Percutaneous Endoscopic Gastrostomy Tubes

Background

Gastrostomy tube placement is used in patients who are unable to maintain adequate oral intake yet have an otherwise intact digestive system. This type of enteral tube is used for patients who will need long-term enteral feeding, generally defined as longer than 4 to 6 weeks. Multiple ways to obtain access to the digestive system exist, including radiologic, surgical, and endoscopic. The most commonly used method is percutaneous endoscopic gastrostomy (PEG). Gastrostomy tubes may also be referred to as G-tubes or PEG tubes. To clarify, the actual definition is: percutaneous (through the skin); endoscopic (pertaining to the examination of the interior of a canal or hollow organ); gastrostomy (establishment of a new opening into the stomach).

How to Use It

Enteral feeding via PEG tube is indicated for patients with dysphagia (difficulty swallowing), which is usually due to neurologic disorders such as Parkinson’s disease, stroke, or multiple sclerosis. A PEG tube may also be placed for patients with oropharyngeal or esophageal malignancies who may have difficulty swallowing.

How It Is Done

PEG tube placement is generally performed in an inpatient setting and requires two operators. A variety of methods to place PEG tubes are available, with the “pull” method being the most common. Preprocedure antibiotics covering skin flora are given to prevent wound infections, and the patient is placed in a supine position. After adequate sedation (or anesthesia, based on specific situation) is achieved, an endoscope is passed through the mouth into the stomach and proximal duodenum.

The mucosa is carefully inspected to ensure there are no anatomical restrictions to the planned procedure, and a proper site for the gastrostomy placement is identified. Typically, a combination of techniques is used—transillumination (visualizing the endoscope light inside the stomach through the abdominal wall) and finger palpation (a second operator presses on the abdominal wall and the endoscopist identifies a clear indentation of the gastric wall inside the stomach). The skin is then cleaned with betadine, and local anesthetic is infiltrated; next, a hollow introducer needle is passed into the stomach and visualized endoscopically. The endoscopist places a snare around the needle to secure it in place, and the second operator next passes a long soft blue wire through the needle into the stomach. The wire is then grasped with the snare and withdrawn retrograde through the esophagus and out of the mouth, thus creating a loop (one end of the wire enters the abdominal wall and the other exits the oral cavity). The oral end of the wire is next attached to a loop at the end of a PEG tube, and the entire assembly is “pulled” through the mouth into the stomach by the second operator applying traction to the wire end that exits the abdominal wall. Once the tapered end of the tube exits the abdominal wall, traction is applied until the internal bolster of the PEG tube rests along the gastric wall. An external bolster is then placed over the tube at the abdominal wall level and the tube is trimmed to a desired length. An access portis then attached to the external end of the tube (typically Y-shaped), and a repeat endoscopy is done to confirm adequate placement of the internal bolster inside the stomach. Standard outcome of the procedure is the creation of a patent tube to allow access to the patient’s stomach for nutrition, hydration, and medication administration. After completion of the procedure, it is recommended to wait 2 hours to begin medication administration via the PEG tube. Feedings may be started 6–8 hours after the procedure.