +/-  using laryngoscope) and pull out through mouth
11. Ensure that the tube is in position against the rear wall of the pharynx without any loops.
12. Cut the end of the NG tube with a scissors/ No cutting if it is a re-routing catheter
    
    Picture 8: The NJT is passes easily through the re-routing catheter when lubricated with silicone oil
13. Thread the NJ tube  into the lumen of the NG  tube or the opening of the re-routing catheter
14. Pull out the NG tube from the nostril and at the same time looking inside the mouth (+/- with the help of a  laryngoscope and of the Magill’s forceps). Make sure the NJ tube is not slipping out of the oesophagus upwards.
15. The NJT is now in trans-nasal position
16. Cut the NJT to desired length and advance the fastening screw over the NJT
    
    Picture 9 and 10: The fixing of the Luerlock connector: Courtesy Fresenius Kabi
17. Insert the metal pin of the Luerlock connector as far as possible into the NJT and screw the fastening screw tightly to the stop.
18. Thread in the connectors
19. Tape the NJ tube at nostril with a y shaped Elastoplasts (stem of the Y on bridge of the nose limbs surround the NJT) and also at the side of the cheek and also behind the ear.
20. Record the length of the tube at nostril and document in the tube care plan.

Corflo PEJ

1. This is a bigger tube and has to guided over a guide wire
2. Insert the scope orally and advance it as far as possible through the stomach towards the intestine
3. Once the desired position has been reached, advance the guide wire through the instrument channel of the scope to reach under observation a position distal to the ligament of Treitz.
4. Approx 100-105cm mark should be at the incisor level when the tip is in jejunum.
5. Withdraw the scope keeping the guide wire in
6. Feed more guide wire as the scope comes out
7. Assistant holds the end of the scope as it comes out of the mouth and then holds the guide wire at lips while the scope is removed
8. So now the guide wire  is placed but coming out through the mouth which needs to be re-routed through the nostril.
   
   Picture 11: Re-routing catheter
9. Pass a supplied re-routing catheter  through the nostril
10. Grab it from oropharynx with a Magill’s forceps ( +/-  using laryngoscope) and pull out through mouth
11. Ensure that the tube is in position against the rear wall of the pharynx without any loops.
12. Thread the guide wire  into the lumen of the re-routing catheter
13. Pull out the re-routing catheter  from the nostril and at the same time looking inside the mouth (+/- with the help of a  laryngoscope and of the Magill’s forceps). Make sure the guide wire  is not slipping out of the oesophagus upwards.
    
    Picture 12: The Corflo NJT with pre-fitted connector
14. Next thread the NJT over the guide wire. Before threading the NJT over the guidewire, flush the tube with 20 ml of water, using a syringe inserted into the access port. Also dip the distal end of NJT in water. These steps are crucial as this flushing and dipping activates the C-19 lubricant to facilitate tube passage over the guidewire.
15. It comes ready with the attachment. So just fix it with adhesive dressings.

Aftercare

1. AXR to confirm the position- the NJT should be free of tension and straight i.e. without loops, in a position distal to the ligament of Treitz.
2. Remember to flush the NJT with 30ml of cool boiled water before and after the feed or at least once a day.
3. It can remain in position for up to four weeks if the tube and the nose are carefully cared for. If enteral feeding is needed after this a PEG-J is recommended.

Here is the link for Naso-jejunal tube insertion video:
No video found so far. One good link is given below for non-endoscopic naso-jejunal tube insertion. http://www.youtube.com/watch?v=HUv13Xy0GwE

Acknowledgement/Bibliography:

1. Guidelines for enteral feeding in adult hospital patients : BSG 2003
2. Niv E et al. Post-pyloric feeding. World J Gastroenterol. 2009 Mar 21;15(11):1281-8.
3. DiSario JA. Endoscopic approaches to enteral nutritional support. Best Pract Res Clin Gastroenterol. 2006;20(3):605-30.
4. Product guide of the respective companies- Fresenius Kabi, Merck Serono and Nutricia

The module covers:

1. Indication of PEG-J tube
2. Contra-indications
3. How to insert a PEG-J tube
4. Aftercare
5. What are the complications

Indication of PEG-J tube

1. Patients with Gastroparesis requiring long term feeding
2. Gastric outlet obstruction as long as obstruction is not impassable
3. Recurrent aspiration pneumonia (although aspiration can still occur from reflux of stomach contents)

Contraindications:

1. Gross ascites
2. Ongoing chest infection
3. Coagulopathy
4. Dementia/Persistent vegetative state

How to insert a PEG-J tube

1. A PEG tube is first placed as usual
   • Just after the PEG is inserted and before the intestinal tube goes through the PEG tube – slide the outer retaining device of the PEG tube, then the pinch valve and then the blue white ring which holds the PEG Y connector over the PEG tube. Do not connect the PEG Y connector at this stage
2. After putting few drops of silicone oil inside of the PEG tube the Intestinal catheter is introduced through the PEG tube and once the tip (weighted bolus) is seen in the stomach, it is grasped with a snare
3. Endoscope is advanced into the pylorus and then into the duodenum
4. If enterosocpe is used the intestinal catheter can be passed into the jejunum but use of enteroscope is  not necessary routinely as the snare can be pushed into jejunum.
5. A forceps can be used as an alternative  to guide the intestinal tube and some might prefer a forceps over a snare as deep inside the jejunum when you are releasing the tip of the intestinal tube you are better assured that the device ( snare/forceps) is properly detached from the tip and not pulling out the intestinal tube on it’s way out.
6. Once the snare is released the assistant can  feed in more intestinal tube by simply pushing more tube in
7. Withdraw the endoscope from the duodenum  taking care that the intestinal tube is not dislodged
8. Once the endoscope is in the stomach remove any loops in the intestinal tube by withdrawing it and then the endoscope  can be withdrawn completely.
9. Next step are the connections of all the adaptors in proper order which can be confusing if not seen before
10. For a Freka PEG-J
    
    Picture1: In order from left: Outer retaining device:2 quick release clamp: 3 blue white ring
    • As mentioned before  ( this step has already been executed before the intestinal tube went in )-Just after the PEG is inserted and before the intestinal tube goes through the PEG tube – slide the outer retaining device ( item no 1 in the above picture) of the PEG tube, then the quick release clamp ( item no 2 in the above picture)  and then the blue white ring  ( item no 3 in the above picture) which holds the PEG Y connector over the PEG tube. Do not connect the PEG Y connector at this stage as this increase the friction while the jejunal tube is being passed.
      
