Percutaneous Endoscopic Gastrostomy (PEG) is a minimally invasive procedure designed to provide long-term enteral nutrition for patients who are unable to swallow effectively. This technique involves the placement of a feeding tube directly into the stomach through the abdominal wall under endoscopic guidance.

Indications

PEG is primarily indicated for patients requiring enteral tube feeding due to chronic swallowing disorders. In cases of terminal illness, the decision to proceed with PEG should be made with strict indication criteria and comprehensive patient counseling to ensure informed consent.

Contraindications

The procedure is contraindicated in the presence of:

• Coagulation Disorders: Patients with impaired blood clotting mechanisms.
• Local Infections: Infections at the planned puncture site.
• Severe Abdominal Conditions: Including peritonitis, peritoneal carcinomatosis, and massive ascites.
• Gastrointestinal Diseases: Active gastric ulcers and Crohn’s disease, which increase the risk of fistula formation.
• Negative Diaphanoscopy: Inadequate visibility of the stomach through the abdominal wall.

Advantages

Compared to Nasal Feeding Tubes:

• Reduced Patient Discomfort: PEG is less burdensome for patients.
• Lower Dislocation Risk: There is a decreased chance of the tube moving out of place.
• Suitability for Long-Term Use: PEG allows for extended feeding periods without the need for frequent replacements.

Compared to Surgical Gastrostomy:

• Minimally Invasive: The procedure involves less surgical intervention.
• No General Anesthesia Required: PEG can be performed without the need for full anesthesia, reducing associated risks.

Disadvantages

Compared to Nasal Feeding Tubes:

• Invasive Nature: PEG requires a more invasive procedure.

Compared to Surgical Gastrostomy:

• Limited Applicability: PEG is not suitable for patients with stenoses in the pharynx or esophagus.
• Higher Complication Rates: There is an increased risk of complications compared to surgical methods.
• Complex Removal Process: Removing a PEG tube is more complicated than removing a surgically placed tube.

Complications

Potential complications from PEG placement include:

• Intra-abdominal Organ Injury: Accidental damage to organs within the abdominal cavity.
• Wound Infections and Peritonitis: Infections at the incision site or within the abdominal cavity.
• Gastrocolic Fistula Formation: An abnormal connection between the stomach and colon.
• Aspiration of Tube Feeding: Inhalation of feeding materials into the lungs.
• Leakage of Gastric Contents: Leakage from the tube channel.
• Pressure Ulcers: Development of pressure sores beneath the retaining plate if it is tightened excessively.

Materials Needed

The following materials are essential for performing a PEG procedure:

• PEG Kit: Includes a puncture needle, pulling thread, and feeding tube.
• Sterile Supplies: Syringes, swabs, needles, drapes, gloves, and a scalpel.
• Local Anesthetic: Typically 5–10 ml of 1% lidocaine.
• Endoscopic Equipment: A gastroscope with necessary accessories.

Preparation

Prior to the procedure, it is crucial to evaluate the patient’s coagulation status:

• International Normalized Ratio (INR): Should be ≤ 1.5.
• Partial Thromboplastin Time (PTT): Should be ≤ 50 seconds.
• Platelet Count: Should be ≥ 50,000/µl.

Additionally, proton pump inhibitors and H2 blockers must be discontinued three days before the procedure to reduce the risk of infection by lowering gastric acidity.

Procedure

The PEG placement is most commonly performed using the pull-through method, which involves several key steps:

1. Gastroscope Insertion: The gastroscope is introduced while the patient is positioned on their left side.
2. Patient Repositioning: The patient is then moved to a supine position.
3. Diaphanoscopy: The stomach is inflated with air, and diaphanoscopy is conducted using the gastroscope’s light source to identify the optimal puncture site, typically on the anterior gastric wall.
4. Marking the Puncture Site: The site is marked where the stomach is best visualized.
5. Site Preparation: The marked area is disinfected, draped, and locally anesthetized.
6. Incision and Puncture: A small incision is made with a scalpel, and the puncture needle is inserted into the stomach. Once the gastric lumen is reached, the steel needle is withdrawn, leaving the plastic cannula in place.
7. Thread Placement: A pulling thread is threaded through the cannula and retrieved using biopsy forceps via the gastroscope.
8. Feeding Tube Insertion: The pulling thread is attached to the feeding tube and both are pulled through the abdominal wall until the tube’s retaining plate rests against the gastric wall.
9. Securing the Tube: The remaining components of the feeding tube are assembled, and a sterile dressing is applied.

Tube Management

The feeding tube can typically be used two hours after placement. It is important to verify gastric emptying through aspiration tests to ensure proper function. If gastric emptying is impaired, the use of prokinetic agents or the placement of a duodenal tube may be necessary.

Tube Removal

To remove the PEG tube:

• Cutting the Tube: The tube is cut near the external abdominal wall.
• Grasping the Retaining Plate: Using a gastroscope, the internal retaining plate is grasped, for example, with a Dormia basket.
• Extraction: The gastroscope, along with the retained portion of the tube, is carefully removed.