Percutaneous endoscopic gastrostomy
Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube is passed into a patient’s stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate.
It provides enteral nutrition despite bypassing the mouth
Enteral nutrition is generally preferable to parenteral nutrition.
Gastrostomy tubes are commonly placed for long-term enteral nutrition in patients un able to maintain sufficient oral intake.
The PEG procedure is an alternative to open surgical gastrostomy insertion.
Mild sedation is typically used for placement.
PEG tubes may also be placed into the small intestine by passing a jejunal extension tube through the PEG tube.
It is the most commonly used method of nutritional support for patients in the community: stroke patients.
Gastrostomy may be indicated: neurological disorders, stroke, anatomical abnormalities, cleft lip and palate, radiation therapy for tumors in head & neck region.
In advanced dementia, PEG placement does not, in fact, prolong life.
A gastrostomy can be used to decompress the stomach contents in a patient with a malignant bowel obstruction, called a venting PEG.
A gastrostomy can also be used to treat volvulus of the stomach, in providing gastric or post-surgical drainage.
Two major techniquesare used for placing PEGs.
The Gauderer-Ponsky technique involves performing a gastroscopy to identify the anterior stomach wall ,
transillumination by the light emitted from the endoscope within the stomach can be seen through the abdominal wall.
An angiocath is used to puncture the abdominal wall through a small incision, and a soft guidewire is inserted through this and pulled out of the mouth.
The feeding tube is attached to the guidewire and pulled through the mouth, esophagus, stomach, and out of the incision.
In the Russell introducer technique, the technique places a wire into the stomach, and a series of dilators are used to increase the size of the gastrostomy: The tube is then pushed in over the wire.
Absolute contraindications:
Inability to perform an esophagogastroduodenoscopy
Uncorrected coagulopathy
Peritonitis
Untreatable massive ascites
Bowel obstruction, unless the PEG is sited to provide drainage.
Relative contraindications
Massive ascites
Gastric mucosal abnormalities: large gastric varices, portal hypertensive gastropathy
Previous abdominal surgery: increased risk of organs interposed between gastric wall and abdominal wall
Morbid obesity
Gastric wall neoplasm
Abdominal wall infection
Intra-abdominal malignancy with peritoneal involvement
Artificial nutrition neither prolongs life nor improves its quality in patients with advanced dementia.
Artificial nutrition may increase the risk of inhaling food, does not reduce suffering, it may cause fluid overload, diarrhea, abdominal pain and local complications, and can reduce the amount of human interaction the patient experiences.
Surgical site infection around the gastrostomy site can occur.
Rare complications:
Gastric ulcer either at the site of the button or on the opposite wall of the stomach.
Perforation of bowel
Puncture of the left lobe of the liver
Gastrocolic fistula
Gastric separation
Gastric part of the tube migrates into the gastric wall.
Endoscopic removal of PEG tube:
When it is no longer required for medical reasons
Persistent infection of PEG site
Failure, breakage or deterioration of PEG tube
“Buried bumper syndrome”
PEG tubes that have rigid, fixed
bumpers can be removed endoscopically.
PEG tubes with a collapsible or deflatable bumper can be removed using by pulling the PEG tube out through the abdominal wall.