The term percutaneous endoscopic gastrostomy clarifies the details of the method of insertion of this

particular type of feeding tube. Percutaneous is a synonym for transdermal., meaning “through the skin.”
An endoscope is a long, slender optical instrument containing a light source and a camera and used to
examine areas deep within the human body. Gastrostomy refers to an opening into the stomach through
the abdominal wall.

Percutaneous endoscopic gastrostomy is a type of feeding tube insertion that is done when the patient is
not expected to be able to take food by mouth for quite some time. Unlike some of the other feeding tube
insertions, percutaneous endoscopicgastrostomy can be done on an outpatient basis. It can be performed
by physicians with a variety of specialties.

PEG Feeding Tubes - Indications and Management

Percutaneous endoscopic gastrostomy (PEG) feeding tubes were first described in1980. Early studies
typically demonstrated it to be an easy and safe technique when compared with the available
alternatives such as open gastrostomy.1 PEG feeding tubes are increasingly used for long term enteral
nutrition. It is used where patients cannot maintain adequate nutrition with oral intake.

Neurological conditions are most commonly associated with such disability and constitute the most
common indication for PEG. Its simplicity has led some to concern about use when there is little or no
clinical benefit.2,3

Care needs to be taken when looking at studies on use of PEG as there are differences in patient
selection which affect for example outcome measures and complications. There are sometimes ethical
factors to consider (see below).4 Several court cases have considered use of PEG feeding in patients
who have lost the capacity for self determination.
Indications
It is important that patients are selected carefully for PEG.2 Indications include difficulties with oral
intake often where obstruction to the upper airway or gastrointestinal tract makes passing
a nasogastrictube difficult. PEG tubes are used in:
• Head and neck cancers. PEG has become the most acceptable and safest method for
long term feeding support.5,6 It is useful particularly when surgery is extensive and when
combined with chemotherapy, radiotherapy or both.6
• Malignant bowel obstruction7 including oesophageal cancer8
• Neurological conditions are the most common indications for PEG and include:
o Stroke (usually the most common indication for PEG and often vertebrobasilar
strokes)2
o Disorders of swallowing
o Multiple sclerosis
o Neurosurgical disease
o Parkinson's disease
o Brain tumours
o HIV encephalopathy
o Neonatal encephalopathy
o Amyotrophic lateral sclerosis9
o Dementia (in which use is common but controversial)
o Head injury patients
• AIDS and HIV encephalopathy (improves nutritional status but not survival10)
 • Crohn's disease11
• Burns patients12
Contraindications and patient selection
PEG insertion is safest with careful patient selection. PEG insertion should be avoided in:13
• Acutely ill patients14
• Patients with short life expectancy
• Patients with severe coughing
PEG insertion method
PEG insertion:

• Can be done as an outpatient procedure

• Takes on average less than 20 minutes
• Requires sedation and upper GI endoscopy
• Can be with either 'push' or 'pull' insertion
• 'Pull' insertion more usual15 and best given with antibiotic prophylaxis16
• PEG tubes are made of polyurethane or silicone with a retaining mechanism
• For feeding longer than 1 month a silicone button (flush with the skin) is used
• Retained usually with intragastric balloon
• Can be done by suitably trained and supervised nurse practitioners17
• Antibiotic prophylaxis now usually recommended18,19,20
Alternatives to PEG for gastrostomy insertion
There are alternative methods of gastrostomy tube insertion to PEG. They are:

