Denni Arrup, BA, RN, CGRN, CFER
November 8, 2014

• History
• Uses
• Contraindications
• Procedure
• Complications
• Equipment

• Definition: Percutaneous Endoscopic
Gastrostomy Tube
• Medical device used to provide nutrition and medications
• Temporary or permanent
• Patients unable to obtain nutrition by mouth, swallow safely or need supplementation

• Made of polyurethane or silicone
• Diameter is measured in French units (each
French unit = 0.33 millimeters). Most common for adults is 20 Fr.
• Classified by site of insertion and intended use

• 3500 years ago to Greek and Egyptian civilizations
• Papyrus writings: Egyptian physicians used reed and animal bladders to rectally feed patients things like milk, broth, wine, whey to treat different complaints
• Rectal feeding – method of choice for thousands of years

• Difficulty accessing upper GI tract without killing the patient. Some things remain important to this day: not killing the patient
• 1598: Capivacceus used a hollow tube with a bladder attached to one end, filled with nutrient solution, down as far as patient’s esophagus
• 1617: Aquapendente (Italian professor of anatomy and surgery) used silver tube as a nasopharyngeal tube

• 1646: Von Helmont devised flexible leather tube for feeding into the top of esophagus
• 1710: Tubing might be used to reach all the way to the stomach
• 1790: Oro-gastric feeding developed by John
Hunter, used a whale bone covered by eel skin attached to a bladder pump.

• 18 th and 19 th centuries: difficult and uncomfortable to keep tube down a person’s throat – rectal feeding was more accepted.
(you thought colonoscopies were messy)
• 1870: Tube was placed in mouth back toward pharynx and mixtures of thick custards, mashed mutton, warm milk, beef broth, eggs and medications were given.

• US President James Garfield was shot and kept alive 79 days by being rectally fed a blend of beef broth and whisky.
• Rectal feeding (nutrient enemas) was popular in the early 1900’s – gone out of fashion
(thankfully).
• Some medical students have re-discovered that colonic absorption is a very fast way to get drunk. Not a very clean method. . .

st
• June 12, 1979 at the Rainbow Babies and
Children’s Hospital, University Hospitals of
Cleveland
• Performed by:
– Dr. Michael W.L. Gauderer, pediatric surgeon
– Dr. Jeffrey Ponsky, endoscopist
– Dr. James Bekeny, surgical resident

st
• Patient: 4 ½ month old child with inadequate oral intake
• Technique was first published in 1980 – gold gold standard for PEG placement

• ‘Fasting girls and spoilt children who refused food’
• Device that looked like a tea pot with a very long spout were used to force-feed patients in mental institutions – mixtures of egg, milk, beef tea and wine thickened with arrowroot

• Dysphagia due to stroke
• Pre-op - for oral/esophageal cancer surgery
• ALS
• Anatomical: cleft lip and palate during the process of correction
• Failure to thrive: premies to adults
• Persistent N/V during pregnancy

• Gastric decompression – major trauma or intestinal obstruction
• Provide gastric or post-surgical drainage

• Liquid form of medication (elixir)
• Carafate slurry
• Administer medications as per guidelines

C ONTRAINDICATIONS

• Inability to perform an EGD
• Peritonitis
• Massive ascites (untreatable)
• Uncorrected coagulopathy
• Bowel obstruction (unless PEG is to be used for drainage)

• Gastric mucosal abnormalities: large gastric varicies, portal hypertensive gastropathy
• Previous abdominal surgery
• Morbid obesity
• Gastric wall neoplasm

Collects all supplies needed for PEG
• PEG kit
• Sterile gloves for GI tech and MD
• Sterile bowl for collecting sharps
• Sterile 4x4’s
• Marking Pen
• Gowns
• Consents for procedure and sedation
• Antibiotics and tubing, if required

• Consent
• Advance directives
• Obtain current set of vital signs, weight (kg), height (cm)

• Patient assessment
• Medications
• Labs
• NPO

• Explain procedure to patient
• Take patient to room
• Insert bite block
• Drape patient

• Perform time out
• Sedation
• Endoscopy performed

• Open PEG Kit
• Scrub
• Mark
• Medicate
• Trocar

• Stylet
• Snare
• Retrieve
• Insert guidewire

• Grab guidewire
• Scope withdrawn
• Guidewire threaded into insertion tube

• MD will pull guidewire – insertion tube comes through skin
• MD pulls insertion tube
• MD positions PEG in place

• GI tech places external bumper and clamp on tube
• MD confirms placement of PEG
• GI tech inserts adapter on tube
• Measurement of tube given to RN for record

• Assess patient – abdominal binder?
• Patient moved to recovery
• Call report to floor or nursing home

C OMPLICATIONS

• Hemorrhage
• Cellulitis
• Gastric ulcer
• Perforation of bowel
• Puncture of left lobe of liver
• Gastrocolic fistula
• Diarrhea

• Flush PEG tube
• Use brush to create opening in clogged tube
• Instill grapefruit juice or lemon-lime soda and let sit 10 minutes
• Much easier to keep the lumen flushed

