1. When to use Adrenaline
2. How to set it up
3. How to actually use it once it is set up

When to use Adrenaline

1. Most commonly it is used as part of dual therapy (submucosal injection) to achieve haemostasis in ulcer bleeding, bleeding AVM, Dieulafoy lesion, MW tear, post polypectomy bleeding and post sphincterotomy bleeding.
2. Sometimes it is used to lift up the polyp base before snare polypectomy
3. It is not used in variceal bleeding.

How to set it up

Picture1: Adrenaline injection

1. Ten ml syringe filled with Adrenaline solution (1:10000 dilution, comes in 10ml ampoules)
2. Injector needle, primed with same solution. In most situations you probably will use a gold probe and use dual treatment with one device.

How to actually use it once it is set up

1. Inject adrenaline in four quadrants at the periphery of the lesion. This should be followed by injection at the centre of the lesion.
2. Assistant pushes the injection hub towards yellow injector stem when you say ‘advance needle’- don’t say ambiguous terms like needle out or needle in.


Picture2: Advance needle: injector hub is pushed towards the yellow stem

3. Inject in the submucosa and inject liberal amount (tamponade effect is probably as important as the vasoconstrictor effect) – 10-15ml should be the total amount. Studies show that at least 13 mls should be injected for optimum haemostasis.
4. After injection is given you say ‘needle back’ (don’t say needle out) and assistant withdraws the needle back in sheath by pulling the hub away from the yellow stem.


Picture3: Needle back: injector hub is pulled away from the yellow stem

5. Although at times when we inject adrenaline subcutaneously at times of giving local anaesthesia, we always aspirate before injecting to make sure we are not injecting in a blood vessel, we have not come across this practice but might not be a bad idea.
6. It should be followed by another modality of achieving haemostasis ( e.g. gold probe, endoclip etc)

Complications:

1. Cardiac tachyarrhythmia can occur particularly in the event of inadvertent intravascular injection
2. Local pressure necrosis (rarely)

Here is the link for Adrenalin injection video

Acknowledgement/Bibliography:

1. Gustavo A et al. Thermal probes alone or with epinephrine for the endoscopic haemostasis of ulcer haemorrhage Best Practice & Research Clinical Gastroenterology June 2000 :14 (3): 443-458
2. Jensen DM et al.CURE multicenter randomized, prospective trial of gold probe vs. Injection & gold probe for hemostasis of bleeding peptic ulcers. Gastrointestinal Endoscopy 1997:Volume 45 (4), Page AB92
3. Arasaradnam RP et al.Acute endoscopic intervention in non-variceal upper gastrointestinal bleeding Postgrad Med J. 2005;81:92-98

1. When to use APC
2. How to set it up- both the cable connection and the settings
3. How to actually use it once it is set up
4. The principle behind APC

When to use APC

1. Mainly in AVMs (particularly GAVE -gastric antral vascular ectasia) and bleeding tumours.
2. It can also be used in base of polyps after snare polypectomy.
3. Rarely used in bleeding gastric and duodenal ulcers.
4. Unblocking of occluded metal stents

How to set it up- both the cable connection and the settings

1. Turn on both the boxes: Top box is normal diathermy unit ERBE ICC200 and bottom box is APC 300
2. Connection of cables:

• Connect the plug of the nessy plate (patient electrode) to the neutral slot of the top box (top box left most plug)- picture1
  
  Picture1: Top box is normal diathermy unit ERBE ICC200 and bottom box is APC 300
• Three pronged connector from lower box goes to the Cut/Coag slot of the top box – picture2- (remove the single probe connector which we use most of the time i.e. polypectomy or hot biopsy)- operator holding it after taking it off -in the picture above (Picture1).
• If you forget to connect this, APC will not work – a frequent cause of ‘APC not working’


Picture2:The plug holes of the top box from left to right– 1) neutral 2) Cut/Coag- which takes the three pronged plug from the bottom box and 3) Bipolar- not important here

• Third plug socket on the top box called bipolar is not used in APC and we just leave the plug as it is
  
  Picture3:The plug holes of the bottom box from left to right-1) goes to the cut/coag hole of the top box- the three pronged cable 2) Not important for us 3) connects to the blue APC catheter
• The ash coloured cable from the bottom box ( furthest on the right- see picture 3 ) goes to the blue APC catheter
  
  Picture4: The APC blue catheter (coutesy www.erbe.nl)

3. The settings on the boxes:

• Set the current setting on the top box by repeatedly pressing the effect select button (bottom button which looks like a loop with an arrow) and the watt select button (middle up/down button)- See picture 5.
  
