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Gastrostomy – Percutaneous Endoscopic


Goals/Objectives

  • Anatomy

  • Indications

  • Techniques

  • Complications

Percutaneous Endoscopic Gastrostomy Placement and Replacement

Paul W. Davis

From Pfenninger JL, Fowler GC: Pfenninger & Fowler's Procedures for Primary Care, 3rd edition (Saunders 2010)

Percutaneous endoscopic gastrostomy (PEG) is the placement of a percutaneous gastrostomy tube with the aid of an endoscope. The PEG technique has largely replaced surgical gastrostomy as the procedure of choice for patients who require long-term enteral nutrition. It was first described in 1980 by for use in children but has since gained wide acceptance for use in patients of all ages. Along with other necessary supplies, commercial PEG tube kits usually contain the PEG tube, an internal bolster (to seal the gastric mucosa), and an external bolster (to stabilize and prevent migration of the tube). Choices for the internal bolster include a balloon, a soft dome, crossbars, a T-bar, a flange, a disk, a three-leaf retainer, and others; most are soft to avoid irritating the gastric mucosa.

The actual PEG placement procedure requires two trained individuals, one of whom must be skilled in esophagogastroduodenoscopy (EGD). The procedure can be performed in the operating room, the endoscopy suite, or at the bedside. Normally, the procedure can be performed under moderate sedation, with a local anesthetic such as lidocaine also used at the cutaneous site. However, if intravenous sedative agents are unlikely to be effective because of a history of prescribed or illicit controlled substance use, or if the patient is at risk of respiratory compromise secondary to oropharyngeal anatomy, risk of aspiration, or a history of obstructive sleep apnea, a third skilled provider will be needed to provide sedation and monitor the airway. Indeed, endotracheal intubation may be advisable because these patients often have underlying conditions that impair handling of secretions. In these circumstances, the assistance of an anesthesiologist, nurse anesthetist, or trained primary care colleague is advantageous.

After PEG placement, there is no reason for routine removal; however, occasionally they require replacement owing to accidental dislodgement or because they have become obstructed, worn out, kinked, or fractured. Although most of these problems can be avoided with diligent care, this chapter also briefly discusses PEG replacement.

Indications

Placement

The decision for PEG placement has to be made on a case-by-case basis, especially when rapidly progressive and incurable diseases are present. Certainly, this includes the various forms of severe dementia.

Most commonly, PEG tube placement is performed for patients who are unable or unwilling to ingest food orally. The usual conditions include major head and neck trauma, esophageal cancer, oropharyngeal cancers, cerebrovascular accidents, esophageal dysmotility, as well as other irreversible neurologic conditions such as amyotrophic lateral sclerosis. When used for provision of nutrients, the choice of PEG placement necessarily requires a functioning gastrointestinal tract and optimally involves a prior discussion with the patient or family concerning prognosis and underlying comorbid conditions. Other uses for the PEG procedure include treatment of gastric volvulus, decompression of patients with an intestinal obstruction or peritoneal carcinomatosis, administration of unpalatable medications to pediatric and mentally impaired patients, and enhanced enteral feeding of patients with hypercatabolic states, such as burn patients.

In brief, PEG tubes have two primary indications:

  • 1.

    Enteral access for feeding or medication administration

  • 2.

    Decompression of the gut

Replacement

  • Accidental PEG dislodgement or removal

  • PEG blockage or obstruction

  • PEG damage (e.g., worn out, kinked, fractured)

Contraindications

Placement

Absolute

In general, any contraindication to endoscopy will apply to PEG insertion as well. In addition, the absence of one of three prerequisites for safe PEG placement is a good reason to abort the procedure. These prerequisites include ability to distend the stomach endoscopically with air, endoscopically visible finger invagination of the anterior gastric wall, and transillumination of the anterior abdominal incision site. Additional absolute contraindications include the following:

  • Pharyngeal obstruction

  • Esophageal obstruction

  • Active coagulopathy

  • Peritonitis

  • Sepsis

  • Recent myocardial infarction

  • Hemodynamic instability

Relative

Either esophageal or oropharyngeal cancer is considered a relative contraindication because there is a theoretical potential for seeding of the gastrocutaneous tract with cancer cells. Although this hazard is rare, it is primarily seen with untreated oropharyngeal cancers, with an incidence of less than 1% in one reported series ( ). Some have advocated use of the Russel or “poke” technique (see later), radiographically placed, or surgically placed gastrostomy tubes as more appropriate in this setting. With these techniques, the PEG tube is not drawn down the esophagus for placement.