      Picture2 : In order from top:1 intestinal luer lock:2 click adaptor:3 PEG  Y connector:4 blue white ring which holds the PEG Y connector
    • After the intestinal tube is positioned and the endoscope is withdrawn – slide the PEG  Y connector ( Item no 3 in above picture ) OVER THE  intestinal tube and fit with the locking device ( Item no 4 in above picture-blue white ring ) already in place on the PEG tube by twisting. The outer white plastic ring would break off leaving the blue ring behind
    • Next slide the click adaptor ( Item no 2 in above picture)  over the intestinal tube and press hard onto the PEG Y connector – you will hear a click
    • Then cut the intestinal tube to desired length and push in the metal pin of the intestinal luer lock ( Item no 1 in above picture)  into the cut end of the intestinal tube.
    • Next advance the intestinal luer lock into the click adaptor and then screw in the click adaptor into it by turning  the PEG tube – AND NOT BY TURNING THE INTESTINAL TUBE – which if done might  dislodge the intestinal tube from the jejunum
11. If using a CORFLO     PEG-J
    
    Picture3: Inner bumper, outer retaining device and quick release clamp Picture4: CORLOCK TWOOMEY Y adaptor Picture5: Not to use CORLOCK-CORPORT Y adaptor
    • As mentioned before  ( this step has already been executed before the intestinal tube went in )-Just after the PEG is inserted and before the intestinal tube goes through the PEG tube – slide the outer retaining device of the PEG tube, then the quick release clamp and then the PEG Y connector ( called CORLOCK TWOOMEY Y ADAPTOR)  over the PEG tube. Normal PEG comes with a CORLOCK-CORPORT Y ADAPTOR which  should not be used with a jejunal tube.
      
      Picture6: Sequence of attachments: Courtesy Merck Serono
    • Seat the silicone plug in the straight limb of the Y connector gently  and introduce the jejunal tube through this
    • After the intestinal tube is positioned and the endoscope is withdrawn  seat the silicone plug firmly into the  Y connector
    • Slide the Adjust-a-Sleeve cap over the jejunal tube and screw it to the Y connector
      
      Picture7: The pink stylet is next to be removed after flushing the side port
    • Remove the stylet from the jejunal tube after flushing the side port with 10ml water.
    • Then cut the intestinal tube to desired length and attach the administration set to the end of the jejunal tube.

Aftercare

1. Aftercare is exactly similar to PEG except that the jejunal tube must not be rotated because of the risk of dislodgement of the intestinal tube from jejunum.
2. Another difference is that AXR is needed to verify position of the tip.
3. The jejunal tube will last up to 6 months and then it needs to be replaced. The PEG should last for as long as it remains functional.
4. Hygiene is of utmost importance as there is no acid barrier in the jejunum as in the stomach
5. To prevent buried bumper syndrome PEG tube aftercare advise include rotation of the tube regularly – for PEG-J however that is contraindicated- instead just push the bumper in and pull back.
6. Additional aftercare is in common with aftercare of PEG
7. Observe the stoma for leakage, inflammation
8. Remove keyhole dressing after 24hours if any applied
9. Clean the skin around the tube with saline water
10. Feeding is usually commenced after 6-12 hours starting with sterile water (refer to local dietician’s protocol)
11. Commence 4 hourly flushing with 20mls of sterile water using a 50ml syringe
12. Flush with 20ml of sterile water before, during and after medication and enteral feed
13. Flush the gastric port with 20ml of sterile water once daily if no contraindication (e.g. gastric outlet obstruction)

Complications:

1. Intraabdominal wall abscess
2. Necrotising fasciitis
3. Peritonitis
4. Colonic perforation
5. Haemorrhage
6. Localised infection
7. Leakage or blockage of the tube
8. Pressure necrosis
9. Mucosal overgrowth around the gastric retaining device
10. Misplacement of the jejunal tube

PEG-J insertion video:
Nothing available online but an excellent DVD available from St Marks/ Fresenius Kabi ( Freka ) which also demonstrate all other enteral feeding access

Acknowledgement/Bibliography:

1. Guidelines for enteral feeding in adult hospital patients : BSG 2003
2. Adler DG et al. Percutaneous transgastric placement of jejunal feeding tubes with an ultrathin endoscope. Gastrointest Endosc 2002; 55: 106-110
3. Sibille A et al. An easier method for percutaneous endoscopic gastrojejunostomy tube placement. Gastrointest Endosc 1998;48(5):514-7.
4. Bumpers HL et al. A simple technique for insertion of PEJ via PEG. Surg Endosc1994 Feb;8(2):121-3.
5. Product guide of the respective companies- Fresenius Kabi and Merck Serono

1. Before you even start
2. Different types of PEG tubes
3. How to do it
4. Aftercare
5. How to remove a PEG tube
6. What to do when PEG tube falls out

Before you even start

1. Patient must have seen a dietician, SALT team and a gastroenterologist –all of whom along with the patient/carer must concur that PEG insertion would be in the best interests of the patient
2. Take consent- use form 4 if unable to consent and the placement is felt to be in the best interests of the patient
3. The patient should be NPO for at least 4 hours
4. Antibiotic prophylaxis with a single shot IV antibiotic an hour before the procedure
5. IV sedation if needed

