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Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement

  • Author: Gaurav Arora, MD, MS; Chief Editor: Danny A Sherwinter, MD  more...
 
Updated: Dec 14, 2015
 

Overview

Percutaneous endoscopic gastrostomy (PEG) is a method of placing a tube into the stomach percutaneously, aided by endoscopy. This technique was first described by Gauderer in 1980.[1] Different variations of the technique include the pull (Ponsky), push (Sachs-Vine), introducer (Russell), and Versa (T-fastener) methods. Of these, the pull method is the most commonly used and is described in this article. PEG tube placement is one of the most common endoscopic procedures performed today, and an estimated 100,000-125,000 are performed annually in the United States.[2, 3, 4, 5]

The image below depicts a PEG tube.

Percutaneous endoscopic gastrostomy tube. Image coPercutaneous endoscopic gastrostomy tube. Image courtesy of Wikimedia Commons.
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Indications

Broadly, the 2 main indications are establishing enteral access for feeding and gut decompression.

  • Patients who are unable to move food from their mouth to their stomach are the ones who commonly need PEG tube placement. This includes those with neurological disorders such as stroke, cerebral palsy, brain injury, amyotrophic lateral sclerosis, and impaired swallowing. In addition, patients who have trauma, cancer, or recent surgery of the upper gastrointestinal or the respiratory tract may require this procedure to maintain nutrition intake.
  • Gut decompression may be needed in patients who have abdominal malignancies causing gastric outlet or small bowel obstruction or ileus.
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Contraindications

Absolute contraindications

See the list below:

  • Uncorrected coagulopathy or thrombocytopenia
  • Severe ascites
  • Hemodynamic instability
  • Intra-abdominal perforation
  • Active peritonitis
  • Abdominal wall infection at the selected site of placement
  • Gastric outlet obstruction (if PEG tube is being placed for feeding)
  • Severe gastroparesis (if PEG tube is being placed for feeding)
  • History of total gastrectomy
  • Lack of informed consent for the procedure

Relative contraindications

See the list below:

  • Presence of oropharyngeal or esophageal malignancy (potential risk of seeding of the PEG tract)
  • Hepatomegaly
  • Esophageal malignancy that will require the use of the stomach as a conduit for recostruction followig definitive esophageal resection 
  • Portal hypertension with gastric varices
  • History of prior abdominal surgeries (possible presence of adhesions and bowel interposition)
  • Peritoneal dialysis
  • History of partial gastrectomy
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Anesthesia

Typically, this procedure is performed under moderate sedation using intravenous midazolam and fentanyl (or meperidine), along with local anesthesia (ie, lidocaine) at the site of tube placement. However, some patients may require deeper sedation with an agent like propofol, and this is usually administered and monitored by an anesthesiologist. For more information, see Procedural Sedation and Local Anesthetic Agents, Infiltrative Administration.

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Equipment

See the list below:

  • Standard upper endoscope
  • PEG kit (commercially available) containing the following:
    • PEG tube
    • Guidewire
    • Snare
    • Syringe, 5 mL
    • Needle, 22 gauge (ga)
    • Sterile fenestrated drape
    • Lidocaine
    • Needle/catheter assembly
    • Surgical blade, No. 11, attached to a scalpel
    • Gauze
    • Lubricant
    • Scissors
    • Swab sticks containing povidone-iodine solution
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Positioning

The patient should be supine, with the head end of the bed elevated at a 30-degree angle to reduce the risk of aspiration.

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Technique

See the list below:

