Percutaneous Endoscopic Gastrostomy (PEG), Percutaneous Endoscopic Gastrostomy and Jejunostomy (PEGJ), and Direct Percutaneous Endoscopic Jejunostomy (DPEJ)
Endashaw Omer, MD
Stephen McClave, MD
The primary indication for enteral feeding is the provision of nutritional support to meet metabolic requirements for patients with inadequate oral intake. Gastric feeding is the most common type of enteral feeding. The goal of enteral nutrition is to prevent loss of weight, correct nutritional deficiencies, rehydrate, promote the growth of children with the potential for growth retardation, and improve the quality of life.1,2
Percutaneous endoscopic gastrostomy (PEG) was first introduced in 1980 by the application of endoscopy to insert a feeding tube into the stomach.3 However, gastric feeding via PEG is not suitable for all patients, especially those whose gastric function is impaired (i. e., gastroparesis) or those who are at risk of aspiration. In these cases, delivery of nutrients directly to the small intestine is a preferred approach.4,5,6
Endoscopic placement of jejunal feeding tubes can be achieved either indirectly, by passing a feeding tube through a PEG tube or existing PEG tract (PEGJ), or directly, by puncturing the small bowel by direct percutaneous endoscopic jejunostomy (DPEJ). The latter overcomes the tendency for frequent tube clogging or obstruction of the narrow lumen of the jejunal extension tube of the PEGJ, providing a more secure and sustained feeding approach. In cases of severe gastroparesis or partial gastric outlet obstruction, the use of DPEJ with a concurrent PEG for venting purposes or converting a PEG tube to PEGJ is recommended. The latter has a gastric port which is used for venting and/or medications and a jejunal port for feeding.7,8
1. Prediction or evidence of inadequate oral intake quantitatively or qualitatively to maintain nutrition for more than 4 weeks.
2. Inability to stabilize or improve nutritional status with the use of oral supplements and/or tips provided by a speech pathologist to improve swallowing.
3. Expectation that the PEG feeding will maintain or improve the quality of life.
4. Palliative drainage of secretions in gastrointestinal obstruction or chronic gastroparesis.
1. Coagulopathy (INR > 1.7, PTT > 50)
2. Platelets < 50,000
3. Interposed organ (liver, colon).
4. Severe peritoneal carcinomatosis
5. Severe noncirrhotic ascites
6. Cirrhotic ascites
8. Anorexia nervosa
9. Severe psychosis
10. Gastric tumor infiltration at the potential site for PEG
11. Peritoneal dialysis
Ethical issues surrounding end-of-life PEG placement can be complicated. Patient autonomy is the most important factor that drives the decision-making process. The patient’s own goals of care define the need for PEG, assuming the likelihood that the feeding tube placement will meet those goals. Any sense of futility on the part of the physician based on perceived short postprocedure patient longevity should not be factored in, as this sets up a clash of values (patient versus physician appreciation of benefit). The principle of justice should be protected, as a patient should never find out that the decision to withhold PEG placement was based on a poor evaluation by some scoring system or committee.9,10
PREPARATION FOR ALL PERCUTANEOUS ENTERAL ACCESS TECHNIQUES
1. The patient should be NPO for at least 4 hours.
2. Antibiotic prophylaxis: Antibiotics administered within several hours of the procedure reduce the risk of postprocedural infection at the PEG/DPEJ site. A first-generation cephalosporin is appropriate coverage in a non-PCN allergic patient. Patients who may already be receiving broad-spectrum antibiotics do not need additional prophylactic antibiotics.11
3. Adequate platelets and clotting parameters are necessary for safe PEG/DPEJ placement. Patients who have had normal labs within a recent period of time, have not had clinical changes,
and have no history of bleeding do not necessarily need lab work done specifically for PEG placement. The international normalized ratio (INR) should be < 1.5 and the platelet count should be > 50,000.