Different types of PEG tubes

1. The main difference between types of tubes are the type of the gastric retaining devices- collapsible e.g. Corflo  and non collapsible e.g. Freka. The non collapsible PEG  is removed with help of endoscopy whereas the collapsible ones are removed transcutaneously.
2. Size of the tube- French or Charriere- CH 12/14/16/18/20. The narrower the gauge the better is the patient tolerance ( 1F=0.3mm eg 12F=3.6mm)

How to do it

1. Percutaneous endoscopic gastrostomy is performed in a supine position and requires two operators, one for endoscopy and one for tube insertion
2. After the endoscope has been passed into the stomach turn the patient on the back
3. Locate the position for insertion of the PEG tube on the anterior abdominal wall by: a. Transabdominal impulse- endoscopically visible bulging when assistant presses the wall. b. Diaphanoscopy i.e.transillumination of the endoscopic light through the abdominal wall at the puncture area. However, lack of diaphanoscopy is no longer a contraindication for PEG tube insertion. c. Negative needle aspiration test (using a syringe containing 5ml saline solution, puncture under continuous aspiration towards the air-filled stomach without prior air aspiration) is safer than an adequate diaphanoscopy
4. A mark is made on the abdominal wall once a site is chosen by firmly pressing a needle cap.
5. The assistant can stand on either site with the  instrument trolley next to him/her.
6. The  chosen puncture site is cleaned extensively using aseptic technique
7. Inject local anaesthetic through all layers of the abdominal wall, slowly advancing the syringe into the gastric lumen- air is aspirated from stomach lumen
8. Make a stab incision of approximately 3 mm for tube size  CH 9, 4-5 mm for tube size CH 15 ( blue) or 6-7 mm for tube size CH 20 into the skin
   
   Picture1 and 2: The trolley and the actual kit for Freka PEG
9. Advance the puncture cannula into the stomach under direct endoscopic view
10. Then remove puncture needle from the cannula
11. The safety air valve automatically closes the lumen of the cannula as soon as the needle is taken out
    
    Picture 3 and 4: The different pieces inside the kit: Courtesy Fresenius Kabi
12. By this time the endoscopist has introduced the endoscope into the stomach and introduced a snare through the biopsy channel.
13. Attach the blue introducer device to the plastic cannula and advance placement wire (double thread)  into the stomach quickly and remove the introducer device immediately, otherwise stomach will deflate
    
    Picture 5: The snare over the plastic sheath- has to be repositioned so that it catches only the placement wire leaving the plastic sheath
14. As soon as the placement wire (double thread)  is visible in the stomach catch it with a snare
15. Steady the snare/biopsy forceps with respect to the endoscope and pull out everything through the mouth Picture 6: Looping the loop
16. Fix the loop the PEG tube with the loop of the placement wire (double thread)  in an interlocking fashion and smear the PEG tube with liberal amount of KY jelly before introduction ( first put placement wire through PEG tip wire loop and then pass the PEG bumper through the placement wire loop and pull the bumper out to lock the two loops together)
17. Now pull the guiding thread through the puncture cannula with your left hand, and at the same time guiding the lubricated PEG tube through the mouth with the right hand
18. When the tip of the PEG tube reaches the puncture cannula, a resistance will be felt. At this point, remove the puncture cannula and further pull will bring out the conical end of the PEG tube through the incision
19. Pull the PEG tube through the abdominal wall until the inner retention plate abuts the inner gastric wall
20. Pull on the tube until  elastic resistance is felt and keep under tension
21. The inner retention plate should be able to be rotated freely and there is no need to check  the retention plate by reintroducing the endoscope
22. Cut the guiding thread of the PEG tube close to the cone
23. Pass the conical end of the PEG tube through the hole of the fixation plate and then through the tube clamp
    
    Picture 7: Fixation of the outer retaining device and rest: Courtesy Fresenius Kabi
24. Close the tube clamp and then cut off the cone of the tube
25. Push the end of the tube through the fixing screw and then push the pin of the Luer-Lock connector as far onto the tube as possible and secure it by turning the fixing screw
26. Pull off the screwing aid (outer white ring) in a downward direction and discard the white ring.
27. Clean and dry the puncture site, fixation plate and tube thoroughly
28. The fixation plate should be snugly fitted to the abdominal wall and should remain under moderate tension for 24 hours to promote good adaptation of the stomach wall to the abdomen the wall. Keep a record of the mark at abdominal wall ( normally 3-4cm)
29. After 24hours, the tube should be loosened. Leave 5 mm free play between the skin and the fixation plate.
30. For intra-gastric feeding a fasting period after peg placement of at least 1-2 hours is recommended. Some authorities suggest fasting period of 6-8hours to prevent chance of peritonitis.

The variation for a Corflo PEG

Picture 8: Inner retaining plate of the Corflo PEG: Other end with the loop
1. The retaining device for a Corflo PEG is collapsible so that it can be pulled out after cutting the tube few cm outside of the abdominal wall.
   