The presence of gastroesophageal reflux with its attendant risk of aspiration has long been considered a contraindication to PEG. Historically, a surgically placed or, more recently, a radiologically placed jejunostomy tube has been preferred. However, jejunostomy does not prevent gastroesophageal reflux and it is now known that PEG placement may actually decrease reflux because the PEG effectively creates an anterior pseudogastropexy.

Other relative contraindications include the following:

  • Portal hypertension

  • Moderate or massive ascites

  • Gastric varices

  • Prior abdominal surgery

  • Peritoneal dialysis

  • Hepatomegaly or splenomegaly

  • Large hiatal hernia

  • Large ventral hernia

  • Open abdominal wound

  • Prior subtotal gastrectomy

  • Morbid obesity

  • Anorexia nervosa

  • Infiltrative or malignant disorders of the stomach

  • Limited life expectancy

Replacement

Absolute

  • Immature PEG tract (e.g., <4 weeks after PEG placement)

  • Existing PEG tube not removable with gentle, constant traction (endoscopic guidance necessary)

  • Nonreplaceable catheter (e.g., needle jejunostomy with 5- to 7-Fr catheter)

Relative

  • Jejunostomy (the tract can be stented with a replacement catheter, but more information should be obtained before resuming feedings)

  • Witzel gastrostomy (these use a more circuitous tunnel and a smaller tube and may be difficult to maneuver)

Equipment and Materials

Placement

The following equipment and supplies are recommended (usually included in commercial PEG kits):

  • Gloves and equipment necessary for clinician to follow universal blood and body fluid precautions

  • Lidocaine 1% to 2% for local anesthesia of the skin and abdominal wall

  • 22- and 25-gauge needles

  • 50 or 10-mL syringe

  • Antiseptic preparation solution such as povidone–iodine or chlorhexidine

  • Scalpel with no. 11 blade

  • 4 × 4 gauze sponges

  • Fenestrated drape

  • Introducer trocar

  • Guidewire (standard or looped end, depending on technique used)

  • Disposable snare for gastroscope

  • Abdominal binder (for confused or impaired patients)

  • PEG tube with external bolster

  • Surgical jelly for PEG tube lubrication

  • Large, 50- to 70-mL (e.g., Toomey) syringe to aspirate gastric contents

  • Adapter to attach Foley catheter to feeding assembly or to cap it off

  • Jejunal tube (if warranted)

  • Low-profile device ( Figure 17-1-1 )

    F igure 17-1-1, Low-profile devices (LPD). A, Bard Button. B, Bard Gauderer “Genie.” C, Cook LPD.

Replacement

  • Gloves and equipment necessary for clinician to follow universal blood and body fluid precautions

  • Antiseptic preparation solution such as povidone–iodine or chlorhexidine

  • 4 × 4 gauze sponges and adhesive tape

  • Surgical jelly for PEG tube lubrication

  • Foley catheter or commercial PEG replacement kit with PEG tube of similar diameter to the original PEG

  • External bolster. (Options include a retainer for a nasogastric tube, a short length [3 cm] of latex or silicone tubing [cut from a Foley catheter or feeding tube] and a plastic cable tie or cut to form a T-bar, or a 0 or 2-0 silk suture. Commercial bolster kits are available; however, they are expensive, are not always available, and often do not properly fit the replacement PEG tube.)

  • Large, 50- to 70-mL (e.g., Toomey) syringe to aspirate gastric contents

  • Adapter to attach Foley catheter to feeding assembly or to cap it off

  • Low-profile device (see Figure 17-1-1 )

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