Percutaneous endoscopic gastrostomy
Percutaneous endoscopic gastrostomy | |
---|---|
Hemorrhage, Gastrointestinal perforation, Gastrocolic fistula, Buried bumper syndrome | |
ICD-9-CM | 43.11 |
OPS-301 code | sec |
Percutaneous endoscopic gastrostomy (PEG) is an
PEG administration of enteral feeds is the most commonly used method of nutritional support for patients in the community. Many stroke patients, for example, are at risk of aspiration pneumonia due to poor control over the swallowing muscles; some will benefit from a PEG performed to maintain nutrition. PEGs may also be inserted to decompress the stomach in cases of gastric volvulus.[2]
Indications
Gastrostomy may be indicated in numerous situations, usually those in which normal (or
In certain situations where normal or nasogastric feeding is not possible, gastrostomy may be of no clinical benefit. In advanced dementia, studies show that PEG placement does not in fact prolong life.[3] Instead, oral assisted feeding is preferable.[4] Quality improvement protocols have been developed with the aim of reducing the number of non-beneficial gastrostomies in patients with dementia.[5]
A gastrostomy can be placed to decompress the stomach contents in a patient with a malignant bowel obstruction. This is referred to as a "venting PEG" and is placed to prevent and manage nausea and vomiting.
A gastrostomy can also be used to treat volvulus of the stomach, where the stomach twists along one of its axes. The tube (or multiple tubes) is used for gastropexy, or adhering the stomach to the abdominal wall, preventing twisting of the stomach.[2]
A PEG tube can be used in providing gastric or post-surgical drainage.[6]
Techniques
Two major techniques for placing PEGs have been described in the literature.
The Gauderer-Ponsky technique involves performing a
- digital pressure is applied to the abdominal wall, which can be seen indenting the anterior gastric wall by the endoscopist.
- transillumination (diaphanoscopy): the light emitted from the endoscope within the stomach can be seen through the abdominal wall.
- a small (21G, 40mm) needle is passed into the stomach before the larger cannula is passed.
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.[2]
In the Russell introducer technique, the Seldinger technique is used to place 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.[7]
Anesthetic management
There are several techniques such as moderate sedation with left transversus abdominis plane block, and moderate sedation with local anesthetic infiltration at feeding tube site.[8]
Contraindications
As with other types of feeding tubes, care must be made to place PEGs into an appropriate population. The following are contraindications to PEG use:[9]
Absolute contraindications
- Inability to perform an esophagogastroduodenoscopy
- Uncorrected coagulopathy
- Peritonitis
- Untreatable (loculated) 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, including previous partial gastrectomy: increased risk of organs interposed between gastric wall and abdominal wall
- Morbid obesity: difficulties in locating stomach position by digital indentation of stomach and transillumination
- Gastric wall neoplasm
- Abdominal wall infection: increased risk of infection of PEG site
- Intra-abdominal malignancy with peritoneal involvement (tumor seeding into formed channel with subsequent failure)
In advanced dementia
The
Complications
- Surgical site infection around the gastrostomy site. Administration of intravenous antibiotics can reduce infection around the gastrostomy site.[11] Prophylaxis with co-amoxiclav decreases the proportion of people developing MRSA infections compared with no antibiotic prophylaxis (in people without cancer) undergoing percutaneous endoscopic gastrostomy insertion.[12]
- Hemorrhage
- Gastric ulcereither at the site of the button or on the opposite wall of the stomach ("kissing ulcer")
- Perforation of bowel (most commonly transverse colon) leading to peritonitis
- Puncture of the left lobe of the liver leading to liver capsule pain
- Gastrocolic fistula: this may be suspected if diarrhea appears a short time after feeding. In this case, the feed goes direct from stomach to colon (usually transverse colon)[13]
- Gastric separation
- "Buried bumper syndrome" (the gastric part of the tube migrates into the gastric wall)[14]
Removal of PEG tubes
Indications
- PEG tube no longer required (recovery of swallow after stroke or brain trauma, or after surgery or radiotherapy for head and neck cancer)
- Persistent infection of PEG site
- Failure, breakage or deterioration of PEG tube (a new tube can be sited along the existing track)
- "Buried bumper syndrome"
Techniques
PEG tubes with rigid, fixed "bumpers" are removed endoscopically. The PEG tube is pushed into the stomach so that part of the tube is visible behind the bumper. An endoscopy snare is then passed through the endoscope, and passed over the bumper so that the tube adjacent to the bumper is grasped. The external part of the tube is then cut, and the tube is withdrawn into the stomach, and then pulled up into the esophagus and removed through the mouth. The PEG site heals without intervention.[citation needed]
PEG tubes with a collapsible or deflatable bumper can be removed using traction (simply by pulling the PEG tube out through the abdominal wall).
History
The first percutaneous endoscopic gastrostomy performed on a child was on June 12, 1979, at the
See also
References
- ^ "Discussion". BCM Gastroenterology Grand Rounds. Baylor College of Medicine. Archived from the original on 2012-03-03. Retrieved 2010-10-16.
- ^ PMID 11150469.
- PMID 12796072.
- ABIM Foundation, AMDA – The Society for Post-Acute and Long-Term Care Medicine, retrieved 20 April 2015.
- PMID 15331474.
- ^ Gail Waldby, "PEG-J Gastrostomy drainage jejunal feeding tubes" "Untitled Document". Archived from the original on 2011-07-16. Retrieved 2010-10-16.
- PMID 3349370.
- ^ Abdalgaleil, Mohamed M; Shaat, Ahmed M; Elbalky, Osama S; Elnagaar, Mohamed S; Kamoun, Amr M (2018-07-01). "Early versus delayed feeding after placement of percutaneous endoscopic gastrostomy tube with safe anesthetic techniques". Menoufia Medical Journal. 31 (3). Medknow Publications: 1058–1063.
- ISBN 978-1-58890-013-5
- ^ Lay summary: "Feeding tubes for people with Alzheimer's disease: When you need them — and when you don't" (PDF). Consumer Reports. Archived from the original (PDF) on 12 December 2013. Retrieved 6 December 2013.
- "White Paper on Surrogate Decision-Making and Advance Care Planning in Long-Term Care". American Medical Directors Association -. Archived from the original on 13 December 2013. Retrieved 6 December 2013.
- Daniel K, Rhodes R, Vitale C, Shega J (May 2013). "Feeding Tubes in Advanced Dementia Position Statement" (PDF). American Geriatrics Society. Archived from the original (PDF) on 21 September 2013. Retrieved 6 December 2013.
- Buff DD (Spring 2006). "Against the Flow: Tube Feeding and Survival in Patients with Dementia" (PDF). AAHPM Bulletin. 7 (1). American Academy of Hospice and Palliative Medicine. Retrieved 6 December 2013.
- PMID 24234575.
- PMID 23959704.
- PMID 19547728.
- PMID 16267197.
- ^ PMID 6780678.