Overview of Percutaneous Endoscopic Gastrostomy Tube
When a patient can’t eat enough by mouth, or it’s not safe for them to eat or drink, doctors may need to find another way to provide them with the nutrition they need. This can involve giving them a blend of proteins or amino acids, carbohydrates, fiber, fats, water, minerals, and vitamins. This blend can be given through a vein, which is called parenteral nutrition. Alternatively, it might be given through a tube that goes right into the stomach or small intestine. This is known as enteral tube feeding.
Sending nutrition directly into the stomach or small intestine is often the preferred method because it has some advantages over parenteral nutrition. For example, it’s less likely to lead to infections, it’s cheaper, it gets the gut working quicker, it helps keep the lining of the gut (mucosa) and the body’s immune system healthy, and it can make a hospital stay shorter.
The tube for enteral feeding can be placed through the nose (either into the stomach, or the first or second part of the small intestine), through the mouth into the stomach, or directly through the skin into the stomach or small intestine. This final method, called a Percutaneous Endoscopic Gastrostomy (PEG) tube, requires a small surgical procedure.
A PEG tube is often a good option for patients who need long-term feeding, typically longer than 4 weeks, through a tube and whose stomach and small intestine are still working. This tube, which goes directly into the stomach, can also be used to relieve pressure in the stomach by letting gases and fluids out. In general, these tubes are mainly used for feeding and relieving pressure in the stomach.
Placing a PEG tube is one of the most common procedures done by a stomach specialist (gastroenterologist). It’s usually a safe procedure, although like any procedure, it can come with minor and major complications.
Anatomy and Physiology of Percutaneous Endoscopic Gastrostomy Tube
Before inserting a medical tube, the doctor first needs to check the patient’s belly and any previous images taken, such as X-rays or scans. This is crucial because any history of surgery could affect where the tube can be appropriately placed. During this procedure, the patient is typically sleeping or very relaxed as a result of sedation and local pain relief (anesthetic).
The doctor, who is well trained with an endoscope (a thin tube with a light and video camera) inserts it to see inside the stomach. They then inflate the stomach to get a better view. The light from the endoscope shines through the patient’s skin, making it show up from the outside. This light helps the doctor mark exactly where they will insert the tube later.
Usually, the tube is placed about 2 cm inwards from the edge of the rib cage (costal margin) and 2 cm below where the ribs meet in the middle of your chest (the tip of the sternum is called the xiphoid process). Once the area is numbed with local anesthesia, they insert the tube. The doctor then checks to make sure it’s in the right place by seeing a direct path (gastrocutaneous fistula) between the front wall of the stomach and the belly wall. This is all done to ensure the correct and safe placement of the tube.
Why do People Need Percutaneous Endoscopic Gastrostomy Tube
A PEG tube, or percutaneous endoscopic gastrostomy tube, is typically used when patients require long-term feeding support (longer than 30 days). This is usually recommended for patients combating moderate-to-severe protein-calorie malnutrition. Certain factors, such as a patient’s expected lifespan, treatment goals, specific illness, and personal choices need to be carefully discussed and understood by both the patient and family before giving informed consent for the procedure.
When used in the right circumstances, a PEG tube can not just improve a patient’s survival rate and nutrition, but also their quality of life. Conditions that may indicate the need for a PEG tube include stubborn health problems like stroke, motor neuron disease, multiple sclerosis, Parkinson’s disease, brain tumours, head and neck cancers, burns, stomach cancer, esophageal cancer, prolonged coma, neurological diseases, developmental disorders, HIV/AIDS, cystic fibrosis, Crohn’s disease, and short bowel syndrome.
These conditions often cause problems like difficulty in swallowing, self-feeding, obstruction in the digestive tract preventing normal food intake, malnutrition due to cancer or limited food or drink intake because of procedures like radiation or chemotherapy. In other cases, a PEG tube might be needed for gastric decompression, which is a process to relieve pressure in the stomach. In all these scenarios, PEG tubes can provide the vital nutrition the patient needs, making them critical for patient treatment plans.
