HARD DECISIONS IN INTENSIVE CARE UNIT

Intensivecareunitkapak

PERCUTANEOUS ENDOSCOPIC GASTROSTOMY

Mustafa Tomruk

Meram State Hospital, Department of Anesthesiology and Reanimation, Konya, Türkiye

Tomruk M. Percutaneous Endoscopic Gastrostomy. In: Turan S, editor. Hard Decisions in Intensive Care Unit. 1st ed. Ankara: Türkiye Klinikleri; 2025. p.321-330.

ABSTRACT

Critically ill patients are often at risk of malnutrition due to acute and chronic diseases, loss of appetite, trauma, and infections. Malnutrition is a major cause of high mortality, morbidity and increased hospital costs. Percutaneous endoscopic gastrostomy (PEG) tubes offer a safe and effective option for providing enteral nutritional support to these patients. PEG tube placement is currently considered one of the most commonly performed endoscopic procedures worldwide. Therefore, understanding the indications and contraindications for tube placement is an essential aspect of modern medicine. The two main reasons for PEG tube placement are to provide enteral nutritional support and facilitate medication administration. However, distal enteral obstruction, unmanageable severe coagulopathy, and hemodynamic instability are the primary contraindications for PEG tube placement in hospitalized patients. Although generally regarded as a safe procedure, PEG tube placement has the potential to result in minor and major complications. Awareness of and the ability to manage these potential complications, along with proper and regular care of the catheter, are crucial. There are different methods for placing a percutaneous PEG tube into the stomach (push, pull, introducer), with the “pull” technique being the most commonly used. General information, application techniques, indications, contraindications, and potential complications related to PEG tube placement in the Intensive Care Unit (ICU) will be evaluated. Information regarding PEG care will also be provided.

Keywords: Complications; Contraindications; Enteral nutrition; Indications; Percutaneous endoscopic gastrostomy; Techniques

