Percutaneous endoscopic gastrostomy

Overview
A percutaneous endoscopic gastrostomy (PEG) is an endoscopic procedure for placing a tube into the stomach. It involves placing a tube into the stomach through the abdominal wall. It is an alternative to surgical gastrostomy. PEG tubes may also be extended into the small bowel. The procedure does not require a general anesthetic, although mild sedation is typically used.

The procedure is performed in order to place a gastric feeding tube as a long-term means of providing nutrition to patients who cannot productively take food orally. 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 nutrition. PEGs may also be inserted to decompress the stomach in cases of gastric volvulus.

History
The first percutaneous endoscopic gastrostomies were performed at the Cleveland Clinic in children.

Indications
Gastrostomy 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 (e.g. cleft lip and palate during the process of correction) or other (e.g. radiation therapy for tumors in head & neck region).

In certain situations, the indication for PEG placement is more debatable. In advanced dementia, studies show that PEG placement does not in fact prolong life. Indeed, work has been done to inform doctors and healthcare staff of the perceived futility of the treatment.

A gastrostomy may also 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 stomach.

Eligibility Criteria
Neurological condition that hinders conducive feeding  Anatomical condition that hinders conducive feeding  Severe failure to thrive/malnutrition (5th percentile or lower)

Benefits
Over a NG-Tube a PEG-Tube can be used in a multiple feeding method infrastructure, allowing a patient for example to receive 2000 calories by pump at night each night and add 500 calories in oral intake.  PEG-Tubes are remarkibly flexible in method of feeding, Intermittant bolus feeds and pumps allow for ultimate versitility.  PEG-Tubes are remarkibly easy to use as they usually have a special connector usually a "Mic-Key" connector that is very low profile and can be hidden quite easily and is very easy to use, open the connector attach the special connection/mediator tube and either connect a pump or syringe and unclip the stop clamp.  PEG-Tubes have a long lifespan of 6 months and can be easily changed in a physicians office or even by a home call nurse in the same gastrostomic opening.

Techniques
Two major techniques for placing PEGs have been described in the literature.

The Ponsky or Bard-Ponsky pull 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. 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 out of the incision.

The Russell introducer technique involves a gastroscopy to evaluate the anatomy. 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.

Contraindications
As with the case of other types of feeding tubes, care must be made to place PEGs into an appropriate population. The following are contraindications to PEG use:
 * Peritonitis
 * Short life span
 * Abdominal wall infection
 * Abdominal burns
 * High aspiration risk
 * Atypical abdominal anatomy (e.g. malrotation)

Complications

 * Cellulitis (infection of the skin) around the gastrostomy opening
 * Peritonitis
 * Gastrocolic fistula: this may be suspected if diarrhea appears a short time after feeding. In this case, the food goes direct from stomach to colon (usually transverse).
 * Gastric separation
 * "Buried bumper syndrome" (the gastric part of the tube migrates into the peritoneal cavity)