LAPEG (Laparoscopic Assisted Percutaneous Endoscopic Gastrostomy): Towards a Safer Percutaneous Endoscopic Gastrostomy Placement

Abstract

Introduction: Percutaneous Endoscopic Gastrostomy (PEG) is a popular procedure for gastrostomy tube placement. There are known complications of PEG placement, particularly inadvertent puncture of the intestine. In addition, a small but significant subset will develop significant gastroesophageal reflux disease and need subsequent fundoplication. Previous PEG placement often requires repositioning of the gastrostomy or impairs the possibility of performing a subsequent laparoscopic fundoplication. Methods: Since 1999 we have used Laparoscopic Assisted Percutaneous Endoscopic Gastrostomy (LAPEG) for patients requiring gastrostomy tubes. A 2 mm video assisted laparoscope is placed percutaneously through the umbilicus. A site on the abdominal wall, 1.5 cm below the right costal margin mid clavicular line, is chosen for gastrostomy site. CO2 pneumoperitoneum is established. Endoscopy is carried out and the light source is identified in the stomach by the laparoscope. A site for gastrostomy is chosen in the mid body of the stomach 1 cm superior to the gastroepiploic arcades. This site is punctured percutaneously and a standard pull technique is used for PEG placement, visualizing the entire procedure through the laparoscope.Results: From 1999-2003, this technique was used in 9 patients with mean age of 8 years (range 2-20 years). All were successfully completed as described above. Complications consisted of 1 retained bolster (buried bumper), which was salvaged by endoscopic assisted replacement of the gastrostomy tube. One patient needed subsequent fundoplication. Fundoplication, when necessary, were performed laparoscopically without having to take down or reposition the previously placed gastrostomy tube.Conclusion: LAPEG eliminates risk of intestinal injury during PEG placement. The gastrostomy tube can be placed strategically in the stomach, so that laparoscopic manipulation of the esophageal hiatus can be subsequently performed as well as assuring that adequate fundus is available for a fundoplication without need to reposition the gastrostomy tube.