Percutaneous Endoscopic Gastrostomy & Tracheostomy 

Usually, this method is employed to feed the patient.

Indications                         

In certain circumstances, percutaneous endoscopic gastrostomy is taken into consideration. The patient has significant facial damage, is unable to swallow, is at high risk of aspirating, has been on mechanical breathing for more than four weeks, and has dementia and severe malnourishment.

Techniques                                     

The most widely used technique is the pull technique, which approximates the stomach to the front abdominal wall without the need for sutures. Other techniques include the push technique and introducer technique, which need the insertion of stay sutures.

Percutaneous Endoscopic Gastrostomy

Tube

There is just one feeding channel because there is only one percutaneous endoscopic gastrostomy tube.

PEGJ Tube

This type of tube is called a percutaneous endoscopic gastrojejunostomy tube, and it has two channels: one for feeding and the other for decompression. Aspiration and reflux risks are decreased by decompression.

When Is Feeding Started After Putting The Percutaneous Endoscopic Gastrostomy Tube?

Although feeding can be done right away, in severely ill patients it is best to wait 24 hours before feeding in order to lower the risk of aspiration.

Contraindications of Percutaneous Endoscopic Gastrostomy

• No endoscopic access
• Significant Ascites 
• Severe coagulopathy 
• Gastric outlet obstruction/Previous gastric resection
• Gastric bypass
• Survival <4 weeks
• Inability to bring the stomach wall to the abdominal wall
• Severe immunocompromised patients (WBC<1)

Also Read: Surgical Ethics And Laws

Relative Contraindications for Percutaneous Endoscopic Gastrostomy

The following are the relative contraindications:  Gastric varices; incapacity to transilluminate through the front abdominal wall; diffuse gastric cancer

Will Percutaneous Endoscopic Gastrostomy Be Used In The Below Cases?

Patients should be given time to heal before having a PEG tube inserted if they have significant morbid obesity, a thick abdominal wall makes it difficult to approach the gastric wall, or if they have an anterior abdominal wall infection or inflammation.

If the patient has ventricular peritoneal shut or continuous ambulatory peritoneal dialysis (CAPD), the PEG tube can be implanted; however, one must wait for 1-2 weeks to avoid infection. If the patient has ascites, the ascitic fluid may need to be drained before the treatment.

If a patient has previously had a laparotomy, PEG can be performed, but a CT scan is still recommended. To determine a safe window between the stomach and the front abdominal wall, a CT scan is performed.

Gas After Percutaneous Endoscopic Gastrostomy

Tube Insertion

Gas in the diaphragm can remain after PEG tube placement for up to four weeks. This is typical and does not indicate that the PEG tube operation was unsuccessful.

Risk of Infection at the Operative Site

Post-PEG infection is a potential early consequence that might happen at the surgical site. If antibiotics are administered in combination with a sufficient skin incision, the infection can be avoided.

Also Read: Spreading of Filariasis in Human

Dislodgement of Percutaneous Endoscopic Gastrostomy

Tube

It is possible for the PEG tube to come loose, which could be fatal. Patients may present with stomach contents spilled if it happens within 10 to 14 days following surgery. This is because the fibrous tract has not yet developed at this point.

A surgical emergency may arise in the event of spillage, necessitating immediate surgery for the patient. This hazard can be avoided by properly fastening the tube. Constrain the traction.

Bronchoscopy  

• The therapeutic indications of bronchoscopy are:
• Insertion of endotracheal tube 
• Removal of foreign body/mucus plug
• Reversal of atelectasis  
• Suction of thick secretion 

Diagnosis

 If a patient has a white patch throughout the recovery period, it's critical to determine whether pneumonia is the cause.

Any white patch used to be diagnosed as pneumonia. Other causes, such as aspiration or pneumonia due to a virus or fungus, are now being explored.

Bronchoalveolar lavage, or BAL, is a diagnostic procedure performed to evaluate patients. After doing a BAL, it was discovered that almost 50% of the patients who were thought to be candidates for pneumonia prophylaxis tested negative.

What Is The Main Issue Of Bronchoscopy?

There are two kinds of patients in the intensive care unit (ICU): intubated patients, who can have a bronchoscopy with ease, and non-intubated patients, who require conscious sedation and medication. Conscious sedation may cause mental status depression, which could necessitate intubation or content aspiration.

Risk from Bronchoscopy

• Patients may develop
• Pneumothorax
• Hypoxia 
• Airway hyperactivity 
• Pulmonary hemorrhage 
• Loss of pulmonary reserve 
• Hypotension/hypertension

Tracheostomy 

In critically ill ICU patients who require ventilatory support, it is the most often performed surgical treatment.

Indication of Tracheostomy

The following conditions are taken into consideration for tracheostomy patients:
• Significant maxillofacial surgical trauma;

• Difficult airway;

• Obstruction of the upper airway, malignancies of the upper airways; angioedema.

Since the patient cannot be intubated in any of the aforementioned circumstances, tracheostomy is advised.  Conditions pertaining to the nervous system (because they are unable to extubate safely)
• Severe agitation/delirium;

 • Spinal cord damage;

• Brain injury (acute or worsening injury);

 • Chronic altered mental status

It is preferable to think about tracheostomy rather than intubating patients in any of the aforementioned situations. Extended use of mechanical ventilation.

Contraindications

Patients in a high ventilatory setting, which includes those with FiO2>70%, PEEP >10 cm of water, or those in an advanced ventilatory setting; elevated intracranial pressure; hemodynamic instability; significant bleeding risk; local infection or cancer at the site of incision; and the ability to predict early mortality are among the patients who require a seven-day waiting period before undergoing anterior neck surgery.

Since there is no absolute contraindication to tracheostomy surgery, all of the aforementioned are relative or temporary contraindications.

How to Perform a Tracheostomy?

There are two ways to perform a tracheostomy: open tracheostomy and percutaneous dilational tracheostomy (PDT). Open tracheostomy is more preferred in the ICU setting. It can be performed on critically ill patients. Early tracheostomy is preferred over late tracheostomy. It is preferably done in less than seven days, especially if it is anticipated that the patient will require ventilatory support. It is also sometimes completed in less than 48 hours.

Perioperative Complications

Enter into a false passage; hurt the esophagus or trachea; induce hemorrhage; damage the anterior Juglar vein or thyroid isthmus; result in loss of airway; and, if treatment is not received, may result in extraluminal implantation. Personnel with specialized training can reduce airway errors.

Placement of Tracheostomy Tube

There are two methods to guarantee that the tracheostomy tube is positioned correctly. Although useful, bronchoscopic guidance does not completely remove the chance of airway loss. The risk of entering the false channel will be decreased by employing the semi-open technique, which involves making a small incision and feeling the trachea with the finger rather than entering percutaneously.

Periprocedural Ultrasonography: This recommended technique will help the surgeon determine whether the thyroid lobe is enlarged and whether a safe passageway exists. It will also provide a better understanding of the anatomy.

Complications of PDT

About 6% of individuals have severe tracheal stenosis. Approximately 40% of individuals experience subclinical tracheal stenosis, which manifests early in the subglottic position.

Hope you found this blog helpful for your NEET SS General Surgery preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.