Overview of Percutaneous Gastrostomy and Jejunostomy

Percutaneous endoscopic gastrostomy (PEG) and percutaneous endoscopic gastro-jejunal (PEG-J) tubes are methods doctors use to provide long-term nutritional support for patients who cannot eat normally. In simpler terms, these are special tubes placed in the stomach or small intestine, respectively, to deliver food directly. These procedures are often chosen over other methods of feeding as they are simpler, less invasive, and less risky.

PEG tube placement first started in 1980 and has a very high success rate of over 95%. The procedure is usually comfortable and safe for the patient, with only light sedation needed and a very low risk of fatality (0.5%).

PEG and PEG-J tubes are most useful for patients who find it hard to eat normally. This difficulty could be due to various reasons such as physical reasons like throat blockages caused by benign or cancerous growths, treatment side effects like radiation therapy for cancer, disorders affecting the movement of food down the esophagus (the tube connecting your throat to your stomach), neurological issues causing difficulty in swallowing, mental health disorders like dementia or cognitive and developmental delays.

In PEG tube placement, a tube is placed directly into the stomach through the wall of the abdomen. PEG-J tube placement involves intervening an extension from the existing PEG tube into the jejunum (part of the small intestine) to enable feeding into the small intestine. This technique is often helpful in patients who are likely to accidentally inhale food into the lungs from the stomach, such as those with gastroparesis (a condition where the stomach doesn’t empty properly), severe heartburn problems, previous surgeries involving the stomach, history of repeated accidental inhalation of meals, or those who are not able to tolerate direct feeding into the stomach. However, it’s important to understand that PEG-J tube placement has not been proven to entirely prevent the accidental inhalation of food.

Why do People Need Percutaneous Gastrostomy and Jejunostomy

A Percutaneous Endoscopic Gastrostomy tube, frequently called a ‘PEG tube’, or a ‘PEG-J tube’, can be placed by a medical professional in situations where a patient isn’t getting enough calories. This is a tube that’s inserted into the patient’s stomach or small intestine to provide nutrients when they’re not able to eat enough by mouth. It’s mainly used in situations where a person needs this special form of feeding for longer than a month. Here are some instances when this might be necessary:

  • When a patient has lowered consciousness levels, possibly due to a head injury or an extended stay in an intensive care unit.
  • Neurological disorders, such as strokes, dementia, Parkinson’s disease, cerebral palsy, multiple sclerosis, or motor neuron disease.
  • Cancer in the esophagus or throat that makes it difficult to swallow.
  • A blockage in the stomach or advanced cancer in the lining of the abdominal cavity (peritoneum) that affects bowel function.
  • When a person has slow emptying of the stomach (gastroparesis).
  • Certain conditions where a patient may be malnourished, like cystic fibrosis, burn wounds, chronic pancreatitis, Short Bowel Syndrome (when a significant portion of the small intestine is missing or doesn’t work properly).
  • In cases of facial trauma that affect the normal eating process.

An important thing to keep in mind is this method of feeding is beneficial only for people who need long-term nutritional support, typically more than 30 days.

When a Person Should Avoid Percutaneous Gastrostomy and Jejunostomy

Before a certain medical procedure is carried out, doctors need to make sure that it is necessary and safe for the patient. This means understanding if there are reasons, or ‘contraindications’, why the procedure should not be done.

Some contraindications mean that the procedure should absolutely not be done:

* If the patient has sepsis, an extreme response to an infection in the body.
* If there are issues with blood pressure and heart rate, known as ‘hemodynamic instability’.
* If there is a buildup of fluid in the abdomen, or ‘severe ascites’.
* If the patient has peritonitis, an inflammation of the membrane lining the abdomen.
* If there is an issue with the patient’s blood clotting, with an INR (a measure of blood clotting) greater than 1.5, or fewer than 50000 platelets per microliter of blood (both problems are known as ‘coagulopathy’).
* If there is an infection on the abdomen where the procedure would be performed.
* If there is an organ in the way of where the procedure should be done (most commonly the colon).
* If the patient has had their entire stomach removed.
* If the patient has not consented to the procedure.
* If the front of the stomach cannot be brought close to the abdominal wall.

