Gastrostomy tubes: Placement and routine care
- Mark H DeLegge, MD, FACG, AGAF
Mark H DeLegge, MD, FACG, AGAF
- Professor of Medicine
- Medical University of South Carolina
- Section Editors
- John R Saltzman, MD, FACP, FACG, FASGE, AGAF
John R Saltzman, MD, FACP, FACG, FASGE, AGAF
- Section Editor — Therapeutic and Diagnostic Endoscopy
- Professor of Medicine
- Harvard Medical School
- Timothy O Lipman, MD
Timothy O Lipman, MD
- Section Editor — Nutrition
- GI-Hepatology-Nutrition Section
- Washington DC Veterans Affairs Medical Center
Gastrostomy tubes may be placed endoscopically, surgically, or radiologically.
This topic will review the placement and routine care of gastrostomy tubes, including management of dysfunctioning gastrostomy tubes, with a focus on percutaneous endoscopic gastrostomy tubes. The indications for gastrostomy tube placement and complications associated with gastrostomy tubes are discussed separately. (See "Gastrostomy tubes: Uses, patient selection, and efficacy in adults" and "Gastrostomy tubes: Complications and their management".)
Options for gastrostomy tube placement — Gastrostomy tubes may be placed endoscopically, surgically, or by radiologically. The choice of procedure will depend on local resources and expertise, anatomic considerations that may affect the ability to place the tube endoscopically or radiologically (eg, inability to endoscopically identify an appropriate placement site because of prior surgery or obesity), and whether the patient is undergoing surgery for other reasons .
Studies comparing surgical gastrostomy with percutaneous endoscopic gastrostomy (PEG) have shown no difference in morbidity or mortality . However, PEG is less expensive and saves time. Thus, surgical gastrostomy is typically reserved for patients who are already going to the operating room for another surgical procedure. Surgical gastrostomy may also be considered for patients in whom a gastrostomy tube cannot be placed either endoscopically or radiologically. Reasons a gastrostomy tube may not be able to be placed endoscopically or radiologically include esophageal obstruction (because placement requires passage of the tube through the esophagus) or the presence of an anatomic aberration that prevents a safe percutaneous approach for PEG tube placement (eg, colonic interposition between the stomach and the abdominal wall).
Whether there is a difference in morbidity and mortality between endoscopic and radiologic gastrostomy tube placement is not clear [3-8].
- Vogt W, Messmann H, Lock G, et al. CT-guided PEG in patients with unsuccessful endoscopic transillumination. Gastrointest Endosc 1996; 43:138.
- Stiegmann GV, Goff JS, Silas D, et al. Endoscopic versus operative gastrostomy: final results of a prospective randomized trial. Gastrointest Endosc 1990; 36:1.
- Laskaratos FM, Walker M, Walker M, et al. Predictive factors for early mortality after percutaneous endoscopic and radiologically-inserted gastrostomy. Dig Dis Sci 2013; 58:3558.
- Galaski A, Peng WW, Ellis M, et al. Gastrostomy tube placement by radiological versus endoscopic methods in an acute care setting: a retrospective review of frequency, indications, complications and outcomes. Can J Gastroenterol 2009; 23:109.
- Cosentini EP, Sautner T, Gnant M, et al. Outcomes of surgical, percutaneous endoscopic, and percutaneous radiologic gastrostomies. Arch Surg 1998; 133:1076.
- Neeff M, Crowder VL, McIvor NP, et al. Comparison of the use of endoscopic and radiologic gastrostomy in a single head and neck cancer unit. ANZ J Surg 2003; 73:590.
- Desport JC, Mabrouk T, Bouillet P, et al. Complications and survival following radiologically and endoscopically-guided gastrostomy in patients with amyotrophic lateral sclerosis. Amyotroph Lateral Scler Other Motor Neuron Disord 2005; 6:88.
- Wollman B, D'Agostino HB. Percutaneous radiologic and endoscopic gastrostomy: a 3-year institutional analysis of procedure performance. AJR Am J Roentgenol 1997; 169:1551.
- Ohno T, Ogawa A, Yanai M, et al. The usefulness and safety of the introducer technique using a bumper-button-type device as compared with the pull method for percutaneous endoscopic gastrostomy. Surg Laparosc Endosc Percutan Tech 2015; 25:e1.
