For enteral nutrition especially in adults, in cases of Mickey PEG(button type) placement only upto 20Fr introducer kits are available making it possible only to place 20Fr tubes initially(push technique) and asking the patient to come back for placement of 24 Fr tube once the tract matures. More visits, more interventions, more costs, more time lost.

This problem can be overcome by simply modifying the technique of placement by push technique with available accessories in endoscopy room. All the steps till introduction of 20Fr sheath of dilatation system are the same. Once the 20 Fr sheath goes in, the inner dilators are removed by rotation. Normally a 20 Fr tube is placed by peeling of the sheath. To place 24 Fr tube, few steps are to be followed more. Once the 20 Fr sheath is in and inner dilators are removed, the 20 Fr sheath is peeled a little (approximately equal to the distance/abdominal wall thickness measured by the measuring ballon of introducer kit) above the skin surface. Then 9mm Savary Gilliard (SG) dilator(8mm not available) is introduced over the guidewire until it fits completely inside the sheath. Peeled sheath is held close to the dilator preparing it to dilate the tract. Then 20 fr sheath along with the SG dilator is pushed inside till the upper margin of the sheath is abutting the skin surface thus dilating the tract. Then sheath and dilator are pulled back till peeled part of sheath is above skin surface and the dilator is removed. Now the 24 Fr tube loaded over the removed dilators is placed inside the partially peeled sheath. 24 Fr tube is pushed inside while peeling the 20 Fr sheath. Once inside the lumen ballon inflated with 5ml NS and tube placement secured. 

Until now 18 Mickey PEG tube (button type) placements have been done in last two years using the modified technique. No events of pneumoperitoneum noted.  Hematoma or bleeding or infection of PEG site are not seen. No peri PEG tube leakage seen. Mild pain at PEG site seen in few patients which resolved in a day or two. No major adverse events noted. All were discharged on the same day. 

24 Fr Mickey PEG tube can be be safely placedd in the first go with simple modification of the technique. Simple modification of the procedure needing no extra skill set.

Done with the available accessories. 

Reduces the number of visits, number of interventions thereby reducing costs and time( for patients as well as heath personnel)

No adverse events related to modification of the procedure.

Future implications –

Such modifications obviates the need for 24 Fr introducer kit. 

8mm dilator is better if available(American dilator)