  Picture5:Finger on the effect settings- select forced and a second click on same button will make the watt A( A for Argon) and then make it 65 by using up/down button
• The setting for lesion in Stomach/Duodenum/Left colon :Auto Coag (Blue right panel) to Effect Forced and Watt A65
• The setting for lesion in right colon :Auto Coag (Blue right panel) to Effect Forced and Watt A40
• The setting for lesion in jejunum/ileum ( as in enteroscopy) :Auto Coag (Blue right panel) to Effect Forced and Watt A30
• We have checked with ERBE Engineers- the yellow Autocut panel is completely irrelevant and does not matter what you set as we use only blue Autocoag pedal (Some endosocpy nurses may insist on the ‘correct setting’ and set a value on the yellow autocut section. This is totally irrelevant).
  
  Picture6: Bottom box APC 300- programme 3, cylinder 2 is empty and see the Coag/Cut settings
• On the bottom box you don’t normally need to change current setting as mostly we don’t touch the settings –
  • Make sure the programme mode is set to 2-3
  • And the both the argon cylinders are not empty – in the picture cylinder 2 is empty
  • The setting for coagulation is normally 2.0L/min and is shown on the picture as selected option.For use of APC in small bowel/right colon reduce to 1.5L/min

4. Open the Argon tank valve
5. Purge (the button on the bottom box which says PUR- see picture 1) before using it and then test it by putting the catheter tip in jelly and press the blue foot pedal and see the gas bubble

How to actually use it once it is set up

1. The probe is passed through the accessory channel of the endoscope so that the blue tip hovers over the target tissue. A black stripe located a few centimetres proximal to the tip should be visualized to prevent damage to the endoscope.
2. The probe should be as close as possible to the lesion without actually touching the lesion. The best way is to actually touch the lesion with the probe and then withdraw a little and then give a burst
3. Bursts are controlled with the blue foot switch
4. If burst happens when the tip is in contact with the tissue- a submucosal bleb will form. This is a harmless event. But this can be dangerous when you are using deep in small bowel eg Double balloon enteroscopy.
5. For right colon use lower settings of CoagA40 in other areas of colon use Coag A65
6. Depth of burn is a function of time of burst and the power setting
7. Short bursts of 0.5secs to 2secs duration
8. Frequently suction off gas to avoid over-insufflations, particularly in the colon.

Advantage over conventional coagulation methods:

1. Depth of injury is limited – typically 3mm– better protection against perforation of thin-walled anatomy.
2. Can be used over relatively large areas using non contact method

Complications of the procedure:

1. Complications are rare. However, like any coagulation method, serious complications can occur, particularly in the right colon. Rare cases of perforations have been reported.
2. Other complications like subcutaneous emphysema and pneumoperitoneum have also been reported. These are likely caused by over distension within the right colon.

The principle behind Argon Plasma Coagulation

Picture7: The principle of APC (courtesy www.erbe.nl)

APC uses argon gas to deliver plasma of evenly distributed thermal energy to a field of tissue adjacent to the probe. A high voltage spark is delivered at the tip of the probe, which ionizes the argon gas as it is sprayed for a distance of 2-10mm from the probe tip in the direction of the target tissue. Current density upon arrival at the tissue surface causes coagulation. The application of the energy to the tissue is uniform, and contact free.

APC equipment thus combines argon gas with a monopolar power source. The electrode in the argon channel of the probe is connected to an electrosurgical generator.

The plasma beam has a tendency to turn away from already coagulated (high impedance) areas toward bleeding or still inadequately coagulated (low impedance) tissue in the areas receiving treatment. This automatically results in evenly applied, uniform surface coagulation.