• Laparoscopic insertion
• Open surgical technique
• Percutaneous radiologically guided gastrostomy (PRG) insertion
There are reports over the years since introduction of PEG in the 1980s with often inconclusive
results.21
• A small study from Ireland and one from London favour PRG in patients with
amyotrophic lateral sclerosis as it avoids the need for sedation or endoscopy.22,23
• One meta-analysis suggested a higher success rate with PRG than with PEG, and less
morbidity than either PEG or surgery.24 However a more recent comparison of a relatively small
number of endoscopic, surgical and laparoscopic placement favoured PEG25 and another
favoured PEG over PRG.26
• A literature review suggested PEG as the procedure of choice for placement of
gastrostomy tubes.27
• A recent prospective randomised trial favoured PEG over surgical gastrostomy
insertion.28
• There is some evidence that polyurethane PEGs are less troublesome than silicone PEGs
(less tube deterioration, less blockage).29
• PEG is preferred in trauma patients.30
• Antibiotic prophylaxis for PEG insertion appears to reduce the incidence of wound
infection.19,20
• Laparoscopic insertion was considered preferable to PEG by one study in children with
PEG insertion having higher complication rate in children and often requiring repeat
anaesthetics.31 An earlier study in children showed similar results for surgical, PRG and PEG
insertion but did not look at the laparoscopic technique.32 A recent study from Norway found
PEG insertion safe and very well tolerated by children and parents but made no comparison
with other techniques.33
Benefits of PEG feeding
Benefits reported include:
 • Well tolerated (better than nasogastric tubes)
• Improved nutritional status
• Ease of usage over other methods (nasogastric or oral feeding) reported by carers
• Satisfactory use by home carers34
• Low incidence of complications
• Reduction in aspiration pneumonia associated with swallowing disorders35
• Cost effective relative to alternative methods particularly when reasonably long
survival expected36
Management after insertion
• Education of carers and patients is essential to reduce tube problems and
complications.37
• A number of studies indicate the support and education of patients should be
multidisciplinary involving:
o Nurses (wound care and ostomy expertise).
o Dietitians (nutritional advice and support).
• Ongoing care involves:
o Inspection and maintainance of the access device (see below).
o Wound care advice.
o Nutritional support and advice.

Care of PEG tube

This routine care can be performed by the patient and/or the carers with suitable training. After about
10 days following insertion asepsis is not required.

• Examine skin around site for infection/ irritation.

• Note measuring guide number at end of external fixation device.
• Remove tube from fixation device and ease away from abdomen.
• Clean stoma site with sterile saline.
• Dry area with gauze.
• Rotate gastrostomy tube to prevent adherence to sides of track.
• Re-attach external fixation device to abdomen.
• Attach gastrostomy tube gently to fixation device and position as before according to
mark/number on tube.
• Avoid use of bulky dressings.
Complications
Morbidity and mortality are generally considered to be low with studies reporting major complications
between 3% and 8% of patients and minor in around 14%.13,38 Mortality from the procedure itself is very
low and less than 1%.39 However other studies report higher and rising complication rates.3 These often
relate to the underlying illnesses with for example higher rates of wound infections in malignant
disease and may also reflect a lowered threshold for PEG insertion.3

Major complications
• Gastric perforation
• Gastrocolic fistula
• Internal leakage30
• Dehiscence30
• Peritonitis30
• Aspiration pneumonia
• Subcutaneous abscess
• Buried bumper syndrome (migration of the internal bumper of the PEG tube into the
gastric or abdominal wall).
Minor complications
• Tube problems:
o Tube blockages
o Tube dislodgements
o Tube degradation
o External leakage
o Unplanned removal30
• Site infections (common but rarely serious10)
Ethical dilemmas
The incidence of dementia is increasing and maintaining nutritional status can become difficult and
expensive as the disease progresses. Patients with dementia often receive feeding tubes when
hospitalised for acute illnesses contrary to their wishes and those of their families. Research indicates
that there is little benefit from aggressive nutritional support with no measurable improvements in life
expectancy, weight or reduction in complications (for example pressure sores and aspiration).40 PEG
tubes are often used inappropriately because of unrealistic and inaccurate expectations of what they
can achieve.41 Feeding tubes have been too often inserted in patients who will not benefit from them
and whose quality of life in a terminal stage of illness will be adversely affected. Multidisciplinary care
and educational programmes have been found to reduce the numbers of patients receiving feeding
tubes inappropriately.42 Some hospitals now have nutrition teams and PEG requests are reviewed by this
team and a consultant to assess whether PEG insertion is appropriate. The use of advance directives
has also been suggested to allow patients with dementia to refuse insertion of a feeding tube in
advance of the dementia progressing.40
Prognosis
There have been few long term follow up studies. One in 199738 showed 49% died and 17% returned to
oral feeding from a population which included roughly half the patients with a diagnosis of cancer and
half with a non-cancer diagnosis. Clearly the overall mortality rate after PEG insertion is high because
of the underlying medical problems.39 A five year prospective study showed few complications from the
procedure itself and improved nutritional status.3

What is percutaneous endoscopic gastrostomy (PEG)?

