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![Techniques
Two major techniques for placing PEGs have been described in the literature.
1,The Gauderer-Ponsky 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 between the wall and the skin:
A,Digital pressure is applied to the abdominal wall, which can be seen indenting the
anterior gastric wall by the endoscopist.
B,Transillumination (diaphanoscopy): the light emitted from the endoscope within the
stomach can be seen through the abdominal wall.
C, small (21G, 40mm) needle is passed into the stomach before the larger cannula is
passed.
2,An 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, esophagus, stomach, and out of
the incision.[2]
In the Russell introducer technique, 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.](https://image.slidesharecdn.com/b1545c06-6f10-4eb2-86f4-301f1341e610-160112141254/85/Percutaneous-Endoscopic-Gastrostomy-7-320.jpg)
![History
The first percutaneous endoscopic gastrostomy
performed on a child was on June 12, 1979 at the
Rainbow Babies & Children's Hospital, University
Hospitals of Cleveland. Dr. Michael W.L. Gauderer,
pediatric surgeon, Dr. Jeffrey Ponsky, endoscopist,
and Dr. James Bekeny, surgical resident, performed
the procedure on a 4 1⁄2-month-old child with
inadequate oral intake.[12] The authors of the
technique, Dr. Michael W.L. Gauderer and Dr. Jeffrey
Ponsky, first published the technique in 1980.[12] In
2001, the details of the development of the
procedure were published, the first author being the
originator of the technique itself.](https://image.slidesharecdn.com/b1545c06-6f10-4eb2-86f4-301f1341e610-160112141254/85/Percutaneous-Endoscopic-Gastrostomy-17-320.jpg)
Percutaneous Endoscopic Gastrostomy
- 1. Percutaneous Endoscopic Gastrostomy and Jejunostomy By Syeda lateefunnisaSabiha Farheen Msc,sem-1 Osmania university college for women
- 2.
- 3. Percutaneous endoscopic gastrostomy •Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube (PEG tube) is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate (for example, because of dysphagia or sedation).
- 4. The PEG procedureis an alternative to open surgical gastrostomy insertion, and does not require a general anesthetic; mild sedation is typically used. 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 gastric volvulus
- 5. 1 Indications 2 Techniques 3Contraindications 3.1 Absolute contraindications 3.2 Relative contraindications 3.3 In advanced dementia 4 Complications 5 Removal of PEG tubes 5.1 Indications 5.2 Techniques 6 History
- 6. Indications Gastrostomy may beindicated in numerous situations, usually those in which normal or nutrition (or nasogastric feeding is impossible. The causes for these situations may be neurological (e.g. stroke), anatomical . A gastrostomy can 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 A PEG tube can be used in providing gastric or post-surgical drainage
- 7. Techniques Two major techniquesfor placing PEGs have been described in the literature. 1,The Gauderer-Ponsky 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 between the wall and the skin: A,Digital pressure is applied to the abdominal wall, which can be seen indenting the anterior gastric wall by the endoscopist. B,Transillumination (diaphanoscopy): the light emitted from the endoscope within the stomach can be seen through the abdominal wall. C, small (21G, 40mm) needle is passed into the stomach before the larger cannula is passed. 2,An 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, esophagus, stomach, and out of the incision.[2] In the Russell introducer technique, 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.
- 10. Contraindications As with othertypes of feeding tubes, care must be made to place PEGs into an appropriate population. The following are contraindications to PEG use • Absolute contraindications • Inability to perform an esophagogastroduodenoscopy • Uncorrected coagulopathy • Peritonitis • Untreatable (loculated) massive ascites • Bowel obstruction (unless the PEG is sited to provide drainage) • Relative contraindications • Massive ascites • Gastric mucosal abnormalities: large gastric varices, portal hypertensive gastropathy • Previous abdominal surgery, including previous partial gastrectomy: increased risk of organs interposed between gastric wall and abdominal wall • Morbid obesity: difficulties in locating stomach position by digital indentation of stomach and transillumination • Gastric wall neoplasm • Abdominal wall infection: increased risk of infection of PEG site • Intra-abdmominal malignancy with peritoneal involvement (tumor seeding into formed channel with subsequent failure)
- 11. In advanced dementia TheAmerican Medical Directors Association, the American Geriatrics Society and the American Academy of Hospice and Palliative Medicine recommend against inserting percutaneous feeding tubes in individuals with advanced dementia and, instead, recommend oral assisted feedings. Artificial nutrition neither prolongs life nor improves its quality in patients with advanced dementia. It may increase the risk of the patient inhaling food, it does not reduce suffering, it may cause fluid overload, diarrhea, abdominal pain and local complications, and can reduce the amount of human interaction the patient experiences.
