Endoscopically placed gastrostomy tubes were first described in 1980 as an alternative to open surgical gastrostomy placement.9 Since then numerous techniques have been developed and described. The Ponsky-Pull method is the most commonly practiced method illustrated here.
Suitable candidates for insertion of PEG tubes for nutritional supplementation include the following:
Common indications for the placement of PEG tubes for nutritional supplementation include patients with stroke, head and neck cancer, as well as brain injury or neurologic disorders such as amyotrophic lateral sclerosis. Conversely, feeding tubes in patients with dementia have not shown improved clinical outcomes and are generally ineffective in prolonging life, improving function, or reducing risk of pressure sores or infections.10
Contraindications to PEG Placement
Absolute contraindications include a nonfunctional GI tract, active GI bleeding, uncorrected coagulopathy, hemodynamic instability, peritonitis, and abdominal wall infection over insertion site. The presence of ascites is a relative contraindication to PEG placement and depends on the amount, location, and type of ascites.
PEG tube insertion is a well-tolerated procedure with low incidence of complications; rates up to 4% have been reported. Complications may relate to either the insertion of the PEG tube or complications thereafter. These include stomal site infection, abdominal wall ulceration, necrotizing fasciitis, peristomal leakage, bleeding, transient gastroparesis, bowel perforation, gastric outlet obstruction from the internal bumper, buried bumper syndrome, colocutaneous fistula, peritonitis, and liver puncture. Pneumoperitoneum may be identified on radiologic imaging post-PEG insertion. This is an expected finding and is not worrisome in the absence of clinical signs of peritonitis.
Insertion of endoscopically placed PEG or PEJ tubes is done with a combination of local anesthesia and sedation. A short-acting benzodiazepine (ie, midazolam) in combination with an opioid such as fentanyl is a common practice. In some instances patients may receive deeper sedation via propofol, or in some cases general anesthesia, under the guidance of a nurse anesthetist or anesthesiologist.
See Figure 98–2 for typical PEG kit components.
A-O Typical PEG kit components.
PEG tube insertion generally requires 2 individuals to perform the procedure. One individual functions as the endoscopist and the other as the surgical assistant.
Preparation and Antibiotic Prophylaxis
The patient is kept NPO the night before the procedure. There is creation of a surgical wound during the creation of the gastrostomy and antibiotic prophylaxis is given to prevent abdominal wall infection. A single dose of a first-generation cephalosporin is given prior to PEG tube insertion to reduce the risk of infection. Patients in the ICU often receive significant antimicrobial coverage and as long as there is preexisting gram-positive organism coverage, additional antibiotics are not required. The patient is supine with the head turned to the side and suction available for significant oral secretions. A routine upper GI examination is performed prior to PEG insertion.
The epigastrium is the typical location for PEG placement but can vary. The final site is dependent on appropriate landmarking. The final location for the gastrostomy tube should be at least an inch away from the costal margins and clear of the xiphoid process.
The stomach is inflated to maximally appose the gastric wall with the abdominal wall. This facilitates the 2 maneuvers to identify a suitable PEG insertion site, the absence of any underlying vessel or interposing tissue such as bowel or liver edge. First is diaphanoscopy, adequate transillumination of the endoscopy light through the abdominal wall. The endoscopy suite lights are dimmed and transilluminated light from the endoscope should be clearly visible on the anterior abdominal wall (Figure 98–3). The second is 1:1 transmission of abdominal wall pressure. The endoscopic view is directed at the gastric wall corresponding to the point of external point pressure. When point pressure is applied to the abdominal wall, the endoscopic image shows 1:1 transmission of movement (Figure 98–4). Mark the site PEG placement with surgical pen marking.
The endoscopy suite lights are dimmed and transilluminated light from the endoscope should be clearly visible on the anterior abdominal wall.
When point pressure is applied to the abdominal wall, the endoscopic image shows 1:1 transmission of movement. (Memorial Sloan Kettering Cancer Center ©2014).
PEG placement requires sterile technique with skin disinfection, sterile gloves, and draping. The landmark is washed with povidone/iodine or chlorhexidine wash, 3 times in concentric swirls starting from the landmark site outwards. After the surgical drape is applied local anesthesia with a total of 3 to 5 mL of 1% lidocaine should be injected subcutaneously, followed by injection toward the gastric lumen. Direct the syringe perpendicular to the abdominal wall and apply local anesthesia with periodic suction to inspect for blood return and possible puncture of a blood vessel. Significant heme return should prompt a different site for PEG insertion. The syringe will puncture into the gastric lumen, seen endoscopically to confirm an acceptable PEG location. The depth and direction of the syringe serves as a guide for insertion of the trocar/catheter apparatus.