Original articles A new form of access for endo-organ surgery The initial experience with percutaneous endoscopic gastrostomy T. Tomonaga, 1 S. G. Houghton, 1 C. J. Filipi, 1 R. A. Hinder, 2 J. Hunter, 3 B. Dallemagne, 4 N. Katkhouda, 5 R. Kozarek, 6 T. R. DeMeester, 5 R. Deeik, 1 Y. Shiino, 1 Z. T. Awad, 1 R. E. Marsh 1 1 Department of Surgery, Creighton University, 601 N. 30th Street, Suite 3740, Omaha, NE 68131, USA 2 Department of Surgery, Mayo Clinic Jacksonville, 4500 San Pablo Road, Jacksonville, FL 32224, USA 3 Department of Surgery, Emory University Hospital, Room H124C, 1364 Clifton Road NE, Atlanta, GA 30322, USA 4 Department de Chirurgie, Centre Hospitalier Saint Joseph, rue de Hesbaye 75, 4000 Liege, Belgium 5 USC Health Care Consultation Center, 1510 San Pablo Street, Suite 514, Los Angeles, CA 90033, USA 6 Virginia Mason Medical Center, 1100 9th Avenue, Seattle, WA 98101, USA Received: 15 September 1998/Accepted: 15 February 1999 Abstract Background: Intraluminal gastric surgery provides a new treatment option for various disease processes. This study assesses the safety of a new large-diameter percutaneous endoscopic gastrostomy (PEG) for intraluminal surgery. Methods: Investigators at six institutions were asked to complete a standard questionnaire to assess the difficulties associated with the assembly and introduction of the PEG, plus intraoperative and postoperative problems related to placement of the device. Results: In terms of assembly; 1.9% of respondents reported difficulty obtaining complete vacuum of the balloon tip, and 3.8% had difficulty fitting the graduated dilator to the bal- loon-tipped cannula. Difficulties associated with introduc- tion of the PEG included disengagement of the dilator from the balloon-tipped cannula (0%), extraction of the dilator- port assembly (0%), difficult PEG pullout (1.9%), abdomi- nal wall bleeding (0%), and difficult PEG dilator separation (7.5%). Intraoperatively, 7.5% of respondents reported in- adequate skin bolster fitting, 1.9% had CO 2 leakage into the peritoneal cavity, 0% had inadvertent PEG extraction, and 0% reported injury to the esophagus, colon, or small intes- tine. Postoperatively, there was a 9.4% rate of wound in- fection, a 1.9% rate of gastrocutaneous fistula, and a 1.9% rate of esophageal, colon, or small intestine injury. Conclusions: The large-diameter PEG is safe and effective for endo-organ surgery. Additional preventive measures for PEG site infection should be investigated. Key words: Endo-organ — Percutaneous endoscopic gas- trostomy — Gastric surgery — Intraluminal surgery — Op- erative port Gastric endo-organ surgery provides a number of advantages for surgeons and patients alike. For the surgeon, this technique combines the intraluminal gastric visualization of traditional gastroesophageal endoscopy with the maneuverability, in- strumentation, and flexibility of laparoscopy. For the pa- tient, endo-organ surgery is a minimally invasive procedure that produces less scarring, a shorter hospital stay, and less postoperative discomfort than conventional laparotomy. Gastric endo-organ surgery is performed utilizing two to three percutaneous endoscopic gastrostomies (PEG) posi- tioned at various places on the gastric wall. In 1991, a PEG was described that allowed the use of 5- and 10-mm stan- dard laparoscopic instruments for endo-organ surgery [5]. This PEG required a second procedure to remove several of the pieces from the stomach. Other ports that permit the use of 5-mm instruments have been described for gastric endo- organ surgery [19]. These ports will not accommodate 10- mm instruments. Sharp trocars introduced through the ab- dominal and gastric walls can result in bleeding. To avoid these complications, Filipi et al. of Creighton University developed and refined a PEG (Fig. 1) that is large enough to allow the use of 5- and 10-mm laparoscopic instruments and also easily removable at the end of the procedure (Cook Surgical, Bloomington, IN, USA) [3, 4]. Our study assesses the safety of this new large-diameter PEG. Patients and methods The indications for gastric endo-organ surgery are similar to those for open gastric surgery. For upper gastrointestinal bleeding, the indications are ulcerations uncontrolled by endoscopic therapeutic maneuvers, bleeding gastric varices unresponsive to transjugular intrahepatic portal systemic stent, and unlocalizable gastric bleeding [4]. For gastric excision, the in- dications are large gastric polyps; benign mucosal, submucosal, or mus- cular tumors; benign gastric ulcers; and superficial gastric malignancies [4]. Lesions on the posterior gastric wall, gastroesophageal junction, or cardia and those near the pylorus are best suited for intraluminal excision [12, 17, 18]. Due to the limitations of PEG positioning, lesions on the Correspondence to: C. J. Filipi © Springer-Verlag New York Inc. 1999 Surg Endosc (1999) 13: 738–741