• SKIP
• Wash PEG site with soap and water as part of daily cleansing routine
• Check VS – temperature
• Check labs - WBC

• Turn the PEG tube – 360 with feedings/flush
• Check for PEG tube measurement

• Occurs
– when the gastric bumper migrates into the gastric wall
– when the external bumper is too tight on the outside, causing pressure on the gastric bumper, eroding into the stomach wall at site of stoma
• Abdominal pain, crepitus around stoma, purulent drainage

R EMOVAL OF PEG

• PEG tube no longer needed
• Persistent infection at the PEG site
• “Buried Bumper Syndrome”
• Failure, breakage or deterioration of PEG tube

• PEG tubes with rigid, fixed internal bumpers are to be removed endoscopically.
• Bumper removed
• Cut tube pushed into stoma
• Insert snare

• Pull snare with scope
• Place endoclip
• Dress skin

N EW U SES

ASPIRE
• Low risk method of weight loss
• Developed by 3 physicians:
– Dr. Sam Klein – Director of the Center for Human
Nutrition at Washington University School of
Medicine in St. Louis, Missouri
- Dr. Moshe Shike – Attending Physician and
Director of Clinical Nutrition at Memorial Sloan
Kettering Cancer Center in New York
- Dr. Stephen Solomon – Attending Physician and
Chief of IR at Memorial Sloan Kettering

Aspire Bariatrics founded in 2005 by
Drs. Klein, Shike and Solomon
• These 3 physicians combined their expertise in the areas of nutrition, obesity, gastroenterology, interventional radiology, percutaneous endoscopic gastrostomy (PEG) tubes and medical device discovery
• Modified and adapted the PEG tube to help patients lose weight

• Minimally invasive
• Reversible
• ‘AspireAssist’ available in Europe
• Clinical trials in the United States
• Dramatic results – patients have lost an average of 46 pounds during the first year

• During an outpatient procedure in an endoscopy center or surgi-center, the patient would meet all the requirements for an endoscopy: NPO for 8 hours, labs and EKG, sleep study if needed, heart and blood pressure medications taken with a sip of water prior to arrival, ride home verified before procedure

• Consent obtained by anesthesia and endoscopist
• Procedure explained to patient with possible complications
• Discharge instructions reviewed with patient so he/she able to care for the fresh PEG
• Diet – normal food, drink and amounts
• Follow up visit scheduled for 10 days

• No diet change needed to begin
• Patient to learn healthier eating habits over time
• Relatively inexpensive – cost of AspireAssist device, PEG tube insertion with anesthesia
• Bariatric surgery very expensive

• After a meal, the patient can attach the
Aspire Assist device to the skin port on the outside of the abdomen. The valve on the skin port is opened to remove 30% of stomach contents into the toilet

• This ‘aspiration’ takes place 20 minutes after consumption of a meal.
• Time needed to perform procedure – 5 to 10 minutes
• Weight loss is attained because 30% of stomach contents removed 3 times/day (with each meal), resulting in less caloric intake in small intestines

• New way to reduce portion size
• Vitamins will be prescribed to keep healthy
• Counseling sessions
• Important to drink plenty of fluids to assist with aspiration

• Care is similar to PEG care –
• Activity is encouraged, no deep-water diving

• Reversible if not needed or wanted
Weight loss achieved
Changed mind
 Removal is same as for PEG removal
 Procedure under sedation to remove device
 Clip the opening on the inside of the stomach
 Steristrips on the outside of the opening
 Closes within 2-3 days.

• 20 Fr PUSH PEG
• 20 Fr PULL PEG
• 24 Fr PUSH PEG
• 24 Fr PULL PEG

• Flow 20 Pull Method
• Flow 20 Push Method
• Peg 20 Jejunal tube
• Peg 24 Jejunal tube

• CORFLO feeding tubes

1
• Familiarize yourself with
PEG procedure
2 • Explore the equipment
3
• Review the steps for a smooth placement

4 • Review contraindications
5 • Review complications
6
• Review removal procedure

• INS
– History
– Procedure
– Contraindications
– Uses

• OUTS
– Removal
– Procedure

 Aadhaar (2012, March 14). You start with a tube…: Tubefeeding – a brief history [Web log post]. Retrieved from http:// youstartwithatube.blogspot.com/2012/03/tubefeeding-briefhistory.html
 Phillips, N. (2006). Nasogastric tubes: An historical context. Medsurg
Nursing, 15(2), 84-88.
 Ponsky, J. (2011). The development of PEG: How it was. J Interv
Gastroenterology, 1(2), 88-89

 Ponsky, J. & Gauderer, M. (1981). Percutaneous endoscopic gastrostomy: a nonoperative technique for feeding gastrostomy. Gastrointestinal Endoscopy,
27(1), 9-11.
 Sullivan, S., Stein, R., Jonnalagadda, S., Mullady, D., & Edmundowicz, S.
(2013). Aspiration therapy leads to weight loss in obese subjects: A pilot study. Gastroenterology, 145(6), 1245-1252.

Q UESTIONS ?