- 12. Complications Major complications arenot common but can occur after PEG tube insertion. mortality after PEG is very rare and is usually due to underlying co-morbidities Cellulitis (infection of the skin) around the gastrostomy site Hemorrhage Gastric ulcer either at the site of the button or on the opposite wall of the stomach ("kissing ulcer") Perforation of bowel (most commonly transverse colon) leading to peritonitis Puncture of the left lobe of the liver leading to liver capsule pain Gastrocolic fistula: this may be suspected if diarrhea appears a short time after feeding. In this case, the feed goes direct from stomach to colon (usually transverse colon) Gastric separation "Buried bumper syndrome" (the gastric part of the tube migrates into the gastric wall)
- 13. POST-INSERTION CARE After PEGtube insertion adequate pain relief should be administered. Many patients report abdominal discomfort after PEG insertion due to inflation of the stomach during the procedure. Traditionally, feeding was delayed until the next day due to the fear of peritoneal leakage risk after feeding. Many studies investigated the safety of early feeding from 1 h to 6 h after PEG insertion, including a meta-analysis which found that feeding initiated as early as 4 h after PEG placement is safe. The stoma should be examined (for signs such as pain, discoloration, swelling, exudation, pus and leakage around the stoma) and cleaned daily. The tube should be rotated about 180 degrees and moved up and down about 1-2 cm in the stoma site on a daily basis after the stoma has completely healed
- 14. Removal of PEGtubes Indications PEG tube no longer required (recovery of swallowafterstroke or surgery for head and neckcancer, or frombraintrauma) Persistent infectionof PEG site Failure, breakage or deteriorationof PEG tube (a new tube canbe sited along the existing track) "Buried bumper syndrome"
- 15. Technique s PEG tubes withrigid, fixed "bumpers" are removed endoscopically. The PEG tube is pushed into the stomach so that part of the tube is visible behind the bumper. An endoscopy snare is then passed through the endoscope, and passed over the bumper so that the tube adjacent to the bumper is grasped. The external part of the tube is then cut, and the tube is withdrawn into the stomach, and then pulled up into the esophagus and removed through the mouth. The PEG site heals without intervention. PEG tubes with a collapsible or deflatable bumper can be removed using traction (simply by pulling the PEG tube out through the abdominal wall).
- 17. History The first percutaneousendoscopic gastrostomy performed on a child was on June 12, 1979 at the Rainbow Babies & Children's Hospital, University Hospitals of Cleveland. Dr. Michael W.L. Gauderer, pediatric surgeon, Dr. Jeffrey Ponsky, endoscopist, and Dr. James Bekeny, surgical resident, performed the procedure on a 4 1⁄2-month-old child with inadequate oral intake.[12] The authors of the technique, Dr. Michael W.L. Gauderer and Dr. Jeffrey Ponsky, first published the technique in 1980.[12] In 2001, the details of the development of the procedure were published, the first author being the originator of the technique itself.
- 18. CONCLUSION Since its introductionin 1980, PEG has gained world- wide acceptance as a safe technique for providing enteral feeding in patients with poor oral intake who have a functional GI system. PEG tube placement has many indications, and is the recommended tube type if not contraindicated. PEG tubes can result in minor or even major complications, but most patients do well with them. The pull technique is the most commonly used method, but other techniques are possible or even necessary in certain situations. Knowing when and how to place PEG tubes, as well as how to manage and even remove them, is an important part of the management of many patients. Quality and safe care of PEG tubes begin at pre-insertion screening and throughout post- insertion aftercare. Prevention of and proper management of complications are critical to ensuring successful outcome.
- 19. Jejunostomy Jejunostomy is thesurgical creation of an opening (fistula) through the skin at the front of the abdomen and the wall of the jejunum (part of the small intestine). It can be performed either endoscopically, or with formal surgery A jejunostomy may be formed following bowel resection in cases where there is a need for bypassing the distal small bowel and/or colon due to a bowel leak or perforation. Depending on the length of jejunum resected or bypassed the patient may have resultant short bowel syndrome and require parenteral nutrition. A jejunostomy is different from a jejunal feeding tube which is an alternative to a gastrostomy feeding tube commonly used when gastric enteral feeding is contraindicated or carries significant risks. The advantage over a gastrostomy is its low risk of aspiration due to its distal placement. Disadvantages include small bowel obstruction, ischemia, and requirement for continuous feeding
- 20. Techniques TheWitzeljejunostomyisthemostcommonmethodof jejunostomycreation.Itis an opentechniquewherethejejunosotomyissited30cm distalto theLigamentof Treitz on theantimesentericborder,withthecathetertunneledina seromusculargroove. Thereare severaltechniquesfor placement,includinga directsurgicalor endoscopic technique,or a more complicatedRoux-en-Yprocedure.The J-tubemayuse a long, catheter-like tube or a button.Depending on the placement type,the tube may be changed at home,or mayneed to be changedat a hospital.A J-tube is helpfulfor individualswith poorgastricmotility,chronicvomiting,or at highriskfor aspirationand in those in whom gastrostomytubesare contraindicated
- 22.