Information regarding The Principle of Argon Plasma Coagulation: (courtesy www.erbe.nl)

Here is the link for APC Video:

Acknowledgement/Bibliography:

1. Rolachon A et al.Is argon plasma coagulation an efficient treatment for digestive system vascular malformation and radiation proctitis? Gastroenterol Clin Biol 2000;24(12):1205-10.
2. Grund KE et al. Argon plasma coagulation (APC) in flexible endoscopy Experience with 2193 applications in 1062 patients. Gastroenterolgy 1998; 114: A603
3. Wilson SA et al. Endoscopic treatment of chronic radiation proctopathy. Curr Opin Gastroenterol 2006;22(5):536-40.
4. ERBE: for kindly letting us use the information and pictures

The module covers:

1. What is Sengstaken-Blakemore tube
2. When to use SB tube
3. What do you need before you start
4. How to actually insert it
5. How to maintain traction
6. Aftercare and removal

What is Sengstaken-Blakemore tube

Sengstaken-Blakemore tube is a 3 lumen tube- one lumen to inflate gastric balloon, a second lumen to inflate oesophageal balloon and a third lumen to aspirate gastric contents. There is no oesophageal suction port. This causes saliva to pool in the oesophagus and thus put patients at risk of aspiration.
Commonly Minnesota tube is referred to as Sengstaken-Blakemore tube

Picture1:Minnesota tube or Modified Sengstaken-Blakemore tube

Minnesota tube- or modified Sengstaken-Blakemore tube is a four lumen tube with an additional lumen to aspirate oesophageal lumen to prevent aspiration from swallowed saliva and blood from the oesophageal varix

Linton-Nachlas tube: Single 600ml gastric balloon only

When to use SB tube

It is used in life threatening upper GI bleed from ruptured oesophageal/gastric varices when traditional treatment with band ligation or glue injection has failed or are not available

This is only temporary method to buy time for more definitive procedures to stop the bleeding.

What do you need before you start

1. The SB tube is normally kept in freezer- it helps insertion by improved stiffness
2. Keep ready two bladder wash syringes for suctioning the oesophageal and gastric lumen, another bladder wash syringe for inflating the gastric balloon
3. Stout metal artery forceps for clamping the balloon ports
4. If oesophageal balloon needs to be inflated in addition to the gastric balloon- You will need:

• A 50cc Luer Lock syringe
• An adaptor whose conical end will fit into the oesophageal port and the Luer lock end will fit into the sphygmomanometer ( the adaptor is available in the chest drain kit )
• A three way valve
• A sphygmomanometer with detachable arm cuff–  to remove the BP cuff and fit the Luer lock end of the chest drain adaptor to fit there

How to actually insert it

1. Debate regarding optimal place for the procedure: Resus vs. theatre: anaesthetist prefers theatre
2. Patient in normal endoscopy position
3. Airway protection- in general, patients who require balloon tamponade to control variceal bleeding should also be intubated. However airway protection is particularly important in
   • Encephalopathy
   • If Sao2<90%
   • Aspiration pneumonia


Picture2: Checking for leak

4. Check the balloons by inflating  air and checking for any leak
5. Smear plenty of KY gel and pass the tube through the mouth like an NG tube- It is kept in the freeze in theatres and Endoscopy unit-to increase the stiffness. Sometimes because of the curled position in which it is stored makes it very difficult to insert like NG tube and a laryngoscope and Magill’s forceps may be needed to guide it past crico-pharyngeus.


Picture3: The setting up of Modified Sengstaken-Blakemore tube

6. Once it has gone up to 45cm mark it’s tip is expected to lie in the gastric lumen- confirm by aspirating stomach content and checking pH – position to be checked later by portable CXR.
7. Once you are sure the tip is in the stomach, inflate the gastric balloon by inflating it with 200ml of air (and put two artery forceps as clamp and also insert the pegs supplied with the tube) and gently tugging it. Some  prefer to put contrast mixed water rather than air.
8. It should slide for some length and then halt as it abuts against the  GOJ –then push additional 50-100ml of air and pull the tube out to exert the pressure on the GOJ.
9. For majority of patients this is enough to stop the variceal haemorrhage. However, oesophageal balloon will need to be inflated, if the bleeding continues in spite of the gastric balloon inflation.
10. Clamp the tube in between air refills
11. Finally fix the tube and  keep a record of the distance of the tip from the incisor teeth- normally around 30-35cm mark
12. Initial success to control bleeding depends on
    • Operator experience
    • Concomitant therapy ( Terlipressin and antibiotics )