Referanslar

  1. Löser C, Aschl G, Hébuterne X, Mathus-Vliegen EM, Muscaritoli M, Niv Y, et al. ESPEN guidelines on artificial enteral nutrition--percutaneous endoscopic gastrostomy (PEG). Clin Nutr, 2005;24(5):848-61. [Crossref]  [PubMed]
  2. Bechtold ML, Brown PM, Escuro A, Grenda B, Johnston T, Kozeniecki M, et al. When is enteral nutrition indicated? JPEN J Parenter Enteral Nutr. 2022;46(7):1470-1496. [Crossref]  [PubMed]
  3. Gauderer MW, Ponsky JL, Izant Jr RJ. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg. 1980;15(6):872-875. [Crossref]  [PubMed]
  4. Gencosmanoglu, R. Percutaneous endoscopic gastrostomy: A safe and effective bridge for enternal nutrition in neurological or non-neurological conditions. Neurocritical Care. 2004;1:309-317. [Crossref]  [PubMed]
  5. Light VL, Slezak FA, Porter JA, Gerson LW, McCord G. Predictive factors for early mortality after percutaneous endoscopic gastrostomy. Gastrointestinal endoscopy. 1995: 42(4);330-335. [Crossref]  [PubMed]
  6. Prakash P, Su A, Mason L, Tabibian JH. Contrast-Enhanced, Fluoroscopically Guided Percutaneous Endoscopic Gastrostomy Tube Placement for the High-Risk Patient. ACG Case Reports Journal. 2022:9(1);740. [Crossref]  [PubMed]  [PMC]
  7. Vogt W, Messmann H, Lock G, Gmeinwieser J, Feuerbach S, Schölmerich J, et al. CT-guided PEG in patients with unsuccessful endoscopic transillumination. Gastrointest Endosc. 1996;43(2)1:138-40. [Crossref]  [PubMed]
  8. Hogan RB, DeMarco DC, Hamilton JK, Walker CO, Polter DE Percutaneous endoscopic gastrostomy-to push or pull: a prospective randomized trial. Gastrointestinal Endoscopy. 1986:32(4); 253-258. [Crossref]  [PubMed]
  9. Taylor CA, Larson DE, Ballard DJ, Bergstrom LR, Silverstein MD, Zinsmeister AR, DiMagno EP. Predictors of outcome after percutaneous endoscopic gastrostomy: a community-based study. Mayo Clin Proc. 1992;67(11):1042-9. [Crossref]  [PubMed]
  10. Chaudhary KA, Smith OJ, Cuddy PG, Clarkston WK. PEG site infections: the emergence of methicillin resistant Staphylococcus aureus as a major pathogen. Am J Gastroenterol 2002;97:1713. [Crossref]  [PubMed]
  11. Jafri NS, Mahid SS, Minor KS, Idstein SR, Hornung CA, Galandiuk S. Meta-analysis: antibiotic prophylaxis to prevent peristomal infection following percutaneous endoscopic gastrostomy. Aliment Pharmacol Ther. 2007:15;25(6):647-56. [Crossref]  [PubMed]
  12. Lee SH, Moon HS, Park JH, Kim JS, Kang SH, Lee ES, et al. Percutaneous Endoscopic Gastrostomy Tube Insertion-induced Superior Mesenteric Artery Injury Treated with Angiography. Korean J Gastroenterol. 2018:25;72(6):308-312.Treated with Angiography. Korean J Gastroenterol 2018; 72:308. [Crossref]  [PubMed]
  13. Sekmenli T, Gündüz M, Akbulut H, Emiroglu H, Koplay M, Ciftci I. Massive hemorrhage: a late complication of replacement percutaneous endoscopic gastrostomy: case report. Arch Argent Pediatr. 2018:1;116(2):e315-e318. [Crossref]
  14. Chong C, Derigo L, Brown D. Massive gastric bleeding: a rarely seen subacute complication of percutaneous endoscopic gastrostomy. Intern Med J. 2007;37:787. [Crossref]  [PubMed]
  15. Richter JA, Patrie JT, Richter RP, Henry ZH, Pop GH, Regan KA, et al. Bleeding after percutaneous endoscopic gastrostomy is linked to serotonin reuptake inhibitors, not aspirin or clopidogrel. Gastrointest Endosc. 2011;74(1):22-34.e1. [Crossref]  [PubMed]
  16. Tsang TK, Eaton D, Falconio MA. Percutaneous ostomy dilation: a technique for dilating the closed percutaneous endoscopic gastrostomy sites and reinserting gastrostomies. Gastrointest Endosc. 1989;35:336. [Crossref]  [PubMed]
  17. Seidner DL, Ghanta RK. Management of a traumatic gastric ulcer with a low-profile gastrostomy tube. Nutr Clin Pract. 2005;20:88-92. [Crossref]  [PubMed]
  18. Nazarian A, Cross W, Kowdley GC. Pneumoperitoneum after percutaneous endoscopic gastrostomy among adults in the intensive care unit: incidence, predictive factors, and clinical significance. Am Surg. 2012;78(5):591-4. [Crossref]  [PubMed]
  19. Blum CA, Selander C, Ruddy JM, Leon S. The incidence and clinical significance of pneumoperitoneum after percutaneous endoscopic gastrostomy: a review of 722 cases. Am Surg. 2009;75:39. [Crossref]  [PubMed]
  20. Rucart PA, Boyer-Grand A, Sautou-Miranda V, Bouteloup C, Chopineau J. Influence of unclogging agents on the surface state of enteral feeding tubes. Journal of Parenteral and Enteral Nutrition. 2011:35(2);255-263. [Crossref]  [PubMed]
