PEG - FROM INDICATIONS TO COMPLICATIONS

Shankar Zanwar

Patients with normal nutrition status can tolerate upto 10 days partial fasting

N-G tube usually reserved for shorter duration - <30 days

N-G tube problems

Irritation Ulceration Bleeding Pneumonia Sinusitis, otitis media Oesophageal Reflux Aspiration Pneumonia Subjective Discomfort Lower Feeding Efficacy

Why PEG Improvement in nutritional status better acceptability overall improvement in quality of life A 4 year study with 210 patients

mean wt. loss without PEG in 3 month - 11.35 wt gain after PEG at 12 month 3.5 kg

Indications neuro-motor cancers Gastric decompresssion miscellaneous

Cerebrovascular diseases Dysphagia after stroke - 45% of

hospitalised patients

N-G - sufficient if support needed is for <30 days

PEG considered after 4 weeks, and further need for continuation reassessed periodically

Amyotrophic lateral sclerosis Standard method of feeding in ALS

Some modification may be needed in view of anatomic deformity

Gastric insufflation during and after the procedure should be minimal – spontaneous lowering of diaphragm restricted

Also PEG has a role in other MNDs, bulbar palsies

Neurological conditions Multiple sclerosis Parkinson’s disease Cerebral palsy Reduced level of consciousness Head injury Intensive care patients

Dementia Contrary to assumptions the use of PEG here is

more disadvantageous than beneficial. Worse prognosis than non-PEG subgroups with

a mortality rate of 54% after 1 mon and 90% after 1 year

Patients do not know why a tube is protruding - frequently attempt to pull it out - restraints.

Patients become more agitated -use of pharmacologic sedation – increased bed sores

Tube feeding may actually result in more suffering than comfort.

Other indications Cancers

Head, neck and esophageal cancers – increased risk of malnutrition

Direct obstructive effect, mucositis due to RT/CT

Prophylactic or therapeutic Gastric decompression

Unresolved GO stenosis or ileus to drain secretions and resolve persistent vomiting

Tracheo-esophageal fistula Polytrauma Burns

Contraindications Serious coagulation disorders (INR > 1.5, PTT > 50

s, platelets < 50000/ mm3 ) Hemodynamic instability Sepsis Severe ascites Peritonitis Abdominal wall infection Marked peritoneal carcinomatosis Interposed organs (e.g. liver, colon) History of total gastrectomy Gastric outlet obstruction (if being used for feeding) Severe gastroparesis

Complications Over all rates of

complications of 314 patients Major – 3% Minor – 13%

More with Elderly Co-existing infections h/o aspiration Severe co-morbids

Larson DE,  Gastroenterology

Pneumo-peritoneum Commonest of all seen in ~ 50% Due to insufflation of air and needle

puncture of gastric wall In absence of peritoneal signs PEG feeding

can be continued Can be confused with ruptured viscera -

contrast radiology study should be done if suspicion is high

Also suspect if free air is present(even small amount) after 72 hours.

Wound infections Suspect when redness a/w purulent discharge or

other signs of systemic inflammation. Occurs when placed though contaminated field Poor technique If no prophylactic antibiotics are used Minor resolve with daily dressing and local

antiseptics Most respond to 1st gen cephalosporin or

quinolones Nasopharyngeal decontamination significantly

reduce risk

Peristomal leaks Usually with in first few days More in malnourished patients, DM, Too tightly placed external bolster – poor

tissue blood flow – tissue breakdown – leaks Treatment – to prevent skin break down -

use of zinc oxide paste – skin protectant If leak already occurred – do not place a

larger size tube through the same tract – distorts tract and does not promote tissue healing

Peristomal leak Treatment – remove PEG for 24 – 48 hours,

permit slight closure of tract spontaneously Now through the same tract tube can be

replaced Useful when leak occurs after 1 month or

more, does not work well with early leaks – poor wound healing

In many with fully mature tract above technique may not work, needing complete removal and placement of PEG at new location

Other minor complications Ileus – rule out perforation – treat with

bowel rest SOS nasogastric decompression Ulcerations – ulcer develops under the

internal bolster or on the gastric wall Loosening of external bolster helps

Clogging – all feeds and medication should be aptly liquefied, bulking agents to be avoided, psyllium Regular flushing before and after each feed Using bicarbonate solution and pancreatic

enzymes prior to flushing in clogged tube may help unclogging

Tube dysfunction – tube deterioration – pitting, ballooning, foul odor – happens d/t yeast implantation on the tube wall. More common with silicone tube than

polyurethane Gastric outlet obstruction – Tube migration in

the duodenum. When external bolster migrate away from abd.

wall. Marinating ext. bolster at its position can prevent

this

Major complications Bleeding

From PEG tract, gastric artery, splenic/mesentric vein, rectus sheath hematoma.