Percutaneous endoscopic gastrostomy (PEG) is a surgical procedure for placing a tube for feeding without having to
perform an open operation on the abdomen (laparotomy). It is used in patients who will be unable to take in food by
mouth for a prolonged period of time. A gastrostomy, or surgical opening into the stomach, is made through the skin
using an a flexible, lighted instrument (endoscope) passed orally into the stomach to assist with the placement of the
tube and secure it in place.

What is the purpose of percutaneous endoscopic gastronomy?

The purpose of a percutaneous endoscopic gastronomy is to feed those patients who cannot swallow food.
Irrespective of the age of the patient or their medical condition, the purpose of percutaneous endoscopic gastronomy
is to provide fluids and nutritiondirectly into the stomach.
Who does percutaneous endoscopic gastronomy?

Percutaneous endoscopic gastronomy is done by a physician. The physician may be a general surgeon,
an otolaryngologist (ENT specialist), radiologist, or agastroenterologist (gastrointestinal specialist).

Where is percutaneous endoscopic gastronomy done?

PEG is performed in a hospital or outpatient surgical facility. It is not necessary to perform a percutaneous
endoscopic gastronomy in an operating room.

Local anesthesia (usually lidocaine or another spray) is used to anesthetize the throat. An endoscope (a flexible tube
with a camera and a light on the end) is passed through the mouth, throat and esophagusinto the stomach. The
physician then makes a small incision (cut) in the skin of the abdomen over the stomach and pushes a needle
through the skin and into the stomach. The tube for feeding then is pushed through the needle and into the stomach.
The tube then is sutured (tied) in place to the skin.

When can the percutaneous endoscopic gastronomy patient go home?

The patient usually can go home the same day or the next morning.

What are the possible complications with percutaneous endoscopic gastronomy?

Possible complications include infection of the puncture site (as in any kind of surgery,) dislodgement of the tube with
leakage of the liquid diet that is fed through the tube into the abdomen, and clogging of the tube.

What are the advantages of percutaneous endoscopic gastronomy?

Percutaneous endoscopic gastronomy takes less time, carries less risk and costs less than a surgical gastrostomy
which requires opening the abdomen. Percutaneous endoscopic gastronomy is a commonly-performed so there are
many physicians with experience in performing the procedure. When feasible, percutaneous endoscopic gastronomy
is preferable to a surgical gastrostomy.

Percutaneous Endoscopic Gastrostomy At A Glance

• Percutaneous endoscopic gastronomy is a procedure that allows nutritional support for patients who cannot
take food orally. Percutaneous endoscopic gastronomy involves placement of a tube through the abdominal wall
and into the stomach through which nutritional liquids can be infused.

• Percutaneous endoscopic gastronomy is a surgical procedure; however, it does not require opening the
abdomen or an operating room. Percutaneous endoscopic gastronomy also does not require general anesthesia.

• Complications of percutaneous endoscopic gastronomy include infection, leakage of nutritional liquids that
are infused and clogging of the tube.

• Percutaneous endoscopic gastronomy is preferable to surgical gastrostomy

Percutaneous endoscopic gastrostomy (PEG) is a surgical procedure used on patients' who have difficulty
swallowing. Percutaneous endoscopic gastrostomy (PEG) is generally performed in an outpatient facility or hospital.
Possible complications with percutaneous endoscopic gastrostomy (PEG) include infection, or leakage of the liquid
diet fed through the tube.

Patient description and indications for PEG

181 cases of PEG were inserted between January 1995

and April 2000. 174 cases were successfully followed up

and reviewed; there was loss of follow up for the

remaining seven patients due to loss of contacts or

irretrievable casenotes. These patients were followed

up for a median duration of 283 (range 2 to 1,740 days).

