Background
Percutaneous endoscopic gastrostomy (PEG), first described by Gauderer in 1980, [1] is a method of placing a tube into the stomach percutaneously, aided by endoscopy. PEG tube placement is one of the most commonly performed endoscopic procedures, and an estimated 100,000-125,000 are performed annually in the United States. [2, 3, 4, 5, 6]
Variations of the technique include the pull (Ponsky), push (Sachs-Vine), introducer (Russell), and Versa (T-fastener) methods. Bronchoscope-guided PEG tube placement has also been described. [7] Of these, the pull method is the most commonly used and is described in this article.
Indications
Broadly, the two main indications for PEG tube placement are as follows:
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Establishment of enteral access for feeding
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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 neurologic disorders such as stroke, cerebral palsy, brain injury, amyotrophic lateral sclerosis, [8] and impaired swallowing. [9] In addition, patients who have trauma, cancer, or recent surgery of the upper gastrointestinal (GI) tract or the respiratory tract may require this procedure to maintain nutritional intake.
Gut decompression may be needed in patients who have abdominal malignancies causing gastric outlet or small-bowel obstruction or ileus.
In pediatric patients, some studies have found that laparoscopy-assisted gastrostomy is associated with a lower risk of major complications than PEG is. [10, 11, 12]
Contraindications
Absolute contraindications for PEG tube placement include the following:
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Uncorrected coagulopathy or thrombocytopenia
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Severe ascites
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Hemodynamic instability
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Intra-abdominal perforation
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Active peritonitis
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Abdominal-wall infection at the selected site of placement
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Gastric outlet obstruction (if the PEG tube is being placed for feeding)
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Severe gastroparesis (if the PEG tube is being placed for feeding)
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History of total gastrectomy
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Lack of informed consent for the procedure
Relative contraindications for PEG tube placement include the following:
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Presence of oropharyngeal or esophageal malignancy (potential risk of seeding of the PEG tract)
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Hepatomegaly
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Esophageal malignancy that will require the use of the stomach as a conduit for reconstruction following definitive esophageal resection; however, a systematic review and meta-analysis by Fang et al found that preoperative PEG was safe in the setting of resectable esophageal cancer and had no adverse effect on gastric tube construction and anastomosis [13]
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Portal hypertension with gastric varices
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History of prior abdominal surgical procedures (possible presence of adhesions and bowel interposition)
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Peritoneal dialysis
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History of partial gastrectomy
Opinions have varied as to whether placement of a ventriculoperitoneal shunt (VPS) constitutes a contraindication for PEG. A systematic review by Oterdoom et al concluded that placement of a VPS in conjunction with a PEG tube was associated with a high but acceptable shunt complication rate and that shunt insertion therefore should not be considered a contraindication for PEG. [14] They suggested that the PEG tube should be placed after the VPS but did not conclusively establish an optimal interval.
A study by Chang et al found that the VPS infection rate remained low even when VPS placement was performed during the same hospitalization as PEG tube placement. [15] A study by Bawazir et al found that PEG was associated with a low complication rate in low-weight children, including several with a VPS. [16]
Outcomes
Although PEG is a relatively safe procedure, acute and chronic complications have been reported, including early mortality. Pih et al conducted a single-center study aimed at determining risk factors associated with complications and 30-day mortality after pull-type (n = 139) and introducer-type (n = 262) PEG. [17] Early mortality was significantly higher in patients with platelet counts lower than 100,000/μL or C-reactive protein (CRP) levels of 5 mg/dL or higher, and it was lower in patients with neurologic disease (eg, dementia, Parkinson disease, neuromuscular disease, or hypoxic brain damage).
A study comparing the outcomes of pull PEG (n = 264) with those of push PEG (n = 59) in acute care settings found that overall complication rates for the two approaches were comparable (20% and 22%, respectively), as were tube dislodgment rates (12% and 9%, respectively); however, the incidence of tube dislodgment associated with major complications was greater for pull PEG (6% vs 2%), though not to a statistically significant degree. [18]
A single-center study comparing the outcomes of pull PEG and push PEG found both to be safe and feasible, with a low PEG-related mortality; however, pull PEG was more frequently associated with buried bumpers, infected placement sites, and granulation tissue formation, whereas push PEG was more likely to be associated with periprocedural bleeding and tube dislodgment. [19]
A retrospective study comparing pull PEG with introducer PEG found both techniques to have high clinical success rates but noted that the introducer technique, though more suitable for patients with esophageal stricture, had a higher rate of tube replacement. [20]
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Placement of percutaneous endoscopic gastrostomy (PEG) tube. Procedure performed by Reuben Garcia-Carrasquillo MD, ColumbiaDoctors, New York, NY. Video courtesy of ColumbiaDoctors (http://www.columbiadoctors.org).
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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.
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Percutaneous endoscopic gastrostomy (PEG) tube. Image courtesy of Wikimedia Commons.
