Overview
Definition:
Percutaneous endoscopic gastrostomy (PEG) is a minimally invasive endoscopic procedure used to place a feeding tube directly into the stomach through the abdominal wall
It provides a route for long-term enteral nutrition, bypassing the oral cavity and esophagus, and is typically performed under conscious sedation or general anesthesia.
Epidemiology:
PEG placement is a common procedure worldwide, with thousands performed annually
Indications are primarily related to dysphagia due to neurological conditions, head and neck cancers, or conditions precluding oral intake
Patient demographics vary widely based on the underlying pathology, but it is more frequently performed in elderly or debilitated patients.
Clinical Significance:
PEG placement is crucial for managing patients with long-term nutritional deficits due to impaired swallowing
It ensures adequate caloric and protein intake, preventing malnutrition, promoting healing, and improving the quality of life for patients with chronic conditions
For surgical residents, understanding its indications, technique, and potential complications is vital for patient management.
Indications
Primary Indications:
Severe dysphagia from neurological disorders such as stroke, amyotrophic lateral sclerosis (ALS), Parkinson's disease, or severe traumatic brain injury
Head and neck malignancies requiring prolonged nutritional support during or after treatment
Severe esophageal strictures or fistulas unresponsive to other methods
Neuromuscular disorders affecting swallowing
Conditions requiring long-term gastric decompression or feeding in critically ill patients.
Contraindications:
Lack of a suitable gastric lumen or adequate abdominal wall space
Peritoneal dialysis or ascites
Significant coagulopathy
Active upper gastrointestinal bleeding or perforation
Uncontrolled infection at the insertion site
Gastric outlet obstruction
Short life expectancy where risks outweigh benefits.
Relative Contraindications:
Previous abdominal surgery with adhesions
Severe immunocompromise
Severe obesity
Gastroparesis not responding to medical management.
Preoperative Preparation
Patient Evaluation:
Thorough medical history and physical examination
Assessment of nutritional status, including weight loss and laboratory parameters (albumin, prealbumin)
Evaluation of coagulation profile (PT/INR, aPTT)
Review of imaging studies to assess gastric anatomy and abdominal wall thickness
Assessment of airway and respiratory status for sedation/anesthesia.
Informed Consent:
Detailed discussion with the patient and/or family about the procedure, its benefits, risks, alternatives, and expected outcomes
Explanation of potential complications such as bleeding, infection, perforation, and tube dislodgement.
Medication Review:
Discontinuation of antiplatelet agents and anticoagulants as per institutional guidelines
Review of medications that may affect gastric motility or be affected by the procedure
Prophylactic antibiotics may be administered.
Bowel Preparation:
Typically, no extensive bowel preparation is required
Patients are usually kept nil by mouth for 6-8 hours prior to the procedure
Clear liquids may be permitted up to 2 hours before if conscious sedation is used.
Procedure Steps
Endoscopic Guidance:
The stomach is insufflated with air to visualize the gastric mucosa
The abdominal wall is transilluminated to identify an optimal insertion site, typically in the left upper quadrant, avoiding the spleen and colon
A small skin incision is made.
Needle Catheter Placement:
A special needle-catheter unit is advanced through the abdominal wall and gastric wall into the gastric lumen under endoscopic visualization
A guidewire is then passed through the needle into the stomach.
Dilatation And Tube Insertion:
The tract is dilated using progressively larger dilators over the guidewire
Once adequate dilation is achieved, the PEG tube (typically a soft silicone tube with a retention disc) is introduced through the tract into the stomach.
Tube Fixation And Confirmation:
The retention disc is positioned on the gastric side, and the external bumper is secured against the skin
The position of the tube is confirmed endoscopically by observing the tube exiting the gastric wall and by the characteristic appearance of the external bumper.
Post Procedure Care:
The gastrostomy site is cleaned and dressed
Patients are monitored for signs of bleeding, peritonitis, or tube dislodgement
Oral intake is usually withheld for a period, and initiation of feeding is guided by institutional protocols.
Postoperative Care
Early Monitoring:
Vital signs monitoring for hemodynamic stability
Assessment of the gastrostomy site for redness, swelling, drainage, or bleeding
Pain management as needed
Monitoring for signs of peritonitis or abdominal distension.
Feeding Initiation:
Initial feeding is typically started 12-24 hours post-procedure with a slow infusion of diluted formula
The rate and concentration of formula are gradually increased as tolerated
Accurate assessment of gastric residual volume is important.
Tube Care:
Regular cleaning of the skin around the gastrostomy site to prevent infection and skin breakdown
Rotation of the tube daily to prevent adherence and skin irritation
Securement of the tube to prevent accidental dislodgement.
Nutritional Support:
Ongoing assessment of nutritional status
Adjustment of feeding regimen based on patient tolerance, caloric needs, and laboratory parameters
Consultation with a dietitian is often beneficial for optimizing enteral nutrition plans.
Complications
Early Complications:
Bleeding at the insertion site or within the stomach
Perforation of the colon or other abdominal organs
Peritonitis
Wound infection
Tube dislodgement
Gastric leakage
Pneumoperitoneum
Localized peritonitis.
Late Complications:
Gastrocolic fistula formation
Stomal stenosis or occlusion
Granulation tissue formation at the stoma site
Tube malfunction (blockage, breakage)
Migration of the internal bumper
Skin erosion or breakdown
Reflux or aspiration pneumonia.
Prevention Strategies:
Careful patient selection and pre-procedure evaluation
Meticulous surgical technique with avoidance of major vessels and adjacent organs
Adequate site preparation and sterile technique
Appropriate management of anticoagulation
Prompt recognition and management of complications
Regular tube care and stoma site monitoring.
Key Points
Exam Focus:
Indications for PEG placement, particularly differentiating from nasogastric tubes
Common insertion site and anatomical structures to avoid (spleen, colon)
Management of common complications like bleeding and peritonitis
Role of endoscopy in the procedure
Timing of initiation of enteral feeding
Tube types and fixation methods.
Clinical Pearls:
Transillumination of the abdominal wall is key to safe insertion
The "pull" technique versus the "push" technique for tube insertion
Importance of securing the tube adequately to prevent dislodgement
Serial assessment of gastric residuals is critical to avoid overfeeding and aspiration
Differentiating leakage from normal stomal drainage.
Common Mistakes:
Placing the tube too high or too low, risking gastrocolic fistula
Failing to adequately dilate the tract, leading to tube obstruction
Inadequate fixation of the tube, resulting in dislodgement
Delayed recognition of peritonitis or wound infection
Starting feeds too aggressively or too early post-procedure.