Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement

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Percutaneous endoscopic gastrostomy (PEG), first described by Gauderer in 1980, ^[1] is a method of placing a tube into the stomach percutaneously, aided by endoscopy. PEG tube placement is one of the most commonly performed endoscopic procedures, and an estimated 100,000-125,000 are performed annually in the United States. ^{[2, 3, 4, 5, 6]}

Variations of the technique include the pull (Ponsky), push (Sachs-Vine), introducer (Russell), and Versa (T-fastener) methods. Bronchoscope-guided PEG tube placement has also been described. ^[7] Of these, the pull method is the most commonly used and is described in this article. 

Broadly, the two main indications for PEG tube placement are as follows:

Patients who are unable to move food from their mouth to their stomach are the ones who commonly need PEG tube placement. This includes those with neurologic disorders such as stroke, cerebral palsy, brain injury, amyotrophic lateral sclerosis, ^[8] and impaired swallowing. ^[9]  In addition, patients who have trauma, cancer, or recent surgery of the upper gastrointestinal (GI) tract or the respiratory tract may require this procedure to maintain nutritional intake.

Gut decompression may be needed in patients who have abdominal malignancies causing gastric outlet or small-bowel obstruction or ileus.

In pediatric patients, some studies have found that laparoscopy-assisted gastrostomy is associated with a lower risk of major complications than PEG is. ^{[10, 11]}

Absolute contraindications for PEG tube placement include the following:

Relative contraindications for PEG tube placement include the following:

Opinions have varied as to whether placement of a ventriculoperitoneal shunt (VPS) constitutes a contraindication for PEG. A systematic review by Oterdoom et al concluded that placement of a VPS in conjunction with a PEG tube was associated with a high but acceptable shunt complication rate and that shunt insertion therefore should not be considered a contraindication for PEG. ^[12] They suggested that the PEG tube should be placed after the VPS but did not conclusively establish an optimal interval.

Although PEG is a relatively safe procedure, acute and chronic complications have been reported, including early mortality. Pih et al conducted a single-center study aimed at determining risk factors associated with complications and 30-day mortality after pull-type (n = 139) and introducer-type (n = 262) PEG. ^[13] Early mortality was significantly higher in patients with platelet counts lower than 100,000/μL or C-reactive protein (CRP) levels of 5 mg/dL or higher, and it was lower in patients with neurologic disease (eg, dementia, Parkinson disase, neuromuscular disease, or hypoxic brain damage).

A study comparing the outcomes of pull PEG (n = 264) with those of push PEG (n = 59) in acute care settings found that overall complication rates for the two approaches were comparable (20% and 22%, respectively), as were tube dislodgment rates (12% and 9%, respectively); however, the incidence of tube dislodgment associated with major complications was greater for pull PEG (6% vs 2%), though not to a statistically significant degree. ^[14] ​

Gauderer MW, Ponsky JL, Izant RJ Jr. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg. 1980 Dec. 15 (6):872-5. [Medline].

Duszak R Jr, Mabry MR. National trends in gastrointestinal access procedures: an analysis of Medicare services provided by radiologists and other specialists. J Vasc Interv Radiol. 2003 Aug. 14 (8):1031-6. [Medline].

Yarmus L, Gilbert C, Lechtzin N, Imad M, Ernst A, Feller-Kopman D. Safety and feasibility of interventional pulmonologists performing bedside percutaneous endoscopic gastrostomy tube placement. Chest. 2013 Aug. 144 (2):436-40. [Medline].

Vanis N, Saray A, Gornjakovic S, Mesihovic R. Percutaneous endoscopic gastrostomy (PEG): retrospective analysis of a 7-year clinical experience. Acta Inform Med. 2012 Dec. 20 (4):235-7. [Medline]. [Full Text].

Lohsiriwat V. Percutaneous endoscopic gastrostomy tube replacement: A simple procedure?. World J Gastrointest Endosc. 2013 Jan 16. 5 (1):14-8. [Medline]. [Full Text].

Rahnemai-Azar AA, Rahnemaiazar AA, Naghshizadian R, Kurtz A, Farkas DT. Percutaneous endoscopic gastrostomy: indications, technique, complications and management. World J Gastroenterol. 2014 Jun 28. 20 (24):7739-51. [Medline]. [Full Text].

Folch E, Kheir F, Mahajan A, Alape D, Ibrahim O, Shostak E, et al. Bronchoscope-Guided Percutaneous Endoscopic Gastrostomy Tube Placement by Interventional Pulmonologists: A Feasibility and Safety Study. J Intensive Care Med. 2018 Sep 24. 885066618800275. [Medline].

