Percutaneous Endoscopic Gastrostomy
Percutaneous Endoscopic Gastrostomyand Jejunostomy By Syeda
lateefunnisa Sabiha Farheen Msc,sem-1 Osmania university college
for women
Tube feeding
Percutaneous endoscopic gastrostomy
Percutaneous endoscopic gastrostomy(PEG) is anendoscopicmedical
procedurein which a tube (PEG tube) is passed into a patient's
stomach through theabdominal wall, most commonly to provide a means
of feeding whenoralintake is not adequate (for example, because
ofdysphagiaorsedation).
The PEG procedure is an alternative to open surgical gastrostomy
insertion, and does not require a general anesthetic; mild sedation
is typically used.PEG administration of enteral feeds is the most
commonly used method of nutritional support for patients in the
community Many stroke patients, for example, are at risk of
aspiration pneumonia due to poor control over the swallowing
muscles; some will benefit from a PEG performed to maintain
nutritionPEGs may also be inserted to decompress the stomach in
cases of gastric volvulus
1 Indications2 Techniques3 Contraindications3.1 Absolute
contraindications3.2 Relative contraindications3.3 In advanced
dementia4 Complications5 Removal of PEG tubes5.1 Indications5.2
Techniques6 History
IndicationsGastrostomy may be indicated in numerous situations,
usually those in which normal or nutrition (or nasogastric feeding
is impossible. The causes for these situations may be neurological
(e.g. stroke), anatomical .A gastrostomy can be placed to
decompress the stomach contents in a patient with a malignant bowel
obstruction. This is referred to as a "venting PEG" and is placed
to prevent and manage nausea and vomiting.A gastrostomy can also be
used to treat volvulus of the stomach, where the stomach twists
along one of its axes. The tube (or multiple tubes) is used for
Gastropexy, or adhering the stomach to the abdominal wall,
preventing twisting of the stomachA PEG tube can be used in
providing gastric or post-surgical drainage
TechniquesTwo major techniques for placing PEGs have been
described in the literature.
1,The Gauderer-Ponsky technique involves performing a
gastroscopy to evaluate the anatomy of the stomach. The anterior
stomach wall is identified and techniques are used to ensure that
there is no organ between the wall and the skin:
A,Digital pressure is applied to the abdominal wall, which can
be seen indenting the anterior gastric wall by the
endoscopist.B,Transillumination (diaphanoscopy): the light emitted
from the endoscope within the stomach can be seen through the
abdominal wall.C, small (21G, 40mm) needle is passed into the
stomach before the larger cannula is passed.2,An angiocath is used
to puncture the abdominal wall through a small incision, and a soft
guidewire is inserted through this and pulled out of the mouth. The
feeding tube is attached to the guidewire and pulled through the
mouth, esophagus, stomach, and out of the incision.[2]
In the Russell introducer technique, the Seldinger technique is
used to place a wire into the stomach, and a series of dilators are
used to increase the size of the gastrostomy. The tube is then
pushed in over the wire.
ContraindicationsAs with other types of feeding tubes, care must
be made to place PEGs into an appropriate population. The following
are contraindications to PEG useAbsolute contraindicationsInability
to perform an esophagogastroduodenoscopyUncorrected
coagulopathyPeritonitisUntreatable (loculated) massive ascitesBowel
obstruction (unless the PEG is sited to provide drainage)Relative
contraindicationsMassive ascitesGastric mucosal abnormalities:
large gastric varices, portal hypertensive gastropathyPrevious
abdominal surgery, including previous partial gastrectomy:
increased risk of organs interposed between gastric wall and
abdominal wallMorbid obesity: difficulties in locating stomach
position by digital indentation of stomach and
transilluminationGastric wall neoplasmAbdominal wall infection:
increased risk of infection of PEG siteIntra-abdmominal malignancy
with peritoneal involvement (tumor seeding into formed channel with
subsequent failure)
In advanced dementiaThe American Medical Directors Association,
the American Geriatrics Society and the American Academy of Hospice
and Palliative Medicine recommend against inserting percutaneous
feeding tubes in individuals with advanced dementia and, instead,
recommend oral assisted feedings. Artificial nutrition neither
prolongs life nor improves its quality in patients with advanced
dementia. It may increase the risk of the patient inhaling food, it
does not reduce suffering, it may cause fluid overload, diarrhea,
abdominal pain and local complications, and can reduce the amount
of human interaction the patient experiences.
