Percutaneous endoscopic gastrostomy 1227310 223821795 2008-07-05T23:58:56Z Jfdwolff 46555 copyedit - some added comments were out of context A '''percutaneous endoscopic gastrostomy''' ('''PEG''') is an [[endoscopy|endoscopic]] procedure for placing a tube into the [[stomach]]. It involves placing a tube into the stomach through the [[abdominal wall]]. It is an alternative to surgical gastrostomy. PEG tubes may also be extended into the [[small bowel]]. The procedure does not require a [[general anesthetic]], although mild sedation is typically used. The procedure is performed in order to place a [[gastric feeding tube]] as a long-term means of providing nutrition to patients who cannot productively take food orally. PEG administration of enteral feeds is the most commonly used method of nutritional support for patients in the community. Many [[stroke]] patients, for example, are at risk of [[aspiration pneumonia]] due to poor control over the swallowing muscles; some will benefit from a PEG performed to maintain nutrition. PEGs may also be inserted to decompress the [[stomach]] in cases of [[volvulus|gastric volvulus]].<ref name=20yrs>{{cite journal |author=Gauderer MW |title=Percutaneous endoscopic gastrostomy-20 years later: a historical perspective |journal=J. Pediatr. Surg. |volume=36 |issue=1 |pages=217–9 |year=2001 |pmid=11150469 |doi=10.1053/jpsu.2001.20058}}</ref> ==Indications== Gastrostomy may be indicated in numerous situations, usually those in which normal or nutrition (or [[nasogastric tube|nasogastric]]) feeding is impossible. The causes for these situations may be neurological (e.g. [[stroke]]), anatomical (e.g. [[cleft lip and palate]] during the process of correction) or other (e.g. [[radiation therapy]] for tumors in head & neck region). In certain situations, the indication for PEG placement is more debatable. In advanced [[dementia]], studies show that PEG placement does not in fact prolong life.<ref>{{cite journal |author=Murphy LM, Lipman TO |title=Percutaneous endoscopic gastrostomy does not prolong survival in patients with dementia |journal=Arch. Intern. Med. |volume=163 |issue=11 |pages=1351–3 |year=2003 |pmid=12796072 |doi=10.1001/archinte.163.11.1351}}</ref> Indeed, work has been done to inform doctors and healthcare staff of the perceived futility of the treatment.<ref>{{cite journal |author=Monteleoni C, Clark E |title=Using rapid-cycle quality improvement methodology to reduce feeding tubes in patients with advanced dementia: before and after study |journal=BMJ |volume=329 |issue=7464 |pages=491–4 |year=2004 |pmid=15331474 |doi=10.1136/bmj.329.7464.491}}</ref> A gastrostomy may also be placed to decompress the stomach contents in a patient with a malignant bowel obstruction. This is referred to as a "venting PEG" and is placed to prevent and manage nausea and vomiting. A gastrostomy can also be used to treat [[volvulus]] of the stomach, where the stomach twists along one of its axes. The tube (or multiple tubes) is used for gastropexy, or adhering the stomach to the abdominal wall, preventing twisting of the stomach.<ref name=20yrs/> ==Techniques== Two major techniques for placing PEGs have been described in the literature. The Ponsky or Bard-Ponsky pull technique involves performing a [[gastroscopy]] to evaluate the [[anatomy]] of the [[stomach]]. The anterior stomach wall is identified and techniques are used to ensure that there is no [[organ (anatomy)|organ]] between the wall and the [[skin]]. An [[catheter|angiocath]] is used to puncture the abdominal wall through a small [[incision]], and a soft guidewire is inserted through this and pulled out of the [[mouth]]. The feeding tube is attached to the guidewire and pulled through the mouth out of the incision.<ref name="pmid3349370">{{cite journal |author=Deitel M, Bendago M, Spratt EH, Burul CJ, To TB |title=Percutaneous endoscopic gastrostomy by the "pull" and "introducer" methods |journal=Can J Surg |volume=31 |issue=2 |pages=102–4 |year=1988 |pmid=3349370 |doi=}}</ref> The Russell introducer technique involves a [[gastroscopy]] to evaluate the anatomy. The [[Seldinger technique]] is used to place a wire into the stomach, and a series of dilators are used to increase the size of the [[gastrostomy]]. The tube is then pushed in over the wire.<ref name="pmid3349370">{{cite journal |author=Deitel M, Bendago M, Spratt EH, Burul CJ, To TB |title=Percutaneous endoscopic gastrostomy by the "pull" and "introducer" methods |journal=Can J Surg |volume=31 |issue=2 |pages=102–4 |year=1988 |pmid=3349370 |doi=}}</ref> ==Contraindications== As with the case of other types of feeding tubes, care must be made to place PEGs into an appropriate population. The following are contraindications to PEG use:{{Fact|date=November 2007}} *[[Peritonitis]] *Short life span *Abdominal wall infection *Abdominal burns *High aspiration risk *Atypical abdominal anatomy (e.g. malrotation) ==Complications== *Cellulitis (infection of the skin) around the gastrostomy opening *Peritonitis *[[Gastrocolic fistula]]: this may be suspected if diarrhea appears a short time after feeding. In this case, the food goes direct from stomach to colon (usually transverse). *Gastric separation *"Buried bumper syndrome" (the gastric part of the tube migrates into the peritoneal cavity)<ref>{{cite journal |author=Walters G, Ramesh P, Memon MI |title=Buried Bumper Syndrome complicated by intra-abdominal sepsis |journal=Age and ageing |volume=34 |issue=6 |pages=650–1 |year=2005 |pmid=16267197 |doi=10.1093/ageing/afi204}}</ref> ==History== The first percutaneous endoscopic gastrostomies were performed at the [[Cleveland Clinic]] in children.<ref>{{cite journal |author=Gauderer MW, Ponsky JL, Izant RJ |title=Gastrostomy without laparotomy: a percutaneous endoscopic technique |journal=J. Pediatr. Surg. |volume=15 |issue=6 |pages=872–5 |year=1980 |pmid=6780678 |doi=10.1016/S0022-3468(80)80296-X}}</ref> ==See also== *[[Feeding tube]] *[[Minimally conscious state]] ==References== {{Reflist}} ==External links== * [http://www.emedicine.com/radio/topic798.htm eMedicine: Percutaneous Gastrostomy and Jejunostomy] {{Digestive system surgical procedures}} [[Category:Gastroenterology]] [[Category:Enteral feeding]] [[Category:Endoscopy]] [[de:Perkutane endoskopische Gastrostomie]] [[nl:Percutane endoscopische gastrostomie]] [[pl:Przezskórna endoskopowa gastrostomia]] [[sv:PEG]]