What Is A Peg Tube? Gastrostomy Procedure |PEG Tube Complications|

What is a PEG Tube (percutaneous endoscopic gastrostomy tube)

What is a peg tubeThe PEG tube is an endoscopically designed artificial access to the stomach. This nasogastric tube is used by people in need of care who are having difficulty swallowing food or are unable to feed. It is placed endoscopically over the abdominal wall as a direct connection to the stomach.

It ensures the long-term nutrition of the patient without being dependent on the mouth. The PEG tube is used to administer ready-made food mixes, liquids, and medicines. The amount of finished food and liquids is decided by the attending physician.




PEG Tube Vs NG Tube

Nasogastric tube and percutaneous endoscopic gastrostomy

NG Tube

The most common method of enteral nutrition is to place a nasogastric tube. Although effective, this method brings many difficulties and complications in clinical application. Because these nutrient tubes are relatively large in diameter and are made of hard rubber or plastic. They cause a lot of discomfort to the patient, often clogging the lumen and forcing the tube to be changed continuously, and the tube is often displaced.


The wall of the tube stimulates the esophageal mucosa for a long time and is prone to esophagitis, and the gastroesophageal reflux often occurs because the nutrient tube destroys the normal cardiac function. Frequent reflux can easily lead to aspiration pneumonia. Long-term use of nasogastric tubes can also easily lead to the destruction of mumps and nasal cartilage.

PEG Tube

Percutaneous endoscopic gastrostomy (PEG) has been used clinically since 1980, providing a safe, effective, and non-surgical approach to establishing long-term enteral nutrition pathways. Clinical application. About 200,000 patients in the United States perform this technology each year. Pon-sky and Gauderer used the drag-and-drop technique for the first time.

Although there are many improved techniques based on this, the drag-and-drop method is still the most commonly used method.

Gastrostomy Procedure

What is a peg tube

Preoperative preparation

Proper preoperative preparation can help reduce complications. Patients should be fasted 8 hours before surgery. Conventional application of antibiotics against G + bacteria, cefazolin can kill such bacteria and other common microorganisms. The patient should take the supine position and raise the head to reduce aspiration.

Since the position is not easy to insert the gastroscope into the esophagus, it usually starts with the left lateral position and then returns to the supine position. The aspirator should promptly absorb the secretions from the pharynx and ensure that the patient maintains sufficient oxygen supply.


During the intravenous anesthesia, nurses should monitor the blood pressure, pulse and oxygen partial pressure during the whole operation.

 

After pulling

patient’s posture, the lidocaine glue or intravenous sedative is taken and the abdominal puncture site is cleaned and disinfected. Reduce the brightness of the room after inserting the gastroscope. When the translucent point of the gastroscope is seen from the abdominal wall, it indicates that the tissue between the stomach and the abdominal wall has been pushed open, and the stomach wall is directly in contact with the abdominal wall.

 

The puncture point of the gastrostomy should be selected at the brightest point of the gastroscope, usually the upper left abdomen. When the finger presses the puncture site of the abdominal wall, the fingertip on the stomach wall can be seen through the gastroscope. After the optimal puncture point is selected, local infiltration anesthesia is performed, and the needle is pulled back while the needle is being drawn.

When the air is drawn, the needle tip can be seen in the stomach at the same time. If the air is drawn before the needle tip is seen, the puncture is usually indicated. The needle enters a gas-filled hollow organ (such as the colon or small intestine) that is interposed between the stomach and the abdominal wall, at which point the puncture point should be reselected.

 

After the local anesthetic is injected at the puncture site, an incision of about 1 cm is cut in the local skin, and then the cannulated needle is inserted into the gastric cavity. Then, a long wire is built into the stomach cavity from the inside of the cannula. After the wire enters the stomach, the wire is clamped under the gastroscope with a biopsy forceps, and then the oral cavity is taken out as the gastroscope is withdrawn.

The end of the PEG tube is fastened to the lead wire outside the mouth, and then the wire is tightened from the puncture site of the abdominal wall, and the PEG tube is introduced from the esophagus into the stomach and pulled out of the body from the puncture site. At this point, insert the gastroscope again, check the position of the PEG tube head, and pay attention to the excessive tension of the gasket in the catheter head.


