Dysphagia due to tumor ulcers and stomatitis induced by chemoradiotherapy is painful;
it is therefore crucial and urgent to establish a surgical enteral feeding route in
patients with head and neck cancer to avoid malnutrition and improve treatment compliance
[1]. However, common trismus caused by surgical resection, reconstruction, and, mostly,
radiation fibrosis often compromise flexible endoscope passage; furthermore, an oral
tumor would raise concern of cancer contamination and inoculation upon percutaneous
endoscopic gastrostomy (PEG) [2]
[3]. Herein, we demonstrate the use of an ultrathin endoscope (5.3 mm diameter; Olympus
VISERA Transnasal Esophagovideoscope, PEF-V; Olympus Medical Systems, Tokyo, Japan),
via the transnasal route as a good alternative for better instrument passage in patients
with head and neck cancer with trismus or when buccal reconstruction integrity would
be a concern.
Patients were placed under transoral or transnasal endotracheal intubation general
anesthesia. The transnasal approach would be preferred in patients with an inter-incisor
distance of less than two fingers for both endotracheal intubation and PEG. The pull
method was our procedure of choice owing to greater control of stomach puncture and
less premature extrusion [4]
[5], and we routinely used a 20 Fr tube (Flow 20 Pull Method; Cook Medical Inc., Bloomington,
Indiana, USA) ([Video 1]). The puncture site chosen was the most transilluminated area over the gastric antral
portion under a dark setting. Our tip to avoid nostril trauma upon passage of the
PEG bumper is to squeeze the bumper with one hand while gently pressing the ipsilateral
nose alae with the other hand to provide proper counter-support ([Fig. 1]). After the PEG procedure, the pressure of the bumper on the gastric mucosa was
checked to avoid buried bumper syndrome, and 2 – 30 mL distilled water was irrigated
over the mucosa in contact with the bumper to prevent tumor inoculation.
Fig. 1 Demonstration of our tip to avoid nostril trauma: gentle finger pressure on the ipsilateral
nose alae provides proper counter-support, with simultaneous squeezing on the bumper
to facilitate passage of the percutaneous endoscopic gastrostomy tube.
Video 1 Steps in the pull-method transnasal ultrathin endoscopy for percutaneous endoscopic
gastrostomy (PEG). (i) Confirmation of successful passage of a 5.3 mm endoscope. (ii)
Inflation of the stomach and localization of the puncture site at the most transilluminated
area. (iii) Puncture and insertion of the guidewire. (iv) Pulling the PEG tube via
the transnasal route. (v) Irrigation with distilled water, and checking the pressure
of the PEG bumper against the gastric wall.
We have not encountered nasal bleeding in our series of 20 cases. Our experience showed
that PEG using a transnasal ultrathin endoscope could be a good alternative approach
when the transoral route is compromised, especially in cases of head and neck cancer.
Endoscopy_UCTN_Code_TTT_1AO_2AK
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high quality video and all
contributions are freely accessible online.
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