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Percutaneous Endoscopic Gastrostomy

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					Percutaneous Endoscopic
  Gastrostomy (PEG)
                   Objectives
•   Indications and contraindications of PEG
•   Upper flexible fiberoptic gastroscopy
    – Principles
    – Procedures
•   Monitoring, sedation
•   Surgical procedure
             PEG: Indications
•   Long-term feeding
•   Mechanical Dysfunction
    – Esophageal obstruction
    – Swallowing disorder
    – Facial fractures
•   Neurologic impairment
    – Stroke
    – Closed head injury
             PEG: Indications
•   Replace nasoenteric feeding tube
    – Reduce risk of aspiration, sinusitis
    – Facilitates tube replacement for mechanical
      problems
•   Permit transfer to long term facility
          Additional Indications
•   Decompressive tube for palliation
    (carcinomatosis, gastric obstruction, severe
    diabetic gastroparesis)
•   Access for repeated endoscopic or surgical
    instrumentation (e.g. bougie)
•   Recirculation of bile
    – Fistula, biliary drain
•   Gastric volvulus
            Contraindications
•   Terminal illness
•   Poorly selected populations have 30 day
    mortality of up to 50% after PEG
•   Exception: palliative, for decompression
             Contraindications
•   Inability to perform upper endoscopy
    – Obstructing esophageal tumor
    – Stricture
•   Ascites
•   Inability to appose gastrotomy to anterior
    abdominal wall
    – Previous subtotal gastric resection
    – Hepatomegaly, esp left lobe
      Relative Contraindications
•   Coagulopathy
•   Portal hypertension
•   Peritoneal dialysis
•   Large hiatal hernia
             PEG: Alternatives
•   Open gastrostomy
    – Additional risks of incision
       » Wound infection
       » Dehiscence
•   Laparoscopic gastrostomy
    – Cost
    – Use of OR Resources
              PEG Techniques
•   Pull vs push technique
•   No outcome difference
•   Pull
    – Popular approach
    – Featured in this program
•   Push
    – Popular for radiologic approach
    – Similar to laparoscopic insertion technique
               Pull Technique
•   Guidewire placed in
    stomach
•   Guidewire brought
    retrograde through
    patient’s mouth
•   PEG tube pulled
    through abdominal
    wall
               Push Technique
•   PEG tube advanced
    via modified Seldinger
    approach
•   May involve dilators,
    peel away introducer
               Push Technique
         Advantages              Disadvantages
•   Single endoscope       •   Loss of
    passage                    pneumoperitoneum
•   Decreased “seeding”        – May require additional
    from oropharynx              T-fasteners
    (bacteria, malignant
    cells w/ head & neck
    ca.)
Surgical Technique
                PEG: Basics

•   Gastric insufflation to bring stomach in
    apposition
•   Placement of catheter into gastric lumen
•   Passage of guidewire into stomach
•   Placement of gastrostomy tube
•   Verification of proper position
               Patient Preparation
•   Monitoring            •   Medications
    – ECG/heart rate          – Local pharyngeal
    – Blood Pressure            anesthesia
                                 » Bupivicaine spray
    – Pulse Oximetry
                                 » Lidocaine gel lubricant
•   Position                  – Sedation
    – Supine                  – Analgesia
    – Lateral Decubitus
             Patient Preparation
•   Bite block
•   May leave NG,
    feeding tube
    – Can follow tube down
      esophagus
•   Must take NG off
    suction to allow for
    insufflation
               Upper Endoscopy
•   Routine flexible
    fiberoptic upper
    endoscopy
•   Complete endoscopy
    recommended
    – 36% incidence of
      anomalies
    – Some may affect
      procedure (ulcer, gastric
      outlet obstruction)
           Confirm safe position
•   Transillumination
    through skin suggests
    no other viscera
    interposed
•   Transillumination
    button (“high beams”)
    on light source
•   May be difficult in
    obesity
    – Can assist with digital
      pressure
                  Confirm Position
•   Endoscopist watches while
    assistant indents abdominal