- Given MF, Hanson JJ, Lee MJ. Interventional radiology techniques for provision of enteral feeding. Cardiovasc Intervent Radiol 2005; 28:692.
- Sedlack RE, Pochron NL, Baron TH. Percutaneous endoscopic gastrostomy placement without skin incision: results of a randomized trial. JPEN J Parenter Enteral Nutr 2006; 30:240.
- Foutch PG, Talbert GA, Waring JP, Sanowski RA. Percutaneous endoscopic gastrostomy in patients with prior abdominal surgery: virtues of the safe tract. Am J Gastroenterol 1988; 83:147.
- Bender JS. Percutaneous endoscopic gastrostomy placement in the morbidly obese. Gastrointest Endosc 1992; 38:97.
- Karhadkar AS, Naini P, Dutta SK. PEG-tube placement in a patient with extreme obesity: overcoming the technical challenges. Gastrointest Endosc 2007; 65:731.
- Bochicchio GV, Guzzo JL, Scalea TM. Percutaneous endoscopic gastrostomy in the supermorbidly obese patient. JSLS 2006; 10:409.
- Shaheen NJ, Crosby MA, Grimm IS, Isaacs K. The use of percutaneous endoscopic gastrostomy in pregnancy. Gastrointest Endosc 1997; 46:564.
- Kynci JA, Chodash HB, Tsang TK. PEG in a patient with ascites and varices. Gastrointest Endosc 1995; 42:100.
- Bechtold ML, Matteson ML, Choudhary A, et al. Early versus delayed feeding after placement of a percutaneous endoscopic gastrostomy: a meta-analysis. Am J Gastroenterol 2008; 103:2919.
- Siddiqui MM, Griffiths MD. Revision of long-term gastrostomy. J Pediatr Gastroenterol Nutr 2012; 55:559.
- Tanaka H, Arai K, Fujino A, et al. Treatment for hypergranulation at gastrostomy sites with sprinkling salt in paediatric patients. J Wound Care 2013; 22:17.
- Metheny N, Eisenberg P, McSweeney M. Effect of feeding tube properties and three irrigants on clogging rates. Nurs Res 1988; 37:165.
- Sriram K, Jayanthi V, Lakshmi RG, George VS. Prophylactic locking of enteral feeding tubes with pancreatic enzymes. JPEN J Parenter Enteral Nutr 1997; 21:353.
- McClave SA, Neff RL. Care and long-term maintenance of percutaneous endoscopic gastrostomy tubes. JPEN J Parenter Enteral Nutr 2006; 30:S27.
- Iber FL, Livak A, Patel M. Importance of fungus colonization in failure of silicone rubber percutaneous gastrostomy tubes (PEGs). Dig Dis Sci 1996; 41:226.
- Blacka J, Donoghue J, Sutherland M, et al. Dwell time and functional failure in percutaneous endoscopic gastrostomy tubes: a prospective randomized-controlled comparison between silicon polymer and polyurethane percutaneous endoscopic gastrostomy tubes. Aliment Pharmacol Ther 2004; 20:875.
- DeLegge RL, DeLegge MH. Percutaneous endoscopic gastrostomy evaluation of device materials: are we "failsafe"? Nutr Clin Pract 2005; 20:613.
- TECHNICAL CONSIDERATIONS
- Options for gastrostomy tube placement
- Techniques for gastrostomy tube placement
- - Endoscopic placement
- - Radiologic placement
- - Surgical placement
- Proper placement of the external bolster
- Special settings
- - Gastric varices
- - Prior abdominal surgery
- - Obesity
- - Pregnancy
- - Ascites
- TYPES OF GASTROSTOMY TUBES
- Endoscopically- and radiologically-placed tubes
- Surgically-placed tubes
- Replacement tubes
- INITIATION OF TUBE FEEDS
- GASTROSTOMY TUBE CARE
- Routine care
- Gastrostomy tube removal
- Managing dysfunctioning gastrostomy tubes
- - Clogging
- - Tube deterioration
- - Early balloon deflation
- Managing complications of tube feeds
- SUMMARY AND RECOMMENDATIONS