Editing PEG insertion


Percutaneous Endoscopic Gastrostomy

* Equivalent results to traditional gastrostomy with lower cost and discomfort

== '''Indications''' ==

* Only consider when it is likely to improve the patient's long-term functional outcomes or quality of life
* Long-term feeding in patients unable to eat but with functional GIT
* Unpalatable medications for children
* Night-time supplementary feeds for IBD patients
* Returning external biliary drainage to GIT
* Gastric decompression in radiation enteritis or carcinomatosis

== '''Contraindications''' ==

* Caution with upper abdominal surgery - traditionally, upper midline laparotomy is a contraindication, requires open gastrostomy
* Severe malnutrition
* Life expectancy <30 days
* Treat oral candidiasis prior to insertion
* Specific conditions
** Advanced dementia - does not improve longevity or QoL - prefer risk feeding
** Prognosis <3 months (apart from venting)
** Anorexia nervosa - does not address psychiatric illness
** Sepsis - risk of exacerbating - NGT feeds until sepsis resolves
** Varices/Portal HTN - risk of bleeding - prefer surgical gastrostomy
** Upper GIT malignancy requiring surgery - prefer jejunostomy
** Peritoneal carcinomatosis
** Ascites/PD - high risk for poor tract formation and peritonitis

== '''Equipment''' ==

* 20Fr is probably a good starting point, especially for first tubes
* Some suggest using 24Fr for first tube
* Austin guidelines are for >20Fr for venting, and 12-16Fr for feeding
* Low-profile tubes potentially have lower risk of catching/pulling, and cosmetically better. Patient needs to have stable weight.
* Silicone tubes require replacement every 6-12 months, and are susceptible to candida colonisation. Polyurethane tubes are thinner-walled, so smaller external diameter can be used, and can last many years with good care, and are less susceptible to candida.

== '''Endoscopic technique''' ==

* Mark skinfolds, bra, waistline if possible prior to procedure
* IV Abx, supine, clip epigastric hair, prep epigastrium, drape
* Sedation - either opioid + benzodiazepine or propofol
* Gastroscopy - rapid inspection of pylorus and duodenum
* Confirm appropriate to proceed endoscopically:
** Transilluminate towards skin to pinpoint optimal access point
** One to one movement between external and internal
** If unable to prove these, will need laparoscopic gastrostomy
* Insert a needle with LA in syringe through to stomach, withdrawing, with no bubbling until stomach (otherwise there's probably some bowel in the way). Withdraw the needle, leaving the sheath in situ.
* Feed the included guidewire/loop suture through the sheath, then 'grab' it from the inside with the included snare, and pull it out through the mouth.
* Attach PEG tube to guidewire, lube up the top of the PEG and pull back into stomach (follow it down with scope) then out through skin
* Head of the catheter should come to lie in loose contact with gastric mucosa - slight tension, but not tight enough to risk gastric ischaemia - some say should still be able to turn it
* Cut PEG at the 'x' (about 20cm from skin) and then attach flange with butterfly clip so the flange is 5-10mm from skin; then place a gauze underneath, and attach the nozzle to the end
* Record how far in at skin
* No need to suture tubes with internal fixator (bolster or balloon)

== '''Surgical-assisted technique''' ==

* Laparoscopic access
* Perform any required adhesiolysis/exposure of anterior stomach
* Place PEG kit needle/sheath through abdominal wall directly into stomach, then feed through guidewire/snare
* Endoscopist grasps wire and pulls out through mouth
* Proceed with remainder of usual PEG procedure

== '''Surgical gastrostomy''' ==

* Laparoscopic access to abdomen
* Tent stomach up with two posterior quadrant sutures with EndoClose
* Purse-string
* Pass PEG through abdo wall and then through stomach
* Inflate balloon and tie purse-string
* Anterior two quadrant sutures

== '''Radiological technique''' ==

* Can be performed under light sedation and LA
* Ideally use NGT to distend stomach with air, so not favoured with complete oesophageal obstruction
* Can insert initial gastrostomies and gastro-jejunostomies

