Prof.Dr. Yusuf Akcan
Why is a PEG (percutaneous endoscopic gastrostomy) tube inserted?
In cases of inability to feed orally that lasts or will continue for more than a month for various reasons, it is medically appropriate and necessary to insert an endoscopic feeding tube into the stomach. The tube inserted into the stomach endoscopically is called PEG (Percutaneous endoscopic gastrostomy).
The most common indications for snagging are as follows.
- Cerebrovascular accidents, strokes, ALS diseases
- Brain traumas – injuries and traffic accidents
- Tumors in the mouth, throat, pharynx, esophagus and related stenoses, and stenoses caused by radiotherapy to these areas
- Severe Alzheimer’s patients
How is the PEG tube inserted? What should I pay attention to?
The following are the points to be considered before, during and after the PEG Tube insertion.
- The patient must have difficulty swallowing that lasts or is expected to last for at least 1 month.
- It must be possible to reach the stomach with endoscopy.. For this reason, sometimes a PEG tube can be inserted prophylactically if necessary before the stenosis progresses.
- There should be no known obstruction in the stomach outlet, duodenum, or lower.
- Before the procedure, male patients, especially the abdominal skin, should be shaved.
- Bleeding time and clotting time should be checked in all patients.
- The procedure takes approximately 10 minutes under sedation.
- with endoscopy It is entered into the stomach. The light of the endoscopy is shined upwards on the abdominal skin from the inside. Red reflection of light (transillumination) is observed on the abdominal skin. By pressing downwards with your finger at these points, compression movements (indentation) inside the stomach should be easily observed.
- In cases where transillumination is not seen or indentation cannot be selected, an attempt is made to pass into the stomach with the needle of a syringe to which negative pressure is applied, as a third safety measure. If air suddenly enters the syringe and the needle is seen in the stomach at that moment, the position is correct and the procedure can be performed. However, when air enters the negative pressure syringe, if the tip of the needle cannot be seen by the endoscopist in the stomach, there may be an intestine in the middle, in which case the procedure should not be performed. This is called the safe tract method. If the procedure continues even though the route where the PEG tube will be inserted has not been shown to be safe, there is a risk of accidentally inserting the PEG tube into the intestines or abdominal cavity.
- After carefully choosing the place where we will insert the PEG tube, we numb the skin with local anesthesia. A sac of approximately 1 cm is applied. It is important to ensure that this incision is not shorter than the diameter of the tube. The aim is for the tube to be able to rotate around itself easily. The purpose of this is to prevent the tube from passing through the skin incision easily and from causing tissue necrosis by compressing the skin edges through which it passes.
- A metallic needle, which is plastic on the outside and can pass a guide wire through, is advanced into the stomach through two pouches. After a safe distance is entered into the stomach. A guide wire is sent through the needle into the stomach. By seeing the endoscopy, she holds the guide wire with her endoscopic fly and pulls it out of the patient’s mouth. The guide wire easily slides through the abdominal skin and through the plastic around the needle. In the meantime, it is necessary to pull it back inside the plastic sheath to prevent the metal needle from contacting and damaging the opposite wall of the stomach.
- One end of the guide wire will be outside the abdominal skin, the other end will pass through the stomach and come out of the mouth.
- The hose part of the PEG Tube is connected to the end of the Guidewire removed from the mouth by means of the hard metal ring at the end.
- When the other end of the guide wire, which is outside the abdominal skin, is slowly pulled, the part in the mouth moves inward. By continuing to pull PEG tube Thanks to the sharp plastic at the end of the tube, the stomach wall passes through the peritoneal membranes and comes out through the skin incision made in the abdomen. The wider mushroom-shaped part at the threaded end of the tube prevents the entire tube from coming out of the stomach mucosa.
- After the inner mushroom part sits in the stomach, a hose is passed through the hole in the middle of the outer mushroom. The outer cork is slid and brought closer to the skin. Stabilizers are placed between the two mushrooms to hold the skin, abdominal wall muscles and stomach wall. The most important thing to pay attention to here is to leave a space of 34 millimeters between the outer mushroom and the skin, allowing the tube to rotate easily around itself. Otherwise, the risk of pressure-related tissue necrosis or infection on the skin will increase. Internal and external cork retainers to prevent stomach contents from leaking Doing it too tightly has negative effects, not positive ones.
- The process is completed after the inner and outer mushrooms are placed properly.. If a safe route has been established, there is no need to go in and look again with endoscopy. But with personal preference There is no harm in testing it by entering the stomach again within 1 minute and easily rotating around the inner mushroom part and by injecting water into the stomach through the PEG tube.
- After the PEG tube is inserted, the more preferred method is to start feeding through the tube and administering medications through the tube, usually 24 hours later. However, recently there have been publications stating that the use of the PEG tube can be started within 4 hours.
How to feed through PEG Tube?
IV fluid support should be continued for the first 24 hours after the peg tube is inserted. A total of 3 liters of fluid support is given in 24 hours, consisting of 1500 ml isotonic serum and 1500 ml 5% dextrose. After 24 hours, feeding through the PEG tube is started as follows.
- The patient’s head should be kept elevated at 45 degrees during feeding periods.
- First, it should be started with a continuous slow infusion, then an intermittent medium-speed infusion, and then a bolus should be started within days.
- After 24 hours, the first infusion through the PEG tube is started as 20 ml of 2.5% dextrose per hour and given for 3-4 hours, then switched to 5% dextrose. The rate increases to 50 ml per hour after 3-4 hours. Water needs are given additionally, spread throughout the day.
- On the second day, enteral nutrition solutions offered by different brands are diluted and given to the patient who can tolerate the above amounts at a rate of 50 ml per hour, after making them isotonic. Meanwhile, if the patient is thirsty, drinking water can be given as an extra 50 ml per hour. For the patient who cannot express her thirst, the amount of water and nutritional solution is determined with the advice of the dietician. When this is not possible, the total daily amount of fluid is given as 3000-3500 ml (water + feeding solutions).
- On the third day, the same nutrients are given at 100 ml per hour for 2 hours. A 2-hour break is taken and 100 ml of feeding fluid is given per hour for 2 hours again.
- These nutrients, which are given intermittently on the fourth day, are given without dilution.
- On the following days, food blended through the tube can also be given. Preferably, feedings should be given in bolus form over 20-30 minutes, 3-4 times a day.
- Since a total of 3000-3500 ml of fluid intake is required until full nutrition (3000-3500 calories/day and 3000-3500 ml of fluid) is required, the patient should be supported with intravenous fluids and nutrition when necessary.
- There are publications indicating that it can be used safely within 4 hours after the PEG tube is inserted in patients who need to be fed urgently or started taking medication with a PEG tube. Instead of waiting 24 hours under the supervision of a doctor, patients can be fed in the same way as above in 4 hours.