When a Person Should Avoid Percutaneous Endoscopic Gastrostomy Tube
There are certain conditions that may prevent a patient from getting a PEG tube placement (a medical procedure to place a feeding tube in the stomach):
- Significant blood clotting disorders (measured by tests such as INR, PTT, PLT which if greater than 1.5 or 50 seconds or if PLT is less than 50,000/mm3, signals a risk)
- Problems with stable blood pressure and heart rate, referred to as hemodynamic instability
- A severe, body-wide infection known as sepsis
- Severe build-up of fluid in the abdomen, known as ascites
- Inflammation of the lining of the abdominal cavity, known as peritonitis
- Infection of the skin on the belly where the tube would be placed
- Presence of cancer in the lining of the abdomen, known as peritoneal carcinomatosis
- Can’t find a secure path to place the tube through skin into the stomach
- A blockage of the outlet of the stomach or severe slow stomach emptying (gastroparesis), which would affect the use of the tube for feeding
- Previous removal of the entire stomach
- The need for extended help with breathing
- If the patient hasn’t fully understood and thus hasn’t given permission for the procedure
Situations that may also cause problems, but don’t outright prevent the surgery include having a history of part of the stomach being removed, or a large hiatal hernia (when part of the stomach pushes into the chest).
Equipment used for Percutaneous Endoscopic Gastrostomy Tube
The following items are used during endoscope/gastroscope procedures, which are specialized equipment used to visually examine your digestive tract:
- The ‘Endoscope/Gastroscope’ is like a mini-camera on a thin, flexible tube that doctors use to look inside your body.
- ‘Alcohol swabs/povidone iodine swabs’ are used to clean your skin beforehand to reduce the risk of infection.
- A ‘No. 11 blade’ is a small, sharp tool used for making an initial incision or cut on the skin.
- ‘Lidocaine’ is a local anesthetic used to numb the particular area on your body where the procedure will be performed. This helps to minimize discomfort.
- Physicians wear a ‘Sterile gown and gloves’ to ensure germs do not enter your body during the procedure.
- A ‘PEG tube kit’ is a set of tools including a 14-to18 gauge needle (a needle of specific thickness and length), a guide wire to help place the needle correctly, a sheath which is like a protective cover, a feeding tube for nutritional support, and a skin disc which helps to secure everything in place.
- Last but not least, a ‘Dressing: 2 x 2 or 4 x 4 gauze, adhesive tape’ is used. This is essentially a bandage that is applied after the procedure to protect the incision spot, help it heal, and prevent infection.
Who is needed to perform Percutaneous Endoscopic Gastrostomy Tube?
A PEG tube placement is a medical procedure. This is done by two doctors, usually a doctor specialized in examining the inside of your body using a tool called an endoscope, and a surgeon, who is a doctor trained to do surgeries. This procedure can be done at your bedside, in an operating room, or in a special room built for endoscopy procedures. An anesthetist, who is a doctor trained in giving you drugs to either numb a part of your body or make you sleep during surgery, and a nurse specialized for endoscopy are also needed. They will help to make you sleep, assist with the endoscopy equipment, and provide mouth suction if needed.
Preparing for Percutaneous Endoscopic Gastrostomy Tube
Before inserting a PEG tube (which is a tube placed in your stomach for feeding purposes), doctors will closely examine your stomach area and review your medical history and any relevant images. This helps to pinpoint the best spot for the feeding tube. To start the procedure, you’ll first be placed on your back with the head of your bed slightly elevated. This position helps keep food and saliva from going down into your windpipe, which could lead to choking or other problems.
A mouth-guard, called a “bite block,” is typically used to keep your mouth open and allow easier access for the medical instrument, or “scope.” A suction device is also on hand to take care of any saliva or secretions and prevent choking risks.
