Continuing Education Activity

Percutaneous endoscopic gastrostomy (PEG) and percutaneous endoscopic gastro-jejunal (PEG-J) tubes are common procedures in the management of patients who require long-term nutritional support. This activity outlines the indications, contraindications, and potential complications of this procedure and highlights the role of an interprofessional team in caring for patients who require and undergo placement of percutaneous gastrostomy and jejunostomy.

Objectives:

• Identify the indications of the placement of percutaneous gastrostomy and jejunostomy tubes.
• Describe the technique required for the placement of percutaneous gastrostomy and jejunostomy tubes.
• Review the potential complications of percutaneous gastrostomy and jejunostomy procedures.
• Outline the importance of collaboration and communication among the interprofessional team to facilitate the appropriate selection of candidates for percutaneous gastrostomy/jejunostomy and its postprocedure management.

Introduction

Percutaneous endoscopic gastrostomy (PEG) and percutaneous endoscopic gastro-jejunal (PEG-J) tubes are common procedures in the management of patients who require long-term nutritional support. They serve as alternatives to enteral feeding and laparotomy-guided placement of feeding tubes. PEG tube placement was first introduced in 1980 and has a success rate of more than 95%. Patients typically require moderate sedation, and the estimated procedure-related mortality is 0.5%. 

PEG and PEG-J tubes are important in patients with barriers to oral feeding, including benign or malignant conditions, iatrogenic causes such as radiation therapy that can lead to mechanical obstruction in the esophagus, motility disorders of the esophagus, neurologic causes resulting in oropharyngeal dysphagia, psychosomatic issues such as dementia, and mental retardation or developmental delay.

In PEG tube placement, a tube is inserted directly into the stomach through the abdominal wall. In PEG-J tube placement, an extension is placed via the existing PEG tube into the jejunum to allow jejunal feeding. The latter is particularly useful in patients at high risk of aspiration from gastric feedings such as those with gastroparesis, gastric outlet obstruction, severe gastroesophageal reflux disease (GERD), gastric resection, history of repeated aspirations, or those who cannot tolerate gastric feeding. The placement of a PEG-J tube, however, has not been shown to prevent aspiration.[1][2][3][4]

Indications

PEG and PEG-J tube placement is indicated when there is a mismatch between calorie intake and metabolic demands. Patients who have poor oral intake and require long-term nutritional support for more than 30 days benefit from these procedures. Common indications include:[5]

• Reduced levels of consciousness, such as in a head injury or prolonged intensive care unit stay.
• Neurologic conditions such as cerebrovascular accidents, dementia, Parkinson disease, cerebral palsy, multiple sclerosis, and motor neuron disease.
• Neoplastic disease-causing dysphagia, such as esophageal cancer, oropharyngeal cancer.
• Gastric outlet obstruction or advanced peritoneal carcinomatosis with bowel obstruction for decompression.
• Gastrointestinal (GI) dysmotility such as that in gastroparesis.
• Malnourishment, cystic fibrosis, burns, short bowel syndrome, chronic pancreatitis.
• Facial trauma

Contraindications

Medical necessity should be established before the procedure. Contraindications can be divided into two groups:[6]

Absolute contraindications:

• Sepsis
• Hemodynamic instability
• Severe ascites
• Peritonitis
• Coagulopathy (international normalized ratio (INR) greater than 1.5 or a platelet count of less than 50000/uL)
• Abdominal wall infection at the site of insertion
• Interposed organs (colon is the most common organ)
• Total gastrectomy
• Lack of informed consent for the procedure
• Failure to apposition the anterior gastric wall with the abdominal wall.

Relative contraindications:

• Obesity (might hinder transillumination during the procedure and finding the appropriate site on the abdominal wall)
• Presence of non-obstructive oropharyngeal or esophageal malignancy
• Hepatomegaly
• Splenomegaly
• Peritoneal dialysis
• Gastric varices
• Partial gastrectomy

Equipment

Several commercially available kits and variations in techniques have been introduced. In gastroenterology practice, an endoscope is needed for the transillumination and performance of the procedure. The technique is summarized below. Generally, the PEG tube kit includes a silicone tube (for example, high-grade silicone dome-bolstered PEG tube), universal retrieval snare, tray packaging to improve the efficiency of the procedure, and external bolsters. Radiologic placement of PEG and PEG-J tubes can be slightly different, and it does not require an endoscope.