How to maintain traction

13. To maintain the pressure on GOJ- you will have to fix the tube with continued traction. We have noticed a variety of practices
    • To hang a bag of 500ml of saline by tying it to the loop of the clamp attached to the tube – the advantage of this technique is
      • Bag of saline is universal as opposed to a tennis ball- but units who use tennis ball normally store one ball with the tube
      • No pressure on the cheeks/lips unlike the tennis ball
      • The traction is measured ( 0.5 kg weight ) unlike unquantifiable traction strength which might vary from person to person
      • See the picture of how to do it below.



b. Pull  the tube and fix it on the side of the cheeks with elastoplasts under tension- not very reliable as    elastoplast may become loose and also the traction force will vary among individuals. However this is the most common practice.

c. Another method is to pull the tube and fix it on the side of the cheeks by passing it through a split tennis ball

14. If oesophageal balloon is inflated pressure should be accurately measured with a sphygmomanometer.
15. Inflate it to 25-40mm Hg. Normal portal pressure is <10 mm Hg; maximal pressure in portal hypertensive patients is never >30 mm Hg, therefore a pressure of 40 mm Hg is sufficient and remember the less the better.

Aftercare and removal:

1. Migration of gastric balloon in oesophagus can cause compression of trachea and respiratory distress. Keep a pair of scissors ready at the bedside in case of emergency – to cut the gastric balloon port to let the air escape
2. Instruction to suction both oesophageal and gastric lumen at intervals of 10 minutes increasing to 30 minutes and after stabilization hourly
3. Frequent oropharyngeal suction
4. Don’t forget antibiotic prophylaxis and continued terlipressin for at least 48hrs
5. Pressure in the oesophageal balloon to be relieved for 10minutes every 2hours to prevent pressure necrosis
6. Repeat endoscopy at 24 hours.
7. The Sengstaken tube should be removed in the endoscopy room
8. First deflate the oesophageal balloon, then take off the traction and finally remove the tube
9. Chance of rebleeding when balloon is deflated  is up to 50%
10. On second endoscopy it should be much easier to band or inject glue as bleeding hopefully would be under control, failing which patient should be referred for urgent TIPSS.
11. Serious complication can occur up to 15-20%
    • Oesophageal ulceration
    • Aspiration pneumonia

Here is the link for Sengstaken tube insertion  video:
No video found so far. One good link is http://emedicine.medscape.com/article/81020-media

Acknowledgement/Bibliography:

1. Helmy A et al. Review article: current endoscopic therapeutic options in the management of variceal bleeding. Aliment Pharmacol Ther. 2001 May;15(5):575-94.
2. Seet E et al. The Sengstaken-Blakemore tube: uses and abuses. Singapore Med J. 2008 Aug;49(8):195-7.
3. Han HY et al. Simple method for inflating and measuring oesophageal balloon pressure of Sengstaken-Blakemore tube. Intern Med J. 2006 Oct;36(10):684-5.
4. Kashiwagi H et al. Technque for positioning the Sengstaken-Blakemore tube as comfortably as possible. Surg Gynaecol Obstet 1991; 172

1. When to use Gold probe
2. Different parts of the Gold probe
3. How it is set up and used
4. Other types of thermal devices in use

When to use Gold probe

1. Mainly in peptic ulcer bleeds
2. Bleeding polyp stalks
3. Dieulafoy lesions
4. Mallory-Weiss tears
5. Arterioveous malformations (AVMs)

Different parts of the Gold probe

Injection Gold Probe Catheter can be used to give injection therapy and also for electro haemostasis. It has also got irrigation capabilities.

Picture1: The gold probe

1. The catheter handle is a thick triangular portion- from its apex emerges the cable leading to the gold tip
2. From the base of the catheter handle arises
   1. The injection hub (with the red/green mark) and
   2. The cable which splits into two further cables
      1. One with the thicker, flange shaped end is the bipolar electrical connector- which is connected to the cable coming from the bipolar socket of the ERBE diathermy box (ICC 200)

      
      Picture2: The electrical connector/ irrigation hub

      2. The other cable takes a saline filled syringe to flush the tip after burning but alternatively you can exchange the adrenaline syringe with a saline filled syringe and flush.
3. The device is supplied in 7Fr (2.3mm) and 10Fr (3.2mm)- 7F and 10F probes require a minimum of 2.8mm and 3.7mm working channels respectively. So use 7F Gold probe if your endoscope is not a therapeutic one (yellow colour as opposed to salmon colour which is therapeutic)
4. The length of the gold probe is usually 210cm but 300cm and 350cm is also available to use in particularly deep in small intestine and colon if needed.