  • Ensure that the patient has been fasting for at least 4 hours, preferably longer, especially if bowel obstruction is present.
  • A first-generation cephalosporin such as cefazolin 1 g should be administered intravenously to reduce the risk of infection at the insertion site (see the image below).[6] If the patient is allergic to penicillin, an alternate antibiotic can be given for gram-positive coverage. If the patient is already taking antibiotics for another indication, additional antibiotics are not needed (but broad-spectrum gram-positive coverage should be ensured).
    Regarding tube-site infections, most catheter-relaRegarding tube-site infections, most catheter-related infections involve local cellulitis, as shown here, with erythema and tenderness. These infections frequently respond to local wound care and oral antibiotics.
  • PEG tube placement is best completed by a 2-person team: one endoscopist and one "skin person" to handle the nonendoscopic portions of the procedure (the skin person can be a physician or a physician's assistant).
  • An esophagogastroduodenoscopy (EGD) is performed with a standard upper endoscope. Suction stomach contents to prevent aspiration. If placing the PEG tube for feeding, the physician should rule out obstruction in the gastric outlet and duodenum by direct examination during the EGD.
  • The stomach is insufflated generously using the air channel on the endoscope.
  • At this time, the room lights should be dimmed. Next, the abdominal wall is transilluminated using the endoscope light. This is visible externally as a bright red or orange light on the abdominal wall. If needed, the endoscope's light intensity can be increased from the base controls.
  • Finger pressure is applied at the point of maximal transillumination, and a focal indentation of the anterior gastric wall is visible endoscopically. This area should be at least 1 inch below the costal margin and away from the xiphoid process.
  • Once a good point on the abdominal wall is selected using the above maneuvers, a surgical pen is used to mark the site.
  • The skin at this site is cleansed using the swab sticks containing povidone-iodine solution (provided in the PEG kit). This should be completed sequentially and in a concentric centrifugal fashion, moving away from the center.
  • The skin person changes into sterile gloves.
  • A sterile drape is placed over the abdomen, with the fenestrated center over the chosen site.
  • Using the 5-mL syringe and the longer needle included in the kit, the site is anesthetized using lidocaine. The same needle can then be used as a "sounding" needle to ensure a safe tract for PEG tube placement. This is completed by passing this needle from the abdominal wall into the stomach (confirmed by endoscopic visualization) and noting its angle of entry. After this needle passes through the skin, continuous suction should be maintained on it; if air bubbles are seen in the syringe before the needle enters inside the stomach, as assessed endoscopically, it may have entered the colon. If this happens, another entry tract should be sought.
  • Next, the scalpel is used to make a horizontal incision (0.5-1.0 cm wide, 2-3 mm deep) at the marked site.
  • The catheter-over-needle is then passed through this incision into the stomach. This maneuver should not be a slow deliberate push as the needle may push the stomach away. Rather, this should be a rapid poke.
  • The needle-catheter should be visible inside the stomach cavity at this time. The endoscopist takes the snare from the kit and passes it through the working channel of the endoscope into the stomach.
  • The skin person removes the needle, leaving the plastic outer sheath of the needle-catheter assembly in place. The looped guidewire is then passed through this catheter into the stomach, where it is caught by the snare. This is then pulled out of the mouth along with the endoscope and is released from the snare and held by the endoscopist.
  • The catheter is then removed by threading back over the guidewire.
  • The PEG tube is then secured to the looped end of the guidewire coming out from the mouth. This is performed by passing the guidewire loop through the PEG tube loop and then passing the other end of the PEG tube through the guidewire loop and then pulling the entire tube through it. This forms a square knot.
  • The PEG tube should then be lubricated.
  • The skin person now pulls the guidewire on the abdominal wall end so that the whole PEG tube goes through the mouth, esophagus, and stomach and emerges out of the incision site. Do this so that the internal bumper sits snugly against the gastric mucosa. However, ensure that excessive tension is avoided.
  • The endoscopist then inserts the endoscope into the stomach to confirm adequate placement.
  • The external bumper is then passed over the external portion of the PEG tube, after the wire loop on the tube has been cut with the scissors and the tube has been lubricated again to facilitate the passage of the bumper over it. The external bumper should be placed about 1-2 cm away from the abdominal wall.
  • The excess portion of the tube, including the terminal dilator, is then cut away with the scissors, leaving approximately 6-8 inches of the tube behind.
  • The feeding adaptor provided in the kit is then pushed into the cut end.
  • Split gauze dressings are then applied over the external bumper (and not between the bumper and abdominal wall to prevent excessive tension on the tissues), and the tube is then looped back and taped to the abdominal wall. The PEG tube can be safely used for feeding 4 hours after the procedure.[7, 8]
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Pearls

See the list below:

  • If transillumination, finger indentation, and adequate gastric insufflation are not achieved, consider aborting the procedure and assess for alternate access.
  • Antibiotic prophylaxis should be given to every patient (unless already on antibiotics) before doing this procedure, to prevent peristomal infection.[6, 9]
  • The internal bumper should not be pulled too tightly against the gastric mucosa.
  • The external bumper should be 1-2 cm away from the abdominal wall.
  • The tube should be flushed and aspirated prior to completion of the procedure to ensure patency while the patient is still sedated.
  • The PEG tube insertion site should be cleaned daily. This can be completed with soap and water.
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Complications

See the list below:

  • Cardiopulmonary compromise associated with oversedation
  • Allergic reaction to the sedatives or antibiotic administered
  • Aspiration
  • Infection of the stomal site
  • Peristomal leakage
  • Bleeding
  • Pneumoperitoneum (common; self-limiting)
  • Transient gastroparesis or, rarely, ileus
  • Inadvertent perforation of the colon or small intestine
  • Gastric outlet obstruction caused by internal bumper migrating distally
  • Gastric wall ulceration with long-standing PEG tubes
  • Inadvertent PEG tube removal (by an agitated or confused patient)
  • Buried bumper syndrome
  • Colocutaneous fistula (becomes apparent at time of PEG tube replacement)
  • PEG tract tumor seeding
  • Peritonitis (if large ascites present)
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Contributor Information and Disclosures
Author

Gaurav Arora, MD, MS Assistant Professor of Internal Medicine, Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center at Dallas, Southwestern Medical School

Gaurav Arora, MD, MS is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, American Association of Physicians of Indian Origin

Disclosure: Nothing to disclose.