The median age was 70.5 (range 24 to 93) years old

and there were 111 males. Cerebrovascular diseases

accounted for more than half of the cases (105 patients,

60.4%). Of these patients, 74 patients had either

multi-infarct dementia or stroke which occurred

more than one month before PEG. Parkinson’s disease

and other neuromuscular disorders (motor neurone

disease, Wilson’s disease, Guillain Barre’s syndrome)

accounted for another 10% of patients. Patients with

nasopharyngeal carcinoma contributed to 21.3% of the

cases. Other malignancies were oesophageal carcinoma

(three patients) and tongue carcinoma (three patients).

Table I. Baseline Clinical Characteristeristics.

Clinical charateristics

Median Age (Range) in years 70.5 (24 to 93)

Cerebrovascular dis. 72.4

Parkinson’s dis. 78.8

Neuromuscular disorders 58.3

Nasopharyngeal carcinoma 56.9

Other malignancies 69.3

Head Injury 55.6

Sex, Male : Female 111 : 63

Race, Chinese : Malay : Indian : Others 151 : 9 : 8 : 6

Indications for PEG, number (%)

Cerebrovascular dis. 105 (60.4)

Parkinson’s dis. 8 (4.6)

Neuromuscular disorders 11 (6.3)

Nasopharyngeal carcinoma 37 (21.3)

Other malignancies 6 (3.4)

Head Injury 7 (4.0)

Co-morbidities, number (%)

Ischaemic heart dis. 54 (31)

Diabetes mellitus 34 (19)

Hypertension 60 (34.8)

COLD 2 (1.2)

Aspiration pneumonia 36 (20.7)

Anti-platelets agents, number (%)

Aspirin 64 (36.8)

Ticlopidine 4 (2.3)

Antibiotic prophylaxis

Ciprofloxacin and cloxacillin 141

Others 33Singapore Med J 2001 Vol 42(10) : 462

There was a high prevalence of co-morbidities such as

ischaemic heart disease, hypertension and diabetes

mellitus (see Table I). About 20% of patients had

suffered from aspiration pneumonia before the insertion

of PEG. Over a third of the patients were on aspirin at

the time of insertion.

1. What is a PEG?

A percutaneous endoscopic gastrostomy (PEG) is a procedure for placing a feeding

tube directly into the

stomach through a small incision in the abdominal wall using an instrument known
as an endoscope.

The procedure is performed as a means of providing nutrition to patients who

cannot take food by

mouth. Many stroke patients, for example, have poor control over their swallowing
muscles and are

unable to safely consume enough food, or they have muscle weakness that allows
food to leak into the

lungs when they swallow things by mouth. Many of these patients will benefit from
a PEG tube in order

to receive adequate nutrition and to prevent them from respiratory problems that
develop when food or

fluids accidentally get into the lungs.

2. What Are the Medical Indications for a PEG?

A PEG should be considered for pediatric and adult patients who are unable to
consume sufficient food

by mouth to meet their daily needs. These patients should be able to digest and
absorb their food once it

arrives in the stomach. The most common medical conditions requiring a PEG
feeding tube are

neurologic conditions associated with poor swallowing, such as experienced by

stroke patients, and
patients with cancers of the oral cavity or esophagus that prevent them from
swallowing. Other diseases

of the esophagus that decrease a patient’s ability to swallow are also common
indications for placing a

PEG feeding tube. Patients with Alzheimer’s disease often lose their ability to
swallow near the end of

their life expectancy. The benefit of PEG tube placement in this patient group
remains questionable.

When a patient is being considered for PEG tube placement, the patient’s life
expectancy after the tube

is placed needs to be considered to determine if placement of a feeding tube is

appropriate.

Indications

Head and Neck Cancer

More than 40,000 new cases of head and neck cancer are reported in the United States each year, with
more than 11,000 deaths occurring annually.[65] Malnutrition is common in this patient population and may
be multifactorial in origin, being due to prior alcohol and/or tobacco use, dysphagia from the tumor, or
treatment-related decreases in appetite and swallowing function.[65] Severe weight loss is seen in more
than half of patients with head and neck cancer undergoing chemoradiation without concurrent nutritional
support.[66,67] Weight loss and malnutrition cause interruptions in treatment, worsen local tumor control, and
are predictors of decreased survival.[68,69]

Pre-treatment placement of a PEG tube has been shown to be effective in reducing weight loss,
hospitalizations for dehydration, and treatment interruptions in these patients.[67,70] A substantial number of
patients require long-term feeding; 1 study reported a median duration of enteral feeding of 7 months.[71] A
significant number of these patients eventually regain the ability to consume oral intake, although
approximately 10% remain dependant on enteral nutrition.[72,73] PEG has been shown to contribute to
improved quality of life in those patients who remain dependent on enteral feedings.[74] Current practice
includes pre-treatment PEG placement in the management of patients with head and neck cancer.
[69]
However, at present, no randomized trials have evaluated the use of enteral feedings vs oral intake or
compared the various types of enteral access in this group of patients.

