Editing Percutaneous endoscopic gastrostomy

{{Short description|Feeding tube going into the stomach through the abdominal wall}}
{{redirect distinguish|J PEG|JPEG}}
{{Infobox medical intervention (new)
| name          = Percutaneous endoscopic gastrostomy
| synonyms      = PEG tube
| image         = Percutaneous endoscopic gastrostomy-tube.jpg
| caption       = Percutaneous endoscopic gastrostomy
| alt           =
| pronounce     =
| specialty     = [[Gastroenterology]]
| uses          =
| complications = Infection, [[Hemorrhage]], [[Gastrointestinal perforation]], Gastrocolic fistula, [[Buried bumper syndrome]]
| approach      =
| types         =
| recovery time =
| other options =
| outcomes      =
| frequency     =
| cost          =
| ICD9          = {{ICD9proc|43.11}}
| MeshID        =
| OPS301        = sec
}}

'''Percutaneous endoscopic gastrostomy''' ('''PEG''') is an [[Endoscopy|endoscopic]] [[medical procedure]] in which a tube ('''PEG tube''') is passed into a patient's stomach through the [[abdominal wall]], most commonly to provide a means of feeding when [[Mouth|oral]] intake is not adequate (for example, because of [[dysphagia]] or [[sedation]]). This provides [[enteral]] nutrition (making use of the natural [[digestion]] process of the [[human gastrointestinal tract|gastrointestinal tract]]) despite bypassing the mouth; enteral nutrition is generally preferable to [[parenteral nutrition]] (which is only used when the GI tract must be avoided). The PEG procedure is an alternative to open surgical [[gastrostomy]] insertion, and does not require a [[general anesthetic]]; [[Procedural sedation and analgesia|mild sedation]] is typically used. PEG tubes may also be extended into the [[small intestine]] by passing a jejunal extension tube ('''PEG-J tube''') through the PEG tube and into the [[jejunum]] via the [[pylorus]].<ref>{{cite web |title=Discussion |work=BCM Gastroenterology Grand Rounds |publisher=Baylor College of Medicine |url=http://www.bcm.edu/gastro/DDC/grandrounds/BCM/8-10-06/09-DISC.HTM |access-date=2010-10-16 |archive-url=https://web.archive.org/web/20120303151733/http://www.bcm.edu/gastro/DDC/grandrounds/BCM/8-10-06/09-DISC.HTM |archive-date=2012-03-03 |url-status=dead }}</ref>

PEG administration of enteral feeds is the most commonly used method of nutritional support for patients in the community. Many [[stroke]] patients, for example, are at risk of [[aspiration pneumonia]] due to poor control over the swallowing muscles; some will benefit from a PEG performed to maintain nutrition. PEGs may also be inserted to decompress the [[stomach]] in cases of [[gastric volvulus]].<ref name=Gauderer01>{{cite journal |author=Gauderer MW |title=Percutaneous endoscopic gastrostomy-20 years later: a historical perspective |journal=J. Pediatr. Surg. |volume=36 |issue=1 |pages=217–9 |year=2001 |pmid=11150469 |doi=10.1053/jpsu.2001.20058}}</ref>

==Indications==
Gastrostomy may be indicated in numerous situations, usually those in which normal (or [[nasogastric tube|nasogastric]]) feeding is impossible. The causes for these situations may be neurological (e.g. [[stroke]]), anatomical (e.g. [[cleft lip and palate]] during the process of correction) or other (e.g. [[radiation therapy]] for tumors in head & neck region).{{citation needed|date=January 2022}}

In certain situations where normal or nasogastric feeding is not possible, gastrostomy may be of no clinical benefit. In advanced [[dementia]], studies show that PEG placement does not in fact prolong life.<ref>{{cite journal |vauthors=Murphy LM, Lipman TO |title=Percutaneous endoscopic gastrostomy does not prolong survival in patients with dementia |journal=Arch. Intern. Med. |volume=163 |issue=11 |pages=1351–3 |year=2003 |pmid=12796072 |doi=10.1001/archinte.163.11.1351|citeseerx=10.1.1.610.6648 }}</ref> Instead, oral [[assisted feeding]] is preferable.<ref>{{Citation |author1 = AMDA – The Society for Post-Acute and Long-Term Care Medicine |author1-link = AMDA – The Society for Post-Acute and Long-Term Care Medicine |date = February 2014 |title = Ten Things Physicians and Patients Should Question |publisher = AMDA – The Society for Post-Acute and Long-Term Care Medicine |work = [[Choosing Wisely]]: an initiative of the [[ABIM Foundation]] |url = http://www.choosingwisely.org/doctor-patient-lists/amda/ |access-date = 20 April 2015}}.</ref> Quality improvement protocols have been developed with the aim of reducing the number of non-beneficial gastrostomies in patients with dementia.<ref>{{cite journal |vauthors=Monteleoni C, Clark E |title=Using rapid-cycle quality improvement methodology to reduce feeding tubes in patients with advanced dementia: before and after study |journal=BMJ |volume=329 |issue=7464 |pages=491–4 |year=2004 |pmid=15331474 |doi=10.1136/bmj.329.7464.491 |pmc=515202}}</ref>