== '''Post-insertion instructions''' ==

* NBM and nil by device for two hours post-insertion, then flush with 30mL water and observe for uncontrolled pain, resistance to flushing or leakage
* If no complications, commence 30mL water flushes hourly for four hours, then device is ready to use for feeding
* Dietician education and Home Enteral Nutrition program (at Austin)
* BD clean at skin with saline/peroxide
* Venting gastrostomies can be used immediately
* Rationalise medications down tube to liquid/soluble/dispersible
* Next day, change dressing (gauze under baseplate)

== '''Complications''' ==

* Leakage
** True significant leakage due to a technical error tends to present in first few days
** Can present as either asymptomatic leakage of gastric fluid around the tube to skin, or leakage to peritoneum causing overwhelming peritonitis and sepsis
** Causes:
*** Inadequate fixation of the stomach against the inner abdominal wall
*** Separation of the two (due to ischaemia and necrosis of the gastric wall from an over-tight seal)
*** Tube migration
*** Distal obstruction
*** Balloon deflation/rupture
*** Incorrectly-sized device
*** DGE
*** Constipation
*** Increased intra-abdominal pressure
** Diagnosis - minor pneumoperitoneum is not diagnostic, because it can be present for 1-2 weeks normally. However, large-volume pneumoperitoneum is highly suggestive of leak. If in doubt, do a contrast study down the PEG.
** Management of 
*** If no intra-peritoneal leakage on contrast study, 'rest' the tube for a week and give IV Abx, to allow it to seal. Then repeat the contrast study before feeding. 
*** If there is obvious peritoneal leakage, manage based on clinical scenario - operate if there is peritonitis or sepsis. Can be done laparoscopically.
**** If everything looks healthy at operation, can do a purse-string around the tube and re-fix to the abdo wall
**** If stomach looks 'bad', remove the tube and staple/suture off the defect, and consider replacing the tube in a healthy location
*** Late leaks - generally behave like a controlled gastro-cutaneous fistula, but can become uncontrolled and cause peritoneal sepsis
* Buried bumper
** When the internal fixator erodes past the stomach wall, and instead sits within the stomal tract
** Risk factors - frequent and inadvertent device traction, rapid weight gain, lapses in exit site care
** Presentation - leakage, blockage, infection/inflammation at exit, pain, inability to advance device within tract
* Bleeding
** Immediate post-procedural bleeding can be controlled with gentle traction on tube
* Minor irritation to skin - close attention to cleansing
* Fungal infection - antifungal powders/creams
* Infection may reflect abscess - can incise to look for pus, and give antibiotics
** Always consider and exclude a necrotising infection
* Migration is generally related to excessive traction and subsequent necrosis
* Gastrocolic fistula - if colon is pierced at insertion
** Frequently patient has diarrhoea
** Free leaks/abscesses must be controlled, but fistulas 
** PEG-associated gastrocolic fistulas may subside when the tube is pulled out, but not necessarily
* Abdominal sepsis following PEG
** Stop feeds, get a tubogram
* PEG pulled out
** Gastrostomy:
*** If early (within four weeks), before a tract has formed, give Abx and NGT, and rebook procedure for 5-7 days
**** Can also attempt to reinsert if it seems like there is a decent tract and no peritonitis or sepsis, but also put in an NGT and 'rest' the stomach for a week on Abx
*** 4-6 weeks - bedside replacement with similar-sized tube, then confirm no leak with tubogram before using again
*** >6 weeks: put in a Foley 20Fr as a temporising measure and then replace it with a feeding tube when available, safe to use straight away if flushing well and pH of aspirate <=5
* Delirious patient pulling PEG out - try an abdominal binder
* Pain
** Consider poor tube positioning - too close to costal margin
* Blocked tube
** See separate topic under 'nutrition'

== '''Alternatives''' ==

* Fluoro-guided - Can't do as big of a tube, gets blocked more often, less reliable internal fixation
* Laparoscopy-assisted PEG
* PEG-J (jejunal extension)

== '''PEG removal''' ==

* At least six weeks post-insertion
* Alternative route available - consider dietician/SP input
* Fast for two hours prior and six hours post
* Consider staged removal of larger devices (>20Fr)
* PPI cover for tracts at higher risk of forming a persistent gastrocutaneous fistula (main proven risk factor is insertion time >8 months)
* Techniques:
** Balloon deflation and pull
** Traction removal
** Cut and push (where traction removal is not possible, and the patient should be able to pass the internal component in stool) - usually do an x-ray one week later

[[Category:Endoscopy]]