Percutaneous endoscopic gastrostomy (PEG)

Percutaneous endoscopic gastrostomy (PEG) is a procedure wherein a thin feeding tube is inserted into a person’s stomach to deliver foods (solid and liquid) and medicines. Since this procedure bypasses the passage of food through the throat and oesophagus, PEG is recommended in individuals with swallowing problems and those at risk of swallowing food into the lungs. Although swallowing difficulty can also be prevented with an alternative procedure, whereby the food is delivered through a tube passing through your nose into the stomach, PEG tube is preferred as its management is easier and it is more comfortable, especially for people who have to use it for prolonged periods. In addition, these tubes are discreet as they can be easily hidden under clothes. Although a PEG feeding tube can last for years, it can get clogged over time. In such a case, the doctor may replace it with a new tube or close the opening in the stomach if you can swallow normally. A PEG feeding tube consists of the following parts:

• Two small discs — on the inside and outside of the opening in the stomach wall — to prevent dislodging of the tube.
• A device to fix the tube to the skin, and a clamp to close the feeding tube during the non-feeding period.
• Two openings at the end of the tube, one to administer medicines or foods and another to flush the contents of the tube.

Your doctor may recommend this surgery in any of the following conditions that may cause swallowing difficulties or complications with swallowing food:

• HIV/AIDS
• Cystic fibrosis
• Burns
• Oesophageal cancer
• Head injury
• Facial surgery
• Crohn’s disease
• Abdominal cancer
• Cancer in the head or neck
• Tracheoesophageal fistula
• Chronic renal failure
• Individuals in a prolonged coma
• Parkinson’s disease
• Multiple sclerosis
• Dementia
• Cerebral tumour
• Cerebral palsy
• Decreased consciousness
• Reduction in physical movements and thought process
• Amyotrophic lateral sclerosis
• People on intensive care

This procedure is contraindicated in the following conditions:

• Sepsis
• Peritonitis
• Severe uncorrectable coagulopathy
• Haemodynamic instability (unstable circulation when the heart is not able to pump blood properly)
• Peritoneal carcinomatosis (a type of cancer affecting the gastrointestinal tract)
• Severe gastroparesis
• Serious ascites
• Interposed organs
• If you have had a total gastrectomy (removal of the entire stomach) in the past)

You can expect the following in the days leading to the surgery:

• A language and speech therapist will assess your ability to swallow, and a dietician will determine your nutritional status.
• The doctor will perform blood tests to assess the ability of your blood to clot and to ensure that your clotting time and blood count are within the expected range. Read more: Bleeding/clotting time test
• Make sure to tell your doctor about all the medications that you currently take.
• Your doctor may recommend you to discontinue certain medicines. For example, you will be asked to stop taking aspirin, clopidogrel, and warfarin a week before the surgery.
• Inform the doctor if you have any allergy to latex or anything else or if you are pregnant.
• You will be asked to avoid eating or drinking anything for at least six hours before the scheduled time of the surgery. If you are already getting fed through a tube inside your nose, the feeding will be discontinued six hours prior to the surgery. Fasting is recommended to minimise the risk of stomach contents passing into the lungs during the procedure.
• You will need to sign a consent form before the surgery.

The procedure involves the following steps:

• You will be asked to lie on the operating table.
• A cannula (a thin plastic tube) will be inserted into your hand or arm.This will be used to give you any fluids and medicines during the surgery.
• Then, you will be taken to the endoscopy room.
• A healthcare paracitioner will attach a device to your fingers to help monitor your oxygen levels. A small tube will be inserted in your nose to deliver oxygen during the procedure.
• Then a mouthguard will be put inside your mouth and you will be asked to bite it gently. This prevents biting of the endoscope or tongue accidentally.
• You will be given a sedative injection through the cannula. It will help you relax during the procedure but will not put you to sleep.
• Secretions in your mouth and throat such as saliva will be removed using suction equipment.
• Next, the surgeon will insert an endoscope into your stomach through your mouth to find a suitable position for inserting the feeding tube. The endoscope is a long flexible tube consisting of a camera at one end. You may feel the endoscope passed down your stomach. However, this sensation does not last for long to make you feel uncomfortable.
• Once the surgeon gets the right place for insertion of the tube, you will be given local anaesthesia to numb your abdomen.
• The surgeon will make a 2 to 3 mm cut on your abdomen and insert a hollow needle through your abdominal wall into your stomach.
• He/she will pass a thread through this needle into your stomach, which is then grasped by the forceps held by the endoscope.
• Using the endoscope, the surgeon will pull the thread through your stomach outside your mouth. 
• He/she will attach the feeding tube to the thread and the pull it (from the other end outside the cut in your abdomen) through your mouth into your stomach until it comes out of your abdominal wall. 
• After this, the surgeon will fixate the tube on your abdominal wall.

This procedure is completed in 15 to 20 minutes. If the doctor feels that insertion of the endoscope is not technically possible in an individual, the feeding tube is inserted either by making a surgical opening in the abdomen or by using X-ray guidance.

Patients are usually required to stay in the hospital under observation for three nights after PEG. You may expect the following during your time at the hospital: 

• Six hours after the procedure, you will be started on a water diet, which you will continue for about 10 hours.
• If this is tolerated well, liquid diet containing all the essential nutrients will be gradually started.
• You may experience some abdominal discomfort after PEG insertion, which may subside with the introduction of feed.
• During the feeding sessions, you will be asked to sit upright at an angle of 30° to 45° to avoid heartburn and passage of food into the lungs.
• Before you are discharged, the dietician will give you instructions on how to use the feeding equipment and about your nutritional and feeding requirements.

At home, you would be asked to keep in mind the following things after a PEG:

• It is common to experience some discharge from the surgery site for the first few days after surgery. You should clean the area regularly using cooled boiled water and gently pat it dry.
• Avoid showering or bathing until the wound has healed completely, which may take up to seven to 10 days. After healing of the incision site, clean the area with warm water and gentle neutral soap.
• Your doctor will suggest you to flush the feeding tube regularly with cooled boiled water (using a special syringe) to keep it from clogging. He/she will explain to you the right way to clean the tube. 
• You will be asked to take all your medications in liquid form. Avoid adding medicines to your feed as it may result in a reaction or chemical instability. Do not administer crushed form of capsules, sustained-release and enteric-coated tablets through your feeding tube.

PEG tube insertion provides essential nutrients to individuals with swallowing difficulty. It also helps such individuals to relieve feelings of thirst and hunger. In addition, it helps the body to maintain a healthy immune system to fight infections, thus improving overall well-being.

When to see the doctor?

Contact the healthcare provider if you experience any of the following after insertion of the feeding tube:

• Diarrhoea
• Constipation
• Hard and swollen stomach after feedings
• Abnormal coughing after feedings
• Shortness of breath after feedings
• Pain that worsens over time
• Bleeding or leakage around the feeding tube
• Irritation or redness at the tube insertion site

Immediately call the healthcare provider if the feeding tube is blocked or is accidentally dislodged from its insertion site and you do not know how to replace it with a new one. The opening in the stomach closes quickly once the feeding tube is out of the insertion site. Hence, it is necessary to contact the surgeon and get a new tube inserted as soon as possible.

Although PEG is a safe surgery, it carries some risks like all other procedures. The possible complications associated with the surgery include:

• Pain at the operated site
• Infection or bleeding at the tube insertion site
• Spread of infection to other abdominal organs
• Damage to the other organs inside the abdomen resulting in bleeding and infection
• Reaction to anaesthesia
• Damage or tear in the throat 
• Passage of feed into lungs
• Blockage of the tube

A follow-up will be scheduled for 2 to 4 weeks after the surgery to check whether the PEG tube is functioning properly and if the tube insertion site is healing well.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.