Key points
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Percutaneous endoscopic gastrostomy (PEG) is a safe and minimally invasive technique that can be conducted in most patients to attain feeding access.
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The operating room is not required for most PEG placement, and the procedure can be done in the intensive care unit or endoscopy suite (wherever moderate sedation is allowed).
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Complication rates occur approximately 10% of the time and are usually minor in nature.
Introduction
Many patients with head and neck cancers have impaired swallowing, leading to either the inability to take nutrition and hydration orally or they have an unacceptable risk for aspiration. Without nutrition, most postoperative patients would fail to heal. When a feeding tube is required, early gastric feeding is the method of choice. In patients with a short-term situation where the inability to take adequate oral nutrition is likely to resolve in less than a week, nasogastric tubes are an acceptable solution. However, given the risks of complication (sinusitis, nasal septal necrosis, and so forth) and patient discomfort, they are not a viable long-term solution. In these cases, percutaneous endoscopic gastrostomy (PEG) tube insertion is a safe, reliable method with minimal major morbidity to attain feeding access in most patients. PEG tubes have been used since 1980 when the procedure was first introduced by Dr Ponsky and colleagues. Currently, the procedure stands as the method of choice to attain long-term gastric feeding access. In situations where a PEG tube is not safe or feasible, an open gastrostomy may be conducted with minimal incision.
Introduction
Many patients with head and neck cancers have impaired swallowing, leading to either the inability to take nutrition and hydration orally or they have an unacceptable risk for aspiration. Without nutrition, most postoperative patients would fail to heal. When a feeding tube is required, early gastric feeding is the method of choice. In patients with a short-term situation where the inability to take adequate oral nutrition is likely to resolve in less than a week, nasogastric tubes are an acceptable solution. However, given the risks of complication (sinusitis, nasal septal necrosis, and so forth) and patient discomfort, they are not a viable long-term solution. In these cases, percutaneous endoscopic gastrostomy (PEG) tube insertion is a safe, reliable method with minimal major morbidity to attain feeding access in most patients. PEG tubes have been used since 1980 when the procedure was first introduced by Dr Ponsky and colleagues. Currently, the procedure stands as the method of choice to attain long-term gastric feeding access. In situations where a PEG tube is not safe or feasible, an open gastrostomy may be conducted with minimal incision.
Surgical technique
Preoperative planning
- 1.
Patients should be hemodynamically stable.
- 2.
Coagulopathy, if present, should be corrected.
- 3.
Organ failure should be corrected or stabilized as much as possible.
- 4.
Sources of sepsis should be addressed.
- 5.
Massive ascites is a contraindication to PEG placement because tract formation is compromised and gastric contamination or leakage may happen.
- 6.
In patients with a prior history of gastric bypass or sleeve, PEG is not a viable procedure and an open gastrostomy tube of the remnant or jejunostomy tube in the case of a sleeve may be necessary.
- 7.
Although not a strict contraindication, patients with a history of major nongastric upper abdominal surgery may benefit from a preoperative noncontrast computed tomography scan of the abdomen to evaluate for potentially adhesed colon or small bowel overlying the stomach.
Preparation and patient positioning
- 1.
Tube feedings should be held for 8 hours before the procedure, and the patient should be nothing-by-mouth to reduce the risk of aspiration and allow the stomach to empty.
- 2.
The patient should be placed in the supine position in slight reverse Trendelenburg position.
- 3.
Ceftriaxone, 1 g/v, should be given for skin infection prophylaxis.
- 4.
Moderate sedation should be induced by a qualified practitioner with their agents of choice.
Surgical procedure (PULL technique)
- 1.
With the patient under moderate sedation, the endoscope is advanced into the stomach as shown in Fig. 1 .
Fig. 1 Insufflating stomach.( Courtesy of S. Fahd Ali, MD, FACS.) - 2.
The stomach is insufflated and digital pressure applied with the endoscope looking at the anterior wall of the stomach for the clearest point of sharp indentation in the left upper quadrant (LUQ) ( Fig. 2 ).
Fig. 2 Digital pressure with sharp indentation and translumination.
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