CHAPTER 200 Percutaneous Endoscopic Gastrostomy Placement and Replacement

Percutaneous endoscopic gastrostomy (PEG) is the placement of a percutaneous gastrostomy tube with the aid of an endoscope. The PEG technique has largely replaced surgical gastrostomy as the procedure of choice for patients who require long-term enteral nutrition. It was first described in 1980 by Gauderer and colleagues for use in children but has since gained wide acceptance for use in patients of all ages. Along with other necessary supplies, commercial PEG tube kits usually contain the PEG tube, an internal bolster (to seal the gastric mucosa), and an external bolster (to stabilize and prevent migration of the tube). Choices for the internal bolster including a balloon, a soft dome, crossbars, a T-bar, a flange, a disk, a three-leaf retainer, and others; most are soft to avoid irritating the gastric mucosa.

The actual PEG placement procedure requires two trained individuals, one of whom must be skilled in esophagogastroduodenoscopy (EGD). Please see Chapter 101, Esophagogastroduodenoscopy, for a full discussion of EGD; this chapter will be limited to the application of EGD for PEG placement. The procedure can be performed in the operating room, the endoscopy suite, or at the bedside. Normally, the procedure can be performed under moderate sedation (see Chapter 2, Procedural Sedation and Analgesia, and Chapter 7, Pediatric Sedation and Analgesia), with a local anesthetic such as lidocaine also used at the cutaneous site (see Chapter 4, Local Anesthesia). However, if intravenous sedative agents are unlikely to be effective because of a history of prescribed or illicit controlled substance use, or if the patient is at risk of respiratory compromise secondary to oropharyngeal anatomy, risk of aspiration, or a history of obstructive sleep apnea, a third skilled provider will be needed to provide sedation and monitor the airway. Indeed, endotracheal intubation may be advisable because these patients often have underlying conditions that impair handling of secretions. In these circumstances, the assistance of an anesthesiologist, nurse anesthetist, or trained primary care colleague is advantageous.

After PEG placement, there is no reason for routine removal; however, occasionally they require replacement owing to accidental dislodgement or because they have become obstructed, worn out, kinked, or fractured. Although most of these problems can be avoided with diligent care, this chapter also briefly discusses PEG replacement.

Indications

Placement

The decision for PEG placement has to be made on a case-by-case basis, especially when rapidly progressive and incurable diseases are present. Certainly, this includes the various forms of severe dementia.

Most commonly, PEG tube placement is performed for patients who are unable or unwilling to ingest food orally. The usual conditions include major head and neck trauma, esophageal cancer, oropharyngeal cancers, cerebrovascular accidents, esophageal dysmotility, as well as other irreversible neurologic conditions such as amyotrophic lateral sclerosis. When used for provision of nutrients, the choice of PEG placement necessarily requires a functioning gastrointestinal tract and optimally involves a prior discussion with the patient or family concerning prognosis and underlying comorbid conditions. Other uses for the PEG procedure include treatment of gastric volvulus, decompression of patients with an intestinal obstruction or peritoneal carcinomatosis, administration of unpalatable medications to pediatric and mentally impaired patients, and enhanced enteral feeding of patients with hypercatabolic states, such as burn patients.

In brief, PEG tubes have two primary indications:

1 Enteral access for feeding or medication administration

2 Decompression of the gut

Replacement

• Accidental PEG dislodgement or removal

• PEG blockage or obstruction

• PEG damage (e.g., worn out, kinked, fractured)

Contraindications

Placement

Relative

Either esophageal or oropharyngeal cancer is considered a relative contraindication because there is a theoretical potential for seeding of the gastrocutaneous tract with cancer cells. Although this hazard is rare, it is primarily seen with untreated oropharyngeal cancers, with an incidence of less than 1% in one reported series (Cruz and colleagues, 2005). Some have advocated use of the Russel or “poke” technique (see later), radiographically placed, or surgically placed gastrostomy tubes as more appropriate in this setting. With these techniques, the PEG tube is not drawn down the esophagus for placement.

The presence of gastroesophageal reflux with its attendant risk of aspiration has long been considered a contraindication to PEG. Historically, a surgically placed or, more recently, a radiologically placed jejunostomy tube has been preferred. However, jejunostomy does not prevent gastroesophageal reflux and it is now known that PEG placement may actually decrease reflux because the PEG effectively creates an anterior pseudogastropexy.

Other relative contraindications include the following:

• Portal hypertension

• Moderate or massive ascites

• Gastric varices

• Prior abdominal surgery

• Peritoneal dialysis

• Hepatomegaly or splenomegaly

• Large hiatal hernia

• Large ventral hernia

• Open abdominal wound

• Prior subtotal gastrectomy

• Morbid obesity

• Anorexia nervosa

• Infiltrative or malignant disorders of the stomach

• Limited life expectancy

Equipment and Materials

Placement

The equipment list in Chapter 101, Esophagogastroduodenoscopy, applies equally to the endoscopy needs of PEG placement. This includes topical benzocaine (e.g., Cetacaine, Hurricaine) spray, if desired. In addition, the following equipment and supplies are recommended (usually included in commercial PEG kits):