How is it set up and used

1. Connect the bipolar electrode end to the bipolar socket of the ERBE box


Picture3: The ERBE diathermy box ( ICC 200)

2. For gold probe:
   1. No patient plate/neutral cable is needed ( in the picture it is left connected from previous use but is not used)
   2. Accessory cable (gold probe in this case) is attached to the bipolar socket in the diathermy box (ICC 200)
   3. Nothing goes in the cut/coag socket (the middle socket in the diathermy box- we just left the plug of the APC in from previous use but it is not needed)
   4. Cutting panel is not needed at all and the setting on the autocut panel is irrelevant and the yellow pedal should not be used.
   5. Chose Autocoag with bipolar effect (as opposed to soft or forced which we used before), power to 15-30W for visible vessels/ Dieulafoy lesion/ Mallory Weiss lesion
   6. Choose power to 10-15W for colonic bleed (AVM/ diverticular bleed)
3. Connect a saline filled syringe to the irrigation hub and inject water until water is visible at the distal tip of the probe
4. Test the probe before passing it through the endoscope by touching the tip to a 1-2ml of saline / KY jelly and depressing the footswitch to activate the probe tip- saline bubbles are to be seen and steam should be emitted
5. Adrenaline filled syringe (1:10000 dilution adrenaline) is attached to the injection hub and pull back on the injection hub until hub locks into position to ensure that the injection needle is completely retracted into the probe tip
6. Turn off the electrosurgical generator during the insertion of the Gold Probe
7. Advance the tip until the gold tip is endoscopically visible through the endoscope
8. For lesions in the duodenum sometime you might find resistance in passing the gold probe when it’s tip reaches tip of the scope- then straighten the scope as much as possible and try again.

To use the gold probe to inject adrenalin

1. After positioning the tip near the lesion – slowly push the injection hub to the catheter handle until full extension of the needle is visible (4-6mm)
   
   Picture4: Pushing the handle in makes the needle to come out of the sheath
2. Under typical endoscopic configurations the green band on the injection hub should be partially visible.
3. Under some very tortuous configurations the green band and/or the red band may be completely hidden. But never push the injection hub past the proximal end of the red band
4. Insert the extended needle into the selected site and inject 1:10000 dilution adrenaline in 2-3ml aliquots and then completely withdraw the needle once finished.
5. Remember the volume of the adrenaline solution is important to exert tamponade effect.

To use the gold probe for electrohaemostasis

1. Identify and position the endoscope proximal to the intended cautery site.
2. Advance the probe until perpendicular or tangential contact is made with the site. Good apposition of the tip to the tissue is important (co-aptive pressure)
3. Using the Blue foot pedal activate the tip to cauterize the site- 2-5secs
4. Irrigate with saline before detaching the tip from the burnt area to avoid sloughing of devitalized tissue.

Other types of thermal devices in use

A) Heater probe ( Unipolar) – Teflon coated hollow aluminium cylinder with inner heating coil- heats tissue directly

B) Bipolar (Multipolar) – generates heat indirectly by passage of electric current. Two electrodes in the tip complete a circuit through non-desiccated tissue.

Types

• HEMArrest- Bard interventional products
• Gold Probe- Microvasive, Boston Scientific
• BICAP- Circon Acmi
• Quick silver- Wilson-Cook Medical Inc.

Here is the link for Gold probe Video:

Acknowledgement/Bibliography:

1. Gustavo A et al. Thermal probes alone or with epinephrine for the endoscopic haemostasis of ulcer haemorrhage Best Practice & Research Clinical Gastroenterology June 2000 :14 (3): 443-458
2. Jensen DM et al.CURE multicenter randomized, prospective trial of gold probe vs. Injection & gold probe for hemostasis of bleeding peptic ulcers. Gastrointestinal Endoscopy 1997:Volume 45 (4), Page AB92
3. Arasaradnam RP et al.Acute endoscopic intervention in non-variceal upper gastrointestinal bleeding Postgrad Med J. 2005;81:92-98
4. Product guide of the respective companies- Boston Scientific

1. When to use Histoacryl glue
2. What is Histoacryl glue
3. How to prepare the glue
4. How to actually use it once it is ready
5. What are the complications

When to use Histoacryl glue

It is used to inject in the gastric varix to achieve haemostasis in case of acute bleeding.

