Percutaneous
Endoscopic Gastrostomy
John P. Grant, MD
Duke University Medical Center
Nutritional Rule!
IF THE GUT WORKS – USE IT
IF NOT – MAKE IT WORK
IF YOU FAIL – TRY AGAIN!
Advantages of Enteral Nutrition
• Stimulates gallbladder emptying and
reduces sludge and stone formation.
• Avoids steatosis by increasing release of
enteroglucagon into portal circulation.
• Maintains gut-associated lymphoid tissue
(GALT).
• Suppresses cytokine response.
Advantages of Enteral Nutrition
• Less expensive
• Less risk of sepsis
• Less nursing time required
Enteral Access
The Gastrostomy Tube
History of Gastrostomy
1837 Egeberg proposed as possible.
1839 Sedillot performed gastrostomy in
dog.
1846 Sedillot performed gastrostomy in 3
patients – all died of peritonitis.
1876 Verneuil performed first successful
gastrostomy in man.
History of Gastrostomy
1891 Witzel developed serosal tunnel.
1894 Stamm - concentric pursestring.
1913 Janeway - permanent gastrostomy.
Beck-Jianu - gastric tube.
1981 Gauderer & Ponsky - PEG tube.
Enteral Access
Percutaneous Endoscopic
Gastrostomy (PEG)
A Simplified Technique for Constructing a Tube
Feeding Gastrostomy
Michael W.L. Gauderer, M.D., and Jeffrey L. Ponsky,
M.D., F.A.C.S., Cleveland, Ohio
Surgery, Gynecology & Obstetrics – January 1981 – Volume 152
Bard PEG Kit
Sherwood, Davis, & Geck PEG Tube
Inverta-PEG from Abbott Laboratories
PEG Gastrostomy
Optimal Exit Site for Gastrostomy Tube
PEG Gastrostomy
PEG Gastrostomy
PEG Gastrostomy
PEG Gastrostomy
PEG Gastrostomy
Number of PEG’s Performed at
Duke University Medical Center
300
Number
250
200
150
100
50
0
85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00
Year
PEG Insertion
Do’s and Don'ts of PEG Gastrostomy
• Do not place in patients with ascites.
• Do not place in patients with gastric
varices.
• Do not attempt placement unless light is
seen sharply through abdominal wall
and/or indentation is clearly visible with
external compression.
Do’s and Don'ts of PEG Gastrostomy
• Do give perioperative antibiotics.
• Do evaluate stomach and pylorus during
endoscopy.
• Do make the exit site 1.5 x diameter of the
feeding tube.
• Do loosen retainer after 5 to 7 days.
Do’s and Don'ts of PEG Gastrostomy
• Do NOT get a chest or KUB x-ray to
evaluate postoperative abdominal pain.
– There will nearly always be free air and it will
often be a considerable amount.
• Order a Gastrografin injection of the tube
to evaluate proper tube placement.
– This test will not always detect a leak about
the tube into the abdominal cavity.
Chest X-ray
Chest X-ray
Pneumoperitoneum
from endoscopy.
Patient did well.
Chest X-ray
Chest X-ray
Leak from
gastrostomy
tube. Patient
had an acute
abdomen and
required
urgent
surgery.
Gastrografin
Tube Check
Gastrografin
Tube Check
Pneumoperitoneum
but no leak from
gastrostomy site.
Patient did well.
Gastrografin
Tube Check
Gastrografin
Tube Check
Obvious leak from
gastrostomy site.
Patient had an
acute abdomen.
Gastrografin
Tube Check
Gastrografin
Tube Check
False negative
Gastrografin
study. Patient
had an acute
abdomen.
Do’s and Don'ts of PEG Gastrostomy
• Make decision on whether to explore the
abdomen based on clinical examination and
laboratory data.
• If leak is present, repair and tack stomach
up to abdominal wall x 4.
• Thoroughly irrigate abdomen.
• Wrap omentum about gastrostomy site.
A PEG can be placed safely in
patients with prior upper or lower
abdominal surgery….
As long as finger indentation or
light transillumination is
satisfactory.
Placement of PEG in Patients with Prior
Abdominal Surgery (1778 tubes)
Hysterectomy
147
Small bowel resection
13
Cholecystectomy
87
Splenectomy
9
Exploratory lap., lysis adhesions
71
Perforated duodenal ulcer
8
Appendectomy
70
Nissen fundoplication
6
Subtotal gastrectomy (BI or BII)
35
Aortobifemoral bypass graft
5
Abdominal Aortic Aneurysm
30
Cesarian section
4
Colectomy
30
Pancreatectomy
3
Ventriculoperitoneal shunt
17
Portocaval shunt
1
Cystectomy with ileal loop
13
Repair diaphragmatic hernia
1
Total with prior surgery: 550
3 failures, no complications
Duke Experience With PEG
34
24
12
3
2
6
1
1
83
1778 Patients
Leakage about gastrostomy site
Exit site infection (8 major)
Peritonitis (12 major: 1 died, 6 exp lap, 5 antibiotics
only)
Colonic injury
Aspiration pneumonia from endoscopy
Bleeding at gastrostomy site
Fracture of alveolar ridge opening mouth in OR
Esophageal laceration on removal (major)
Overall 4.7%
Major 1.3% (23)
Complications of PEG Gastrostomy
Author
Duke PEG
1.3%
#
Years
Ponsky
307
1983
Sangster
155
Miller
Minor
All
2
2
4
1988
5
25
29
330
1988
7
7
14
Saunders
136
1991
4
3
7
Gibson
334
1992
32
5
37
Total 1262
4.0%
3.3%
7.3%
Duke PEG 1778
1.3%
3.4%
4.7%
10%
8%
18%
Stamm 1438
1934-80
Major
4.7%
Alternate Enteral Access
Laparoscopic Gastrostomy
Ross Laparoscopic Gastrostomy Kit
Trocar Sites and Gastrostomy Exit Site
10-mm trocar
Laparoscopic Gastrostomy Movie
Advantages PEG
• Does not require general anesthesia.