4. Correct coagulopathy.
5. Two physicians (scope and skin persons) are needed for most of the procedures.
6. Place patient in supine position on endoscopy table.
PEG (PERCUTANEOUS ENDOSCOPIC GASTROSTOMY): PONSKY PULL AND SACKS-VINE PUSH TECHNIQUE
Upper endoscope, commercially available PEG kit (available in sizes 16 FR to 24 FR, all are designed to be removed by traction method), abdominal binder for patients who are anticipated to inadvertently pull out their PEG tubes.
1. Delineate landmarks on the anterior abdominal wall. Using an indelible marker, mark the coastal margin and midline. Percuss both RUQ and LUQ to evaluate for low lying left lobe of the liver and enlarged spleen.
2. Pass the scope in the standard fashion through the mouth into the stomach. Dim room lights to allow transillumination of the endoscope light. Insufflate the stomach while the skin person applies pressure on area of transillumination with a fingertip looking for area of specific focal indentation of anterior gastric wall. Preferred location is on the patient’s right side of midline, close to the umbilicus. This ensures the shortest most perpendicular distance from skin to stomach and positions the stoma in the antrum or distal body. Such placement facilitates conversion of PEG to PEGJ if the need arises. Mark the identified site.
3. The selected site should be away from the xiphoid process or ribs by at least 2 cm to avoid damage to nerves and vasculature beneath the ribs and to prevent pain if the tube abuts bony tissue. Avoid incisional scars from previous abdominal surgery if possible, as adhered loops of bowel may be present at these sites which might get inadvertently punctured during PEG placement.
4. Disinfect the site of PEG placement with chlorhexidine or povidone-iodine (betadine).
5. Place sterile drape over the site.
6. Anesthetize the site with lidocaine—create a wheal by intradermal injection.
7. Foutch safe-tract technique.12 This additional step is done to confirm that there is no intervening loop of bowel. After puncturing the skin with a needle and syringe containing 2 to 3 mL of saline or lidocaine, aspirate while simultaneously advancing the needle into the stomach. As soon as the tip of the needle passes into the gastric lumen (seen on endoscopy), bubbles should appear in the syringe. This helps ensure the absence of an intervening loop of bowel. If bubbles are seen before the needle tip appears in the stomach, the needle has likely traversed through an intervening loop of bowel, and a separate site should be selected.
8. Make a superficial horizontal incision (about 1 cm long) using the scalpel enclosed in the PEG kit.
9. A catheter (plastic sheath) with indwelling trocar is inserted in a thrusting motion through the incision to create the fistula tract through the abdominal wall and anterior gastric wall. The scope person passes a snare through the scope into the stomach.
10. The scope person snares the trocar and sheath within the gastric lumen. The skin person removes the metal part of the trocar leaving the outer plastic sheath (sealing the trocar with his/her finger to maintain insufflation of the stomach).
11. Pass a single-stranded guidewire (Sacks-Vine technique) or double-stranded vinyl string loop (Ponsky technique) through the trocar. The scope person opens the snare, sliding off the catheter onto the guidewire or string (Fig. 8.1A).
12. The skin person feeds the wire/string, while the scope person withdraws the scope and wire/string together (Fig. 8.1B). At this point, the guidewire/string enters the skin, passes through the anterior gastric wall, and exits the mouth.
13. Two techniques
A. Push technique (Sacks-Vine) uses a PEG tube with a long plastic leader. It is passed over the guidewire which is held taut by the skin person. As the tip of the leader tube emerges out through the incision site, it is grabbed and pulled by applying counter pressure to the abdomen.
B. Pull technique (Ponsky) uses a double-stranded loop of a vinyl string. The PEG tube has a separate string loop at its end. Attach the string exiting the mouth to the loop of the PEG tube in a luggage tag fashion. The skin person pulls the PEG tube through the mouth, down the esophagus, and out through the gastric wall via the skin incision site (Fig. 8.1C).
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