A gastrostomy can be placed to decompress the stomach contents in a patient with a malignant bowel obstruction. This is referred to as a "venting PEG" and is placed to prevent and manage nausea and vomiting.

A gastrostomy can also be used to treat [[volvulus]] of the stomach, where the stomach twists along one of its axes.  The tube (or multiple tubes) is used for gastropexy, or adhering the stomach to the abdominal wall, preventing twisting of the stomach.<ref name=Gauderer01/>

A PEG tube can be used in providing gastric or post-surgical drainage.<ref>Gail Waldby, "PEG-J Gastrostomy drainage jejunal feeding tubes" {{cite web |url=http://surgnurseslinks.com/caluso.htm |title=Untitled Document |access-date=2010-10-16 |url-status=dead |archive-url=https://web.archive.org/web/20110716165120/http://surgnurseslinks.com/caluso.htm |archive-date=2011-07-16 }}</ref>

==Techniques==
[[Image:PEG tube kit.jpg|thumb|right|200px|PEG tube, cannula and guidewire (Pull Technique)]]
Two major techniques for placing PEGs have been described in the literature.

The Gauderer-Ponsky technique involves performing a [[gastroscopy]] to evaluate the [[anatomy]] of the [[stomach]].  The anterior stomach wall is identified and techniques are used to ensure that there is no [[organ (anatomy)|organ]] between the wall and the [[skin]]:
* digital pressure is applied to the abdominal wall, which can be seen indenting the anterior gastric wall by the endoscopist.
* transillumination (diaphanoscopy): the light emitted from the endoscope within the stomach can be seen through the abdominal wall.
* a small (21G, 40mm) needle is passed into the stomach before the larger cannula is passed.
An [[catheter|angiocath]] is used to puncture the abdominal wall through a small [[Surgical incision|incision]], and a soft guidewire is inserted through this and pulled out of the [[mouth]].  The feeding tube is attached to the guidewire and pulled through the mouth, esophagus, stomach, and out of the incision.<ref name=Gauderer01/>

In the Russell introducer technique, the [[Seldinger technique]] is used to place a wire into the stomach, and a series of dilators are used to increase the size of the [[gastrostomy]].  The tube is then pushed in over the wire.<ref name="pmid3349370">{{cite journal |vauthors=Deitel M, Bendago M, Spratt EH, Burul CJ, To TB |title=Percutaneous endoscopic gastrostomy by the "pull" and "introducer" methods |journal=Can J Surg |volume=31 |issue=2 |pages=102–4 |year=1988 |pmid=3349370 }}</ref>

== Anesthetic management ==
There are several techniques such as moderate sedation with left transversus abdominis plane block, and moderate sedation with local anesthetic infiltration at feeding tube site.<ref>{{Cite journal|last1=Abdalgaleil|first1=Mohamed M|last2=Shaat|first2=Ahmed M|last3=Elbalky|first3=Osama S|last4=Elnagaar|first4=Mohamed S|last5=Kamoun|first5=Amr M|date=2018-07-01|title=Early versus delayed feeding after placement of percutaneous endoscopic gastrostomy tube with safe anesthetic techniques|url=http://www.mmj.eg.net/text.asp?2018/31/3/1058/248726|journal=Menoufia Medical Journal|publisher=Medknow Publications|volume=31|issue=3|pages=1058–1063}}</ref>

==Contraindications==
As with other types of feeding tubes, care must be made to place PEGs into an appropriate population.  The following are contraindications to PEG use:<ref>Gastroenterological endoscopy. Meinhard Classen, G. N. J. Tytgat, Charles J. Lightdale. 2002. {{ISBN|978-1-58890-013-5}}</ref>