There are also some contraindications that might make a procedure more difficult or risky, but not impossible or completely unsafe:

* If the patient is obese, it might make it harder to see inside the abdomen during the procedure or to find a suitable site for operation.
* If the patient has a non-blocking tumor in their mouth or esophagus.
* If the liver (hepatomegaly) or spleen (splenomegaly) are unusually large.
* If the patient is on peritoneal dialysis, a treatment for kidney failure.
* If the patient has gastric varices, enlarged veins in the stomach.
* If the patient has only had part of their stomach removed.

Equipment used for Percutaneous Gastrostomy and Jejunostomy

In simpler terms, a variety of available kits and different procedures have been developed to assist doctors. In the field of stomach and digestive health, a tool called an endoscope is used for making certain procedures possible. I’ll try to describe the method in simple terms.

Typically, the kit for a specific procedure, like inserting a PEG tube, carries a silicone tube (normally, a top-quality silicone, dome-shaped tube for PEG placement), a snare to retrieve any objects, a tray to organize tools thereby making the procedure smoother, and some external supports.

How a PEG or PEG-J tube is placed using X-ray guidance can be a bit different, and this technique doesn’t require the use of an endoscope.

Who is needed to perform Percutaneous Gastrostomy and Jejunostomy?

A stomach and intestine specialist, along with a second doctor and supporting team such as a nurse, are all required to perform the procedure. Generally, this procedure is done with moderate sedation, which is a state of deep relaxation. However, an anesthetist or anesthesia doctor, who is responsible for putting patients asleep, is often present if a higher form of sedation is needed for some patients. If this procedure is done by the X-ray team, then the stomach and intestine specialist won’t be present.

Preparing for Percutaneous Gastrostomy and Jejunostomy

Before a medical procedure can take place, a patient or their legal representative must provide informed consent. This is an agreement or permission granted in full knowledge of the possible consequences. Afterwards, patients are generally asked to avoid eating or drinking anything for about 8 hours, often overnight. Antibiotics are also administered 30 minutes to 1 hour prior to the procedure, to help prevent infections.

Depending on the patient’s risk for MRSA, a type of bacteria that is resistant to many antibiotics, different preventative measures must be taken:

In patients who do not have MRSA or those considered to be at low risk for it, a dose of cefazolin, an antibiotic, is given through an IV. For patients less than 120 kg, 2 grams of cefazolin is used, while for patients 120 kg or more, 3 grams is used. If a patient is allergic to penicillin or cephalosporin, another antibiotic called clindamycin is used instead. If the procedure takes a long time, another dose of the antibiotic may be needed four hours after the first one.

#For patients who test positive for MRSA or are at risk for MRSA, they might be advised to undergo decontamination if possible. Antibiotic therapy preferred in these cases is typically vancomycin. It is given via an IV, and the dose is usually based on patient’s weight. The infusion should start 1 to 2 hours before the surgical procedure begins. If the surgery takes longer than expected, there is no need for an extra dose of this antibiotic.

How is Percutaneous Gastrostomy and Jejunostomy performed

There are a few different ways to insert a feeding tube, also known as a PEG tube (Percutaneous Endoscopic Gastrostomy Tube). We will talk about the three most popular methods:

Before we begin, there is one common step in all procedures – figuring out the best spot on the belly for the tube insertion. This is done with a special light and indentation technique using an endoscope, a tube-like instrument with a light and camera at the end.

1. The “pull” technique: This common method was initially designed by a team led by Gauderer. Here, a string is tied to a needle, and this needle is inserted through the belly into the stomach. With the help of an endoscope, the string is caught and pulled out through the mouth. The outside end of the PEG tube is attached to this string, and then the string is pulled back through the tummy, which essentially pulls the tube from the mouth through the esophagus, the stomach, and then out via the tummy.

