Definition & Overview
Percutaneous endoscopic gastrotomy tube insertion is recommended for those whose ability to swallow is impaired or are unable to move food from the mouth to the stomach due to underlying medical conditions.
Who Should Undergo and Expected Results
Percutaneous endoscopic gastrotomy tube insertion becomes necessary when patients are unable to orally take in enough food to meet their nutritional needs as a result of various medical conditions, which may include:
- Stroke, either acute ischemic or haemorrhagic
- Amyotrophic lateral sclerosis
- Brain injury
- Cerebral palsy
- Crohn’s disease
- Cystic fibrosis
- Oropharyngeal and oesophageal malignancy
- Short bowel syndrome
A percutaneous endoscopic gastrotomy tube insertion is also beneficial for patients who require an alternative method of nutritional intake due to the following:
- Traumatic injuries, especially those affecting the head
- Severe burn injuries
- Recent surgery in the upper gastrointestinal or respiratory tract
The procedure, which is proven safe even for infants as low as 2.3 kg in weight, is also performed on children in cases of:
- Craniofacial abnormalities
- Neurological disorders causing dysphagia or inability to swallow
- Cancer resulting in malnutrition
However, the procedure is contraindicated in patients who suffer from the following medical issues:
- Active peritonitis
- Hemodynamic instability
- Infection in the abdominal wall
- Intra-abdominal perforation
- Oropharyngeal or oesophagal malignancy
- Peritoneal dialysis
- Total gastrectomy
- Ventral hernia
Once placed, the PEG tube is expected to support the patient’s enteral feeding and nutritional needs. Patients are typically trained on the proper use and maintenance of the tube following the procedure.
How is the Procedure Performed?
A percutaneous endoscopic gastrotomy tube insertion is performed in a hospital operating room, with the patient under moderate to deep sedation, depending on his needs or medical condition. Local anaesthesia and an antibiotic agent are administered at the insertion site to reduce the pain level and the risk of infection. Paediatric patients are placed under general anaesthesia.
To reduce the risk of aspiration, the patient is placed in a supine position with his head slightly elevated at a 30-degree angle. Using a standard upper endoscope and a PEG kit, the procedure is performed using any of the following techniques:
- Ponsky or pulling technique
- Sachs-Vine or pushing technique
- Russell or introducer technique
- T-fastener or Versa technique
Among all four, the Ponsky or pull technique is the most widely used. It involves inserting an endoscope through the mouth which is then guided toward the stomach. The camera attached to the end of the tube provides the doctor with an image of the patient’s stomach lining and the selected insertion site. Once the image is ready, the doctor makes a small incision in the abdominal wall to essentially provide the tube with an exit point. The entire procedure takes between 30 and 45 minutes.
It is normal for patients to experience slight abdominal discomfort following the procedure. Also, in order to avoid peritoneal leakage, feeding is delayed until after 24 hours. The doctor also first examines the stoma for signs of infection. Once the stoma has healed, the tube is rotated 180 degrees and moved 1-2 cm in the stoma site at least once every day.
Patients are taught on how to use and maintain the tube and are advised to flush it before and after each feeding session or each time medication is administered in order to prevent clogging and tube blockage, especially when a small-bore feeding tube is used.
Possible Risks and Complications
Although it is a generally safe procedure, there is still a possibility that some risks and complications may arise during or after the tube has been inserted. These potential complications, which can be classified as endoscopic technical problems, procedure-related complications, or delayed complications associated with wound care and tube usage, include:
- Accidental perforation of the small or large intestines
- Allergic reaction to the sedative, anaesthesia, or antibiotic used
- Buried bumper syndrome
- Colocutaneous fistula
- Gastric outlet obstruction
- Gastric wall ulceration
- Necrotising fasciitis
- PEG tract tumour seeding
- Peristomal leakage
- Transient gastroparesis or ileus
Some patients have a higher risk of developing complications, especially systemic infection, if they have certain medical conditions, such as diabetes mellitus, low albumin levels, and chronic obstructive pulmonary disease.
It is also normal for patients to feel uncomfortable at first due to the tube. In some cases, confused or agitated patients may inadvertently remove the PEG tube. This requires immediate medical attention.
Arora, G. “Percutaneous endoscopic gastrotomy (PEG) tube placement.” Medscape. http://emedicine.medscape.com/article/149665-overview#a9
Rahnemai-Azar AA., Rahnemaiazar AA., et al. “Percutaneous endoscopic gastrostomy: indications, technique, complications, and management.” World J Gastrolenterol. 2014 Jun 28; 20(24): 7739-7751. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4069302/