Percutaneous Endoscopic Gastrostomy (PEG)
In 1980, Dr. Jeffery Ponsky in Cleveland Ohio developed new non-operative technique called Percutaneous Endoscopic Gastrostomy, commonly called "PEG." Percutaneous means "going through the skin. So, this feeding tube bypasses the mouth and esophagus by passing through the skin and muscle of the abdominal wall directly into the stomach.
This technique can be done without the need for general anesthesia or a major abdominal incision. It is usually performed by a gastroenterologist. Using a endoscope to guide placement, a tunnel can be created between the skin and the stomach with only a 1/2" incision. PEG is particularly well suited for patients who have an increased risk for surgery. It can be performed in approximately 15
minutes, requires minimal sedation rather than general anesthesia, and can be accomplished at the bedside, if necessary. PEG has a low complication rate and is successful in over 95% of cases.
ENTERAL FEEDING FORMULAS
Liquid nutritional formulas are put into the tube and directly into the stomach - bypassing the disturbed swallowing function. These solutions can provide complete nutrition. Common solutions are Jevity and Ensure. The doctor and dietitian usually work together to determine which formula is best for each individual, and how much formula will be needed to meet that patient's nutritional needs. In addition, water and medications can be given through the tube.
CONTRAINDICATIONS FOR PEG PLACEMENT
PEG placement is not for everybody. It is still a surgical procedure with some risk and best serves those with a reversible problem or long term need for nutritional support. Poor candidates for a PEG would include:
- Patients with a terminal illness. It is not appropriate to use a PEG tube in those with a limited life expectancy. They can be treated with a NG tube or thin feeding tube inserted through the nose.
- Patients with a tight blockage of the esophagus. A PEG obviously can't be done if the endoscope cannot be passed through the esophagus into the stomach. This might happen in a case of a very narrow esophagus from cancerous invasion.
- Patient with a blockage of the digestive tract can not be fed through a PEG tube - although a PEG is sometimes used in the circumstance to help deflate a blocked and swollen stomach.
- Patients with peritonitis - a serious infection within the abdomen sometimes caused by a ruptured organ like the appendix. (This can also result from premature PEG tube removal.)
- Patients with severe liver failure and massive abdominal fluid collection (ascites)
- Patients with poor blood clotting either from liver disease, a blood disorder, or due to a "blood thinner" such as Coumadin blood thinners. Clotting disorders must be corrected before PEG placement can be done.
- Patients with kidney failure on peritoneal dialysis
- Patients with a deformed stomach usually from a large large hiatal hernia or prior stomch surgery
- Patients who are morbid obesity - over 100 pounds overweight.
- Patients with stomach cancer if the cancer is directly in the path of the PEG tube or if the cancer blocks the drain of the stomach (pylorus).
USE OF THE PEG
Typically, use of the PEG for medications can gebin immediately after it is placed. After approximately 4 hours, its OK to initiate feeding with an enteral formula. The patient should be sitting upright or in a reclined position maintaining one’s head up at least 30 degrees while being fed through the tube.
In general, this is a relatively safe procedure, however, complications due occur. The most frequent complication is infection of the skin at the tube insertion site. This can occur is up to 20% of cases. The risk is minimized by giving prophylactic antibiotics at the time of tube placement. Other reported complications that occur with less frequency include peritonitis, aspiration pneumonia, bleeding and bowel perforation. Because these procedures are usually being performed on elderly or very ill patients, any of the complications could be associated with a poor outcome.
Frequently Asked Questions (FAQ)
- How do I unblock the tube? Flushing tubes with water before and after feedings will prevent most blockages. If the formula, water, or medication will not go in, first check that the tube is not kinked. Occasionally, the tube will be blocked by residues from formula or medication. To remove the blockage, place a syringe into the blocked tube. Gently pull back on the plunger to remove the blockage. If the blockage remains, use the syringe to instill water into the tube. The tube may also be milked with the fingers. Place one hand holding the tube securely at the base. With the other hand run your thumb and forefinger down the tube to remove the blockage. If both methods fail, call your doctor.
2. What if the tube is pulled out? Confused patients may try to remove the tube. It is very important NOT to pull out the tube in the first two weeks after PEG tube placement. Serious complications could occur. But, once the tract has healed, there is not much risk in removal of the tube. The opening in the abdominal wall will probably leak for a few days and then eventually seal itself - much like a pierced ear. If the patient pulls at the tube, do not panic. Cover the opening with a small, light dressing and call the patient's doctor.
3. What if the stoma looks infected? Once the initial healing takes place infection of the stoma is uncommon. Clean the area several times a day as prescribed. If signs of skin irritation (redness, soreness, pain, swelling, unusual drainage) persist, call the patient's doctor.
4. What if there is leakage at the stoma? Leakage may occur because the tube has pulled away from the abdominal wall or because the stoma site is enlarged. If the stoma site has enlarged, the doctor may need to replace the tube. Contact the doctor if the leakage does not stop.
5. What if the feeding tube becomes disconnected? If the feeding tube becomes disconnected, estimate the amount of formula lost, reattach the feeding tube, and continue feeding, adding the estimated amount of lost formula.
6. What if the tube is shorter or longer than usual? The length of the tube when originally placed is noted. Ask the patient's doctor or health care provider about marking the tube where it should be located. The tube should have a small amount of "play," but if the tube has become longer or shorter than the original length by more than the number of inches noted, it may be migrating (moving). Call the patient's doctor if there is a significant change in the tube's length.
7. What feeding solution is used? There are many nutritional supplements on the market that can be given through the PEG tube. Nutritional prescriptions are usually provided by the physician or dietician.
8. How much feeding solution is given? Every patient is given a unique nutritional prescription. Some patients can't eat at all and depend completely on the feeding tube for all of their nutrition. They may receive as much as 8 cans a day (2400 calories). Other just need a little help and require less.
9. Can the patient still eat and swallow once the PEG feeding tube is inserted? For some patients, swallowing is either impossible or associated with high risk of aspiration pneumonia. These patients cannot take anything by mouth. Other patients, who still have an intact swallowing mechanism, may take nourishment orally and supplement any caloric deficits with tube feeding