Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement

Case Overview

Percutaneous Endoscopic Gastrostomy (PEG) is a minimally-invasive medical procedure that has revolutionized long-term enteral feeding for patients unable to maintain adequate oral intake.¹ First described by Gauderer et al. in 1980, PEG involves the placement of a feeding tube directly into the stomach through the abdominal wall, guided by endoscopic visualization.² This procedure creates a safe and effective route for enteral nutrition, fluid administration, and medication delivery.

PEG tubes are primarily used for long-term enteral nutrition in patients with impaired swallowing or inadequate oral intake, decompression of the gastrointestinal tract, and administration of medications. Common indications for PEG placement include neurological disorders such as stroke,³ multiple sclerosis (MS),⁴ and Parkinson's disease;⁵ head and neck cancers;^6–8 severe dysphagia; prolonged coma or vegetative states;⁹ congenital abnormalities of the upper gastrointestinal tract; and severe malnutrition or cachexia.¹⁰ PEG offers several advantages over other long-term feeding methods, including a lower risk of aspiration compared to nasogastric tubes, improved patient comfort and cosmetic appearance, a lower rate of inadvertent removal compared to nasogastric tubes, and the potential for long-term use with minimal complications.^11–13

This video provides a comprehensive, step-by-step demonstration of the PEG tube placement procedure, offering valuable insights into the technique and considerations involved. International guidelines recommend prophylaxis with a penicillin-based or a cephalosporin-based therapy 30 min before PEG placement.¹⁴ For anesthesia, the author prefers general orotracheal intubation and general anesthesia. However, some teams prefer to perform endoscopic gastrostomy with conscious sedation, local anesthesia, and the supervision of an anesthesiologist. The procedure is initiated by advancing the endoscope into the patient's oral cavity. A slight tilt may be applied to the patient's head to facilitate passage. A jaw thrust is often employed to improve visualization. The base of the tongue is carefully followed, with the endoscope typically advanced 5–7 cm to reach this point. The esophagus must be kept centered in the endoscopic view throughout the advancement. Continuous insufflation is performed to maintain luminal patency. The gastroesophageal junction (GEJ) is typically encountered at approximately the 50-centimeter mark on the endoscope.

Upon entering the stomach, further insufflation is performed to achieve maximal  gastric distension. This facilitates the introduction of the guide wire and moves the colon away from the stomach, reducing the risk of inadvertent colon puncture and avoiding the challenges encountered during this procedure.

The endoscope is maneuvered to obtain a comprehensive view of the gastric anatomy, including the identification of key landmarks such as the pylorus.

The location for PEG tube placement is confirmed using two primary methods:

1. One-to-one motion assessment: An assistant applies pressure to the left of the midline in the epigastric region. The endoscopist observes the gastric wall, looking for an equivalent response to the external pressure. This one-to-one correspondence helps ensure that no other organs (such as the colon) are interposed between the abdominal wall and the stomach.
2. Transillumination: The room lights are dimmed or turned off completely. The endoscope's light intensity is maximized, and an attempt is made to visualize the light through the abdominal wall. This transillumination, when successful, helps mark the optimal site for incision. However, it's noted that in patients with higher body mass indices, this technique may be challenging or impossible to achieve.

In cases where transillumination is not achievable due to the patient's body habitus, an alternative method is employed. A small-gauge "finder" needle is utilized. This needle is carefully inserted through the abdominal wall under endoscopic visualization. If the needle is observed to penetrate the gastric wall, it confirms the correct location and effectively rules out the presence of interposed organs such as the colon. If the PEG cannot be safely placed due to failure to achieve the above maneuvers, the proceduralist should either abort the procedure or convert to an alternative method (e.g. open or laparoscopic gastrostomy).

Once the appropriate site is identified, the area is prepped and draped in a sterile fashion. Local anesthetic is administered to the skin and subcutaneous tissues. A small incision, approximately 2 cm in length, is made just to the left of the midline in the epigastric region. After examining the stomach, ensuring there are no local contraindications, and determining the puncture site, it is advisable to remove the nasoenteric tube before puncturing the stomach and introducing the guide wire. This can simplify the process of capturing the guide wire with the snare. Furthermore, the assistance of a nurse to handle the endoscopic snare can free the endoscopist's hands to manipulate the endoscope more effectively.

