Continuing Education Activity

Parenteral and enteral feedings are considered in patients with insufficient oral intake or contraindications to anything by mouth. Nutritional support provided includes protein or amino acids, carbohydrates, fiber, fat, water, minerals, and vitamins. Parenteral nutrition refers to the delivery of calories and nutrients via a vein whereas enteral tube feeding refers to delivering nutrition via a tube directly into the gut (stomach, duodenum, or jejunum). Enteral feeding is superior to total parenteral nutrition (TPN) due to fewer infectious complications, reduced cost, earlier gut function, preservation of gut mucosa and immune function, and reduced hospital length of stay. This activity describes the indications, contraindications, technique of PEG tube insertion, and highlights the role of the interprofessional team in the management of patients requiring nutrition.

Objectives:

• Identify the technique of PEG tube insertion.
• Describe the indications for PEG tube.
• Review the complications of a PEG tube.
• Outline interprofessional team strategies for improving care coordination and communication to advance management of patients requiring a PEG tube and improve outcomes.

Introduction

Parenteral and enteral feedings are considered in patients with insufficient oral intake or contraindications to anything by mouth. Nutritional support provided includes protein or amino acids, carbohydrates, fiber, fat, water, minerals, and vitamins. Parenteral nutrition refers to the delivery of calories and nutrients via a vein whereas enteral tube feeding refers to delivering nutrition via a tube directly into the gut (stomach, duodenum, or jejunum). Enteral feeding is superior to total parenteral nutrition (TPN) due to fewer infectious complications, reduced cost, earlier gut function, preservation of gut mucosa and immune function, and reduced hospital length of stay.[1] Enteral tube feeding is placed via the nose (nasogastric/nasoduodenal/nasojejunal), mouth (orogastric), or direct percutaneous route (percutaneous endoscopic gastrostomy/gastrojejunostomy tube). Although other methods of enteric feeding, such as nasal and oral tubes, are performed bedside or by interventional radiology, percutaneous needs surgical intervention. 

Percutaneous endoscopic gastrostomy (PEG) tubes serve as the favorable route of feeding and nutritional support in patients with a functional gastrointestinal (GI) system who require long-term enteral nutrition, usually beyond 4 weeks.[2] As PEG tubes provide direct percutaneous access to the stomach, another indication for PEG placement includes stomach decompression. Broadly, the major uses for PEG tube include nutrition supplementation and stomach decompression. PEG tube placement is one of the most common endoscopic procedures and is a relatively safe procedure, barring minor and major complications.[2]

Anatomy and Physiology

Prior to insertion, the provider visualizes the patient's abdomen and reviews any imaging as prior surgery may prevent proper tube placement. The patients are usually sedated and provided local anesthetic. A physician familiar with the endoscope inserts the gastroscope and inflates the stomach. The light source is visible through the skin, and the clinician marks the area for insertion of the tube, usually 2-cm medial to the costal margin and 2-cm below to the xiphoid process. After local sedation, they insert the tube and visualize a gastrocutaneous fistula or direct track between the anterior gastric wall and abdominal wall to confirm placement.[3]

Indications

PEG tube is indicated in patients for long-term feeding (more than 30 days) with moderate-to-severe protein-calorie malnutrition.[2] Clinically, the patient's realistic life expectancy and goals, diagnosis, and ethical preferences need to be considered and discussed with the patient and family to obtain informed consent. In some conditions, not only is the patient's survival and nutritional status improved but also their quality of life. Such conditions for which patients are referred for PEG placement include stroke, motor neuron disease, multiple sclerosis, Parkinson disease, cerebral tumors, head and neck cancers, burns, cystic fibrosis, abdominal malignancy, esophageal malignancy, prolonged coma, neurologic diseases and psychomotor retardation, HIV/AIDS, cystic fibrosis, Crohn disease, short bowel syndrome, and distal gastric obstruction.[2] In these conditions, dysphagia, impaired self-feeding, obstruction of gastrointestinal tract preventing enteral access, malnutrition secondary to malignancy or reduced oral nutrition supplementation from radio/chemotherapy, or need for gastric decompression are all the main indications for PEG placement.

Contraindications

Absolute contraindications to PEG tube placement include the following[2]:

• Serious coagulation disorders (INR greater than 1.5, PTT greater than 50 seconds, PLT less than 50,000/mm3)
• Hemodynamic instability
• Sepsis
• Severe ascites
• Peritonitis
• Abdominal wall infection at the placement site
• Peritoneal carcinomatosis
• Lack of a safe tract for percutaneous insertion
• Gastric outlet obstruction and severe gastroparesis (if used for feeding)
• History of total gastrectomy
• Prolonged ventilation assistance
• Lack of informed consent

Relative contraindications include a history of partial gastrectomy and large intrathoracic hiatal hernia.[4]

Equipment

• Endoscope/Gastroscope
• Skin preparation: Alcohol swabs/povidone iodine swabs
• No. 11 blade
• Lidocaine for local sedation
• Sterile gown and gloves
• PEG tube kit including 14-to18 gauge needle, a guide wire, sheath, feeding tube, skin disc
• Dressing: 2 x 2 or 4 x 4 gauze, adhesive tape

Personnel

PEG tube placement is performed with 2 operators, usually an experienced endoscopist and surgeon, at the bedside, operating room, or endoscopy suite. An anesthetist and endoscopy nurse are also required to provide sedation and aid with endoscopy equipment and oral suction as needed.[4]