   Picture 9: Fixing the outer retaining device of the Corflo PEG
2. The first piece of the outer retaining device has got a 90 degree bend and the PEG tubing is pressed into the groove of it the second piece is pushed into the first piece
   
   Picture 10: The sequence of different pieces for the Corflo PEG
3. The sequence of the inner retaining device, two piece outer retaining device and quick release clamp
   
   Picture11: The CORLOCK-CORPORT Y Adaptor : Courtesy Merck Serono
4. Untwist the skirt from the Y adaptor (CORLOCK-CORPORT Y adaptor )and pass the PEG tube through the narrow end of the skirt
5. Push the PEG tube onto the barbed end of the Y-adaptor
6. Push the skirt onto the Y-adaptor

Aftercare

1. Ideally before the first feed is started the patient should be seen by the dietician who explains it to the patient or the carer.
2. For daily cleaning -loosen the clamp device of the outer fixation plate and pull back the fixation plate
3. Carefully clean the puncture site, the tube and the underside of the fixation plate and let the puncture site dry properly
4. Push the tube carefully 3-4 cm into the stoma and rotate through 180 degrees every time the dressing is changed. At least once a week but no more than once a day. It is important for the tube to move freely in the stoma to prevent the retention plate becoming embedded(buried bumper syndrome)
5. Then pull and that you gently until resistance is felt, and  push the fixation plate back to snugly fit to the skin with a free play of 5mm.
6. During  the first wound healing phase, the dressing should be changed daily; after that, the frequency of dressing changes will depend on the condition of the site in question (approximately every 2-3 days)
7. The puncture site should rechecked by a health care professional  at least once a day in the first week after the tube has been positioned.
8. In any case, the dosage of the feed should be increased gradually. For pump controlled continuous tube feeding, which is the preferred method, always use the enteral feeding pumps which are commercially available

How to remove a PEG tube

Notes on Freka PEG tube removal (needs endoscopic removal)

1. Insert the gastroscope into the stomach
2. The assistant cuts off the luerlock adapter and remove the tube clamp and the outer fixation plate
3. Advance the tube into the stomach slightly
4. Catch the inner retention plate with a snare and cut the tube off at level with the abdominal wall and pull the inner plate with rest of the tube out with the gastroscope
5. Then apply an adhesive dressing. Patient can eat immediately after removal of a PEG tube.
6. Some trusts cut the Freka PEG tube close to the skin and push it into the stomach (this method should not be used if there is any suscpicion of distal stricturing ) and expect the inner rigid retaining device to be passed per rectum in due course (not advised by the company)

Notes on Corflo  PEG tube removal (does not need endoscopy for removal)

1. Remove the fixation device
2. Make sure the inner bumper is rotating freely before pulling the tube
3. Cut the tube 4-5 inches away from the abdominal wound (this also cuts a small capillary tube inside the tube which deflates the inside bumper
4. Pull the tube out while stabilizing the exit site with fingers
5. The hole should close in 24hours

What to do when PEG falls out

1. The tract even it is established can close very fast (within 4 hours)- so to maintain the patency at least a similar French size Foley catheter needs to be inserted into the stomach.
2. Do not use anything more than mild pressure to insert a Foley’s catheter
3. Then later when available either change that to a replacement balloon PEG which can be inserted at bedside ( easy and quick but short lifespan and needs change) or endoscopic reinsertion of PEG (needs endoscopy but long life) or a RIG tube (radiologically inserted gastrostomy) can be placed without the need for screening ( advantage of non-balloon collapsible inner retaining device and no need for endoscopy and longer life compared to replacement balloon PEG)
4. Don’t confuse replacement balloon PEG with low profile button PEG ( which is normally used for cosmetic reason)
5. If there is a tract but uncertainty where that is leading up to – guidewire can be inserted with caution and a PEGogram obtained to confirm intragastric location.

Complications of PEG insertion:

1. Intraabdominal wall abscess
2. Necrotising fasciitis
3. Peritonitis
4. Colonic perforation
5. Haemorrhage
6. Localised infection
7. Leakage or blockage of the tube
8. Pressure necrosis
9. Mucosal overgrowth around the gastric retaining device

Here is the link for PEG insertion video:

Further reading: Indications, Insertion, Trouble shooting, Buried Bumper Syndrome and Patient information

Acknowledgement/Bibliography:

1. Guidelines for enteral feeding in adult hospital patients : BSG 2003
2. Angus F et al. The percutaneous endoscopic gastrostomy tube. Medical and ethical issues in placement. Am J Gastroenterol 2003; 98: 272-277
3. Korula J et al. A simple and inexpensive method of removal or replacement of gastrostomy tubes. JAMA 1991; 265:1426-28
4. Product guide of the respective companies- Fresenius Kabi and Merck Serono

]]> https://www.gastrotraining.com/endoscopy/independent-endoscopist/upper-gastrointestinal-therapy/stomach-endoscopy/peg-stomach-endoscopy-endoscopy/peg-tube-insertion/feed 0 https://www.gastrotraining.com/endoscopy/independent-endoscopist/upper-gastrointestinal-therapy/oesophagus-upper-gastrointestinal-therapy-independent-endoscopist-endoscopy/oesophageal-dilatation/oesophageal-stricture-dilatation https://www.gastrotraining.com/endoscopy/independent-endoscopist/upper-gastrointestinal-therapy/oesophagus-upper-gastrointestinal-therapy-independent-endoscopist-endoscopy/oesophageal-dilatation/oesophageal-stricture-dilatation#comments Mon, 09 Aug 2010 07:09:40 +0000 Gastro Training http://www.gastrotraining.com/?p=2607 The module covers:

1. When to use balloon dilatation
2. What is a TTS balloon
3. How to assess the length of the stricture
4. How to set it up
5. Which size of balloon to choose
6. How to actually use it once it is set up
7. Situation when stricture is impassable with scope- the need for screening
8. Aftercare
9. Titbits

When to use balloon dilatation

• It is normally used to dilate benign oesophageal strictures- eg peptic stricture, post operative stricture, post radiotherapy stricture, corrosive injury related stricture.
• This is not used for dilatation of achalasia – a separate Achalasia balloon is used.
• Malignant strictures are treated with self expanding metal stents rather than by dilatation as risk of oesophageal perforation is high.

What is a TTS balloon

1. CRE ™ ( controlled radial expansion ) wire guided Balloon Dilatation Catheter (Boston Scientific)  is  commonly called TTS ( Through the scope) balloon
2. It is capable of being inflated to three distinct and progressively larger size diameters depending on the inflation pressures.
   