2. The “push” technique: This is quite similar to the “pull” method but uses a different approach. A guidewire is put into the stomach (much like in the “pull” method) and taken out through the mouth. Then, the feeding tube is pushed over the guidewire so that it enters the stomach and comes out via the belly.

3. Introducer (Russell) technique: This method uses a technique called the Seldinger method. Here, a guidewire is used for placement into the stomach under endoscopic view. A tube, along with a sheath (a protective cover), is slipped over the guidewire. After the guidewire is taken out, the PEG tube is inserted through the sheath.

For a better idea of how these processes work, there are several videos available online for free. Videos provided by national medical societies are generally reliable and informative.

Possible Complications of Percutaneous Gastrostomy and Jejunostomy

Inserting a feeding tube through the skin and into the stomach, a process known as percutaneous endoscopic gastrostomy (PEG), is generally a safe procedure. It works well for at least 95% of patients. However, there can be complications. The risk of these complications may increase for patients with other existing health conditions.

Sometimes, PEG tube complications can be severe and include:

– Bleeding: This can occur in the PEG tract, the tube that was created during the procedure. The bleeding could come from the stomach artery, veins connected to the intestines, and hematoma (a collection of blood outside of the blood vessels). In mild cases, pressing over the skin on the abdomen may stop the bleeding. In severe cases, doctors may need to explore the area using endoscopy or surgical methods.

– Aspiration pneumonia: This is a serious and potentially deadly complication, which occurs when food or fluids enter the lungs. The risk increases if the patient is being fed high volumes of food and lying flat.

– Buried bumper syndrome: This happens when there is excessive tension applied on the tube’s internal and external stoppers causing tissue damage to the wall of the stomach. In response, the tube may move towards the abdominal wall leading to leakage, feeding problems, and/or discomfort and swelling at the insertion site.

– Necrotizing fasciitis: This is a deadly but rare infection that involves soft tissues. An emergency surgery is needed to remove dead tissues and bacteria, along with strong antibiotics to fight the infection.

– Perforation of bowel: This is a tear in the bowel wall, which can be life-threatening. The presence of unusual pain, changes in heart rate or blood pressure could point towards this.

– Metastatic seeding: This is a rare complication where a patient with head and neck cancer has cancer cells spreading to their PEG site. Imaging techniques like a CT scan of the abdomen and a biopsy can diagnose this condition.

Apart from major complications, there are also minor ones like:

– Wound infection: The most common minor complication where the PEG tube’s site gets infected leading to redness and pus. Mild infections are managed with antibiotics but severe infections might require more in-depth investigation and treatment.

– Tube leakage to the abdominal cavity: This can lead to an infection of the lining of the abdomen (peritonitis).

– Inadvertent PEG removal: This is the accidental removal of the PEG tube.

– Stoma leakage: This is leakage from the hole, or the stoma created for the PEG tube.

– Pneumoperitoneum: This is the abnormal presence of air within the abdominal cavity, common after a PEG tube insertion because of air entering the abdomen during the procedure.

– Tube blockage: This happens primarily with fine tubes where the food, medications, or incompatible feeds clog the tube. This can be remedied by pushing warm water into the tube with a 50mL syringe using a pull-push method or gentle squeezing.

What Else Should I Know About Percutaneous Gastrostomy and Jejunostomy?

Placement of PEG/PEG-J tubes is a routine medical procedure with a variety of uses. This means that doctors, nurses, and other members of the hospital team should have a deep understanding of why and when this procedure is used, who it might not be suitable for, and any potential problems that could arise.

Just to clarify, PEG/PEG-J tubes are special types of feeding tubes that are inserted into your stomach or intestines through a small surgical cut on your abdomen. They are used to give nutrients directly to your digestive system when you are unable to eat or drink adequately due to illness or surgery.

