Percutaneous Endoscopic Gastrostomy

Capecomorin S. Pitchumoni Indications and Contraindications

Indications ■ Failure to thrive

■ Poor oral intake

Dysphagia: mechanical or neurogenic Common situations where PEG is required: Neurological:

- Stroke with neurogenic dysphagia

- Multiple sclerosis

- Motor neuron disease

- Cerebral palsy

- Myotonic dystrophy Mechanical dysphagia:

- Esophageal carcinoma

- Head and neck malignancy Advanced dementia with poor oral intake

Contraindications

Severe co-morbidity or sepsis Expected survival less than 6weeks Abdominal wall infection Coagulopathy

Multiple abdominal surgeries Intestinal obstruction Partial gastrectomy

Preoperative Investigations/Preparation for the Procedure

■ Consent/written advanced directives

■ Cardiorespiratory status assessment

■ Baseline laboratory parameters

Procedure

STEP 1 Preparation

The patient's general condition is reevaluated 24h prior to and a few hours prior to PEG insertion; acuity of illness could have changed the expected survival. A single dose of IV antibiotic is administered.

The abdomen is examined for scars/signs of ascites or cellulitis, and the skin over the abdomen is cleaned using povidone iodine.

STEP 2 Esophagogastroduodenoscope

The esophagogastroduodenoscope is passed into the stomach.

The stomach is examined to rule out local contraindications, such as tumor, severe erosive gastritis, gastric varices, large ulcer, and outlet obstruction.

STEP 3 Air inflation

Inflation of the stomach with air, so that its anterior wall abuts the anterior abdominal wall, pushing away any bowel loops from in between.

STEP 4 Transillumination

Transillumination is attained through the anterior abdominal wall after darkening the room.

The assistant makes a finger impression over the point of transillumination (A).

Failure to transilluminate implies presence of intervening bowel loops, making the procedure unsafe.

This indentation must be clearly visible through the endoscope, which is already positioned facing the anterior abdominal wall (B).

Gastrostomy Procedure

STEP 5 Local anesthesia

After marking this point on the skin using a blunt tip or marker, the assistant injects a local anesthetic into the skin and makes a shallow 5-mm cut using a scalpel.

An 18G hollow needle is passed through this incision, piercing the gastric wall, thus entering the endoscopic field.

STEP 6 Introduction of a guidewire

The assistant passes a guidewire through the needle.

This is grasped by a snare that is passed through the endoscope. The scope and the guidewire are pulled out through the mouth as one unit, as the assistant feeds more wire as needed into the stomach.

Peg Transilluminate

STEP 7

Pull through

The tapering end of the lubricated PEG tube is threaded over the wire and pushed through the mouth into the esophagus and the stomach, while the assistant pulls the wire back through the incision. This is called a "pull" PEG as the assistant pulls the PEG out through the anterior abdominal wall by pulling on the wire. As more wire is pulled out, the tapered tip of the PEG tube becomes visible and the process is continued until only about 3-4cm of the PEG tube remains deep to the skin. The markings on the tube help determine the length.

The tube is trimmed in length, and a feeing port is attached to the tip after anchoring the tube to the anterior abdominal wall using a plastic stopper.

Procedure:"Push PEG"

This procedure is currently less popular.

Alternatively, after withdrawing the needle, a trochar can be passed with a plastic removable catheter around it.

The trochar is then withdrawn, and the feeding tube is passed through the catheter into the stomach.

The catheter is removed, leaving the feeding tube in place, which is then fixed to the abdominal wall. This is called "Push PEG," as it involves pushing the feeding tube into the stomach through the abdominal wall incision.

The stopper now approximates the anterior wall of the stomach to the abdominal wall.

Feeding is generally commenced on the following day, after the patient is examined.

STEP 8

Trimming the length

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