Hi guys, welcome back. Let's continue our discussion of endoscopic management and palliation, a patient with dysphagia. Now we're going to start discussing the possibility and the options for enteral feed. As well as debulking and wrapping up everything we discussed from the previous section to tie everything in together. One of the other things that we are often called upon to provide in patients that have failure to thrive is a way to deliver nutrition to these patients. And Enteral Feeding is a way we can do that. This is something that we can offer the patient to have an intact GI tract but, themselves are unable to consume sufficient nutrient to maintain their medical need for whatever that reason that maybe. There are a couple of options, we have percutaneous endoscopic gastrostomy which is the PEG tube and we have a PEGJ which is a percutaneous endoscopic jejunostomy, placed for people who are not expected to gain function within 30 days. If somebody who presents with a stroke, and they are recovering and they're doing quite well, we aren't keen on jumping to place PEG tubes in those patients. We'd like to see if they can regain function. If you have somebody that isn't going to have function in a 30 days out, and is unlikely to recover function at all that's sort of the optimal patient population. It allows for us to deliver nutrition downstream from an area of obstruction. Here you can see a cartoon drawing of a Dobhoff and a PEG tube. Functionally a Dobhoff is just a special NG tube that is small bore and it's very flexible. Depending on where you have the tip of that it can either be a nasogastric tube, where the tip is in the stomach. You can have a nasoduodenal tube, where the tip in duodenum. Or nasojejunal tube, where the tip is advanced all the way into jejunum. Oftentimes we use that in patients who have pancreatitis or we need to feed down stream. Here you also have the gastrostomy tube Or the PEG tube, where the external tip is at the skin surface and we go directly in percutanously and place the tube within the stomach. You also have a jejuostomy tube, percutaneously you can puncture a jejunum. And place the tip of the tube within the jejunum as well. Here's just a sort of expanded closeup view of what we do and if we're placing a PEG tube. This blue line is supposed to represent our endoscope. And you have a light here at the end of it. Then we have somebody manipulating and working at the skin surface, usually we have two people. Either two endoscopists, or an endoscopist and tech helping us here at this point. We use the process of, or the method of transillumination, so with our endoscope tip in place we identify within the stomach where we want to have the G tube placed. That light on the end of the scope tip will shine through the stent. Almost like when you were a kid and you put a flashlight on the tip of your nose or on your thumb and you're going to see fingernail glow on the other side. The same thing. That sort of marks the site externally. We puncture, we put in a wire in the tube. And here you can see what this is suppose to represent is a balloon or the internal gastric bumper if you will, that keeps this tube in place. You've got the bumper, you've got the lumen of your tube here, and you have the external portion at the skin. Contra-indications of PEG and a PEGJ placement. The absolute contraindications is the inability to bring the gastric wall in apposition with the abdominal wall. If there's something in between the two, we cannot put something from the outside and ingrate something on the inside. That would set the patient up for a world of hurt. If the patient has a pharyngeal or esophageal obstruction, we obviously can't get down into the stomach with our scope and we can't place a PEG tube then. And if the person has a significant coagulopathy. You also have relative or sort of soft contraindications that you really need to keep into consideration and keep in mind whenever you're considering a patient for a PEG or PEGJ placement. If you have ascites either neoplastic, or if you have neoplastic inflammatory, or infiltrative disease of the stomach itself in the abdominal wall. That's all tissue that we have to go through and we are counting on anchoring our placed tube, and so if you have abnormal tissue, that's not going to behave with the same elasticity and pliability. You need to keep that in mind because your complication rate can go up. If somebody has had a previous gastric resection for altered anatomy, hepatomegaly. The reason there is because if the liver is the way, we may be trans-illuminating and go right through the liver and not realize it. Obesity. Again is harder for us to see through a large layer of adipose tissue and you're going to have a very weak signal whenever you're trans-illuminating inside versus externally on the skin and thus those issues can impare and limit our ability to place a PEG successfully. PEG should not be used for nutritional support when a GI tract obstruction is present. If you have somebody with down stream obstruction, feeding them and putting food in up top is not the way to go. Serious complications that we always warn people about are aspiration, bleeding Injury to internal organs. That sort of comes into play when we can either transilluminate through liver, or we can transilluminate through small bowel or colon. All have been reported, not frequently, but all can happen. Perforation, buried bumper syndrome, which is essentially where the internal gastric bumper erodes through, and you have the bumper dislodge. It ends up somewhere between the gastric wall and the skin, floating sort of within the peritoneum as at sound, so bad thing to have. You don't want to have somebody with that. Prolonged ileus, wound infections, necrotizing fasciitis, and, rarely death. It has been reported that people have developed jejunal volvulus with their PEJs. Minor complications include tube occlusion, maceration from feeding tube leakage around the skin, or peri-stomal pain and breakdown. You can develop pneumo-peritoneum. And you can develop a fistula from the gastro-colic or colo-cutaneous, etc., depending on sort of what the two organs that are involved. We can also provide debulking whenever you're discussing somebody that has a malignancy that can be done chemically via tumor injection of absolute ethanol. This provides transient improvement and you do have to repeated frequently but people do report the improvement in quality of life. There is laser ablation as well, versus stenting the median survival is better but there's actually no improvement in quality of life or dysphagia scores despite restoration of patency. If you look at it from sort of broad picture perspective, it doesn't really make a lot of sense. The perforation rate has about 7% when we're talking about this. You can also use Photo Dynamic Therapy to debulk, it's taken the place of laser ablation because it's equivalent in efficacy and there are fewer complications. But you also have to keep in mind that after chemo and radiation therapy the tissue has been altered and is really, really abnormal at that point in time so you have a much higher complication rate. Okay so at the end of all of this what do I want you to be able to walk away? With, if somebody's esophageal luminal diameter is less than 13 millimeters, there's going to be reporting dysphagia and you know that straight away if they starts complaining about that to you. The aim of endoscopy is at improving delivery of nutrition and improving symptoms. In addition to being able to figure out what the underlying etiology is and whether or not we can provide any endoscopic therapy in the management of it. When you have somebody who is complaining of dysphagia and fistula, secondary to esophageal cancer, stenting is the way to go. Let's revisit those prelecture questions now that you have all the tools you need to answer them. Number 1, patients begin to complain of dysphagia when the esophageal luminal area narrows to? And that is less that 13 millimeters. Number 2. The optimal stent type in malignant obstruction. Is a partially covered metal stent. This allows the stent to anchor where it needs to anchor till it reduces the risk of migration. But it also prevents tumor tissue from growing into the stent and resulting in obstruction sooner down the road. Number 3. A patient with metastatic esophageal cancer presents for a PEG. Which is a contraindication? Anybody that has a downstream obstruction from where you are trying to place food in is an absolute contraindication to placing a PEG. Somebody that presented a colonic obstruction should not be getting a PEG to placed. All right. Thanks very much for listening. Hopefully you were able to take something away from that and you have an understanding on appreciation on how to approach your patients who were complaining of dysphasia when you're disgusting and anascopic management.