   Picture1 and 2: Higher ATM will produce greater dilatation: ATM is shown on the outer dial
3. It is designed to pass through the working channel of an endoscope and accept a guide wire through it’s lumen
4. Standard sizes are
   • 8-9-10mm
   • 10-11-12mm
   • 12-13.5-15mm
   • 15-16.5-18mm
5. Usually length of balloon is 5cm and is same for different balloons and they differ only in the post inflation diameters.
6. While choosing the size, remember a standard gastroscope tip is 10mm diameter and if cannot pass the stricture then oesophageal lumen is less than 10mm.
7. It will come with a guide wire is situ
   • Confirm the blue guide wire tip is positioned inside the transparent catheter tip and move the locking device switch to ON position. This will prevent guide wire movement during the scope introduction.
     
     Picture3 and 4: The blue guide wire is visible just inside the tip of the balloon: The guide wire is seen protruding from guide wire port; the white lock is on, so that wire will not move
   • Once endoscope is in position if you want to use the guide wire make sure the locking device switch is in OFF position and then you can advance the guide wire through the stricture.
   • But very often, a separate jagwire is used rather than the guide wire supplied, particularly in impassable strictures when the lumen is not clearly visible distal to the stricture ( radiological screening is mandatory in these cases)
   • The balloon hub of the catheter is attached to an integrated inflation system such as ALLIANCE™ or other 60cc inflation device with a gauge to monitor the balloon pressure.


Picture5 and 6: The Alliance single use syringe/Gauge assembly: The actual inflation device- blue knob to green arrow will allow inflation, blue knob to red arrow allow deflation while if it is vertical the piston moves freely either way- position when you initially fix the filled syringe to the inflation device

8. And during the passage of the balloon through the biopsy channel spray the outside of the catheter with silicone gel and suck the balloon in.
9. Do not test the balloon- it might not pass through the channel then.
10. Bougies use shearing force rather than radial force and are infrequently used for dilatation.

How to assess the length of the stricture

1. If you can pass the stricture it is easy to calculate.
2. If not- to get an idea about the length of the stricture – under fluoroscopy measure the distance between the tip of the endoscope (keep it the level of the stricture) and the stomach air shadow. The diameter of the normal gastroscope tip is 10mm
3. It is better to squirt some contrast above the stricture and delineate the whole length.
4. It is unusual for the benign strictures to be very long.
5. Remember the length of balloon is fixed and is 5cm and is same for different balloons and they differ only in the post inflation diameter.

What do you need

1. You will need different sized CRE balloons
2. The inflation device
3. The Alliance single use syringe/Gauge assembly ( it includes a 50ml syringe to be filled with water ( or contrast if screening is needed)

Which size of balloon to choose

1. Remember the tip of a normal endoscope is roughly 10mm- if it does not pass start with a 8-9-10mm CRE TTS balloon
2. Although unless you inflate to the manufacturer’s recommended pressure 3ATM for 8mm dilatation, 5.5ATM for 9mm dilatation and 9ATM for 10mm dilatation the balloon diameter will not be what you are hoping
3. However most gastroenterologists stay below the limit. Be guided by the radiological waist ( how much of the ‘predilatation waist’ is gone) and repeat the procedure at a later date rather than be aggressive.

How to actually do it

1. Pass the endoscope up to the point of stricture
2. Pass the CRE balloon catheter through the biopsy channel after spraying the outside with silicone gel and sucking the balloon flat.
3. The assistant will prepare the device by
   • Aspirating  water in the syringe up to the red mark and fit in the inflation device
   • Connect the balloon port of the catheter to  the inflation device
4. Pass the half of the length of the balloon through the stricture
5. Keep the guide wire locked in and make sure it is inside the tip of the balloon- it is quite stiff and gives the balloon some stiffness.
6. Once the balloon is across the stricture you can remove the wire after sliding the white locking device to off position
7. The assistant will inflate the balloon with water by squeezing  the inflation device repeatedly
8. Blue knob to green arrow will allow inflation, blue knob to red arrow allow deflation while if it is vertical the piston moves freely either way- position when you initially fix the filled syringe to the inflation device
   
   Picture7: Before you start inflating the blue knob to be turned to green arrow
9. Maintain the endoscopic view of the balloon all the time
10. At first fill it only partially to make sure the balloon is sitting across the stricture i.e.  to catch the stricture
11. Then increase the pressure gradually noting the manometer reading.
12. This is the time when the balloon might slip- called cone effect.
13. The balloon will slip  upwards if the major portion of the balloon happens to be above the stricture( then maintain inward push on the balloon catheter  )
14. The balloon will slip downwards if the major portion of the balloon happens to be below the stricture (then you need to exert outward pull)
15. Each balloon will pass through 3 different diameter depending on inflation
16. Remember not to dilate it too much in one endosocpy session
17. Keep the pressure on for 60 secs – if pressure falls ( say from 3 ATM to 2ATM as the stricture dilates ) –and increase it back to the pressure of 3 ATM.
18. After successful dilatation try to go through the stricture and have a careful look. Minor mucosal tear and slight bleeding is expected.

