1. Percutaneous Endoscopic Gastrostomy
John P. Grant, MD
Duke University Medical Center

2. Nutritional Rule! IF YOU FAIL – TRY AGAIN! IF NOT – MAKE IT WORK
IF THE GUT WORKS – USE IT
IF NOT – MAKE IT WORK
IF YOU FAIL – TRY AGAIN!

3. Advantages of Enteral Nutrition
Stimulates gallbladder emptying and reduces sludge and stone formation.
Avoids steatosis by increasing release of enteroglucagon into portal circulation.
Maintains gut-associated lymphoid tissue (GALT).
Suppresses cytokine response.

4. Advantages of Enteral Nutrition
Less expensive
Less risk of sepsis
Less nursing time required

5. Enteral Access
The Gastrostomy Tube

6. History of Gastrostomy
1837
Egeberg proposed as possible.
1839
Sedillot performed gastrostomy in dog.
1846
Sedillot performed gastrostomy in 3 patients – all died of peritonitis.
1876
Verneuil performed first successful gastrostomy in man.

7. History of Gastrostomy
1891
Witzel developed serosal tunnel.
1894
Stamm - concentric pursestring.
1913
Janeway - permanent gastrostomy. Beck-Jianu - gastric tube.
1981
Gauderer & Ponsky - PEG tube.

8. Percutaneous Endoscopic Gastrostomy (PEG)
Enteral Access
Percutaneous Endoscopic Gastrostomy (PEG)
A Simplified Technique for Constructing a Tube Feeding Gastrostomy Michael W.L. Gauderer, M.D., and Jeffrey L. Ponsky, M.D., F.A.C.S., Cleveland, Ohio Surgery, Gynecology & Obstetrics – January 1981 – Volume 152

9. Bard PEG Kit

10. Sherwood, Davis, & Geck PEG Tube

11. Inverta-PEG from Abbott Laboratories

12. PEG Gastrostomy

13. Optimal Exit Site for Gastrostomy Tube

14. PEG Gastrostomy

15. PEG Gastrostomy

16. PEG Gastrostomy

17. PEG Gastrostomy

18. PEG Gastrostomy

19. Number of PEG’s Performed at Duke University Medical Center

20. PEG Insertion

21. Do’s and Don'ts of PEG Gastrostomy
Do not place in patients with ascites.
Do not place in patients with gastric varices.
Do not attempt placement unless light is seen sharply through abdominal wall and/or indentation is clearly visible with external compression.

22. Do’s and Don'ts of PEG Gastrostomy
Do give perioperative antibiotics.
Do evaluate stomach and pylorus during endoscopy.
Do make the exit site 1.5 x diameter of the feeding tube.
Do loosen retainer after 5 to 7 days.

23. Do’s and Don'ts of PEG Gastrostomy
Do NOT get a chest or KUB x-ray to evaluate postoperative abdominal pain.
There will nearly always be free air and it will often be a considerable amount.
Order a Gastrografin injection of the tube to evaluate proper tube placement.
This test will not always detect a leak about the tube into the abdominal cavity.

24. Chest X-ray

25. Chest X-ray
Pneumoperitoneum from endoscopy. Patient did well.

26. Chest X-ray

27. Chest X-ray
Leak from gastrostomy tube. Patient had an acute abdomen and required urgent surgery.

28. Gastrografin Tube Check

29. Gastrografin Tube Check
Pneumoperitoneum but no leak from gastrostomy site. Patient did well.

30. Gastrografin Tube Check

31. Gastrografin Tube Check
Obvious leak from gastrostomy site. Patient had an acute abdomen.

32. Gastrografin Tube Check

33. Gastrografin Tube Check
False negative Gastrografin study. Patient had an acute abdomen.

34. Do’s and Don'ts of PEG Gastrostomy
Make decision on whether to explore the abdomen based on clinical examination and laboratory data.
If leak is present, repair and tack stomach up to abdominal wall x 4.
Thoroughly irrigate abdomen.
Wrap omentum about gastrostomy site.

35. A PEG can be placed safely in patients with prior upper or lower abdominal surgery….
As long as finger indentation or light transillumination is satisfactory.

36. Placement of PEG in Patients with Prior Abdominal Surgery (1778 tubes)
Hysterectomy
147
Cholecystectomy 87
Exploratory lap., lysis adhesions 71
Appendectomy 70
Subtotal gastrectomy (BI or BII) 35
Abdominal Aortic Aneurysm 30
Colectomy
Ventriculoperitoneal shunt 17
Cystectomy with ileal loop 13
Small bowel resection 13
Splenectomy 9
Perforated duodenal ulcer 8
Nissen fundoplication 6
Aortobifemoral bypass graft 5
Cesarian section 4
Pancreatectomy 3
Portocaval shunt 1
Repair diaphragmatic hernia
Total with prior surgery: failures, no complications

37. Duke Experience With PEG 1778 Patients34
Leakage about gastrostomy site 24
Exit site infection (8 major) 12
Peritonitis (12 major: 1 died, 6 exp lap, 5 antibiotics only) 3
Colonic injury 2
Aspiration pneumonia from endoscopy 6
Bleeding at gastrostomy site 1
Fracture of alveolar ridge opening mouth in OR
Esophageal laceration on removal (major)
83 Overall 4.7% Major 1.3% (23)

38. Complications of PEG Gastrostomy
Duke PEG % %
Author # Years Major Minor All
Ponsky
307
1983 2 4
Sangster
155
1988 5 25 29
Miller
330 7 14
Saunders
136
1991 3
Gibson
334
1992 32 37
Total
1262
4.0%
3.3%
7.3%
Duke PEG
1778
1.3%
3.4%
4.7%
Stamm
1438
10% 8%
18%

39. Alternate Enteral Access
Laparoscopic Gastrostomy

40. Ross Laparoscopic Gastrostomy Kit

41. Trocar Sites and Gastrostomy Exit Site
10-mm trocar

44. Laparoscopic Gastrostomy Movie

45. Advantages PEG Does not require general anesthesia.
Minimal OR time (15-20 minutes).
Prior surgery of little concern.
Can evaluate gastric and duodenal mucosa.
But: can injure colon or liver and poses serious problem if accidentally removed.