  21. Behnken I, Gaschott T, Stein J. Enterale Ernährung: Medikamentenapplikation über Sonden [Enteral nutrition: drug administration via feeding tube]. Z Gastroenterol. 2005;43(11):1231-41. [Crossref]  [PubMed]
  22. Clancy MJ, Hunter DC. Tube migration causing gastric outlet obstruction: an unusual complication of percutaneous endoscopic gastrostomy. Endoscopy 2000;32:58. [Link]
  23. Galat SA, Gerig KD, Porter JA, Slezak FA. Management of premature removal of the percutaneous gastrostomy. Am Surg 1990; 56:733. [Link]
  24. Schrag SP, Sharma R, Jaik NP, Seamon MJ, Lukaszczyk JJ, Martin ND, Hoey BA, Stawicki SP. Complications related to percutaneous endoscopic gastrostomy (PEG) tubes. A comprehensive clinical review. J Gastrointestin Liver Dis. 2007;16(4):407-18. [PubMed]
  25. Patel PH, Willis M. Thomas, E. Percutaneous endoscopic gastrostomy tube deterioration: how common is the problem?. The American Journal of Gastroenterology, 1987;82(8):806-806. [Link]
  26. Cave DR, Robinson WR, Brotschi EA. Necrotizing fasciitis following percutaneous endoscopic gastrostomy. Gastrointest Endosc 1986;32:294. [Crossref]  [PubMed]
  27. Hucl T, Spicak J. Complications of percutaneous endoscopic gastrostomy. Best Pract Res Clin Gastroenterol 2016;30:769. [Crossref]  [PubMed]
  28. Kahveci G, Dağcı S, Atalay R. Perkütan endoskopik gastrostomide hipergranülasyon dokusu bakımına farklı bir bakış: Olgu sunumu ve literatürün gözden geçirilmesi. Endoskopi Gastrointestinal. 2019;27(2):65-67. [Crossref]
  29. Martindale R, Witte M, Hodges G, Kelley J, Harris S, Andersen C. Necrotizing fasciitis as a complication of percutaneous endoscopic gastrostomy. JPEN J Parenter Enteral Nutr. 1987;11(6):583-5. [Crossref]  [PubMed]
  30. Venu RP, Brown RD, Pastika BJ, Erikson LW Jr. The buriedbumper syndrome: a simple management approach in two patients. Gastrointest Endosc. 2002;56:582. [Crossref]  [PubMed]
  31. Berger SA, Zarling EJ. Colocutaneous fistula following migration of PEG tube. Gastrointest Endosc 1991;37:86. [Crossref]  [PubMed]
  32. Denning NL, Abd El-Shafy I, Hagen J, Stylianos S, Prince JM, Lipskar AM. Outpatient curettage and electrocautery as an alternative to primary surgical closure for pediatric gastrocutaneous fistulae. J Surg Res. 2018;229:96-101. [Crossref]  [PubMed]
  33. Hameed H, Kalim S, Khan YI. Closure of a nonhealing gastrocutanous fistula using argon plasma coagulation and endoscopic hemoclips. Can J Gastroenterol 2009; 23:217. [Crossref]  [PubMed]  [PMC]
  34. Hosseini M, Lee JG. Metastatic esophageal cancer leading to gastric perforation after repeat PEG placement. Am J Gastroenterol. 1999;94(9):2556-8. [Crossref]  [PubMed]
  35. Alagaratnam TT, Ong GB. Wound implantation--A surgical hazard. Br J Surg. 1977;64(12):872-5. [Crossref]  [PubMed]
  36. Seres D, Parsons PE, Lipman TO, Finlay G. Nutrition support in critically ill patients: An overview. UpToDate. 2014. [Link]
  37. McClave SA, DiBaise JK, Mullin EG, Martindale RG. ACG clinical guideline. Nutrition therapy in the adult. Am J Gastroenterol. 2016;111(3):315-34. [Crossref]  [PubMed]
  38. Heyland DK, Patel J, Compher C, Rice TW, Bear DE, Lee ZY, et al. EFFORT Protein Trial team. The effect of higher protein dosing in critically ill patients with high nutritional risk (EFFORT Protein): an international, multicentre, pragmatic, registry-based randomised trial. Lancet. 2023:18;401(10376):568-576. [Crossref]  [PubMed]
  39. Kahveci G, Çelik S. Perkütan endoskopik gastrostomi tüpü ile beslenen hastanın hazırlığı, takibi ve taburculuk eğitimi. Yoğun Bakım Hemşireliği Dergisi, 2020:24(1);22-31. [Link]
  40. Sobotka L. ed. Klinik nütrisyon temelleri. Çev. ed. Gündoğdu RH. Ankara: Bayt Yayın; 2017: 314-6. [Link]
  41. Friginal-Ruiz AB, Lucendo A. Percutaneous endoscopic gastrostomy. A Practical overview on ıts ındications, placement conditions, management, and nursing care. Gastroenterology Nursing. 2015;38(5):354-68. [Crossref]  [PubMed]
  42. Kahveci G, Dağcı S, Atalay R, et al. A rare complication of percutaneous endoscopic gastrostomy: Necrotizing fasciitis. Endoscopy Gastrointestinal 2020;28:31-34. [Crossref]
  43. Azar AR, Rahnemaiazar AA, Naghshizadian R, Kurtz A, Farkas DT. Percutaneous endoscopic gastrostomy: ındications, technique, complications and manageent. World J Gastroenterol. 2014;20(24):7739-51. [Crossref]  [PubMed]  [PMC]