Situation when stricture is impassable with scope- the need for screening

1. When the stricture is impassable but it is a very short segment stricture and you can clearly see the lumen distally – you can proceed as above
2. Other than that the dilatation needs to take place under radiological screening according to the following steps
3. Here you might need an additional three way tap and a 20ml syringe filled with contrast solution and use it as follows
4. Introduce the scope up to the point of stricture
5. Introduce a white tube/ ERCP cannula through the biopsy channel so that it’s tip rests just above the stricture
6. Pass the guide wire through the white tube/ERCP cannula and then through the stricture
7. Advance the white tube over the guide wire
8. Remove the guide wire and inject contrast and screen to make sure the white tube is in the stomach
9. Reintroduce the guide wire and withdraw the endoscope and the white tube by pull/push technique leaving the guide wire in.
10. Introduce the TTS balloon over the guide wire and simultaneously introduce the endosocpe along side up to point of stricture
11. Advance the balloon through the stricture
12. Inflate the balloon with contrast after catching the stricture with the balloon – two ways it can be done- either normally by the inflation device or better in the following way
    • Inflate the balloon with contrast by inflating from the 20ml syringe fitted to the TTS balloon catheter via a three way tap
    • In this way the balloon will catch the stricture easily rather than by the slow inflation with the inflation device
    • Once you think you got the stricture, change the three way tap to the inflation device and start inflating again
13. Rest is similar to the procedure without the screening but here you keep a careful eye on the screen and look for the stricture and gradual dilatation. Sometime a residual waist will remain in first attempt at dilatation for very tight strictures.
14. If dilatation is successful it is expected that you will see blood and minor mucosal laceration
15. Inject contrast proximal to the stricture and look for any leak

Aftercare:

1. CXR after 2-4hrs to exclude oesophageal perforation- this is not routine practice particularly if straightforward procedure and post dilatation visual check and contrast check is ok but is a safe practice.
2. If OK patient can eat and drink
3. Admit the patient if subcutaneous emphysema, persistent or worsening pain and evaluate for perforation
4. Follow up in clinic to assess the response- prefer to calculate a dysphagia score pre and post procedure

Titbits:

1. Previously Eder-Peustow dilatation olives or Savary-Gillard dilators ( Wilson-Cook) was standard- which exerts an unnecessary longitudinal shear force on top of radial dilatation force but has the advantage of tactile sensation of the feeling of resistance which acts as a safeguard- no good evidence that these are more dangerous or less effective than the TTS dilator.


Picture8 and9: Eder-Peustow dilatation olives on flexible shaft

Picture 10: Savary-Gillard PVC dilators

2. The TTS balloon dilatators are standard these days but these does not provide any tactile feedback.
3. With these dilators the rule of 3 is- do not more than three consecutive dilatation at 1mm increment
4. Remember 1F=0.3mm eg 7F=2.1mm
5. Lumen of 13mm is enough to relieve the symptom of dysphagia

Here is the link for Oesophageal stricture dilatation video:

Acknowledgement/Bibliography:

1. Tytgat GN. Dilation therapy of benign esophageal stenoses. World J Surg 1989; 13:142-148
2. Marks RD et al. Peptic strictures of the esophagus. Am J Gastroenterol 1993; 88:1160-1173
3. Scolapio JS et al. A randomized prospective study comparing rigid to balloon dilators for benign esophageal strictures and rings. Gastrointest Endosc 1999; 50: 13-17
4. Product guide of the respective companies- Boston Scientific

1. What do you need
2. Assessment of the stricture- choosing the length of stent
3. Basic principles
4. Choosing the stent
5. How to choose the diameter of the stent
6. How to deploy
7. Aftercare
8. Complications
9. Titbits

What do you need

1. Stent
2. ERCP cannula and long guidewire (450cm)
3. Lipoidol contrast
4. Injector needle or simple paper clip attached to adhesive tape
5. Paediatric gastro/colonoscope if  available for impassable stricture

Assessment of the stricture and choosing the length of the stent:

• Ideally assess the length and anatomy of the stricture by direct vision if possible.
  • Most centres that does frequent oesophageal stenting will have a paediatric endoscope.
  • Paediatric gastroscope is usually 3mm diameter and paediatric colonoscope 7mm diameter and most of the strictures will allow these paediatric scopes to pass.
• You have to leave at least 2-3 cm above the top of the stent and the upper oesophageal sphincter ( cricopharyngeal )
• How to estimate the length of the stricture, if the stricture is impassable:
  • Under fluoroscopy measure the distance between the tip of the endoscope (keep it the level of the stricture) and the stomach air shadow. The tumour normally then can be all the way down to the GOJ but more commonly a few centimetres only ( be guided by the CT Scan findings )
  • Other techniques that can be used
    • Once you opacify the stomach rugal fold by injecting the contrast through the ERCP cannula- withdraw while injecting and as it passes through the stricture it delineates the stricture.
    • Inflate a biliary dilatation balloon 15mm and withdraws until it is stuck where the stricture begins.
• Mark the top end of the stricture with
  • A metal clip taped to the bare skin at the proximal end of the stricture (fluroscopically)
  • Or inject contrast intramucosally at the top of the stricture
  • Put an endoclip at the top end of the stricture
• If you under estimate the length of the tumour then you might have to dove tail another stent through the first stent-so if  in doubt go for the longer stent in the first instance.
• Stent should be 3-4cm more than the stricture length – 2cm above and 2cm below the stricture plus the stricture length, so for a stricture of 5cm the stent length would be 5+2+2= 9cm

How to assess the diameter of the stent

If adult gastroscope cannot pass the stricture , the diameter of the stricture is less than 10mm
Choose the diameter which is 1-4mm larger than the largest reference oesophageal diameter, to achieve secure placement
Standard stent is of 18mm diameter but if the scope can pass the stricture bigger diameter may be needed e.g. 22mm

Basic principles

When you can pass the stricture with the gastroscope

• Measure the actual length of the stricture with paediatric/adult gastroscope and whether the GOJ is involved
• If using adult gastroscope inject Lipoidol contrast to tattoo the top and bottom of the stricture (for tattooing the lower end of the stricture you will have to do J manoeuvre )
• If using a paediatric scope to measure then introduce adult gastroscope to tattoo only the top of the stricture as it cannot take a injector needle through it’s biopsy channel
• After tattooing pass a jagwire into the stomach ( no need for white tube/ERCP cannula or injecting contrast into stomach)
• Some centres do not mark the lower end of the stricture with contrast if they can go through the stricture and some centres mark the top end with other  devices ( see above)