After the examination is completed, the gastroscope is withdrawn, and the root of the PEG tube is attached to the card outside the abdominal wall so that the stomach wall and the abdominal wall are kept in close contact, and the PEG tube is fixed.

 

PEG was originally designed to provide a long-term enteral nutrition pathway for patients with normal gastrointestinal function but not oral feeding. All patients who are expected to have no nutrients for more than 2 weeks or more should receive nutritional support.

If the patient has a normal gastrointestinal function and the enteral nutrition support time is not more than 30 days, a nasogastric tube or a nasogastric tube can be placed for nutritional support. If the enteral nutrition time is expected to be 30 days, a gastrostomy should be considered.

These patients may be severe neurological dysphagia or developmental disorders, oropharyngeal traumatic or neoplastic obstruction, or critically ill patients who require prolonged tracheal intubation.

 

The range of PEG indications has been expanding and has been applied to burn patients (even though the skin of burn sites), facilitating the implementation of high-calorie nutrition support in the intestine. It has also been used in patients with esophageal cancer and head and neck cancer who are receiving adjuvant therapy. Patients with severe maxillofacial trauma can also benefit from PEG.

 

Non-nutritive applications of PEG include gastric emptying disorders, inoperable intestinal obstruction for gastrointestinal decompression; can also be applied to children taking medication and biliary fistula; patients with external drainage bile reinfusion; an esophageal hiatal hernia and gastric torsion Multiple PEG was placed in the patient as a method of gastric fixation.


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Contraindications to PEG fall into three categories:

  1. Absolute,
  2. Relative, 
  3. Potential contraindications.

 

Absolute contraindications include coagulopathy, peritonitis, peritoneal dialysis, gastric varices, no stomach, and any disease that cannot be examined by gastroscopy.



Relative contraindications and those previously considered to be absolute contraindications, but can be treated with PEG after ultrasound imaging, good preoperative preparation, and aggressive treatment.

Gastrostomy Tube Feeding

Once the PEG tube is safely placed, the next question is how to feed through it. The preferred interstitial feeding is because it is easier to implement (no pumping required), well tolerated, and physiologically compliant. The choice of formula should be based on the patient’s energy needs, tolerance, and the specific conditions of the systemic disease.

The amount of gastric residue should be measured routinely until it is fully tolerated, and if it is found to be greater than 100 ml, the problem of intolerance should be considered.

Peg Tube Replacement

Replace the PEG tube when it is worn, obstructed, and paralyzed.

 

When the PEG tube is prematurely and rashly removed, it is prone to peritonitis. It must be discovered in time, and the nasogastric tube negative pressure drainage, intravenous rehydration, and antibiotic treatment. If the patient has signs of peritonitis or bacteremia, an emergency laparotomy should be performed at this time.

 

Some PEG tubes require endoscopic removal when they are removed or replaced. The design is now more practical and does not require endoscopic extraction, but is directly removed from the body. Gauderer et al. invented a low profile gastrostomy tube with a skin fixation device with an anti-reflux valve that allows nutrient solution infusion near the skin stoma.



The device can be placed after the previously placed gastrostomy tube is removed or placed directly upon establishment of the PEG channel. For patients in need of monitoring, it is more appropriate to place a standard nutrient tube in the device, which is convenient for the caregiver to operate.

 

PEG Tube Complications:

(1) Incision infection, stenosis of the fistula, displacement of the fistula, obstruction of the fistula, and hematoma of the incision. Wound infections are more common.

(2) Serious complications include: bleeding, aspiration, peritonitis, internal cushion syndrome, stomach cramps, etc.

(3) Attention to prevent infection, aseptic operation, strict adherence to operating procedures, postoperative care, etc. can effectively prevent complications.  (Read more…)




The following conditions are not contraindications for PEG, but care must be taken when handling, as complications are likely to occur.

1. Including postoperative surgery, dilated small intestine fistula, ventriculomegaly shunt, and severe heart disease. If you can accurately operate and see the light transmission point, abdominal surgery is not a contraindication, but such patients must find a safe puncture site when puncture.

 

2. Good skin care after gastrostomy is very important, and it is often seen that secretions or granulation occur around the orifice due to rejection. This is easier to handle, and the secretions can be scrubbed with hydrogen peroxide and exposed locally. The granulation tissue can be cauterized with a silver nitrate solution to avoid the use of an airtight dressing because it tends to damage the underlying skin.


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