What is (PEG) Placement of Feeding Tubes

EG stands for percutaneous endoscopic gastrostomy.

It is a procedure in which a flexible feeding tube is placed through the abdominal wall and into the stomach.

PEG allows nutrition, fluids and/or medications to be put directly into the stomach, bypassing the mouth and oesophagus.

When Does One Require a PEG?

If you have trouble swallowing or can’t eat or drink enough through your mouth, you may just need a feeding tube. You may get one through your nose or mouth for a few days or weeks while you recover from an illness.

But if you have long-term or serious reasons why you’re unable to eat, such as dementia or terminal cancer, you may need to undergo a fairly simple surgery called a PEG.

Your surgeon generally cuts through the skin of your belly and inserts the tube right into your stomach to deliver a liquid food mixture or a formula.

How is the PEG Performed?

Your doctor will use a lighted flexible tube called an endoscope to guide the creation of a small opening through the skin of the upper abdomen and directly into the stomach.

This procedure allows the doctor to place and secure a feeding tube into the stomach.

Patients generally receive an intravenous sedative and local anaesthesia, and an antibiotic is given by vein before the procedure.

Patients can usually go home the day of the procedure or the next day.

 

3 Different PEG Placements

There are, however, three different methods in which a PEG can be placed.

The method used by your doctor will depend on a variety of factors, the most common technique being the aforementioned endoscopic placement.

1.    Endoscopic

Even within this method, there are variations in methodology. The most common is referred to as the “Push and Pull Technique” and is the method that will be described below.

The doctor needs to be assisted by another operator (apart from the normal support staff).

Before the PEG tube placement, an antibiotic is given to the patient.

Once this has been done, the doctor will make sure there are no obstructions, such as oesophagal obstruction or an ulcer at the site where the PEG tube would be placed, that may get in the way of the PEG tube placement. This is achieved by performing an upper endoscopy.

With the endoscope in the stomach, the second operator will find an appropriate point on the abdomen by looking for transillumination (light from the endoscope inside the stomach) through the abdominal wall.

The position is confirmed when the second operator presses on the chosen area with one finger, and a clear indentation of the gastric wall is seen by the doctor with the endoscope.

This technique that combines the second operator pressing with a finger and the doctor looking for the point of the press with the endoscope increases the safety of PEG tube insertion.

Once an appropriate site on the abdomen is selected, the abdominal wall is cleaned with an iodine-based solution, and the second operator dons sterile gloves.

A local anaesthetic is injected at the site. A small skin incision may then be made at the site (approximately 1 cm in length).

The medical team will then insert the PEG tube going through several technical steps.

2.    Radiological

Radiologically-inserted gastrostomy tubes are placed using fluoroscopic-guidance. Radiologic insertion of a gastrostomy tube requires that the stomach be distended (swollen) with air.

This is often done with a nasogastric tube (one that goes to the stomach via the nose) though alternative techniques may also be used.

Once the stomach is distended, an appropriate site is chosen using fluoroscopy (typically the mid-body of the stomach). A 2-cm square around the site is designated, and a local anaesthetic is injected at the four corners.

The doctor then performs a gastropexy to prevent the stomach from moving up into the chest.

Following this, the tube is placed after some more anaesthetic, an incision, and a couple more technical steps.

3.    Surgical

Surgical gastrostomy can be carried out either laparoscopically (minimally invasive) or using an open approach.

Laparoscopic gastrostomy tube placement is performed similarly to radiologic gastrostomy tube placement.

After the laparoscope is inserted, the gastrostomy site is chosen and grasped. T-fasteners are then used to affix the stomach to the abdominal wall, and the gastrostomy tube is placed.

Open insertion of a gastrostomy tube involves the creation of a midline incision. The stomach is located, and a gastric incision is made.

The gastrostomy tube is then inserted, and the gastric and midline incisions are closed.

The Day Before Your Procedure

Instructions for eating and drinking before PEG Surgery

• Do not eat anything after midnight the night before your surgery. This includes hard candy and gum.
• Between midnight and up until 2 hours before your scheduled arrival time, you may drink a total of 300ml of water.
• Starting 2 hours before your scheduled arrival time, do not eat or drink anything. This includes water.

How Should I Care for the PEG Tube?

• Always wash hands before handling your PEG tube.
• Clean the site with soap and water daily. DO NOT use hydrogen peroxide or any special cleansers. You may use a q-tip or gauze to swab gently around the site. Rinse well and pat dry. This may be done in the shower.
• Apply a clean dressing to the site. This should be changed daily or as needed. This dressing should be placed over the external bumper.
• When changing the dressing, look for redness on your skin, drainage on the old dressing, or leakage at the site of insertion. If found, report to your doctor.
• Tape the tube to your skin to prevent tugging on the skin leading to skin breakdown. Paper tape works well and is gentle on your skin.
• Turn the bumper (or sometimes called a bolster, the piece of soft plastic that sits on the skin to prevent the tube from slipping back into the stomach) and tube halfway at least twice a day to prevent skin breakdown. Also gently push and pull the tube in and out – 1/2 cm each day.
• Flush tube with 30 ml of water at least once a day.

 

How are Feedings Given? Can I Still Eat and Drink?

Specialized liquid nutrition, as well as fluids, are given through the PEG tube.

If the PEG tube is placed because of swallowing difficulty (e.g. after a stroke), there will still be restrictions on what you can take in orally.

Although a few PEG patients may continue to eat or drink after the procedure, this is a very important issue to discuss with your doctor as instructions will vary based on your specific case.

Complications from PEG Placement

While not common, complications can occur with the PEG placement.

Possible complications include pain at the PEG site, leakage of stomach contents around the tube site, and dislodgement or malfunction of the tube.

Possible complications include infection of the PEG site, aspiration (inhalation of gastric contents into the lungs), bleeding and perforation (an unwanted hole in the bowel wall).

Your doctor can describe symptoms that could indicate a possible complication.

How long do these tubes last? How are they removed?

PEG tubes can last for months or years. This, naturally, varies case-by-case.

However, because they can break down or become clogged over extended periods, they might need to be replaced.

Your doctor can easily remove or replace a tube without sedatives or anaesthesia, although your doctor might opt to use sedation and endoscopy in some cases.

Your doctor will remove the tube using firm traction and will either insert a new tube or let the opening close if no replacement is needed.

PEG sites close quickly once the tube is removed, so accidental dislodgement requires immediate attention.

PEG vs. PEJ

When preparing for a PEG tube placement, you may hear the term “PEJ”. Let’s clear up any possible confusion around the terms ‘PEG’ and ‘PEJ’.

A PEG tube is a feeding tube that is placed in your stomach.

If the tube can’t be placed into your stomach, you may have a PEJ tube placed instead. A PEJ tube is placed in your jejunum, which is the second part of your small intestine.

The tube is placed during an endoscopy (a procedure that lets your doctor see inside your stomach and small intestine).

A PEJ tube placement is, therefore, a similar procedure to a PEG tube placement with the only difference being that the tube gets inserted into the jejunum instead of the stomach.

If you need long-term nutrition support, your doctor may convert your PEG into a low-profile gastrostomy button into your stomach.

Your doctor may convert your PEJ into a low-profile jejunostomy button into your small intestine. With both of these buttons, you will attach the feeding adapter to get nutrition.

Summary

A PEG tube placement is a fairly straightforward procedure.

It may sound complicated to a first-time reader but it’s standard practice to help patients who have feeding complications and shouldn’t be feared.

If you would like to book an appointment with a gastrointestinal (GI) specialist or would simply like more information on a particular GI topic, don’t hesitate to use our online booking form or call us at 021 551 8678.