Post on 14-Feb-2017
PEG - FROM INDICATIONS TO COMPLICATIONS
Shankar Zanwar
Patients with normal nutrition status can tolerate upto 10 days partial fasting
N-G tube usually reserved for shorter duration - <30 days
N-G tube problems
Irritation Ulceration Bleeding Pneumonia Sinusitis, otitis media Oesophageal Reflux Aspiration Pneumonia Subjective Discomfort Lower Feeding Efficacy
Why PEG Improvement in nutritional status better acceptability overall improvement in quality of life A 4 year study with 210 patients
mean wt. loss without PEG in 3 month - 11.35 wt gain after PEG at 12 month 3.5 kg
Indications neuro-motor cancers Gastric decompresssion miscellaneous
Cerebrovascular diseases Dysphagia after stroke - 45% of
hospitalised patients
N-G - sufficient if support needed is for <30 days
PEG considered after 4 weeks, and further need for continuation reassessed periodically
Amyotrophic lateral sclerosis Standard method of feeding in ALS
Some modification may be needed in view of anatomic deformity
Gastric insufflation during and after the procedure should be minimal – spontaneous lowering of diaphragm restricted
Also PEG has a role in other MNDs, bulbar palsies
Neurological conditions Multiple sclerosis Parkinson’s disease Cerebral palsy Reduced level of consciousness Head injury Intensive care patients
Dementia Contrary to assumptions the use of PEG here is
more disadvantageous than beneficial. Worse prognosis than non-PEG subgroups with
a mortality rate of 54% after 1 mon and 90% after 1 year
Patients do not know why a tube is protruding - frequently attempt to pull it out - restraints.
Patients become more agitated -use of pharmacologic sedation – increased bed sores
Tube feeding may actually result in more suffering than comfort.
Other indications Cancers
Head, neck and esophageal cancers – increased risk of malnutrition
Direct obstructive effect, mucositis due to RT/CT
Prophylactic or therapeutic Gastric decompression
Unresolved GO stenosis or ileus to drain secretions and resolve persistent vomiting
Tracheo-esophageal fistula Polytrauma Burns
Contraindications Serious coagulation disorders (INR > 1.5, PTT > 50
s, platelets < 50000/ mm3 ) Hemodynamic instability Sepsis Severe ascites Peritonitis Abdominal wall infection Marked peritoneal carcinomatosis Interposed organs (e.g. liver, colon) History of total gastrectomy Gastric outlet obstruction (if being used for feeding) Severe gastroparesis
Complications Over all rates of
complications of 314 patients Major – 3% Minor – 13%
More with Elderly Co-existing infections h/o aspiration Severe co-morbids
Larson DE, Gastroenterology
Pneumo-peritoneum Commonest of all seen in ~ 50% Due to insufflation of air and needle
puncture of gastric wall In absence of peritoneal signs PEG feeding
can be continued Can be confused with ruptured viscera -
contrast radiology study should be done if suspicion is high
Also suspect if free air is present(even small amount) after 72 hours.
Wound infections Suspect when redness a/w purulent discharge or
other signs of systemic inflammation. Occurs when placed though contaminated field Poor technique If no prophylactic antibiotics are used Minor resolve with daily dressing and local
antiseptics Most respond to 1st gen cephalosporin or
quinolones Nasopharyngeal decontamination significantly
reduce risk
Peristomal leaks Usually with in first few days More in malnourished patients, DM, Too tightly placed external bolster – poor
tissue blood flow – tissue breakdown – leaks Treatment – to prevent skin break down -
use of zinc oxide paste – skin protectant If leak already occurred – do not place a
larger size tube through the same tract – distorts tract and does not promote tissue healing
Peristomal leak Treatment – remove PEG for 24 – 48 hours,
permit slight closure of tract spontaneously Now through the same tract tube can be
replaced Useful when leak occurs after 1 month or
more, does not work well with early leaks – poor wound healing
In many with fully mature tract above technique may not work, needing complete removal and placement of PEG at new location
Other minor complications Ileus – rule out perforation – treat with
bowel rest SOS nasogastric decompression Ulcerations – ulcer develops under the
internal bolster or on the gastric wall Loosening of external bolster helps
Clogging – all feeds and medication should be aptly liquefied, bulking agents to be avoided, psyllium Regular flushing before and after each feed Using bicarbonate solution and pancreatic
enzymes prior to flushing in clogged tube may help unclogging
Tube dysfunction – tube deterioration – pitting, ballooning, foul odor – happens d/t yeast implantation on the tube wall. More common with silicone tube than
polyurethane Gastric outlet obstruction – Tube migration in
the duodenum. When external bolster migrate away from abd.
wall. Marinating ext. bolster at its position can prevent
this
Major complications Bleeding
From PEG tract, gastric artery, splenic/mesentric vein, rectus sheath hematoma.