Hemodyanmically unstable – fluid resuscitation Controlled by – pressure abdominal wound Sometimes in the PEG tube itself – tighten ext.

bolster against abdominal wall – pulls internal bolster against the gastric mucosa

Release after 48 hours – avoid PEG tract breakdown.

In uncontrollable bleeds endoscopic or surgical methods

Necrotizing fasciitis Very rare, potentially fatal rapidly spreading infection along the surgical

planes. Traction and pressure on PEG tube main factors

that increase risk Keeping ext. bumper 1-2cm away from the

abdominal wall takes the pressure away Treatment – immediate surgical debridement,

ICU care and empirical broad-spectrum antibiotics.

Internal organ injury Colon, small bowel, rarely liver and spleen Elderly > young – lax mesentry May develop signs of peritoneal irritation CT with water soluble contrast or

fluoroscopy may help localization Any active leakage mandates surgery

Colo-cutaneous fistula When there is interposition of bowel, usually

the splenic flexure, b/w the ant. Gastric wall and ant. Abdominal wall

Patients are often asymptomatic except for transient fever or ileus

Usually discovered months later when tube is removed for replacement

At this time when the tube is passed blindly through the tract it does not find it’s way back in to the stomach

After restarting feeding– diarrhea and dehydration

Treatment - remove the PEG tube and allow the fistula to close spontaneously

Surgery in non responding cases Prevention – In case of doubt use of

needle with syringe and suction, sudden bolus of air or stool while withdrawal suggest passage through the bowel

Tumor seeding Occurs during the ‘push’ or ‘pull’ method

when the tube is in contact with the oropharyngeal cancer during insertion

Diagnosis is delayed until the metastasis enlarges

Confirmed by CT and biopsy

Buried bumper syndrome Described as early as 3 weeks of placement Excess tension between internal and ext.

bumper Migration of tube towards the in abdominal wall Tube may dislodge anywhere between the

abdominal wall and the skin along the PEG tract Present as feeding problems, peristomal

leakage, pain and swelling at the PEG site

Complications – perforation of stomach and peritonitis

Treatment Introduction of balloon dilator or S-G dilator

with a slightly greater diameter than the probe, through the lumen and push it into the gastric cavity until the retainer is unstuck.

Putting the new probe by pull method, inserting the guide wire through the lumen of buried bumper, when the guide wire is pulled new probe drags the old and unstucks it

Making incision with the needle knife or APC on the lining that covers the internal retainer may also help unstuck it.

Prevention – regular checking of PEG tube position Leaving a gap of nearly 1-2cm Daily rotation of tube to 180-3600

Procedure Pre procedure – 6 hour fasting

Antibiotics (e.g. cefazolin 1g IV) 30 mins before procedure

Thorough cleansing of oropharyngeal cavity Under analgesic sedation Keeping the kit ready In supine decubitus Before procedure complete survey till

the duodenum

Procedure

Procedures Pull technique – Ponsky – Gauderer method Push technique – Sacks Vine method Introducer technique – Russell method

Endoscope is inserted only once all other steps identical to previous technique until trocar insertion

Then the guide is introduced and trocar removed Through this Foley type gastrostomy tube is passed Balloon is then inflated, sheath is removed, the

probe is pulled until it stops and then the external retainer fixed

Post procedure care Cleansing with soap water once a day,

no bandage or dressing is needed to cover

Rotating the peg tube daily Flush before and after each feed

Removal and replacement If the indication of PEG insertion has gone

the tube can be removed as in ischemic strokes

Usually a waiting period of 2-3 weeks needed - tract maturation time

After removal the fistulous hole closes spontaneously

If the internal bumper is soft just need to pull out snugly, if hard cut the exterior of tube and remove the rest endoscopically

Replacement Due to effect of acid the tube may deteriorate No exact time limit mentioned for

replacement Two types of probes available

One with balloon retainer With circular retainer

Easy to place in the tract where the previous tube was placed.

Can be done without endoscopy

Feeding early vs late Traditionally delay for several hours to a

day Meta-analysis shows no difference

between early (>4hours) and late Bechtold ML Am JGastroenterol.

2008 Few centers prefer using water after 4

hours and feeding from the next day

Feeding protocol Standard formulae – initiate @ 50cc/hr until

unless contraindicated If tolerated gradually increase up by

25cc/hr every 4-8 hours till target achieved Usual feeding rate should be 2Kcal/cc Residual evaluation

Check residual q4hrly If residual volume is more than ½ of the last

bolus – withhold next feed Continuous feed - if residual >2X the hourly

rate – review tube

Special setting Obesity – Trans illumination is difficult,

larger incision is needed, fat tissue spread until ant rectus fascia reached External wound to be sutured or clipped Use of spinal needle can be done in BMI

>40 as introducer needle

PEG vs Surgical gastrostomy Comparative studies show no differences

in mortality and morbiditiesStiegmann, Gastrointest Endosc.

But PEG is less expensive and saves time

Surgical gastrostomy - better when patient going for other operation

Alternative indication is when difficult to get a comfortable endoscopic access