• Minimal OR time (15-20 minutes).
• Prior surgery of little concern.
• Can evaluate gastric and duodenal
mucosa.
• But: can injure colon or liver and poses
serious problem if accidentally removed.
Advantages Lap G-Tube
• Avoid injury to colon or liver.
• Securely attach stomach to abdominal
wall, less concern accidental removal.
• Gastrostomy tube easier to remove and
replace.
• But: does require general anesthesia
and up to 45 minutes OR time.
Enteral Access
Button Gastrostomy
Stomate Button Gastrostomy – Abbott Labs
Can replace standard G-tube after 3-4 weeks
PEG Tube Complications
Necrotizing Fasciitis
Necrotizing Fasciitis
Necrotizing Fasciitis
Necrotizing Fasciitis
Necrotizing Fasciitis
• Occurs most commonly in settings of:
– Concomitant infections, multiple
antibiotics
– Malnutrition, elderly, diabetics
– Low output syndromes
– Steroids, chemotherapy, or
immunosuppression
Treatment of Necrotizing Fasciitis
• Ensure adequate nutrition continues.
– Nasojejunal tube, jejunostomy, TPN
• Neutralize gastric acid.
• Give antibiotic (Keflex) via feeding tube.
Treatment of Necrotizing Fasciitis
• ± Give systemic antibiotics.
• Change dressing qid, antibiotic
ointment.
• Protect skin (drainage bag).
• If all else fails – remove feeding tube.
Necrotizing Fasciitis
PEG Tube Complications
Hypertrophic Granulation
Tissue
Normal PEG Exit Site
Hypertrophic Granulation Tissue
Tissue Sharply Cut Away
Base Cauterized with Silver Nitrate
Complications of Enteral Nutrition
Accidental Tube Withdrawal
Accidental Tube Withdrawal
PEG Gastrostomy
• <72 hours: Emergent laparotomy
(laparoscopy) to replace tube and
secure stomach to abdominal wall.
• >3 to 7 days: Replace in radiology
under fluoroscopy.
• >7 days: Replace at bedside checking
placement with tube check in radiology.
Accidental Tube Withdrawal
Laparoscopic Gastrostomy
• <72 hours: Replace in radiology under
fluoroscopy.
• >72 hours: Replace at bedside with
tube check in radiology.
• >7 days: Replace at bedside checking
placement by aspiration of residuals.
Complications of PEG
Patient Selection
Patient Selection
Scolapio et al. NCP 15:36, 2000
• 32 patients received PEG following stroke.
• 9/14 (64%) died within 4 weeks
• Cost-benefit ratio favors PEG placement only
in patients likely to survive and have
dysphagia for > 4 weeks.
Patient Selection
Scolapio et al. NCP 15:36, 2000
• Patients likely to regain swallow function
< 4 weeks:
– Age < 60
– Limited comorbidities
– Nonhemorrhagic stroke
– Mild oropharyngeal dysphagia
Patient Selection
Grant et al. J.A.M.A. 279:1973, 1998
• Mortality in 81,105 patients, 65 years or
older, with Cerebrovascular disease,
neoplasms, fluid and electrolyte disorders,
and aspiration pneumonia.
– In-hospital mortality was 15.3 %
– 30 day mortality was 23.9 %
– 1 year mortality was 63.0 %
– 3 year mortality was 81.3 %
Patient Selection
Abuksis et al. Am. J. Gastroenterol., 95:128, 2000
• Two groups of patients were compared:
Group 1 - patients from nursing homes
Group 2 - hospitalized patients
Group 1
Group 2
30-Day Mortality Overall Mortality
13%
38%
29%
66%
Patient Selection
Abuksis et al. Am. J. Gastroenterol., 95:128, 2000
• They concluded:
– Patients hospitalized with acute illness are
at high risk for serious adverse events
after PEG insertion and the procedure
should be avoided.
– Only stable patients benefit from early
gastrostomy.
Mortality Following PEG in ICU’s
DUMC 1998-1999
100
Number
80
60
ALIVE
40
DEAD
20
0
21%
38%
NICU
MICU
Days to Death: Ave = 16
Median = 13
Patient Selection
Stable Patients
• All stable patients can be considered for
early gastrostomy if feeding access
anticipated to be needed for >30 days.
Patient Selection
Acutely Ill Patients
• All acutely ill patients should be nourished
by nasoenteric tube for the first 30 days.
• If surviving 30 days, acutely ill patients
can be considered for a gastrostomy on
an individual basis.
– The tube should be placed about 1
week prior to discharge from the
hospital.
Percutaneous
Endoscopic Gastrostomy
John P. Grant, MD
Duke University Medical Center
Loosen retention disk after 5 to 7 days
Pull tube out and release
If tube pulls back in:
Stomach probably not
attached. Retighten disk
and recheck in 3-5 days.
If tube does not pull
in: Stomach is
probably attached.