Percutaneous endoscopic gastrostomy

A percutaneous endoscopic gastrostomy (PEG) is an endoscopic procedure for placing a tube into the stomach through the abdominal wall. PEG tubes may also be extended into the small bowel. The first percutaneous endoscopic gastrostomies were performed at the Cleveland Clinic in children.^[1]

The procedure is performed in order to place a gastric feeding tube as a long-term means of providing nutrition to patients who cannot productively take food orally. 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]

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Indications

Gastrostomy may be indicated in numerous situations, usually those in which normal or nutrition (or nasogastric) feeding is impossible. The causes for these situations may be neurological (e.g. stroke), anatomical (e.g. cleft lip and palate during the process of correction) or other (e.g. radiation therapy for tumors in head & neck region).

In certain situations, the indication for PEG placement is more debatable. In advanced dementia, studies show that PEG placement does not in fact prolong life.^[3] Indeed, work has been done to inform doctors and healthcare staff of the perceived futility of the treatment.^[4]

A gastrostomy may also 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.

Techniques

Two major techniques for placing PEGs have been described in the literature.

The Ponsky or Bard-Ponsky pull technique involves performing a gastroscopy to evaluate the anatomy of the stomach. The anterior stomach wall is identified and techniques are used to ensure that there is no organ between the wall and the skin. 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 out of the incision.^{[citation needed]}

The push technique involves a gastroscopy to evaluate the anatomy. 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.^{[citation needed]}

Contraindications

As with the case of other types of feeding tubes, care must be made to place PEGs into an appropriate population. The following are contraindications to PEG use:^{[citation needed]}

Peritonitis
Short life span
Abdominal wall infection
Abdominal burns
High aspiration risk
Atypical abdominal anatomy (e.g. malrotation)

Complications

Cellulitis (infection of the skin) around the gastrostomy opening
Peritonitis
Gastrocolic fistula: this may be suspected if diarrhea appears a short time after feeding. In this case, the food goes direct from stomach to colon (usually transverse).
Gastric separation
"Buried bumper syndrome" (the gastric part of the tube migrates into the peritoneal cavity)^[5]

References

^ Gauderer MW, Ponsky JL, Izant RJ (1980). "Gastrostomy without laparotomy: a percutaneous endoscopic technique". J. Pediatr. Surg. 15 (6): 872–5. PMID 6780678.
^ Gauderer MW (2001). "Percutaneous endoscopic gastrostomy-20 years later: a historical perspective". J. Pediatr. Surg. 36 (1): 217–9. PMID 11150469.
^ Murphy LM, Lipman TO (2003). "Percutaneous endoscopic gastrostomy does not prolong survival in patients with dementia". Arch. Intern. Med. 163 (11): 1351–3. doi:10.1001/archinte.163.11.1351. PMID 12796072.
^ Monteleoni C, Clark E (2004). "Using rapid-cycle quality improvement methodology to reduce feeding tubes in patients with advanced dementia: before and after study". BMJ 329 (7464): 491–4. doi:10.1136/bmj.329.7464.491. PMID 15331474.
^ Walters G, Ramesh P, Memon MI (2005). "Buried Bumper Syndrome complicated by intra-abdominal sepsis". Age and ageing 34 (6): 650–1. doi:10.1093/ageing/afi204. PMID 16267197.