Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement

CHAPTER 1

Hi, my name is Amory de Roulet. I am one of the Trauma and Critical Care fellows at the Massachusetts General Hospital. The case that we'll be presenting today is a percutaneous endoscopic gastrostomy tube. This is a patient that is on the neurosurgical service who suffered an MCA stroke last month, also found to have an MCA aneurysm, status post stent placement. He had been on cangrelor, but we asked for the neurosurgery team to switch to a ticagrelor drip because of its shorter half-life and its better safety profile with procedures. This was held for six hours before our procedure today. Starting the procedure today, we started with endoscopic placement into the stomach. It can be difficult to intubate the esophagus, and there are numerous tricks that can be used that I recommend that novice endoscopists look up prior to their first time performing EGDs. Once we established access to the stomach, we insufflated. And once the stomach was insufflated, before making any incisions, we tried to confirm two things: one is one-to-one movement. When you push down on the skin, you want to see an equivalent reaction on the gastric wall. The second thing, which we were not well able to obtain, was transillumination, because this can be somewhat dependent on body habitus. With transillumination, you turn the light on the scope to maximum intensity, and you hope to see a transillumination of the light across the skin, and it marks where you should make your incision. Instead, I used a finder needle, and we were able to see the part of the stomach where the finder needle was able to penetrate, and this marked where we wanted to make our incision. Once we made our incision, we stick that same finder needle that has a plastic catheter sheath around the outside into the stomach, you remove the needle, and then you insert a looped wire through the catheter and into the stomach. The endoscopist then snares that wire, brings it out through the patient's mouth, attaches the PEG tube, and then brings the PEG tube back into the stomach, where I, as the operator, then are able to pull it out through the incision. Before making the PEG too tight, the endoscopist will reestablish entry into the stomach, and under visualization, we'll mark the length of the PEG tube where the internal bumper fits snugly onto the gastric mucosa but you can still easily rotate the PEG tube. You don't want the PEG tube to be secured too tightly because there's a risk of gastric ischemia and even necrosis. Once you figure out how tight the PEG tube is placed on the skin, you insert an external bumper that will then fasten a PEG tube in the appropriate location. You then place a stopper onto the PEG tube, and then you cut it to length and you can attach a bag. Postoperatively, I like to leave my PEG tubes for six hours to drainage, and then between 6 and 12 hours post-procedure, it can be used for medications. And then after 12 hours, it can be used to start tube feeds at a goal rate if the patient is able to tolerate it. For this patient, I stop the ticagrelor drip six hours before the procedure and will plan to resume it nine hours post-procedure. There is a small risk of bleeding, but it's something that I anticipate seeing either through drainage in the stomach or through the skin. The procedure proceeded smoothly. The only issue worth noting was the lack of transillumination, which I anticipate was the result of the patient's body habitus.

CHAPTER 2

Tilt it so it's going this way. Yep. Great. So I'll give a little jaw thrust. Follow the base of the tongue. You should be about five to seven centimeters in to get to the base, so you may be a little deep. Look to the right. Great. Insufflate. All right, come down. Stay, keep the esophagus in the center of the screen. Yes. Go. Great. All right, I'm gonna let go of the jaw thrust. Keep on advancing down to the stomach. Keep insufflating. Keep the esophagus in the center of the screen. Yep, go, go, go. So you see secretions on the right side of the screen, so you know that's posterior. Yeah, just like you're doing bronchoscopy, try and keep the lumen of the esophagus in the center of the screen. Insufflate at about the 50-centimeter mark. We'll probably be around the GEJ. Looks like we're about there. Perfect. Good job. All right, so enter the stomach.

CHAPTER 3

All right, Cat, what I'm gonna have you do is right to the left of midline in the epigastrium, you're gonna push down. All right, you see where we're pushing down? Yeah. All right, so what we're looking for is one-to-one motion, meaning that every time Cat pushes down, you see about an equivalent response of the gastric wall. Great. Now we're gonna turn off the room lights. I'll turn on the transillumination, and we're gonna look to see that you could see transillumination through the gastric wall and the skin, which will mark where we make an incision. The concern being that if there is colon, you may still see, maybe not quite one-to-one motion, but close to one-to-one. You want to get right on the wall. Me? Yeah. Okay. He's a little bit obese, so it might be a little bit hard to see. Come out. Come back from the wall a bit. Push down. Okay. I think the transillumination should work. All right, try again. All right. I think his obesity may preclude it, so we will look with a small local needle, and if it is able to penetrate through the gastric wall, then that also excludes colon. So I'm gonna scrub. Is that pylorus? All right, so come back. Come back a bit. All right. Go back towards the pylorus. Nope. All right.

CHAPTER 4

So I'm gonna make a small wheel with the local, but more importantly, come back out a bit. All right. Do you have the longer finder needle? Yeah. That's the only one that I have. Okay. So we're just to the left to midline, making a small, two-centimeter incision.

CHAPTER 5

This is a finder needle that has a small catheter on it. Yeah, I know. I'm trying to get a good trajectory so it comes through straight. Nope. Sometimes it skives and it's not very helpful. See, it's skiving. Okay. Perforated.

CHAPTER 6

Wire. This is a wire that we place through the small catheter. Great. There we go.

