Percutaneous Endoscopic Gastrostomy John P. Grant, MD Duke University Medical Center

Nutritional Rule! IF YOU FAIL – TRY AGAIN! IF NOT – MAKE IT WORK IF THE GUT WORKS – USE IT IF NOT – MAKE IT WORK IF YOU FAIL – TRY AGAIN!

Advantages of Enteral Nutrition Stimulates gallbladder emptying and reduces sludge and stone formation. Avoids steatosis by increasing release of enteroglucagon into portal circulation. Maintains gut-associated lymphoid tissue (GALT). Suppresses cytokine response.

Advantages of Enteral Nutrition Less expensive Less risk of sepsis Less nursing time required

Enteral Access The Gastrostomy Tube

History of Gastrostomy 1837 Egeberg proposed as possible. 1839 Sedillot performed gastrostomy in dog. 1846 Sedillot performed gastrostomy in 3 patients – all died of peritonitis. 1876 Verneuil performed first successful gastrostomy in man.

History of Gastrostomy 1891 Witzel developed serosal tunnel. 1894 Stamm - concentric pursestring. 1913 Janeway - permanent gastrostomy. Beck-Jianu - gastric tube. 1981 Gauderer & Ponsky - PEG tube.

Percutaneous Endoscopic Gastrostomy (PEG) Enteral Access Percutaneous Endoscopic Gastrostomy (PEG) A Simplified Technique for Constructing a Tube Feeding Gastrostomy Michael W.L. Gauderer, M.D., and Jeffrey L. Ponsky, M.D., F.A.C.S., Cleveland, Ohio Surgery, Gynecology & Obstetrics – January 1981 – Volume 152

Bard PEG Kit

Sherwood, Davis, & Geck PEG Tube

Inverta-PEG from Abbott Laboratories

PEG Gastrostomy

Optimal Exit Site for Gastrostomy Tube

PEG Gastrostomy

PEG Gastrostomy

PEG Gastrostomy

PEG Gastrostomy

PEG Gastrostomy

Number of PEG’s Performed at Duke University Medical Center

PEG Insertion

Do’s and Don'ts of PEG Gastrostomy Do not place in patients with ascites. Do not place in patients with gastric varices. Do not attempt placement unless light is seen sharply through abdominal wall and/or indentation is clearly visible with external compression.

Do’s and Don'ts of PEG Gastrostomy Do give perioperative antibiotics. Do evaluate stomach and pylorus during endoscopy. Do make the exit site 1.5 x diameter of the feeding tube. Do loosen retainer after 5 to 7 days.

Do’s and Don'ts of PEG Gastrostomy Do NOT get a chest or KUB x-ray to evaluate postoperative abdominal pain. There will nearly always be free air and it will often be a considerable amount. Order a Gastrografin injection of the tube to evaluate proper tube placement. This test will not always detect a leak about the tube into the abdominal cavity.

Chest X-ray

Chest X-ray Pneumoperitoneum from endoscopy. Patient did well.

Chest X-ray

Chest X-ray Leak from gastrostomy tube. Patient had an acute abdomen and required urgent surgery.

Gastrografin Tube Check

Gastrografin Tube Check Pneumoperitoneum but no leak from gastrostomy site. Patient did well.

Gastrografin Tube Check

Gastrografin Tube Check Obvious leak from gastrostomy site. Patient had an acute abdomen.

Gastrografin Tube Check

Gastrografin Tube Check False negative Gastrografin study. Patient had an acute abdomen.

Do’s and Don'ts of PEG Gastrostomy Make decision on whether to explore the abdomen based on clinical examination and laboratory data. If leak is present, repair and tack stomach up to abdominal wall x 4. Thoroughly irrigate abdomen. Wrap omentum about gastrostomy site.

A PEG can be placed safely in patients with prior upper or lower abdominal surgery…. As long as finger indentation or light transillumination is satisfactory.

Placement of PEG in Patients with Prior Abdominal Surgery (1778 tubes) Hysterectomy 147 Cholecystectomy 87 Exploratory lap., lysis adhesions 71 Appendectomy 70 Subtotal gastrectomy (BI or BII) 35 Abdominal Aortic Aneurysm 30 Colectomy Ventriculoperitoneal shunt 17 Cystectomy with ileal loop 13 Small bowel resection 13 Splenectomy 9 Perforated duodenal ulcer 8 Nissen fundoplication 6 Aortobifemoral bypass graft 5 Cesarian section 4 Pancreatectomy 3 Portocaval shunt 1 Repair diaphragmatic hernia Total with prior surgery: 550 3 failures, no complications

Duke Experience With PEG 1778 Patients 34 Leakage about gastrostomy site 24 Exit site infection (8 major) 12 Peritonitis (12 major: 1 died, 6 exp lap, 5 antibiotics only) 3 Colonic injury 2 Aspiration pneumonia from endoscopy 6 Bleeding at gastrostomy site 1 Fracture of alveolar ridge opening mouth in OR Esophageal laceration on removal (major) 83 Overall 4.7% Major 1.3% (23)

