PEG Tube – Percutaneous Endoscopic Gastrostomy and Tube Feeding via a PEG Tube

If a patient requires tube feeding, it should always be administered via the gastrointestinal tract whenever possible.

Tubes inserted into the stomach through the nose or mouth can only be left in place for a short time. If enteral (tube) feeding is required for longer than 2–3 weeks, it makes sense to have a PEG tube inserted. In this procedure, the tube is inserted into the stomach from the outside through the skin (percutaneously). It can remain in place for months or even years.

Doctors use PEG tubes when patients are unable to eat a normal diet (sufficiently) over an extended period of time @ Martha Kosthorst /AdobeStock

There are many different indications for percutaneous endoscopic gastrostomy, e.g.,

• swallowing disorders caused by neurological or muscular conditions,
• cancers in the head and neck region,
• other cancers associated with significant weight loss (cachexia), and
• in cases of failure to eat due to dementia.

The decision must be carefully weighed, and the patient’s individual clinical course and prognosis must always be taken into account.

Gastroenterology is a subspecialty of internal medicine that deals with the diagnosis and treatment of diseases of the human digestive tract. A gastroenterologist is a specialist in internal medicine who has completed additional training in gastroenterology.

There are different procedures for placing a feeding tube through the abdominal wall. Percutaneous endoscopic gastrostomy is performed under sedation (anesthetic injection) or brief anesthesia in the endoscopy suite with appropriate monitoring.

It is recommended to administer antibiotics intravenously shortly before PEG placement. The abdomen is disinfected and covered with a sterile drape.

Thread-Pulling Method for PEG Tube Placement

First, a gastroscopy is performed to rule out any relevant conditions or narrowings in the stomach.

Then, a large amount of air is introduced into the stomach via the gastroscope to locate the optimal puncture site in the darkened space. After local anesthesia, a small incision is made in the abdominal wall, and the puncture is performed with a hollow needle. A guide wire is then inserted through the puncture site; this wire is grasped from the inside using endoscopic forceps and then guided out through the mouth.

The tube is secured to the guide wire. The second surgeon then withdraws the guide wire from the puncture site, allowing the PEG tube to be guided through the opening. Once in the stomach, the percutaneous endoscopic gastrostomy is secured in place with a plate to prevent it from slipping out. Finally, adapters are connected and a sterile dressing is applied.

Direct Puncture Method for PEG Tube Placement

If narrowing in the pharynx, throat, or esophagus prevents the PEG tube from being passed through, a different approach must be taken.

Gastroscopy is performed using a thinner endoscope, and the optimal puncture site is identified as described above.

However, the stomach is first secured to the anterior abdominal wall with 2–3 sutures using a special suturing device (gastropexy system). A puncture is then made in this area using a trocar (puncture instrument) with a sheath, and a balloon catheter is placed. Here, a balloon prevents the PEG tube from slipping out.

Jet-PEG (jejunal tube through PEG)

An additional tube is inserted through the existing PEG (which must be 15 Charrière in size) and then advanced into the small intestine (jejunum) via endoscope.

This method allows for direct feeding through the small intestine and, if necessary, relieves pressure on the stomach.

This is necessary in cases of

• strictures at the gastric outlet or in the duodenum,
• gastric motility disorders, and
• severe gastroesophageal reflux (food flows back into the esophagus)

EPJ (Endoscopic Percutaneous Jejunostomy)

If it is not possible to puncture the stomach, the small intestine can also be punctured directly. This is necessary, for example, after stomach and esophageal surgery. The technique used is the thread-pulling method, as with PEG placement.

Button Systems

Four weeks after puncture, the system can be replaced with a second one. So-called button systems are small balloon systems that are very small and inconspicuous from the outside.

This is indicated for children and patients who are still very mobile and independent, but it is also an option in cases of local wound complications. The tube can be used on the day of the procedure, usually starting with water or tea; the transition to a liquid diet is complete after just a few days. Showering and bathing are also not a problem as the process progresses.

During PEG placement, injuries and/or perforations may occur in the throat, esophagus, stomach, and intestines. A misdirected puncture can also injure adjacent organs and blood vessels. This, in turn, can lead to bleeding and infections, such as peritonitis. In an emergency, this requires immediate surgery.

Otherwise, the risks associated with a PEG are similar to those of a gastroscopy. The subsequent course of recovery depends heavily on adequate care and proper handling of the tube system.

Typical complications that may arise include:

• blockage of the PEG tube
• ingrowth of the retaining plate into the stomach wall (buried bumper syndrome), possibly with an abscess and tube obstruction
• tube breakage or detachment
• skin irritation or infection at the exit site
• Leaks
• Pain caused by nerve irritation or a skin tunnel that is too narrow

During the first week, the dressing must be changed daily; thereafter, only 2–3 times a week, depending on the condition of the skin. Later, the PEG tube can be left without a dressing. The PEG tube must be flushed regularly with water or tea—after each tube feeding and after each medication administration.

The retaining plate should be moved 1–2 times a week to prevent it from growing into the stomach wall. This is often overlooked and, combined with overly tight external fixation, frequently leads to what is known as “buried bumper syndrome.”