Hemodyanmically unstable – fluid resuscitation Controlled by – pressure abdominal wound Sometimes in the PEG tube itself – tighten ext.
bolster against abdominal wall – pulls internal bolster against the gastric mucosa
Release after 48 hours – avoid PEG tract breakdown.
In uncontrollable bleeds endoscopic or surgical methods
Necrotizing fasciitis Very rare, potentially fatal rapidly spreading infection along the surgical
planes. Traction and pressure on PEG tube main factors
that increase risk Keeping ext. bumper 1-2cm away from the
abdominal wall takes the pressure away Treatment – immediate surgical debridement,
ICU care and empirical broad-spectrum antibiotics.
Internal organ injury Colon, small bowel, rarely liver and spleen Elderly > young – lax mesentry May develop signs of peritoneal irritation CT with water soluble contrast or
fluoroscopy may help localization Any active leakage mandates surgery
Colo-cutaneous fistula When there is interposition of bowel, usually
the splenic flexure, b/w the ant. Gastric wall and ant. Abdominal wall
Patients are often asymptomatic except for transient fever or ileus
Usually discovered months later when tube is removed for replacement
At this time when the tube is passed blindly through the tract it does not find it’s way back in to the stomach
After restarting feeding– diarrhea and dehydration
Treatment - remove the PEG tube and allow the fistula to close spontaneously
Surgery in non responding cases Prevention – In case of doubt use of
needle with syringe and suction, sudden bolus of air or stool while withdrawal suggest passage through the bowel
Tumor seeding Occurs during the ‘push’ or ‘pull’ method
when the tube is in contact with the oropharyngeal cancer during insertion
Diagnosis is delayed until the metastasis enlarges
Confirmed by CT and biopsy
Buried bumper syndrome Described as early as 3 weeks of placement Excess tension between internal and ext.
bumper Migration of tube towards the in abdominal wall Tube may dislodge anywhere between the
abdominal wall and the skin along the PEG tract Present as feeding problems, peristomal
leakage, pain and swelling at the PEG site
Complications – perforation of stomach and peritonitis
Treatment Introduction of balloon dilator or S-G dilator
with a slightly greater diameter than the probe, through the lumen and push it into the gastric cavity until the retainer is unstuck.
Putting the new probe by pull method, inserting the guide wire through the lumen of buried bumper, when the guide wire is pulled new probe drags the old and unstucks it
Making incision with the needle knife or APC on the lining that covers the internal retainer may also help unstuck it.
Prevention – regular checking of PEG tube position Leaving a gap of nearly 1-2cm Daily rotation of tube to 180-3600
Procedure Pre procedure – 6 hour fasting
Antibiotics (e.g. cefazolin 1g IV) 30 mins before procedure
Thorough cleansing of oropharyngeal cavity Under analgesic sedation Keeping the kit ready In supine decubitus Before procedure complete survey till
the duodenum
Procedure
Procedures Pull technique – Ponsky – Gauderer method Push technique – Sacks Vine method Introducer technique – Russell method
Endoscope is inserted only once all other steps identical to previous technique until trocar insertion
Then the guide is introduced and trocar removed Through this Foley type gastrostomy tube is passed Balloon is then inflated, sheath is removed, the
probe is pulled until it stops and then the external retainer fixed
Post procedure care Cleansing with soap water once a day,
no bandage or dressing is needed to cover
Rotating the peg tube daily Flush before and after each feed
Removal and replacement If the indication of PEG insertion has gone
the tube can be removed as in ischemic strokes
Usually a waiting period of 2-3 weeks needed - tract maturation time
After removal the fistulous hole closes spontaneously
If the internal bumper is soft just need to pull out snugly, if hard cut the exterior of tube and remove the rest endoscopically
Replacement Due to effect of acid the tube may deteriorate No exact time limit mentioned for
replacement Two types of probes available
One with balloon retainer With circular retainer
Easy to place in the tract where the previous tube was placed.
Can be done without endoscopy
Feeding early vs late Traditionally delay for several hours to a
day Meta-analysis shows no difference
between early (>4hours) and late Bechtold ML Am JGastroenterol.
2008 Few centers prefer using water after 4
hours and feeding from the next day
Feeding protocol Standard formulae – initiate @ 50cc/hr until
unless contraindicated If tolerated gradually increase up by
25cc/hr every 4-8 hours till target achieved Usual feeding rate should be 2Kcal/cc Residual evaluation
Check residual q4hrly If residual volume is more than ½ of the last
bolus – withhold next feed Continuous feed - if residual >2X the hourly
rate – review tube
Special setting Obesity – Trans illumination is difficult,
larger incision is needed, fat tissue spread until ant rectus fascia reached External wound to be sutured or clipped Use of spinal needle can be done in BMI
>40 as introducer needle
PEG vs Surgical gastrostomy Comparative studies show no differences
in mortality and morbiditiesStiegmann, Gastrointest Endosc.
But PEG is less expensive and saves time
Surgical gastrostomy - better when patient going for other operation
Alternative indication is when difficult to get a comfortable endoscopic access