• Gloves and equipment necessary for clinician to follow universal blood and body fluid precautions

• Lidocaine 1% to 2% for local anesthesia of the skin and abdominal wall

• 22- and 25-gauge needles

• 50 or 10-mL syringe

• Antiseptic preparation solution such as povidone–iodine or chlorhexidine

• Scalpel with no. 11 blade

• 4 × 4 gauze sponges

• Fenestrated drape

• Introducer trocar

• Guidewire (standard or looped end, depending on technique used)

• Disposable snare for gastroscope

• Abdominal binder (for confused or impaired patients)

• PEG tube with external bolster

• Surgical jelly for PEG tube lubrication

• Large, 50- to 70-mL (e.g., Toomey) syringe to aspirate gastric contents

• Adapter to attach Foley catheter to feeding assembly or to cap it off

• Jejunal tube (if warranted)

• Low-profile device (Fig. 200-1)

Figure 200-1 Low-profile devices (LPD). A, Bard Button. B, Bard Gauderer “Genie.” C, Cook LPD.

Replacement

• Gloves and equipment necessary for clinician to follow universal blood and body fluid precautions

• Antiseptic preparation solution such as povidone–iodine or chlorhexidine

• 4 × 4 gauze sponges and adhesive tape

• Surgical jelly for PEG tube lubrication

• Foley catheter or commercial PEG replacement kit with PEG tube of similar diameter to the original PEG

• External bolster (Options include a retainer for a nasogastric tube, a short length [3 cm] of latex or Silicone tubing [cut from a Foley catheter or feeding tube] and a plastic cable tie or cut to form a T-bar, or a 0 or 2-0 silk suture. Commercial bolster kits are available; however, they are expensive, are not always available, and often do not properly fit the replacement PEG tube.)

• Large, 50- to 70-mL (e.g., Toomey) syringe to aspirate gastric contents

• Adapter to attach Foley catheter to feeding assembly or to cap it off

• Low-profile device (see Fig. 200-1)

Preprocedure Patient Preparation

The patient or legal guardian or family member who will be caring for the patient and assisting with tube feedings should be given a general description of EGD and the PEG placement or replacement procedure. Any available alternatives should be discussed. The possible risks and complications of these procedures need to be explained along with the symptoms and signs that might suggest late complications and problems. It is very important that caregivers be included in this conversation because patients requiring PEG frequently suffer from cognitive or neurologic impairments. Informed consent forms should be signed before EGD and PEG placement. It is prudent to provide a patient education handout and instructions to follow before the procedure(s). Diagrams and photographs are particularly useful for helping patients and families understand the anatomy and altered feeding pathway proposed with PEG placement.

Before PEG replacement, there may be an opportunity to explore with the patient or family whether PEG feeding is still the desired method of nutritional support. There may also need to be a discussion about PEG care to avoid the need for future replacement. The patient should experience minimal discomfort with PEG replacement; if there is more than minimal discomfort, the PEG should not be manipulated. Small children or anxious patients may benefit from mild sedation.

For PEG placement, it is essential to know if the patient is taking any anticoagulants or platelet-inhibiting medications and to withhold these for an appropriate interval before the procedure to minimize any risk of bleeding. The patient must have all solids and liquids withheld for at least 8 hours before the procedure to minimize risk of esophageal reflux and aspiration. Solids may need to be withheld for longer if diabetic gastroparesis or a similar neuropathic condition is present. The presence of a large phytobezoar in the gastric lumen may impair visualization of the gastric indentation by the assistant’s finger as well as the sounding needle. Unless EGD is necessary, these precautions are not needed for PEG replacement.

Antibiotic Prophylaxis

Although antibiotic prophylaxis is neither necessary nor recommended for endoscopic procedures according to the most recent American Heart Association guidelines (see Chapter 221, Antibiotic Prophylaxis), preprocedure antibiotic administration is recommended before PEG insertion because of the risk of infection of the gastrocutaneous tract from oropharyngeal and cutaneous flora. It is important to recognize that PEG placement is a “clean” procedure, not a sterile procedure, and every effort should be made to make it as clean as possible. Usually, a cephalosporin or fluoroquinolone is satisfactory unless special considerations are present, such as methicillin-resistant Staphylococcus aureus (MRSA) or Enterococcus colonization of the skin or oropharyngeal cavity. Refer to recommendations later in the discussion of abscess and wound infection in the section on Postprocedure and Late Complications. If there is no sign of local irritation or infection and only minimal discomfort is experienced during the procedure, antibiotic prophylaxis is rarely necessary during PEG replacement.

Technique

Placement

14 The assistant then inserts the catheter rapidly through the skin incision and into the gastric lumen (Fig. 200-3), making certain that the catheter is directed at the same angle with respect to the skin as was just used with the sounding needle. This rapid “poke” should not be too slow or cautious; an assertive poke is necessary to ensure that the tip of the catheter successfully penetrates the tough gastric serosa instead of merely rebounding from the gastric wall.

15 As soon as the tip of the needle catheter enters the gastric lumen, the endoscopist snares it to hold it in place (Fig. 200-4). The assistant then withdraws the inner needle, leaving the outer plastic “introducer catheter” in place.