Indications

PEG is used as a method of enteral nutrition in patients with nutritional disorders that make oral feeding difficult. Compared to other methods, such as nasogastric tube feeding, PEG is more effective, improves the quality of life of patients, and has a lower risk of complications. It is recommended to consider PEG creation when the patient will need nutritional support for a longer period of time, i.e. more than 2-3 weeks.

PEG is currently most commonly used in patients with neurological diseases and head and neck cancers.

Indications for PEG procedure

List of conditions for which this procedure is considered:

• Ear, nose and throat cancers
• Stroke
• Craniocerebral injuries
• Brain tumors
• Parkinson's disease
• Amyotrophic lateral sclerosis
• Multiple sclerosis
• Cerebral palsy
• Dementia syndromes
• Burns
• Fistula
• Coma
• Cystic fibrosis
• Multiple organ injuries
• Crohn's disease
• Facial reconstructive surgery
• Acquired Human Immunodeficiency (AIDS)
• Some congenital diseases (e.g. tracheoesophageal fistula)

Contraindications

As with any procedure, contraindications to PEG can be divided into two categories: absolute and relative.

Absolute contraindications

• Coagulation disorders
• Significant displacement of internal organs (intestines, liver)
• Multiple peritoneal metastases
• Significant ascites
• Anorexia
• Sepsis
• Hemodynamic instability
• Post-gastrectomy condition
• Lack of patient's consent (if the patient is unconscious – lack of court's consent)

Relative contraindications

• Hepatomegaly, splenomegaly
• Peritoneal dialysis
• Large stomach varices
• Condition after partial gastric resection
• Severe obesity
• Extensive abdominal surgery

It is worth noting that a previous partial gastrectomy using the Rydygier or Billroth II methods is not an absolute contraindication to PEG. Although this procedure may increase the risk of aspiration pneumonia, it is usually safe. Lack of endoscopic transillumination of the skin is not a contraindication to PEG, as long as other criteria suggest appropriate placement of the puncture.

Description of the procedure

The Clinic uses the pull technique for PEG insertion, named after the authors – Ponsky-Gauderer. Currently, this is the most commonly used method, due to its safety and the fact that the best adhesion of the stomach wall to the abdominal wall is achieved during the pulling of the tube.

This method involves inserting an endoscope into the stomach, examining the duodenum and stomach, and excluding any pathology that would prevent the procedure from being performed. The patient is then placed on his or her back, and the stomach is filled with air in order to achieve the best possible adhesion of its anterior wall to the inner surface of the abdominal wall.

The endoscopist must assess and select the most convenient site for performing a gastrostomy procedure. This is usually the central part of the stomach body on the anterior wall. However, the selection of the appropriate site for the procedure depends primarily on the location where the stomach is most closely adhered to the abdominal wall. Such a location is a place where the stomach wall clearly protrudes under the influence of external finger pressure, and at the same time, clear transillumination of the endoscopic light can be observed on the abdominal skin.

Then, the area around the selected site is disinfected, the skin is locally anaesthetized, and an incision of the skin and subcutaneous tissue of about 10 mm in length is made. A skin incision of 5-10 mm in length is usually used, which allows for the free drainage of fluids leaking from the tissues damaged during the passage of the gastrostomy tube and reduces the force needed to pass the tube.

The next step is to insert a thick needle with a sheath into the stomach, through which a stiff thread is passed after the needle is removed. Then the thread is caught in a loop previously inserted into the stomach through the biopsy channel of the endoscope and, together with the gastroscope, slowly pulled out through the patient's mouth. The end of the gastrostomy tube is tied to the thread from the side of the patient's mouth. The set prepared in this way is pulled out from the skin side, which causes the gastrostomy tube to be pulled out through the stomach wall and abdominal wall.

The gastrostomy tube has a stopper at its inner end, which is supposed to ensure its stability in the stomach. A scale on the tube indicates the distance from this stopper, which makes it easier to orient the tube in the proper position. After the tube has been passed, if anatomical conditions allow, the endoscope is reinserted into the stomach to check the position of the tube and the inner stopper on the stomach wall.

The final step of the procedure is to place the external restrictor, cut the tubing to the correct length, and connect the feeding and irrigation ports. The PEG kit contains all the tools needed to perform the procedure.

Complications after surgery

• Choking
• Bleeding
• Damage to internal organs
• Necrotizing fasciitis
• Displacement of the internal stop to the abdominal wall
• Gastrostomy tube prolapse
• Granulation tissue hyperplasia
• Skin infection around the stoma
• Peristomal leaks
• Pneumoperitoneum
• Implantation of cancer cells at the injection site

Antibiotic prophylaxis

Patients undergoing PEG are at increased risk of infection due to their advanced age, malnutrition, weakened immune system, and comorbidities. Randomized studies have shown a significant reduction in the risk of peristomal infections with prophylactic antibiotics. It is usually recommended to administer an antibiotic such as cefazolin 1 g intravenously 30-60 minutes before the procedure. This method of preventing infections is now widely used.

 

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