ComplicationsMajor complications are not common but can occur
after PEG tube insertion. mortality after PEG is very rare and is
usually due to underlying co-morbiditiesCellulitis (infection of
the skin) around the gastrostomy siteHemorrhageGastric ulcer either
at the site of the button or on the opposite wall of the stomach
("kissing ulcer")Perforation of bowel (most commonly transverse
colon) leading to peritonitisPuncture of the left lobe of the liver
leading to liver capsule painGastrocolic fistula: this may be
suspected if diarrhea appears a short time after feeding. In this
case, the feed goes direct from stomach to colon (usually
transverse colon)Gastric separation"Buried bumper syndrome" (the
gastric part of the tube migrates into the gastric wall)
POST-INSERTION CAREAfter PEG tube insertion adequate pain relief
should be administered. Many patients report abdominal discomfort
after PEG insertion due to inflation of the stomach during the
procedure. Traditionally, feeding was delayed until the next day
due to the fear of peritoneal leakage risk after feeding. Many
studies investigated the safety of early feeding from 1 h to 6 h
after PEG insertion, including a meta-analysis which found that
feeding initiated as early as 4 h after PEG placement is safe.
The stoma should be examined (for signs such as pain,
discoloration, swelling, exudation, pus and leakage around the
stoma) and cleaned daily. The tube should be rotated about 180
degrees and moved up and down about 1-2 cm in the stoma site on a
daily basis after the stoma has completely healed
Removal of PEG tubesIndicationsPEG tube no longer required
(recovery of swallow after stroke or surgery for head and neck
cancer, or from brain trauma)Persistent infection of PEG
siteFailure, breakage or deterioration of PEG tube (a new tube can
be sited along the existing track)"Buried bumper syndrome"
TechniquesPEG tubes with rigid, fixed "bumpers" are removed
endoscopically. The PEG tube is pushed into the stomach so that
part of the tube is visible behind the bumper. An endoscopy snare
is then passed through the endoscope, and passed over the bumper so
that the tube adjacent to the bumper is grasped. The external part
of the tube is then cut, and the tube is withdrawn into the
stomach, and then pulled up into the esophagus and removed through
the mouth. The PEG site heals without intervention.
PEG tubes with a collapsible or deflatable bumper can be removed
using traction (simply by pulling the PEG tube out through the
abdominal wall).
HistoryThe first percutaneous endoscopic gastrostomy performed
on a child was on June 12, 1979 at the Rainbow Babies &
Children's Hospital, University Hospitals of Cleveland. Dr. Michael
W.L. Gauderer, pediatric surgeon, Dr. Jeffrey Ponsky, endoscopist,
and Dr. James Bekeny, surgical resident, performed the procedure on
a 4 12-month-old child with inadequate oral intake.[12] The authors
of the technique, Dr. Michael W.L. Gauderer and Dr. Jeffrey Ponsky,
first published the technique in 1980.[12] In 2001, the details of
the development of the procedure were published, the first author
being the originator of the technique itself.
CONCLUSIONSince its introduction in 1980, PEG has gained
world-wide acceptance as a safe technique for providing enteral
feeding in patients with poor oral intake who have a functional GI
system. PEG tube placement has many indications, and is the
recommended tube type if not contraindicated. PEG tubes can result
in minor or even major complications, but most patients do well
with them. The pull technique is the most commonly used method, but
other techniques are possible or even necessary in certain
situations. Knowing when and how to place PEG tubes, as well as how
to manage and even remove them, is an important part of the
management of many patients. Quality and safe care of PEG tubes
begin at pre-insertion screening and throughout post-insertion
aftercare. Prevention of and proper management of complications are
critical to ensuring successful outcome.
JejunostomyJejunostomy is the surgical creation of an opening
(fistula) through the skin at the front of the abdomen and the wall
of the jejunum (part of the small intestine). It can be performed
either endoscopically, or with formal surgeryA jejunostomy may be
formed following bowel resection in cases where there is a need for
bypassing the distal small bowel and/or colon due to a bowel leak
or perforation. Depending on the length of jejunum resected or
bypassed the patient may have resultant short bowel syndrome and
require parenteral nutrition.A jejunostomy is different from a
jejunal feeding tube which is an alternative to a gastrostomy
feeding tube commonly used when gastric enteral feeding is
contraindicated or carries significant risks. The advantage over a
gastrostomy is its low risk of aspiration due to its distal
placement. Disadvantages include small bowel obstruction, ischemia,
and requirement for continuous feeding
TechniquesThe Witzel jejunostomy is the most common method of
jejunostomy creation.It is an open technique where the jejunosotomy
is sited 30 cm distal to the Ligament of Treitz on the
antimesenteric border, with the catheter tunneled in a seromuscular
groove.There are several techniques for placement, including a
direct surgical or endoscopic technique, or a more complicated
Roux-en-Y procedure. The J-tube may use a long, catheter-like tube
or a button. Depending on the placement type, the tube may be
changed at home, or may need to be changed at a hospital. A J-tube
is helpful for individuals with poor gastric motility, chronic
vomiting, or at high risk for aspiration and in those in whom
gastrostomy tubes are contraindicated
https://en.wikipedia.org/wiki/Percutaneous_endoscopic_gastrostomy
http://emedicine.medscape.com/article/149665-overview#a3
https://en.wikipedia.org/wiki/Jejunostomy
References