46. Advantages Lap G-Tube Avoid injury to colon or liver.
Securely attach stomach to abdominal wall, less concern accidental removal.
Gastrostomy tube easier to remove and replace.
But: does require general anesthesia and up to 45 minutes OR time.

47. Enteral Access
Button Gastrostomy

48. Stomate Button Gastrostomy – Abbott Labs
Can replace standard G-tube after 3-4 weeks

49. PEG Tube Complications
Necrotizing Fasciitis

50. Necrotizing Fasciitis

51. Necrotizing Fasciitis

52. Necrotizing Fasciitis

53. Necrotizing Fasciitis
Occurs most commonly in settings of:
Concomitant infections, multiple antibiotics
Malnutrition, elderly, diabetics
Low output syndromes
Steroids, chemotherapy, or immunosuppression

54. Treatment of Necrotizing Fasciitis
Ensure adequate nutrition continues.
Nasojejunal tube, jejunostomy, TPN
Neutralize gastric acid.
Give antibiotic (Keflex) via feeding tube.

55. Treatment of Necrotizing Fasciitis
± Give systemic antibiotics.
Change dressing qid, antibiotic ointment.
Protect skin (drainage bag).
If all else fails – remove feeding tube.

56. Necrotizing Fasciitis

57. PEG Tube Complications
Hypertrophic Granulation Tissue

58. Normal PEG Exit Site

59. Hypertrophic Granulation Tissue

60. Tissue Sharply Cut Away

61. Base Cauterized with Silver Nitrate

62. Complications of Enteral Nutrition
Accidental Tube Withdrawal

63. Accidental Tube Withdrawal PEG Gastrostomy
<72 hours: Emergent laparotomy (laparoscopy) to replace tube and secure stomach to abdominal wall.
>3 to 7 days: Replace in radiology under fluoroscopy.
>7 days: Replace at bedside checking placement with tube check in radiology.

64. Accidental Tube Withdrawal Laparoscopic Gastrostomy
<72 hours: Replace in radiology under fluoroscopy.
>72 hours: Replace at bedside with tube check in radiology.
>7 days: Replace at bedside checking placement by aspiration of residuals.

65. Complications of PEG
Patient Selection

66. Patient Selection Scolapio et al. NCP 15:36, 2000
32 patients received PEG following stroke.
9/14 (64%) died within 4 weeks
Cost-benefit ratio favors PEG placement only in patients likely to survive and have dysphagia for > 4 weeks.

67. Patient Selection Scolapio et al. NCP 15:36, 2000
Patients likely to regain swallow function < 4 weeks:
Age < 60
Limited comorbidities
Nonhemorrhagic stroke
Mild oropharyngeal dysphagia

68. Patient Selection Grant et al. J.A.M.A. 279:1973, 1998
Mortality in 81,105 patients, 65 years or older, with Cerebrovascular disease, neoplasms, fluid and electrolyte disorders, and aspiration pneumonia.
In-hospital mortality was 15.3 %
30 day mortality was 23.9 %
1 year mortality was 63.0 %
3 year mortality was 81.3 %

69. Abuksis et al. Am. J. Gastroenterol., 95:128, 2000
Patient Selection
Abuksis et al. Am. J. Gastroenterol., 95:128, 2000
Two groups of patients were compared:
Group 1 - patients from nursing homes
Group 2 - hospitalized patients
30-Day Mortality
Overall Mortality
Group 1
13%
38%
Group 2
29%
66%

70. Abuksis et al. Am. J. Gastroenterol., 95:128, 2000
Patient Selection
Abuksis et al. Am. J. Gastroenterol., 95:128, 2000
They concluded:
Patients hospitalized with acute illness are at high risk for serious adverse events after PEG insertion and the procedure should be avoided.
Only stable patients benefit from early gastrostomy.

71. Mortality Following PEG in ICU’s DUMC 1998-1999
38%
21%
Days to Death: Ave = Median = 13

72. Patient Selection Stable Patients
All stable patients can be considered for early gastrostomy if feeding access anticipated to be needed for >30 days.

73. Patient Selection Acutely Ill Patients
All acutely ill patients should be nourished by nasoenteric tube for the first 30 days.
If surviving 30 days, acutely ill patients can be considered for a gastrostomy on an individual basis.
The tube should be placed about 1 week prior to discharge from the hospital.

74. Percutaneous Endoscopic Gastrostomy
John P. Grant, MD
Duke University Medical Center

75. Loosen retention disk after 5 to 7 days
Pull tube out and release
If tube pulls back in: If tube does not pull Stomach probably not in: Stomach is attached. Retighten disk probably attached. and recheck in 3-5 days.