Personnel

A gastroenterologist/endoscopist, a second operator, and support staff, including a nurse, are needed to perform the procedure. While this procedure is typically performed with moderate sedation, an anesthetist/anesthesiologist is usually present when monitored anesthesia care is the recommended type of sedation for certain patients. When these tubes are placed by the radiology team, a gastroenterologist/endoscopist is not present.

Preparation

Informed consent must be obtained from the patient or their legal representative. Patients should fast overnight (about 8 hours) and receive prophylactic intravenous antibiotics 30 minutes to 1 hour prior to the procedure.[7][8]

The following antibiotic regimens are preferred depending on the methicillin-resistant Staphylococcus aureus (MRSA) status:

In patients who test negative for MRSA or when the MRSA risk is absent, cefazolin 2 g for patients weighing less than 120 kg or 3 g for patients weighing more than or equal to 120 kg intravenously (IV). If penicillin or cephalosporin hypersensitivity is present, clindamycin 900 mg IV is preferred. If the procedure is prolonged, another dose of cefazolin should be given 4 hours after the first dose (6 hours for clindamycin).

In patients who test positive for MRSA or in those where MRSA risk is present, decontamination should be attempted if feasible. Vancomycin 15 mg/kg (maximum 2 g) IV given over 60 to 90 minutes with the infusion starting within 120 minutes before surgical incision is preferred. Redosing is not necessary if the procedure is prolonged.

Technique or Treatment

Several different techniques have been developed for PEG tube insertion. Herein we describe the three most commonly used:

The first step of all techniques involves finding the PEG tube insertion site on the abdominal wall via endoscopic trans-illumination and one-to-one indentation.

The "pull" technique is most commonly used and was initially introduced by Gauderer et al. A string is attached to a needle and inserted via the abdominal wall into the stomach. It is grasped with endoscopic biopsy forceps or a snare, and then the endoscope is retracted, taking out the string through the esophagus and mouth. Then the string is attached to the external end of the PEG tube, and the string is pulled back through the abdominal wall. This results in pulling the tube from the mouth to the esophagus, the stomach, and then outside the body through the abdominal wall.[9]

In the "push" technique, a guidewire is inserted into the stomach (similar to the "pull" technique) and is pulled out through the mouth as the endoscope is retracted. Then, the feeding tube, the external end going first, is pushed over the guidewire, goes into the stomach, and comes out of the puncture site.[10]

The introducer (Russell) technique utilizes the Seldinger method. A guidewire is placed into the stomach under endoscopic view. Then, a dilating catheter, as well as sheath, is passed over the guidewire. After removal of the guidewire, the PEG tube is advanced through the peel-away sheath.

Several videos are available for free and can be viewed online. We recommend the videos published by national medical societies.

Complications

Percutaneous endoscopic gastrostomy tube insertion is generally considered a safe procedure and is successful in at least 95% of patients. However, complications can occur. While most studies report low procedure-related mortality, the mortality rate may increase in patients with underlying comorbidities.[11]

Complication rates of PEG-J have not been studied separately, and are believed to be similar to those associated with PEG tube placement.

Major Complications

• Hemorrhage
• Aspiration pneumonia
• Buried bumper syndrome
• Necrotizing fasciitis
• Perforation of bowel
• Metastatic seeding

Hemorrhage involves bleeding from the PEG tract, gastric artery, mesenteric or splenic vein injuries, and rectus sheath hematoma.[12][13] While applying pressure over the abdominal wall might be sufficient for mild cases, endoscopic or surgical exploration may be required in select cases.

Aspiration pneumonia is a serious as well as a potentially fatal complication associated with PEG tube feeding. Its risk increases with high-volume feeding and prone position.[14]

The buried bumper syndrome occurs when there is excessive tension between the external and internal bumpers causing ischemic necrosis of the gastric wall, which may lead to migration of the PEG tube towards the abdominal wall. As a result, the tube may dislodge, resulting in peristomal leakage, feeding problems, and/or swelling and pain at the insertion site.[15] The tube should be removed as soon as the diagnosis is made to avoid serious complications such as peritonitis and gastric perforation.

Necrotizing fasciitis is very rare. Pressure and traction on the PEG tube are known to increase its risk. Keeping the external bumper away by 1 to 2 cm from the abdominal might help prevent it. It is an acute surgical emergency and requires broad-spectrum antibiotics, intensive care support, and surgical debridement.

Any intra-abdominal organ is at risk of injury during PEG tube placement. Diagnosis can be challenging since most patients who require PEG tubes are often unable to communicate abdominal discomfort. Hemodynamic instability should prompt thorough investigation, and a computed tomography scan (CT) of the abdomen with water-soluble enteric contrast or fluoroscopy may be useful.