Coauthor(s)

Frank J Lukens, MD Assistant Professor of Medicine, Program Director of GI Fellowship Program, Director of Endoscopy and Endoscopic Training, Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The University of Texas Health Science Center at Houston Medical School

Frank J Lukens, MD is a member of the following medical societies: American Society for Gastrointestinal Endoscopy, Texas Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Laurie Scudder, DNP, NP Nurse Planner, Medscape; Senior Clinical Professor of Nursing, George Washington University

Disclosure: Nothing to disclose.

Chief Editor

Danny A Sherwinter, MD Attending Surgeon, Department of Mimially Invasive Surgery and Bariatrics, Associate Program Director, Department of Surgery, Maimonides Medical Center; Director of Minimally Invasive and Bariatric Surgery, American Society for Metabolic and Bariatric Surgery (ASMBS) Center of Excellence

Danny A Sherwinter, MD is a member of the following medical societies: American College of Surgeons, American Society for Metabolic and Bariatric Surgery, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

Andrew J Duffy, MD, FACS Assistant Professor of Surgery, Section of Gastrointestinal Surgery, Associate Program Director of the Surgical Residency Program, Director of the Yale Surgical Skills and Simulation Center, Department of Surgery, Yale School of Medicine; Attending Surgeon, Yale-New Haven Hospital

Andrew J Duffy, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, Phi Beta Kappa, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

References
  1. Gauderer MW, Ponsky JL, Izant RJ Jr. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg. 1980 Dec. 15(6):872-5. [Medline].

  2. Duszak R Jr, Mabry MR. National trends in gastrointestinal access procedures: an analysis of Medicare services provided by radiologists and other specialists. J Vasc Interv Radiol. 2003 Aug. 14(8):1031-6. [Medline].

  3. Yarmus L, Gilbert C, Lechtzin N, Imad M, Ernst A, Feller-Kopman D. The Safety and Feasibility of Interventional Pulmonologists Performing Bedside Percutaneous Endoscopic Gastrostomy Tube Placement. Chest. 2013 Feb 7. [Medline].

  4. Vanis N, Saray A, Gornjakovic S, Mesihovic R. Percutaneous endoscopic gastrostomy (PEG): retrospective analysis of a 7-year clinical experience. Acta Inform Med. 2012 Dec. 20(4):235-7. [Medline]. [Full Text].

  5. Lohsiriwat V. Percutaneous endoscopic gastrostomy tube replacement: A simple procedure?. World J Gastrointest Endosc. 2013 Jan 16. 5(1):14-8. [Medline]. [Full Text].

  6. Jafri NS, Mahid SS, Minor KS, Idstein SR, Hornung CA, Galandiuk S. Meta-analysis: antibiotic prophylaxis to prevent peristomal infection following percutaneous endoscopic gastrostomy. Aliment Pharmacol Ther. 2007 Mar 15. 25(6):647-56. [Medline].

  7. Bechtold ML, Matteson ML, Choudhary A, Puli SR, Jiang PP, Roy PK. Early versus delayed feeding after placement of a percutaneous endoscopic gastrostomy: a meta-analysis. Am J Gastroenterol. 2008 Nov. 103(11):2919-24. [Medline].

  8. Choudhry U, Barde CJ, Markert R, Gopalswamy N. Percutaneous endoscopic gastrostomy: a randomized prospective comparison of early and delayed feeding. Gastrointest Endosc. 1996 Aug. 44(2):164-7. [Medline].

  9. Sharma VK, Howden CW. Meta-analysis of randomized, controlled trials of antibiotic prophylaxis before percutaneous endoscopic gastrostomy. Am J Gastroenterol. 2000 Nov. 95(11):3133-6. [Medline].

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Regarding tube-site infections, most catheter-related infections involve local cellulitis, as shown here, with erythema and tenderness. These infections frequently respond to local wound care and oral antibiotics.
Percutaneous endoscopic gastrostomy tube. Image courtesy of Wikimedia Commons.
 
 
 
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