Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement 

Updated: Jun 01, 2020
Author: Gaurav Arora, MD, MS; Chief Editor: Danny A Sherwinter, MD 

Overview

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:

  • Establishment of enteral access for feeding
  • 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:

  • 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 the PEG tube is being placed for feeding)
  • Severe gastroparesis (if the PEG tube is being placed for feeding)
  • History of total gastrectomy
  • Lack of informed consent for the procedure

Relative contraindications for PEG tube placement include the following:

  • 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 reconstruction following definitive esophageal resection 
  • Portal hypertension with gastric varices
  • History of prior abdominal surgical procedures (possible presence of adhesions and bowel interposition)
  • Peritoneal dialysis
  • 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.[13] 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.[14]

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.[15] 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 disase, 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.[16] ​

 

Periprocedural Care

Equipment

In addition to a standard upper endoscope, equipment used in percutaneous endoscopic gastrostomy (PEG) tube placement includes a PEG kit (commercially available) that contains the following:

  • PEG tube (see the image below)
  • Guide wire
  • Snare
  • Syringe, 5 mL
  • Needle, 22 gauge
  • Sterile fenestrated drape
  • Lidocaine
  • Needle-catheter assembly
  • Surgical blade, No. 11, attached to a scalpel
  • Gauze
  • Lubricant
  • Scissors
  • Swab sticks containing povidone-iodine solution
Percutaneous endoscopic gastrostomy (PEG) tube. Im Percutaneous endoscopic gastrostomy (PEG) tube. Image courtesy of Wikimedia Commons.

Patient Preparation

Anesthesia

Typically, this procedure is performed with 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 such as propofol, and this is usually administered and monitored by an anesthesiologist. For more information, see Procedural Sedation and Local Anesthetic Agents, Infiltrative Administration.

Positioning

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

 

Technique

Placement of Percutaneous Endoscopic Gastrostomy Tube

Percutaneous endoscopic gastrostomy (PEG) tube placement is best completed by a two-person team that includes an endoscopist and a "skin person" to handle the nonendoscopic portions of the procedure. (The skin person can be a physician or a physician assistant.) One approach to this procedure is shown in the video below.

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).

Ensure that the patient has been fasting for at least 4 hours, preferably longer, especially if bowel obstruction is present.

A first-generation cephalosporin (eg, cefazolin 1 g) should be administered intravenously to reduce the risk of infection at the insertion site (see the image below).[17] 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-rela 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.

The authors' approach is as follows. Esophagogastroduodenoscopy (EGD) is performed with a standard upper endoscope. Stomach contents are suctioned to prevent aspiration. If the PEG tube is being placed for feeding, the physician should rule out obstruction in the gastric outlet and duodenum through direct examination during EGD.

The stomach is insufflated generously via 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 necessary, 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 2.5 cm below the costal margin and away from the xiphoid process.

Once a good point on the abdominal wall is selected by using the above maneuvers, a surgical pen is used to mark the site.

The skin at this site is cleansed by using the swab sticks containing povidone-iodine solution (provided in the PEG kit). This step 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.

The site is anesthetized with lidocaine delivered via the 5-mL syringe and the longer needle included in the kit. The same needle can then be used as a "sounding" needle to ensure a safe tract for PEG tube placement. This is accomplished by passing this needle from the abdominal wall into the stomach (confirmed by endoscopic visualization) and noting its angle of entry.

After the 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, which may allow the needle to push the stomach away; rather, it 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 guide wire 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 it back over the guide wire.

The PEG tube is then secured to the looped end of the guide wire coming out from the mouth. This is performed by passing the guide wire loop through the PEG tube loop and then passing the other end of the PEG tube through the guide wire 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 guide wire 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. This should be done in such a way that the internal bumper sits snugly against the gastric mucosa, with care taken to 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 15-20 cm 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, so as 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.[18, 19]

If transillumination, finger indentation, and adequate gastric insufflation are not achieved, consider aborting the procedure and assess for alternate access.

Before this procedure is done, antibiotic prophylaxis should be given to every patient (unless the patient is already on antibiotics) so as to prevent peristomal infection.[17, 20]

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 before 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 accomplished with soap and water.

Complications

Potential complications include the following:

  • Cardiopulmonary compromise associated with oversedation
  • Allergic reaction to the sedatives or antibiotic administered
  • Aspiration
  • Infection of the stomal site
  • Peristomal leakage
  • Bleeding
  • Pneumoperitoneum (common and typically 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 is present)
 

Questions & Answers