If you cannot go through the stricture

• Mark the top of the stricture/tumour with Lipoidol contrast tattoo at the top only  on two opposite walls ( or use other devices – see above)
• Pass a ERCP cannula  first through the scope ( with a Jagwire through it with the soft tip) up to the beginning of the stricture- do not push the ERCP cannula through the stricture at this stage – it can perforate
• Push guide wire gently into the stomach under fluoroscopic screening
• Learn to identify the stomach shadow and the diaphragm on the fluoroscopy
• Push the cannula  over the guide wire into the stomach under screening
• Inject contrast in the stomach to make sure you are in stomach- you might have to withdraw the cannula if it hits the gastric rugal folds.
• Keep injecting contrast as you withdraw the cannula until you delineate the whole stricture.
• Take ERCP cannula out keeping the jagwire in – pull/push exchange
• Once you are sure that the jagwire is in the stomach/duodenum take the scope out while pushing the guide wire in simultaneously ( left hand pulling out the scope holding the knob and right hand pushing the guide wire in
• The assistant at head end supports  the end of the scope as it comes out the mouth so that it does not suddenly drop causing the jagwire to dislodge and when the scope is out of mouth , assistant will secure the jagwire and then remove  the scope completely

Choosing the stent

• Type- covered and non-covered: advantage of non-covered stent is there is less chance of stent migration but more chance of stent blockage because of tumour ingrowth. Most gastroenterologists use partially covered i.e. non-covered at the end flanges or a sleeve of non-covered segment around the covered midsection (e.g. Niti-S)
• Top/proximal release or bottom/distal release: Most use bottom release but in case of high tumour top release may be preferable as it can be deployed with direct endoscopic visualization ( most companies produce both variety).
• Dimension – varies from 15-18-22mm diameter and 70-100-120mm length. Most common diameter used is 18mm. End flanges are wider and normally 23mm. Choosing the length has already been discussed above.
• Removable or non-removable – when chemo/radiotherapy shrinks the tumour size obviating the need for the stent. Most companies produce both the types but non-removable is the one most commonly used. Removable stent will have a string at the proximal end which can be grasped with a forceps and the stent can be pulled out.
• Different makes from different companies are available:
  1. Pyramed: Niti-S
  2. Alveolus Inc: Alimaxx-E
  3. Boston Scientific: Ultraflex and newer wallflex
• Other variables like foreshortening, radial force, delivery system diameter ( Pyramed’s Niti-S is 16F whereas Boston’s ultraflex is 18F) and flares also come into consideration but beyond the scope of our discussion.
• Recently biodegradable stents are being used to treat benign oesophageal strictures which require frequent dilatations ( SX-ELLA stent)
• Also Pyramed has come up with a TTS oesophageal stent which will be available in very near future.

How to deploy

Picture1and 2: The top green marker in Alveolus stent: The stent has just began to open

• Jelly on the stent tip
• Hold the tip of the stent with the left hand and glide it over the guide wire while holding the guide wire with the other hand
• Screen- the proximal, midpoint and the distal end of the stent is marked with radio-opaque marker. The proximal end will also have a coloured marker for most stent if you are using scope alongside technique.
• Stop when the middle marker of the stent is at the mid-point of the stricture- you might have to zoom out to see all the three markers of the stent
• Or stop when the top of the stent assembly  is 2cm above the top tattoo ( if under direct endoscopic vision see the top marker – eg. Green marker  in Alimax-E)
• Once you start to deploy ( slight variation of actual technique depending on which company you are using, but principle is same)- remember about halfway there is a period of no return for most of the stent ie you can resheath and reposition before you cross this point if you are too far in or out and redeploy again. But once you cross this point you cannot resheath.
• Remember the cone effect-
  • The stent will slip  upwards if the major portion of the stent happens to be above the stricture at the time of deployment( then maintain inward push on the stent assembly  )
  • The stent will slip downwards if the major portion of the stent happens to be below the stricture (then you need to exert outward pull)
• Some gastroenterologists pass the endoscope along side again after passing the stent assembly through the stricture over the guide wire and then pull or push the stent under endoscopic view to keep 2cm of stent above the stricture- advantage is that you are 100% sure that top of the stent is opening above the stricture. Another advantage of the scope alongside technique is that you don’t have to mark the top end of the stricture.
• Throughout the deployment monitor the screen and endoscopic view ( if the scope is alongside) to ensure the waist is developing at the centre of the stent
• Go back with the endoscope and squirt some contrast just at the top of the stent and ensure contrast passes freely into the stomach and there is no contrast leak to suggest any perforation.

Alimaxx-E stent ( Alveolus Inc)

• Pull the white flange of the handle to white flange first
  
  Picture3 and 4: This phase is reversible and stent is half open
  
  Picture5: This is completion and stent is irreversibly deployed
• On screening you will see the stent opening up from below
• Look for flaring of the bottom end – if it does not, the lower end might not have passed the stricture- particularly when you estimated the length of the stricture because it was impassable
• This half is reversible and you can re-sheath the stent
• Then pull the  blue  flange  to the white flange
• This is  irreversible
• Continuously pull outwards as the stent deploys otherwise the stent will slip into the stomach as it opens from below
• Look for the shoulder and flaring above and below the shoulder- the shoulder corresponds to the area of the stricture

Niti-S ( Pyramed)

• Unlock the valve of the Y connector handle once the stent is in position for deployment, by rotating the screw counter clockwise
  
  Picture 6 and 7: Niti-S oesophageal stent- the Y connector handle and the inner shaft: the stent opening at the bottom
• Hold the end ( hub on the inner shaft) and keep it fixed while withdrawing  the outer sheath by holding at the locking screw  ( in contrast to push the inner shaft)
• Visualize the stent fluoroscopically to verify full deployment
• The stent opens from bottom ( if using a top release stent – deployment technique is reverse i.e. push the inner shaft rather than pull the outer sheath)

Ultraflex ( Boston)

• Proximal release covered stent can be deployed under endoscopic method
• After passing the stent assembly over the guide wire pass the endoscope up to the stricture and position the endoscope along the delivery system immediately above the visual marker band ( tight black suture area at the proximal end of the stent- we use TIPPEX to make it even more prominent before passing the stent in)
• Hold the delivery catheter stationary with one hand and using the other hand , grasp the finger ring attached to the handle and pull the finger ring to release and unravel the suture.
• Monitor the stent release fluoroscopically and or  endoscopically.
• Keep the delivery system between the identified stricture margin.