Complications of PEG Gastrostomy Duke PEG 1.3% 4.7% Author # Years Major Minor All Ponsky 307 1983 2 4 Sangster 155 1988 5 25 29 Miller 330 7 14 Saunders 136 1991 3 Gibson 334 1992 32 37 Total 1262 4.0% 3.3% 7.3% Duke PEG 1778 1.3% 3.4% 4.7% Stamm 1438 1934-80 10% 8% 18%

Alternate Enteral Access Laparoscopic Gastrostomy

Ross Laparoscopic Gastrostomy Kit

Trocar Sites and Gastrostomy Exit Site 10-mm trocar

Laparoscopic Gastrostomy Movie

Advantages PEG Does not require general anesthesia. Minimal OR time (15-20 minutes). Prior surgery of little concern. Can evaluate gastric and duodenal mucosa. But: can injure colon or liver and poses serious problem if accidentally removed.

Advantages Lap G-Tube Avoid injury to colon or liver. Securely attach stomach to abdominal wall, less concern accidental removal. Gastrostomy tube easier to remove and replace. But: does require general anesthesia and up to 45 minutes OR time.

Enteral Access Button Gastrostomy

Stomate Button Gastrostomy – Abbott Labs Can replace standard G-tube after 3-4 weeks

PEG Tube Complications Necrotizing Fasciitis

Necrotizing Fasciitis

Necrotizing Fasciitis

Necrotizing Fasciitis

Necrotizing Fasciitis Occurs most commonly in settings of: Concomitant infections, multiple antibiotics Malnutrition, elderly, diabetics Low output syndromes Steroids, chemotherapy, or immunosuppression

Treatment of Necrotizing Fasciitis Ensure adequate nutrition continues. Nasojejunal tube, jejunostomy, TPN Neutralize gastric acid. Give antibiotic (Keflex) via feeding tube.

Treatment of Necrotizing Fasciitis ± Give systemic antibiotics. Change dressing qid, antibiotic ointment. Protect skin (drainage bag). If all else fails – remove feeding tube.

Necrotizing Fasciitis

PEG Tube Complications Hypertrophic Granulation Tissue

Normal PEG Exit Site

Hypertrophic Granulation Tissue

Tissue Sharply Cut Away

Base Cauterized with Silver Nitrate

Complications of Enteral Nutrition Accidental Tube Withdrawal

Accidental Tube Withdrawal PEG Gastrostomy <72 hours: Emergent laparotomy (laparoscopy) to replace tube and secure stomach to abdominal wall. >3 to 7 days: Replace in radiology under fluoroscopy. >7 days: Replace at bedside checking placement with tube check in radiology.

Accidental Tube Withdrawal Laparoscopic Gastrostomy <72 hours: Replace in radiology under fluoroscopy. >72 hours: Replace at bedside with tube check in radiology. >7 days: Replace at bedside checking placement by aspiration of residuals.

Complications of PEG Patient Selection

Patient Selection Scolapio et al. NCP 15:36, 2000 32 patients received PEG following stroke. 9/14 (64%) died within 4 weeks Cost-benefit ratio favors PEG placement only in patients likely to survive and have dysphagia for > 4 weeks.

Patient Selection Scolapio et al. NCP 15:36, 2000 Patients likely to regain swallow function < 4 weeks: Age < 60 Limited comorbidities Nonhemorrhagic stroke Mild oropharyngeal dysphagia

Patient Selection Grant et al. J.A.M.A. 279:1973, 1998 Mortality in 81,105 patients, 65 years or older, with Cerebrovascular disease, neoplasms, fluid and electrolyte disorders, and aspiration pneumonia. In-hospital mortality was 15.3 % 30 day mortality was 23.9 % 1 year mortality was 63.0 % 3 year mortality was 81.3 %

Abuksis et al. Am. J. Gastroenterol., 95:128, 2000 Patient Selection Abuksis et al. Am. J. Gastroenterol., 95:128, 2000 Two groups of patients were compared: Group 1 - patients from nursing homes Group 2 - hospitalized patients 30-Day Mortality Overall Mortality Group 1 13% 38% Group 2 29% 66%

Abuksis et al. Am. J. Gastroenterol., 95:128, 2000 Patient Selection Abuksis et al. Am. J. Gastroenterol., 95:128, 2000 They concluded: Patients hospitalized with acute illness are at high risk for serious adverse events after PEG insertion and the procedure should be avoided. Only stable patients benefit from early gastrostomy.

Mortality Following PEG in ICU’s DUMC 1998-1999 38% 21% Days to Death: Ave = 16 Median = 13

Patient Selection Stable Patients All stable patients can be considered for early gastrostomy if feeding access anticipated to be needed for >30 days.

Patient Selection Acutely Ill Patients All acutely ill patients should be nourished by nasoenteric tube for the first 30 days. If surviving 30 days, acutely ill patients can be considered for a gastrostomy on an individual basis. The tube should be placed about 1 week prior to discharge from the hospital.

Percutaneous Endoscopic Gastrostomy John P. Grant, MD Duke University Medical Center

Loosen retention disk after 5 to 7 days Pull tube out and release If tube pulls back in: If tube does not pull Stomach probably not in: Stomach is attached. Retighten disk probably attached. and recheck in 3-5 days.