===Absolute contraindications===
* Inability to perform an [[esophagogastroduodenoscopy]]
* Uncorrected [[coagulopathy]]
* [[Peritonitis]]
* Untreatable (loculated) massive [[ascites]]
* [[Bowel obstruction]] (unless the PEG is sited to provide drainage)

===Relative contraindications===
* Massive [[ascites]]
* Gastric mucosal abnormalities: large [[gastric varices]], portal hypertensive gastropathy
* Previous [[abdominal surgery]], including previous partial [[gastrectomy]]: increased risk of organs interposed between gastric wall and abdominal wall
* [[Morbid obesity]]: difficulties in locating stomach position by digital indentation of stomach and transillumination
* Gastric wall [[neoplasm]]
* Abdominal wall [[infection]]: increased risk of infection of PEG site
* Intra-abdominal malignancy with peritoneal involvement (tumor seeding into formed channel with subsequent failure)

===In advanced dementia===
The [[American Medical Directors Association]], the [[American Geriatrics Society]] and the [[American Academy of Hospice and Palliative Medicine]] recommend against inserting percutaneous feeding tubes in individuals with advanced dementia and, instead, recommend oral assisted feedings. Artificial nutrition neither prolongs life nor improves its quality in patients with advanced dementia. It may increase the risk of the patient inhaling food, it does not reduce suffering, it may cause fluid overload, diarrhea, abdominal pain and local complications, and it can reduce the amount of human interaction the patient experiences.<ref>Lay summary: {{cite web|url= http://consumerhealthchoices.org/wp-content/uploads/2013/05/ChoosingWiselyFeedingTubeAGS-ER.pdf|title= Feeding tubes for people with Alzheimer's disease: When you need them — and when you don't|publisher= Consumer Reports|access-date= 6 December 2013|archive-url=https://web.archive.org/web/20131212112432/http://consumerhealthchoices.org/wp-content/uploads/2013/05/ChoosingWiselyFeedingTubeAGS-ER.pdf|archive-date=12 December 2013}}
* {{cite web|url= http://www.amda.com/governance/whitepapers/surrogate/clinical.cfm?printPage=1&#Tube_feeding|title= White Paper on Surrogate Decision-Making and Advance Care Planning in Long-Term Care|publisher= American Medical Directors Association -|access-date= 6 December 2013|archive-url= https://web.archive.org/web/20131213225530/http://www.amda.com/governance/whitepapers/surrogate/clinical.cfm?printPage=1&#Tube_feeding|archive-date= 13 December 2013|url-status= dead}}
* {{cite web|url= http://www.americangeriatrics.org/files/documents/feeding.tubes.advanced.dementia.pdf|title= Feeding Tubes in Advanced Dementia Position Statement|last1= Daniel|first1= Kathryn|last2= Rhodes|first2= Ramona|last3= Vitale|first3= Caroline|last4= Shega|first4= Joseph | name-list-style = vanc |date= May 2013|publisher= American Geriatrics Society|access-date= 6 December 2013|archive-url= https://web.archive.org/web/20130921060726/http://www.americangeriatrics.org/files/documents/feeding.tubes.advanced.dementia.pdf|archive-date= 21 September 2013|url-status= dead}}
* {{cite journal|url= http://www.aahpm.org/pdf/06springcoverarticle.pdf|title= Against the Flow: Tube Feeding and Survival in Patients with Dementia|last1= Buff|first1= Daniel D. | name-list-style = vanc |date= Spring 2006|publisher= American Academy of Hospice and Palliative Medicine|journal= AAHPM Bulletin|volume= 7|issue= 1|access-date= 6 December 2013}}</ref>