Preparation

Prior to PEG placement, it is important to visualize the patient's abdomen, past medical and surgical history, and any relevant imaging to optimize the location of the tract for feeding tube insertion. The patient is positioned supine with the head of the bed raised to 30 degrees to prevent aspiration. A bite block is usually used to allow for more open access to the scope, and suction is also made available for secretions and prevent the risk of aspiration. If the patient is not comatose, the patient usually undergoes mild sedation with only 1 to 2 mg of benzodiazepine and a small dose of narcotic to relax the patient. The patient also receives location anesthetic, generally lidocaine, at the tube insertion site. The site is then made sterile with alcohol, povidone-iodine swabs, or sterile soaps and the field is prepped with sterile drapes.[4]

Technique or Treatment

There are 3 techniques for PEG tube placement: the peroral pull technique (Ponsky), the peroral push technique (Sacks-Vine), and the direct percutaneous procedure (Russell), of which the first is the most commonly used.[5] All of these techniques have the same initial steps. After the preparation mentioned above, the endoscope is passed into the stomach via the mouth and the stomach is insufflated and transilluminated. The area is marked for insertion (about 2-cm medial to the costal margin and 2-cm below the xiphoid process), and lidocaine is injected. A small incision is made with the no. 11 blade and a 14- to-18-gauge needle is passed through the incision and identified on the endoscopy camera.

Russell Technique

Russell technique is rarely used. After the setup above, the guidewire is passed through the needle and identified inside the stomach by the camera and the needle is removed. The dilator is passed over the guide wire and then the sheath until visible in the stomach. The feeding tube is then passed through the sheath into the stomach, and after visualizing the tube, the balloon of the feeding tube is inflated inside the stomach, and the tube is pulled to the anterior abdomen and clipped percutaneously via a skin disc. The length of the tube at the level of the skin (approximately 3 to 4 cm) and tightness is noted.[5]

Sacks-Vine Technique 

Sacks-Vine technique (preoral push) has the guidewire passed through the needle and entrapped by a snare passed through the endoscope. Once the wire is securely entrapped, the needle is removed, and the endoscope with the snare and guide wire is withdrawn from the mouth. Once enough guide wire is visible through the mouth, the feeding tube is inserted over the wire and pushed down through the mouth. The tapered end of the feeding tube is caught as it emerges on the skin and is withdrawn to approximately 3 to 4 cm from the anterior abdominal wall. The guide wire is then withdrawn, and the endoscope is reinserted into the stomach to ensure proper positioning of the feeding tube. The skin disc is secured over the feeding tube to hold the tube in place, and the length of the tube and tightness are noted.[5]

Ponsky Technique

Ponsky technique (preoral pull) is the most commonly used and is similar to the Sacks-Vine technique; however, it requires pulling the feeding tube rather than pushing it. A braided suture is passed through the needle and entrapped by a snare passed through the endoscope. The needle is removed, and the endoscope with the snare and suture is withdrawn from the mouth. The feeding tube is attached to the rope is withdrawn from the stomach as the tube is carefully guided from the patient's mouth into the stomach and pulled through the anterior abdominal wall. The endoscope is re-inserted into the mouth to visualize the proper positioning of the feeding tube on the stomach wall. The skin disc is placed to hold the tube in position, and the length and tightness of the tube are noted.[5]

Post-operatively, the site should be kept clean, and the stoma should be examined for any signs of infection (erythema, pain,  purulent leakage). Traditionally, feeds were started on the following post-operative day. However, many studies found that feeding initiated as early as 4 hours after PEG placement is safe.[5] The tube should be rotated 180 degrees and moved up and down about 1 to 2 cm in the stoma site daily after the stoma has healed and should be flushed before and after each feed to prevent tube blockage.[5]

Complications

Although PEG tube placement is a relatively safe procedure, there are several minor and major complications to note. Some minor complications reported include peristomal wound infection, granuloma formation, tube leakage into the abdominal cavity causing peritonitis, stoma leakage, inadvertent PEG removal, tube blockage, pneumoperitoneum, and gastric outlet obstruction. Major complications include aspiration pneumonia (particularly with a weak lower esophageal sphincter), hemorrhage, buried bumper syndrome, perforated viscus, necrotizing fasciitis, colonic fistula (due to misplacement of the PEG tube), and metastatic seeding.[5]

Clinical Significance

PEG tube is indicated in patients for long-term feeding (more than 30 days) with moderate-to-severe protein-calorie malnutrition. Clinically, the patient's realistic life expectancy and goals, diagnosis, and ethical preferences need to be considered and discussed with the patient and family to obtain informed consent. In some conditions, not only is the patient's survival and nutritional status improved but also their quality of life.

Enhancing Healthcare Team Outcomes

Assessing and optimizing nutrition status in patients is an interprofessional team effort. Multiple protocols and recommendations based on the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) have shown clear evidence that an organized, interprofessional approach to enteral management versus non-team effort provides the most positive effects for patient care (Level 1).[5] PEG tube insertion requires an experienced endoscopist, surgeon, and an anesthetist; however, after placement of the tube, management requires an entire nutrition support team. A well-organized nutrition support team consists of a physician, nurse, and nutritionist. Multiple studies have shown a reduction in mortality, hospital costs, length of hospital stay, and readmission rates in community and university hospital centers which have implemented this interprofessional team-based approach to nutrition status of patients.[5]