Tumor seeding of the stoma is a rare complication in patients with head and neck cancer. While some believe that it occurs during insertion when the equipment comes in contact with cancer, others believe it is caused by lymphangitic/hematogenous spread.[16][17][18][19][20] CT of the abdomen and biopsy is useful for diagnosis.

Minor Complications

• Wound infection
• Tube leakage to the abdominal cavity may lead to peritonitis
• Inadvertent PEG removal
• Stoma leakage
• Pneumoperitoneum
• Tube blockage
• Gastric outlet obstruction

The infection of the tube site is the most common minor complication post-PEG tube placement. Redness around the stoma site and purulent drainage may be seen. The topical application of antibiotics is sufficient in mild cases, but severe cases require thorough investigation and treatment.

Peristomal leakage is more common in debilitated patients and requires a thorough investigation to rule out other complications. The PEG tube should be removed, and the track allowed to heal completely, followed by the placement of a new tube if medically indicated.

In the case of tube dislodgement, if it happens after the tract has matured, the tube can be replaced blindly without endoscopy. Otherwise or in cases of doubt, a water-soluble contrast should be instilled into the PEG tube to confirm the position.

Gastric outlet obstruction is rare and occurs when the tube migrates forward into the pyloric area. CT scan of the abdomen helps evaluate the position of the tube. Maintaining the position of the external bumper 1 cm to 2 cm from the abdominal wall helps prevent this complication.

Pneumoperitoneum is found in a lot of cases of PEG tube insertion, secondary to the insufflation of the abdomen during the procedure. The presence of air more than 72 hours post-placement or presence of peritoneal signs should prompt further evaluation.

Tube blockage occurs especially in small-bore feeding tubes due to feeding with thick formulas, medications crushed inadequately, or incompatibility between medications and enteral feeds. If the tube gets blocked, certain measures can help- attach a 50 mL syringe filled with warm water to the tube and carry out a pull and push technique or try gentle squeezing of the tube. Pancreatic enzymes mixed with bicarbonate solution can be used prior to flushing with warm water.[21]

Clinical Significance

PEG/PEG-J tube placement is a common procedure with numerous indications. Hence, clinicians and support staff should be aware of its indications, contraindications, and complications.

Enhancing Healthcare Team Outcomes

Prior to placement of the percutaneous endoscopic gastrostomy and percutaneous endoscopic gastro-jejunal tubes, a detailed discussion with the patient and the caregiver should be undertaken regarding the goals of care. It is important to define realistic goals and expectations, with aims to improve or maintain a patient's quality of life, minimize suffering, and provide access for nutrition and medication delivery. Patient's and family members' beliefs regarding tube feedings should be ascertained. Risks associated with the procedure, including the risk of anesthesia as well as potential complications, should be discussed. Appropriate backup of surgery, as well as interventional radiology, should be available in case percutaneous PEG tube placement fails or complications develop. Adequate preparation and detailed discussion help align treatment with goals of care, patient's preference, and prognosis and eventually leads to better patient satisfaction and outcomes.

Nursing, Allied Health, and Interprofessional Team Interventions

The PEG tube track takes about four weeks to mature. PEG tube can be removed when it is no longer needed or deemed medically necessary. The method of removal of the tube depends on the type of PEG tube. In cases where the type of PEG tube inserted cannot be ascertained, or there is a concern for potentially serious complications during removal, upper endoscopy should be performed for removal. After removal, the site should be cleaned and covered with gauze, and monitored. The track usually closes within 24-48 hours. Non-closure might require further investigation and surgical closure.

Nursing, Allied Health, and Interprofessional Team Monitoring

Due to the inflation of the stomach during the procedure, a lot of patients complain of abdominal discomfort after PEG tube insertion. Adequate pain control should be administered post-procedure. Feeding can be initiated as early as 4 hours after the procedure, although traditionally they are started after 24 hours after successful placement.

The stoma should be examined thoroughly for discoloration, swelling, discharge (especially if purulent), and leakage. The stoma should be cleaned daily. To ensure its patency, the caregiver/staff should rotate the tube 180 degrees and move the tube up and down (about 1 cm to 2 cm) in the stoma daily, once it is completely healed.

To prevent clogging of the tube, it should be flushed before and after each feed as well as after administration of medicine. Bulking agents and resins should never be administered via the PEG tube to prevent clogging.