Aftercare

• Liquid diet for 24 hrs and consider a CXR in 2 hours  to check for stent position and exclude perforation.
• PPI, if the stent traverses the GOJ
• Eating advise to patients
  • Even after the stent insertion patient can not eat normal diet – must be blenderized or semisolid or THOROUGHLY chewed
  • Eat upright
  • Frequent sips of liquid during and following the meal

Complications:

• Tumour overgrowth: Options are treatment with Laser followed by re-stenting through the existing stent ( dove tailing)
• Bottom end not opening – balloon dilatation or dove tailing if under estimation of stricture length.
• Stent migration into stomach: migrated stents are very often left alone in teh stomach ( intestinal obstruction with the stent is a possibility). However, you can snare one end of the stent and close to make that end to make a cone and pull out carefully.

Titbits:

• For duodenal or colonic stents principles are the same
• Standard duodenal stents are 20mm and colonic 22mm
• All non covered to prevent migration
• TTS type only
• Use inflated biliary balloon pull back technique to identify the distal end of the stricture.

Here is the link for oesophageal stent insertion  video:

1. Video 1
2. Video 2

Acknowledgement/Bibliography:

1. Knyrim K et al.A controlled trial of an expansile metal stent for palliation of esophageal obstruction due to inoperable cancer. N Engl J Med 1993; 329:1302-1307
2. Austin AS et al.Placement of oesophageal self-expanding metallic stents without fluoroscopy. Gastrointest Endosc 2001; 54:357-359
3. Siersema PD et al.Self-expanding metal stents for complicated and recurrent oesophagogastric cancer. Gastrointest Endosc 2001; 54: 579-586
4. Product guide of the respective companies- Alveolus, Pyramed and Boston Scientific

1. What is BOTOX
2. When to use BOTOX
3. How to make up the solution and ready the device
4. How to actually use it once it is set up

What is BOTOX

BOTOX contains Clostridium botulinum type A neurotoxin complex.

Botulinum toxin injected into the Lower Oesophageal Sphincter (LOS) of patients with achalasia/or pylorus poisons the excitatory acetylcholine-releasing neurons thereby producing a therapeutic decrease in LOS/pylorus pressure

Picture1: BOTOX Allergan 100units, powder for solution for injection Containing Clostridium botulinum type A neurotoxin complex

When to use BOTOX

1. Achalasia- ONLY TO treat elderly or infirm patients for whom pneumatic dilation and surgical myotomy has unacceptable risks. The long-term safety and efficacy remain uncertain
2. Gastroparesis- not very good evidence.

How to make up the solution and ready the device

1. Equipments
   • Injector needle
     
     Picture2: Injector needle
   • Botox (100units)
   • 2ml syringe to calculate needle volume
   • 5ml syringe to draw up after Botox powder has been diluted
2. Dose:
   • Achalasia: 100 units (25units in four sectors) in the GOJ
   • Gastroparesis (idiopathic or diabetic): 100 units (25units in four sectors) in the pylorus
     
     Picture3 and 4: Needle volume is 2ml-1ml=1ml
3. Making up the BOTOX
   • The botox in the vial is almost invisible
   • To determine how much water to dissolve it into first determine the volume of normal saline you need to prime the injection needle
   • Standard injection needle volume is 1ml ( as shown above to see the water drop from the tip you push from 2ml to 1ml)- but always check your needle dead space volume before actual start
   • Then inject 4ml of NS into the vial and gently swirl it without agitation (agitation inactivates botox) and withdraw it into the 5ml syringe.
   • Each ml=25units
   • If your needle volume is more say 1.5ml then dissolve the powder with four times the needle volume so that one fourth of the solution  will have 25units

How to actually use it once it is set up

1. These patients are prone to aspirate particularly when regurgitation of old food is the predominant symptom.
2. The patient is advised to fast for at least 12 hours prior to the procedure +/- liquid diet for one or two days preceding the injection
3. After the completion of diagnostic OGD come back to GOJ
4. It is easier to inject on a retroflexed view ( J manoeuvre in the fundus)
5. Prime the injection needle with 1ml of Botox solution
6. When ready say ‘advance needle’ and then Inject 1ml =25U in sector 1 and when finished say ‘ needle back’
7. Similarly inject in sector 2 and 3
8. In sector 4 inject 1ml of NS   which will push the remaining Botox from the injection needle channel.
9. For treatment of gastroparesis inject 25 units in 4 sectors in the pylorus.
10. Make sure the needle is in the muscle layer rather than submucous layer.
    
    Picture6: Fundal retroflexed view:Actual injection needle in use
    
    Picture5: After the GOJ injections

Acknowledgement/Bibliography:

1. Storr M et al.Treatment of achalasia: the short-term response to botulinum toxin injection seems to be independent of any kind of pretreatment. BMC Gastroenterol. 2002; 2: 19.
2. Pasricha PJ et al. Intrasphincteric botulinum toxin for the treatment of achalasia. N Engl J Med. 1995 Mar 23;332(12):774-8.
3. Fishman VM et al. Symptomatic improvement in achalasia after botulinum toxin injection of the lower esophageal sphincter. Am J Gastroenterol. 1996 Sep;91(9):1724-30.
4. Product guide of the respective companies- Allergen