Frequently asked questions

1. Why is a Percutaneous Gastrostomy or Jejunostomy tube necessary for my condition? 2. What are the potential risks and complications associated with the placement of these tubes? 3. How long will I need to have the tube in place, and what is the process for removing it? 4. Will I be able to eat or drink normally while the tube is in place, or will I need to rely solely on the tube for nutrition? 5. Are there any dietary restrictions or special care instructions I should follow while using the tube?

Percutaneous gastrostomy and jejunostomy are medical procedures that involve the insertion of a feeding tube into the stomach or small intestine. These procedures are typically performed on individuals who are unable to eat or swallow food due to various medical conditions. The insertion of a feeding tube allows for the delivery of nutrition and medication directly into the digestive system, which can help maintain adequate nutrition and hydration.

There could be several reasons why someone might need Percutaneous Gastrostomy and Jejunostomy. Some possible reasons include: 1. Difficulty or inability to eat or swallow: If a person is unable to eat or swallow due to a medical condition or injury, a gastrostomy and jejunostomy tube can be inserted to provide nutrition and hydration directly into the stomach and small intestine. 2. Malnutrition or weight loss: If a person is experiencing significant weight loss or malnutrition due to a medical condition, a gastrostomy and jejunostomy tube can be used to provide adequate nutrition and help improve their overall health. 3. Neurological disorders: Certain neurological disorders, such as stroke, Parkinson's disease, or amyotrophic lateral sclerosis (ALS), can affect a person's ability to eat or swallow. In such cases, a gastrostomy and jejunostomy tube can ensure that they receive proper nutrition and hydration. 4. Cancer treatment: Some cancer treatments, such as radiation therapy or chemotherapy, can cause difficulty in eating or swallowing. A gastrostomy and jejunostomy tube can be used to provide nutrition and hydration during the treatment period. 5. Chronic illnesses: Individuals with chronic illnesses, such as cystic fibrosis or Crohn's disease, may require a gastrostomy and jejunostomy tube to ensure adequate nutrition and hydration. It is important to consult with a healthcare professional to determine if Percutaneous Gastrostomy and Jejunostomy is necessary and appropriate for an individual's specific medical condition.

You should not get Percutaneous Gastrostomy and Jejunostomy if you have contraindications such as sepsis, hemodynamic instability, severe ascites, peritonitis, blood clotting issues, infection on the abdomen, obstruction by an organ, previous stomach removal, lack of consent, or inability to bring the front of the stomach close to the abdominal wall. Additionally, there are some contraindications that may make the procedure more difficult or risky, such as obesity, non-blocking tumor in the mouth or esophagus, enlarged liver or spleen, peritoneal dialysis, gastric varices, or partial stomach removal.

The text does not provide specific information about the recovery time for Percutaneous Gastrostomy and Jejunostomy.

To prepare for Percutaneous Gastrostomy and Jejunostomy, the patient needs to provide informed consent and avoid eating or drinking anything for about 8 hours prior to the procedure. Antibiotics are also administered 30 minutes to 1 hour before the procedure to prevent infections. Depending on the patient's risk for MRSA, different preventative measures may need to be taken, such as administering cefazolin or vancomycin.

The complications of Percutaneous Gastrostomy and Jejunostomy include bleeding, aspiration pneumonia, buried bumper syndrome, necrotizing fasciitis, perforation of the bowel, metastatic seeding, wound infection, tube leakage to the abdominal cavity, inadvertent PEG removal, stoma leakage, pneumoperitoneum, and tube blockage.

Symptoms that may require Percutaneous Gastrostomy and Jejunostomy include lowered consciousness levels, neurological disorders, difficulty swallowing due to esophageal or throat cancer, stomach blockage or advanced abdominal cancer affecting bowel function, slow emptying of the stomach (gastroparesis), malnutrition in conditions like cystic fibrosis or chronic pancreatitis, and facial trauma affecting eating.

There is no specific information provided in the given text about the safety of Percutaneous Gastrostomy (PEG) and Jejunostomy (PEG-J) tubes in pregnancy. It is recommended to consult with a healthcare professional for personalized advice and to assess the potential risks and benefits in the context of an individual's pregnancy.

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