CHAPTER 7

So what I need you to do now, Chloe, is to grab the snare. The snare is on top of the tower there. You'll... Just the... Sometimes it's helpful to have an assistant help you with the snare. Yep, nope. Nope, you wanna leave that cap on, otherwise you lose your insufflation pressure. Okay, but there's a hole in the middle of it. All right. And it goes in as long as the endoscope is, so you have a long ways to go. Once you get to about 60 centimeters or so, you're gonna want to actually look up at the screen as you keep feeding it in because it'll come right in front of you. Yeah, so we've lost a little bit of the insufflation. And this can actually be a difficult step of the operation. So right now you see how the catheter is pushed along the gastric wall. Okay, great. So now you'll open up the snare. So insufflate the stomach, 'cause it's lost most of its distension. Once it's insufflated, open the snare. You'll see it open outside. Great. And what you're gonna do is you're gonna move the endoscope until you can place the snare overlying the blue catheter. Try and get the nasogastric tube out of your view. So, if you can go under it... And you can ask for help with the snare. You don't have to do everything by yourself. Okay. Great. So try and lasso the wire. I'll try and get it off the gastric wall to help you a bit. You are close. All right. Beautiful. Close the snare. Oh, a little bit deeper. Yep. Nope, you're gonna lose it. You gotta come down a bit. Yep. Little farther, yep. Nope. Okay, so great. So now you'll pull once the snare is closed. Is it locked tight? It is, yes. That's great. You'll pull the endoscope out with the snare, and it will pull this wire. Okay. So I'll feel it feed through my fingers. That's great. Perfect. All right. So now the wire will stay in, the catheter can come out, and the next step is for you to load the PEG onto the wire. So release the wire from the snare.

CHAPTER 8

Great. Feed the PEG through... Yep, through the wire. Nope. So open up the wire and feed the PEG through. And then place the PEG through the hole at the end. See how it forms a loop? Yes. Place the PEG through the hole. Yep. All the way to the bottom. Correct. Great. Now form it tight and it should form a connection between the wire and the PEG. It does. Perfect. All right, so now you'll help guide it into the oropharynx. Nope, that will be the last part. The first part will be here. Yep. And I'll start pulling gently on my wire. Okay, make sure there are no knots. Is there a knot at the bottom there? No. Okay, great. You can pull that tight, 'cause I'll end up cutting that with a scissor. That's great. So feed that over his tongue. Great. I'm getting caught a bit, so can we make sure, nope. Can we make sure that there's no wire or anything around his tongue? Yep. Just open his mouth and place - right on top of his tongue. You can scissor his mouth open with your left hand and then guide with your right hand. He's biting. Can we have a little bit more... A little bit more paralytic? Yes. Okay. So scissor open his mouth with the left hand and then guide the PEG on top of his tongue. And then, yep, then I can do the rest. That's great. Yep. And there's always a little bit of tension in coming out through the stomach and through the skin. Okay. That's perfect. So as this comes through the esophagus, try and follow with the EGD. You can't really see it come through, but I usually pull it until I can see the numbers on the tubing itself. You never want to pull it without visualization to less than five centimeters. So I pulled it to five centimeters here, and that should be just about hubbing the gastric wall.

CHAPTER 9

It's always easier to intubate the esophagus after the PEG has been through it. Great. Okay. So the PEG is just about hubbed, so we can turn the room lights on at this point. I have it at four centimeters. It easily rotates clockwise and counterclockwise. As I pull on it, you still see the one-to-one motion. So at this point, you can desufflate the stomach and come out. We can also pull the nasogastric tube out. You okay if I cut it down?

CHAPTER 10

Yep, so we cut the wire. After the wire is cut, we slide on the the hub. This will secure the PEG in position at four centimeters at the skin. And we always mark in our brief operative note where the hub is at. And then this is the lock. This also can slide on easily.

CHAPTER 11

We cut our tube to the desired length. And then there's an adapter - that we can then place onto a bag. I never use my PEG tubes immediately for feeding. I leave it to gravity drainage for six hours. Overnight, nursing can use the PEG tube for medications, and then the next morning, they can start with feeding. As long as the patient can tolerate tube feeds and they've been on it before, it's not necessary to start at a trickle rate. I don't routinely check gastric residuals For a dressing, we place a 4x4. I don't routinely suture my PEGs into place. But in certain patient populations where you think they're at high risk for pulling the PEG, I'll place a nylon suture through these two holes and then treat it like a drain stitch and wrap it around a couple of times. Thank you for fashioning this. And then what would you like? Do you want just that as is or do you want a Tegaderm tape? We don't need a Tegaderm on top, just a piece of tape. Okay. And that concludes the procedure. Nice job.

CHAPTER 12

Here are three tips that I have to offer for novice operators for PEG tubes. One is there is a button on the endoscope, air insufflation, and also water irrigation is the same button. If you just place your finger gently over the button, it will insufflate air but not irrigate with water. If you push too hard, you will irrigate with water. So often novice endoscopists either don't push that button or they push it too hard. You always wanna be insufflating even in the oropharynx because intubating the esophagus can sometimes be the most difficult part of this procedure. Secondly, I like to keep just a narrow, a very small angle at the end of the endoscope, almost imagining that it is similar to a Mac blade used for intubation because that will come down the posterior oropharynx behind the base of the tongue, and then you'll be looking up into the esophagus. The third thing that I typically do to facilitate intubation of the esophagus is ask my anesthesia colleagues or a, you know, co-surgeon to perform a jaw thrust. This will oftentimes elevate the esophagus and facilitate entry into the esophagus.