Stroke

Up to 16% of stroke patients have clinical or laboratory evidence of malnutrition at presentation, and
because nutritional status declines rapidly after stroke, half of all surviving patients have evidence of
malnutrition at the time of hospital discharge to a rehabilitation facility.[75,76] Indeed, 47% of these patients
have dysphagia upon admission to a rehabilitation facility.[75,76] Dysphagia is a major risk factor for
malnutrition in stroke patients.[77]Despite the high prevalence of malnutrition in these patients, nutritional
supplementation in this population is controversial.

Small, single-center studies suggest that malnutrition is associated with poor outcome and an increased
risk of death, poor functional outcome, infection, pressure sores, and increased hospital lengths of stay in
stroke patients.[78] Another study showed that the level of serum albumin after stroke predicted survival,
although the study did not control for stroke severity. [79] A third study showed that malnutrition at time of
admission to a rehabilitation unit was associated with prolonged length of stay and worse functional
outcome.[80]

Despite the association between malnutrition and poor outcome in stroke patients, there are very few
trials examining nutritional supplementation in this population. One small randomized trial showed that
oral supplementation after stroke improved nutritional parameters.[81] A retrospective study showed a
decreased length of stay in patients who received early enteral nutrition after stroke.[82] Finally, a small
single-center study demonstrated decreased case fatality rates in stroke patients who received PEG
feeding rather than nasogastric tube feeding.[83]

The FOOD (Feed or Ordinary Diet) trials were 3 large multicenter prospective randomized trials designed
to answer several questions about nutritional supplementation in hospitalized stroke patients. The first
trial compared outcomes in stroke patients who were able to swallow who were randomized to either a
regular diet or a regular diet and oral supplements.[84] At 6 months, there was no difference in survival or
functional outcome between the 2 groups, although only 8% of patients were malnourished at baseline.
[84]
These findings suggest that routine nutritional supplementation is not necessary in adequately
nourished stroke patients who can swallow. The second and third FOOD trials studied dysphagic stroke
patients.[85] The second trial randomized 859 patients to either early enteral feeding via nasogastric tube or
PEG within 7 days of stroke or to avoidance of early enteral feeding (ie, no feedings for more than 7
days). There were nonstatistically significant trends toward reductions in death or poor outcome in the
early feeding group at 6 months.[85] The third trial randomized 321 stroke patients who could not tolerate
oral intake, to either PEG or nasogastric feedings. There were nonstatistically significant trends toward
increased rates of death or poor outcome in the PEG group compared with the nasogastric tube group at
6 months.[85]

Thus, early enteral feeding may be beneficial in dysphagic stroke patients, but the evidence is not
definitive. Early feeding can be accomplished with a nasogastric tube and a change to a PEG placement
only needs to be contemplated if long-term feeding is needed. However, a recent consensus statement by
the European Society of Enteral and Parenteral Nutrition endorses PEG placement in dysphagic stroke
patients without discussion of timing of feeding or type of enteral access.[86]

Dementia

PEG placement in patients with dementia continues to be a major area of controversy. Approximately 4
million individuals in the United States have dementia; this number will continue to rise as the population
ages.[87] It is estimated that Alzheimer's disease affects approximately 50% of the population older than
the age of 85.[88] Both malnutrition and dysphagia are very common in patients with dementia.
[89,90]
Dysphagia has been identified in up to half of institutionalized patients with dementia.[90] Not
surprisingly, patients with dementia constitute a large group of patients undergoing PEG. In 1995, 40,000
patients with dementia received a PEG tube placement, which comprised 30% of all PEG placements that
year.[91-93]
The decision by physicians and caregivers to place a PEG tube is often motivated by goals of providing
nutrition and hydration, reducing the risk of aspiration pneumonia, improving pressure ulcers, improving
nutritional parameters, and improving survival.[94] The evidence supporting the role of PEG in achieving
these goals, however, is scarce. PEG is also often contemplated as a strategy to facilitate transfer of the
patient from an acute care to a long-term care facility, to increase caregiver convenience, and to comply
with long-term care facility policies that patients must maintain certain nutritional parameters.[94]