    wall at proposed insertion
•   Should see simultaneous
    indentation of gastric
    mucosa
•   Failure to see
    –   Reassess position
    –   Intervening viscerae
    –   Impossible apposition
    –   Inadequate insufflation
                  Site Preparation
•   PEG kit opened after
    endoscopic confirmation of
    entry site
•   Select anticipated PEG
    insertion site
    – Entry ~2 cm below costal
      margin
•   Prep left upper quadrant
    with antiseptic prep of
    choice
    – May be included in kit
              Surgical Technique
•   Kit contains:
    –   Local/syringe
    –   introducer
    –   Prep & drape
    –   Guidewire
    –   Endoscopic snare
    –   Scalpel
    –   Hemostat
    –   PEG
    –   External Bumper
             Surgical Technique
•   With area prepped and
    draped, reconfirm
    insertion site
•   Inject local anesthetic
    – Skin and SQ
    – Fascia
•   Make incision
    – Alternate: incision
      after wire placed
                 Endoscopist
•   Retrieves snare, PEG
    tube from kit

•   Advances snare into
    biopsy channel of
    endoscope
                        Access
•   Insert needle/catheter
    assembly
•   Safe tract technique
    – Continuous aspiration
      via syringe
    – Return of air without
      visualization of needle
      in stomach signifies
      malposition
    – Remove, retry
                  Endoscopist
•   While puncture
    performed, advance
    snare near intended
    puncture site
•   Snare the catheter
    prior to removal of
    needle to prevent loss
                         Access
•   Remove
    syringe/needle
•   Cover catheter to
    prevent loss of
    insufflation
•   Advance guidewire
    into stomach
    – Incision at insertion
      site if not placed
      previously
                  Endoscopist
•   After wire passed
    through catheter,
    endoscopist uses snare
    to grasp wire
•   Wire advanced
•   Snare/wire pulled out
    of mouth with
    endoscope as a unit
                  Endoscopist
•   Endoscopist secures
    PEG tube to mouth
    end of guidewire
•   PEG internal bumper
    can be snared to allow
    easy passage of
    endoscope
•   Assembly passed back
    into stomach
             PEG Tube Position
•   Guidewire pulled
    through skin incision
•   PEG follows, tract
    dilated by conical
    dilator at end of PEG
•   Countertraction at skin
    level with non-
    dominant hand
    facilitates passage
              PEG Tube Position
•   PEG tube advanced
    – Two resistance points
       » GE Junction
       » Final position @ gastric
         mucosa
•   Usually in position
    when external marker
    between 2-4 cm at
    skin level
              PEG Tube Position
•   Guidewire cut at tapered
    end of tube
•   Skin disk/external bumper
    applied over introducer
    and slid to skin surface
•   Bumpers should prevent
    movement but not blanch
    skin
•   Endoscopy may confirm
    no blanching of mucosa
       Completion of Procedure
•   Snare placed into biopsy channel
•   Endoscope removed
•   Option: place antibiotic ointment and/or
    dressing under skin disk
•   Tube cut to appropriate length
•   Adapter secured to cut end of tube
Complications & Pitfalls
         Complications of PEG
•   Direct, major complications: 4%
•   Mortality from complications: 25%
•   High mortality attributed to patient
    population
    – Debilitated
    – Cannot tolerate additional insult
    Pneumoperitoneum after PEG
•   Expected event
    – Up to 36%
•   Contributing factors
    – Excessive air insufflation
    – Prolonged procedure time
    – Multiple percutaneous needle punctures of the stomach
•   Peritonitis
    – <1% of PEGs
    – ~30% mortality
    Pneumoperitoneum after PEG
•   No additional studies warranted unless signs
    of inflammation, peritonitis
•   Contrast study
    – May detect gross extravasation
•   CT Scan Abdomen
    – Extravasation
    – Lack of apposition with abdominal wall
    – Free fluid, suggestive of visceral perforation,
      hemorrhage
     Dislodgement of PEG Tube
•   Concern when occurs prior to maturation of
    gastrocutaneous tract
•   Initial Rx
    – Nasogastric suction
    – Broad spectrum antibiotics
•   Surgery
    – Failure to improve
    – Overt peritonitis, sepsis