Gastric varix occur in 20% patients of portal hypertension and risk of gastric variceal bleeding varies from 55% to 78% with a bleeding related mortality rate of 45%

It is tissue glue and can be issued to glue cut surface e.g. small incised wound in place of steristrip.

What is Histoacryl glue

Histoacryl® is an acrylic resin (N-butyl-2-cyanoacrylate) which rapidly polymerises in the presence of water joining the bonded surfaces together. It is available in 0.5ml ampoule.

Picture1: Histoacryl® glue

It is diluted in Lipiodol as it does not affect polymerization of cyanoacrylate and allow imaging should it embolize in the rare event.

Picture2:The diluent Lipiodol ultrafluid 100%v/v

How to prepare the glue

1. Wear protective eye goggles and gloves.
2. Draw 1ml  of Lipiodol  in a 2ml Luer lock syringe ( Lipiodol comes in 10ml ampoule)
3. Use of Luer lock syringe is preferable as it is quite hard to push the glue through the injection needle and there is a chance that the syringe can come loose from the injection needle spraying the glue everywhere.
4. Before you snap open the tip of the Histoacryl ampoule hold it vertically and tap the narrowed tip so that the solution settles in the bottom
5. Next draw  the whole ampoule (0.5ml of Histoacryl® ) of glue in the same syringe  and  gently shake
6. The glue has to be freshly made immediately before the injection into the varix.
7. Keep acetone handy as it is only dissolvable in acetone.

How to actually use it once it is ready

1. Use Large channel gastroscope (3.7 or 6mm working channel)
2. Prime the injection needle with 2ml of Lipiodol (some centre uses saline) to prevent injection of air into the varices and also to prevent glue settling in the gastroscope. Some centres use saline only.
3. It is preferable to use bigger bore injection needle (19G) as the glue mixture is very viscous and very hard to inject. Some centre uses injector needle with metal body/sheath rather than plastic body/sheath
4. Keep few 2ml syringes ready loaded with water for injection and 2-3 of 2ml syringes ready loaded with the glue mix.
5. Glue injection is usually done in retroflexed view. Once the needle is in the varix inject the glue mix. Remember once the syringe is empty, all the glue is still sitting in the injector needle (volume of the glue mix is 1.5ml and injector needle volume is 1.5-2ml)
6. Follow immediately with 2ml of water for injection flush to drive the glue mix from the lumen of the injection needle into the varix.
7. Withdraw the needle from the varix and flush another 2ml of water into the gastric lumen before withdrawing the needle back into the sheath- to prevent any glue mix from being left in the needle and occluding the needle or gastroscope.
8. Do not wait for the glue to solidify in the varix and then withdraw the needle for the fear of the hole made by you hosing- that might cause the needle to stick – forceful removal will result in de-roofing of the varix.
9. Withdraw the needle from the varix while assistant keeps flushing saline after the whole glue mix has been injected.
10. In event of the needle getting stuck in the varix- simply withdraw the needle into the sheath- keep the sheath attached to the varix. Cut the needle outside the scope and withdraw the scope. Subsequent management is not clearly defined – but watchful expectancy would not be a bad idea!
11. After the glue is injected prevent any temptation to suction. It is better to remove the suction button to avoid inadvertent suction of glue in the suction channel.
12. Limit each injection to 1ml to prevent embolism but can be repeated to completely obliterate all the tributaries.
13. Obliteration of the varix can be checked by probing with the injection needle when obliterated varix will feel firm whereas normal varix will feel spongy.
14. Because of fear of injection needle sticking to the scope, some centres practice withdrawing the scope with the needle in situ and the cut the tip of the needle outside before withdrawing the needle out of the scope.
15. Reported initial haemostasis rate of 87% to 100% with rebleeding  rate ranging from 24% to 50%.