Given the difficult moral and ethical issues surrounding PEG placement in patients with dementia, there
are no randomized trials comparing PEG placement with observation in this population. The majority of
data on PEG outcomes in this population comes from retrospective case series or cohort studies.

Several studies have evaluated short-term (30 day) and long-term mortality in patients undergoing PEG.
Some smaller studies exclusively comprise patients with dementia, whereas larger studies involve
patients with multiple diagnoses, including dementia. Investigators reported a 22% 30-day mortality rate in
a group of 150 patients undergoing PEG tube placement, 35% of whom had dementia.[95] Another study
evaluated 350 hospitalized patients undergoing PEG and found a 30-day mortality of 28%, which
increased to 54% in the subgroup of patients with dementia.[96] Other larger studies that involve more
heterogeneous populations report 30-day mortality rates ranging from 9% to 31%.[94]

Long-term survival rates reported in larger studies of heterogeneous cohorts of PEG patients range from
39% to 66%.[94] A 1-year mortality of 63% was reported in a study involving >81,000 hospitalized Medicare
beneficiaries who underwent PEG placement.[91] Long-term studies in dementia patients have shown
either no survival benefit or even worse outcome with PEG placement. One study found a 6-month
mortality of 44% in patients undergoing PEG, which was considerably higher than the 26% mortality
observed in the control group.[97] Another study found no difference in overall mortality between nursing
home residents with dementia undergoing PEG and comparable patients who were continued on oral
nutrition.[98] Yet another study found that among nursing home residents with chewing and swallowing
difficulty, mortality at 1-year was higher for those patients undergoing PEG placement.[99]

PEG placement has generally not been shown to improve nutritional parameters in patients with
dementia.[95,97,100] Nor has PEG placement been shown to improve pressure ulcer healing or functional
status in these patients.[94,95,100,101] There is also no evidence that PEG placement reduces the risk of
infection, and in fact some studies suggest higher rates of infections and bacteremia in patients with a
PEG tube.[101]

Although difficult to evaluate, on the basis of the available evidence, PEG placement does not seem to
improve the quality of life in patients with dementia. A questionnaire survey of caregivers found that 5
weeks after PEG placement, only 19% of caregivers thought the patients' quality of life had improved.
[102]
Tube placement has been associated with social isolation and denial of oral feeding.[94,101] PEG
placement often leads to agitation and the frequent need to restrain the patient; 1 study found use of
restraints in 71% of patients post PEG.[103]

Whether patients with dementia and decreased oral intake experience hunger and thirst has not been
evaluated. However, studies involving other groups of patients with end-stage illness suggest this is not a
major problem. A prospective study of mentally aware terminally ill patients, mainly with cancer, showed
that 62% did not experience hunger or thirst.[104] Small amounts of fluid or ice chips were very effective in
relieving hunger or thirst in patients with these symptoms.[104] Tube feeding has clearly been associated
with adverse effects in patients with dementia, including increased abdominal discomfort, nausea, and
vomiting.[105]
Current evidence suggests that PEG placement does not prolong survival, improve nutritional
parameters, or prevent complications in patients with dementia. PEG placement does not improve and
may in fact worsen the quality of life in this group of patients.

Indications

Broadly, the 2 main indications are establishing enteral access for feeding and gut decompression.

• 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 neurological disorders such
as stroke, cerebral palsy, brain injury, amyotrophic lateral sclerosis, and impaired swallowing. In
addition, patients who have trauma, cancer, or recent surgery of the upper gastrointestinal or the
respiratory tract may require this procedure to maintain nutrition intake.
• Gut decompression may be needed in patients who have abdominal malignancies causing gastric
outlet orsmall bowel obstruction or ileus.