      Buried Bumper Syndrome
•   Excessive traction on PEG tube
•   Overtightening of skin disk
    – Ischemic necrosis of the gastric mucosa
    – Migration of the internal bolster into the gastric
      or abdominal wall
•   Prevention
    – Confirm some laxity at initial insertion
      Buried Bumper Syndrome
•   Findings
    – Resistance to flow
    – PEG tube fixed, with surround subcutaneous
      erythema
•   Endoscopy
    – Ulceration, mucosal dimpling
    – Nonvisualization internal bumper
      Buried Bumper Syndrome
•   Treatment
    – Dissection of the buried appliance from the
      abdominal wall
    – Replace with new gastrostomy tube
    – Large gastrocutaneous fistula may warrant
      laparotomy/resection
     Peristomal Wound Infection
•   5-30% of cases
•   Prophylactic Antibiotics
    – Single dose 30 minutes before procedure
    – Narrow spectrum (e.g. cefazolin)
•   Skin incision
    – Large enough to easily admit tube
    – Smaller incision allows entrapment of bacteria
       postop infection
           Necrotizing Fasciitis
•   Rare, devastating complication
•   43% mortality
•   Initial presentation with cellulitis
•   Source control essential
    – May mandate surgical closure of PEG site
     Gastrocolocutaneous Fistula
•   Early presentation
    – Drainage of feculant material at PEG site
•   Late
    – Detected after tube replacement: diarrhea
•   Colonic interposition during placement
    – Dx: gastrograffin study, CT scan
                 Hemorrhage
•   2.5% of cases
•   Repeat endoscopy indicated for Dx,
    possible Rx
•   Often related to gastric ulceration under
    internal bumper
    – Pressure necrosis
    – Friction
•   Caution in patients with coagulopathy
                  Aspiration
•   Clinically evident aspiration rare
•   50-60% mortality rate
•   Related to
    – Initial illness
    – Positioning and sedation during procedure
•   Monitor residuals, appropriate interventions
    if increased
               Tube Migration
•   Inadequate stabilization
•   Proximal migration
    – Vomiting, aspiration
•   Migration into distal stomach
    – Gastric outlet obstruction
    – Distention, vomiting
•   Distal migration (small bowel)
    – Dumping syndrome
Postoperative Care
         Postoperative Nursing
•   Local care to prevent complications
    – Especially important while gastrocutaneous
      fistula is maturing
•   Allow slack on tubing to prevent
    pressure/traction complications
    Resumption of Enteral Nutrition
•   Immediate resumption of enteral nutrition is
    possible following PEG placement
•   Some surgeons maintain NPO, straight
    drainage for 12-24 hours
•   Postop “ileus” may be related to degree of
    insufflation
     – Should suction air prior to endoscope removal
            Tube Replacement
•   Replace for occlusion, leakage, cosmesis
•   May wish to replace with “low profile” tube
•   Can also use foley, Malecott, dePezzer
    – Inflate foley with water not saline to prevent
      crystallization
•   When fistula matured, simple replacement
    through existing hole possible
    – Consider gastrograffin study to confirm
      position
              PEG Removal
•   Removed when indication for placement
    resolved
•   Gastrocutaneous fistula should be mature
•   Removal technique dependent on PEG
    features
                 PEG Removal
•   Rigid internal bumper
    –   Mandates repeat endoscopy
    –   PEG tube cut at skin
    –   Bumper snared endscopically
    –   Bumper may be obstructive, must be removed
               PEG Removal
•   Malleable internal
    bumper
     – Remove via
       traction technique
     – Initially rotate
       tube to disengage
       from fibrous tract
                 PEG Removal
•   Secure tube in one
    hand
•   Continuous steady
    traction
    – Caution: “spray” of
      gastric fluids
•   May wrap tube around
    hand
•   Bumper inverts and
    PEG removed
                PEG Removal
•   Fistula closes within 24 hours
•   Persistant fistula
    – Granulation tissue/inflammation
    – Silver nitrate sticks
    – Rarely require resection/operative closure

				
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posted:4/25/2008
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