The "finder" needle with an outer catheter sheath is inserted through the incision and advanced through the abdominal wall. Care is taken to achieve the correct trajectory, ensuring that the needle enters the stomach in a straight path. This step may require multiple attempts to achieve the optimal angle and position.

Once the needle has successfully entered the stomach (as confirmed endoscopically), the inner needle is removed, leaving the outer catheter sheath in place. A looped guidewire is then carefully threaded through this catheter into the gastric lumen.

After the wire is extracted through the patient's mouth, the PEG tube is attached to the wire. The wire is released from the snare, and the PEG tube is threaded along the wire. The tube is placed through the hole at the end of the wire, forming a loop. This loop is tightened to create a secure connection between the wire and the PEG tube. The tube is then guided into the oropharynx, with care taken to ensure it passes smoothly over the patient's tongue. The patient's mouth may be held open using a "scissoring technique", with one hand while the other hand guides the tube. As the tube is pulled through the esophagus and stomach, tension is felt as it emerges through the abdominal wall incision. The endoscope is used to follow the tube's progress through the esophagus, although direct visualization of the tube passing through may not always be possible. The tube is typically pulled until the markings on the tubing are visible. It is crucial never to pull the tube to less than 5 cm without direct visualization to prevent potential complications.

Once the PEG tube is in place, endoscopic visualization is reestablished. This step is often easier to perform after the PEG tube has passed through the esophagus. The tube's placement is assessed, and its proper placement is confirmed by ensuring the tube can be easily rotated both clockwise and counterclockwise, and that one-to-one motion is still observable when the tube is gently pulled.

At this point, the stomach is deflated, and the endoscope is withdrawn. If present, the nasogastric tube may also be repositioned. The external portion of the wire is then cut.

After cutting the wire, an external bumper is slid onto the PEG tube to secure it in position at the predetermined length (e.g., 4 cm from the skin). This positioning is documented in the brief operative note. A locking mechanism is then applied to further secure the tube.

The PEG tube is cut to the desired length, and an adapter is attached to allow for connection to feeding bags or syringes. It's important to note that immediate use of the PEG tube for feeding is not recommended. Instead, the tube is typically left to gravity drainage for approximately 6 hours, often overnight. After this period, the tube can be used for medication administration, and feeding can be initiated the following morning, assuming the patient has previously tolerated tube feeds.

A 4x4 gauze dressing is applied around the insertion site. The dressing is secured with tape. While suturing of the PEG tube is not routinely performed, in patients at high risk of pulling the tube, a nylon suture may be placed through the designated holes on the external bumper and secured like a drain stitch.

Throughout the procedure and in the immediate postoperative period, careful attention is paid to patient comfort, proper tube positioning, and the integrity of the insertion site. Regular monitoring and assessment are crucial to ensure successful PEG tube placement and function. One potential complication to consider in the immediate postprocedure period is buried bumper syndrome (BBS), which occurs when the internal fixation device of the cannula (bumper) migrates alongside the stoma tract out of the stomach. The disc can end up anywhere between the stomach mucosa and the surface of the skin. We avoid BBS by two ways: first, by clearly communicating to all members of the physician and nursing teams caring for the patient NOT to pull tightly on the PEG tube. Secondly, every morning the rounding team should ensure that the PEG tube is not secured tightly and that the tube can easily be rotated 360 degrees without significant resistance.

For novice endoscopists, several tips can enhance the procedure: maintain gentle pressure on the air insufflation button for continuous insufflation, keep a slight angle at the tip of the endoscope similar to a Macintosh laryngoscope blade, and collaborate with anesthesia colleagues. As medical technology continues to advance, PEG remains a cornerstone procedure in the field of clinical nutrition, offering a reliable solution for patients requiring long-term enteral access.

In conclusion, this detailed video demonstration of the PEG tube placement procedure is a crucial educational resource for medical professionals. It provides comprehensive visualization of a complex procedure, demonstrates real-time problem-solving, emphasizes safety considerations, and offers valuable tips for practitioners.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.