What are the complications

1. Complication associated with Histoacryl® injection are embolism, sepsis, fistula and adherence of the needle to the glue within the varix
2. Damage to the scope if glue settles down in the biopsy channel fixing the injection needle to it

Here is the link for Intravariceal Cyanoacrylate (Histoacryl ) injection video

Video 1

Video 2

References/ Acknowledgement

1. Seewald S et al: A standardized injection technique and regimen ensures success and safety of N-butyl-2-cyanoacrylate injection for the treatment of gastric fundal varices (with videos): Volume68,No3:2008 Gastrointestinal Endoscop
2. Sohendra N et al: Endoscopic obliteration of large oesophagogastric varices with bucrylate.Endoscopy 1986: 18:25-6
3. Jalan R et al: UK guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut; 46 (suppl III)
4. Poole hospital protocol for treatment of gastric varices using Histoacryl® glue

1. When to use endoclips
2. Different parts of the endoclip
3. How to set it up and fire the endoclip

When to use endoclips

1. Endoclip is a device commonly used to clip a bleeding vessel particularly in the context of a bleeding ulcer or a Dieulafoy lesion.
2. Other uses are to achieve haemostasis in bleeding from sphincterotomy and to stop bleeding from the base of a polyp after polypectomy.

Different parts of the endoclip

An Olympus QuickClip device has been shown, however the principles are the same for all types of endosclips. It comes both for upper GI and lower GI applications.

1. Starting with the tip/clip which is covered in a plastic sheath.
2. 

Picture1: The red stopper prevent the yellow slider to move so that the clip stays in side the sheath

2. Next is the handle with the yellow slider.

3.In between the two stays the red stopper

3. The thumb-rest ring
4. 
   Picture2: The yellow slider, red stopper and the firing handle
5. How to set it up and fire
6. This is mainly operated by the endoscopy nurse but you need to know the working of the endoclip.
7. Pass the tip of the endoclip which goes through the biopsy channel and make sure the red stopper is intact and the clip is retracted inside the sheath which is normally the case as you take it out of the packaging.
8. The red stopper prevents the clip coming out of the sheath accidentally.
9. When the endoscopist is in right position and ready to deploy the clip he will ask to open the clip. This is when you/assistant should remove the red stopper
10. Pull the yellow tube towards the slider and this would bring the clip out of the sheath.
11. 
    Picture3: The pulling of the yellow slider to the handle makes the clip to come out of sheath but it is not fully open to deploy yet
12. To get the clip in correct position the endoscopist might ask you to rotate the clip. Clip can be rotated by rotating the handle.
13. When everything is ready the endoscopist pushes the clip to the vessels and ask you to fire
14. Now before actually firing you will have to prime the clip
15. If you look carefully there is a waist at the bottom of the clip ( making the clip to look like X rather than V) and the clip in this stage is not completely open and there is less gripping power.
16. 
    Picture4: Olympus Quickclip: Courtesy Olympus
17. Before firing the waist need to vanish so that the clip is completely open and looks like letter V.
18. The same movement which fires the clip will get rid off the bottom waist but you have to be careful not to go all the way which than will fire the clip.
19. 
    Picture 5: Note that the bottom waist has vanished and clip looks like letter V
20. You will hear two distinct sound – the first faint click indicates the waist at the bottom is gone and the clip is ready to fire and the second louder click indicates that the clip has been fired.
21. Lastly fire by pulling the handle towards the thumb rest.

Picture 6: The firing grip and pull the handle towards the thumb-first click means the clip is primed and the second click means the clip is fired- second click is much louder and harder

Here is the link for Endoclip video:

1. Video 1
2. Video 2

Acknowledgement/Bibliography:

1. Tang SJ et al. Endoscopic hemostasis using endoclip in early gastrointestinal hemorrhage after gastric bypass surgery. Obesity surgery 2007; 17: 1261-1267
2. Ohta S et al. Hemostasis with endoscopic hemoclipping for severe gastrointestinal bleeding in critically ill patients. Am J Gastroenterol 1996;91:701-4.
3. Yoshikane H et al. Endoscopic repair by clipping of iatrogenic colonic perforation. Gastrointest Endosc 1997; 46:464-6.
4. Product guide of the respective companies- Olympus

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

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