==Complications==
* Surgical site infection around the gastrostomy site. Administration of intravenous antibiotics can reduce infection around the gastrostomy site.<ref>{{cite journal | vauthors = Lipp A, Lusardi G | veditors = Lipp A | title = Systemic antimicrobial prophylaxis for percutaneous endoscopic gastrostomy | journal = The Cochrane Database of Systematic Reviews | issue = 11 | pages = CD005571 | date = November 2013 | volume = 2013 | pmid = 24234575 | pmc = 6823215 | doi = 10.1002/14651858.cd005571.pub3 | publisher = John Wiley & Sons, Ltd | collaboration = The Cochrane Collaboration }}</ref> [[Preventive healthcare|Prophylaxis]] with [[Amoxicillin/clavulanic acid|co-amoxiclav]] decreases the proportion of people developing MRSA infections compared with no antibiotic prophylaxis (in people without cancer) undergoing percutaneous endoscopic gastrostomy insertion.<ref>{{cite journal | vauthors = Gurusamy KS, Koti R, Wilson P, Davidson BR | title = Antibiotic prophylaxis for the prevention of methicillin-resistant Staphylococcus aureus (MRSA) related complications in surgical patients | journal = The Cochrane Database of Systematic Reviews | issue = 8 | pages = CD010268 | date = August 2013 | pmid = 23959704 | doi = 10.1002/14651858.CD010268.pub2 | collaboration = Cochrane Wounds Group | pmc = 11299148 }}</ref>
* [[Hemorrhage]]
* [[Gastric ulcer]] either at the site of the button or on the opposite wall of the stomach ("kissing ulcer")
* Perforation of [[Intestine|bowel]] (most commonly [[transverse colon]]) leading to [[peritonitis]]
* Puncture of the left lobe of the [[liver]] leading to liver capsule pain
* Gastrocolic fistula: this may be suspected if diarrhea appears a short time after feeding. In this case, the feed goes direct from stomach to colon (usually [[transverse colon]])<ref>{{cite journal|journal=J Minim Access Surg|date=January–March 2008|volume=4|issue=1|pages=1–4|pmid=19547728|
doi=10.4103/0972-9941.40989|
pmc=2699054|title= Malposition of percutaneous endoscopic-guided gastrostomy: Guideline and management|author1=Siamak Milanchi |author2=Matthew T Wilson |doi-access=free }}</ref>
* Gastric separation
* "[[Buried bumper syndrome]]" (the gastric part of the tube migrates into the gastric wall)<ref>{{cite journal |vauthors=Walters G, Ramesh P, Memon MI |title=Buried Bumper Syndrome complicated by intra-abdominal sepsis |journal=Age and Ageing |volume=34 |issue=6 |pages=650–1 |year=2005 |pmid=16267197 |doi=10.1093/ageing/afi204|doi-access=free |citeseerx=10.1.1.573.2018 }}</ref>

==Removal of PEG tubes==
[[Image:PEG removal.jpg|thumb|right|200px|Endoscopic removal of PEG tube]]

===Indications===
* PEG tube no longer required (recovery of swallow after [[stroke]] or brain trauma, or after surgery or radiotherapy for [[head and neck cancer]])
* Persistent infection of PEG site
* Failure, breakage or deterioration of PEG tube (a new tube can be sited along the existing track)
* "Buried bumper syndrome"

===Techniques===
PEG tubes with rigid, fixed "bumpers" are removed endoscopically. The PEG tube is pushed into the stomach so that part of the tube is visible behind the bumper. An endoscopy snare is then passed through the endoscope, and passed over the bumper so that the tube adjacent to the bumper is grasped. The external part of the tube is then cut, and the tube is withdrawn into the stomach, and then pulled up into the esophagus and removed through the mouth. The PEG site heals without intervention.{{citation needed|date=January 2022}}

PEG tubes with a collapsible or deflatable bumper can be removed using traction (simply by pulling the PEG tube out through the abdominal wall).

==History==
The first percutaneous endoscopic gastrostomy performed on a child was on June 12, 1979, at the [[Rainbow Babies & Children's Hospital]], [[University Hospitals of Cleveland]]. Michael W.L. Gauderer, pediatric surgeon, Jeffrey Ponsky, endoscopist, and James Bekeny, surgical resident, performed the procedure on a {{frac|4|1|2}}-month-old child with inadequate oral intake.<ref name=Gauderer80>{{cite journal |vauthors=Gauderer MW, Ponsky JL, Izant RJ |title=Gastrostomy without laparotomy: a percutaneous endoscopic technique |journal=J. Pediatr. Surg. |volume=15 |issue=6 |pages=872–5 |year=1980 |pmid=6780678 |doi=10.1016/S0022-3468(80)80296-X}}</ref> The authors of the technique, Michael W.L. Gauderer and Jeffrey Ponsky, first published the technique in 1980.<ref name=Gauderer80/> In 2001, the details of the development of the procedure were published, the first author being the originator of the technique itself.<ref name=Gauderer01/>

==See also==
* [[Feeding tube]]
* [[Minimally conscious state]]

==References==
{{reflist|30em}}

==External links==
* [http://www.emedicine.com/radio/topic798.htm eMedicine: Percutaneous Gastrostomy and Jejunostomy]

{{Digestive system surgical procedures}}
{{Authority control}}

[[Category:Enteral feeding]]
[[Category:Endoscopy]]
[[Category:Digestive system surgery]]