If you are not unconscious, you may receive a small dose of relaxing medicines (like benzodiazepine and a mild narcotic) to calm your nerves during the procedure. In addition, a local numbing medicine, typically lidocaine, is used at the site where the feeding tube will be inserted. Lastly, the chosen spot on your stomach is thoroughly cleaned and made germ-free with alcohol, povidone-iodine swabs, or sterile soaps. Sterile drapes are also used to keep the area clean during the procedure.
How is Percutaneous Endoscopic Gastrostomy Tube performed
There are three methods to place a PEG tube, which is a tube inserted into your stomach to give you nutrition when you can’t eat or swallow normally. These methods include: the peroral pull technique (Ponsky), the peroral push technique (Sacks-Vine), and the direct percutaneous procedure (Russell). The most commonly used method is the peroral pull technique (Ponsky).
In each of these methods, the initial steps are the same. Firstly, an endoscope (a long, thin tube with a light and camera at its end) is inserted into your stomach through your mouth. Your stomach is then inflated and illuminated, and the best spot for tube insertion is marked and numbed with lidocaine (a local anesthetic). A small cut is made at this spot where a needle is inserted, which can be seen on the display from the camera attached to the endoscope.
In the Russell Technique, which isn’t used often, a wire is passed through the needle into your stomach and the needle is removed. The feeding tube is then inserted over this wire into your stomach and secured in place. The tube should sit about 3 to 4 cm from your belly.
In the Sacks-Vine or peroral push technique, a wire is passed through the needle and into your stomach. The wire is then pulled out through your mouth, and a feeding tube is pushed down over this wire, from your mouth to your stomach. Again the tube’s end coming out of your belly should sit 3-4 cm from the skin.
In the Ponsky or peroral pull technique, which is the most commonly used method, rather than pushing a wire through the needle, it’s a braided string. The feeding tube attached to this string is pulled from your mouth into your stomach and through your belly.
In all techniques, after the tube is placed, the area around it (known as the stoma) should be cleaned and checked regularly for signs of infection like redness, pain, or pus. Your doctor will also recommend to start feeding through the tube 4 hours after it’s placed and give you specific instructions on how to care for it at home, like moving the tube around a little bit to prevent it from sticking to the inside of your stomach, and flushing it out before and after each use to prevent any blockages.
Possible Complications of Percutaneous Endoscopic Gastrostomy Tube
: Even though placing a tube into the stomach through the skin (a PEG tube) is usually safe, there can still be some smaller and larger problems. Smaller issues can include infections around the place where the tube goes in (stoma), bumpy tissue build-up (granuloma), leaking from the tube into the belly causing inflammation (peritonitis), leakage from the stoma, accidental removal of the PEG tube, blockages in the tube, gas buildup in the belly area (pneumoperitoneum), and blockages of the stomach opening.
More serious complications can include inhaling food or liquid into the lungs (aspiration pneumonia) – which can happen if the muscle at the bottom of the esophagus is weak, bleeding, a syndrome known as buried bumper (where the inner bumper of the tube becomes lodged in the stomach wall), perforation of an organ in the abdomen, a dangerous soft tissue infection (necrotizing fasciitis), a connection between the colon and the skin due to misplacement of the PEG tube (colonic fistula), and spread of cancer at the PEG tube site.
What Else Should I Know About Percutaneous Endoscopic Gastrostomy Tube?
A PEG tube is a type of feeding tube used in people who need long-term help with eating and drinking. This is particularly helpful for those who are suffering from moderate-to-severe malnutrition due to lack of protein and calories.
It’s important for doctors to discuss this treatment option thoroughly with the patient and their family. They will need to consider the patient’s current health situation, how long they are expected to live, their comfort and lifestyle goals, and their personal beliefs.
This detailed conversation allows the patient and their family to provide informed consent, meaning they fully understand and agree to the treatment plan. In many situations, using a PEG tube for feeding not only helps improve the patient’s physical health such as their nutritional status and likelihood of survival, but it also boosts their quality of life.