Kak M, Issa NP, Roos RP, Sweitzer BJ, Gottlieb O, Guralnick A, et al. Gastrostomy tube placement is safe in advanced amyotrophic lateral sclerosis. Neurol Res. 2017 Jan. 39 (1):16-22. [Medline].

Gomes CA Jr, Andriolo RB, Bennett C, Lustosa SA, Matos D, Waisberg DR, et al. Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances. Cochrane Database Syst Rev. 2015 May 22. CD008096. [Medline].

Baker L, Beres AL, Baird R. A systematic review and meta-analysis of gastrostomy insertion techniques in children. J Pediatr Surg. 2015 May. 50 (5):718-25. [Medline].

Sandberg F, Viktorsdóttir MB, Salö M, Stenström P, Arnbjörnsson E. Comparison of major complications in children after laparoscopy-assisted gastrostomy and percutaneous endoscopic gastrostomy placement: a meta-analysis. Pediatr Surg Int. 2018 Dec. 34 (12):1321-1327. [Medline].

Oterdoom LH, Marinus Oterdoom DL, Ket JCF, van Dijk JMC, Scholten P. Systematic review of ventricular peritoneal shunt and percutaneous endoscopic gastrostomy: a safe combination. J Neurosurg. 2017 Oct. 127 (4):899-904. [Medline].

Pih GY, Na HK, Ahn JY, Jung KW, Kim DH, Lee JH, et al. Risk factors for complications and mortality of percutaneous endoscopic gastrostomy insertion. BMC Gastroenterol. 2018 Jun 28. 18 (1):101. [Medline]. [Full Text].

Kulvatunyou N, Zimmerman SA, Sadoun M, Joseph BA, Friese RS, Gries LM, et al. Comparing Outcomes Between “Pull” Versus “Push” Percutaneous Endoscopic Gastrostomy in Acute Care Surgery: Under-Reported Pull Percutaneous Endoscopic Gastrostomy Incidence of Tube Dislodgement. J Surg Res. 2018 Dec. 232:56-62. [Medline].

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 Mar 15. 25 (6):647-56. [Medline].

Bechtold ML, Matteson ML, Choudhary A, Puli SR, Jiang PP, Roy PK. Early versus delayed feeding after placement of a percutaneous endoscopic gastrostomy: a meta-analysis. Am J Gastroenterol. 2008 Nov. 103 (11):2919-24. [Medline].

Choudhry U, Barde CJ, Markert R, Gopalswamy N. Percutaneous endoscopic gastrostomy: a randomized prospective comparison of early and delayed feeding. Gastrointest Endosc. 1996 Aug. 44 (2):164-7. [Medline].

Sharma VK, Howden CW. Meta-analysis of randomized, controlled trials of antibiotic prophylaxis before percutaneous endoscopic gastrostomy. Am J Gastroenterol. 2000 Nov. 95 (11):3133-6. [Medline].

Gaurav Arora, MD, MS Assistant Professor of Internal Medicine, Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center at Dallas, Southwestern Medical School

Gaurav Arora, MD, MS is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, American Association of Physicians of Indian Origin

Disclosure: Nothing to disclose.

Frank J Lukens, MD Assistant Professor of Medicine, Program Director of GI Fellowship Program, Director of Endoscopy and Endoscopic Training, Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The University of Texas Health Science Center at Houston Medical School

Frank J Lukens, MD is a member of the following medical societies: American Society for Gastrointestinal Endoscopy, Texas Medical Association

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Laurie Scudder, DNP, NP Nurse Planner, Medscape; Senior Clinical Professor of Nursing, George Washington University

Disclosure: Nothing to disclose.

Danny A Sherwinter, MD Attending Surgeon, Department of Mimially Invasive Surgery and Bariatrics, Associate Program Director, Department of Surgery, Maimonides Medical Center; Director of Minimally Invasive and Bariatric Surgery, American Society for Metabolic and Bariatric Surgery (ASMBS) Center of Excellence

Danny A Sherwinter, MD is a member of the following medical societies: American College of Surgeons, American Society for Metabolic and Bariatric Surgery, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Andrew J Duffy, MD, FACS Assistant Professor of Surgery, Section of Gastrointestinal Surgery, Associate Program Director of the Surgical Residency Program, Director of the Yale Surgical Skills and Simulation Center, Department of Surgery, Yale School of Medicine; Attending Surgeon, Yale-New Haven Hospital

Andrew J Duffy, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, Phi Beta Kappa, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement

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