Who places gastrostomy (gastrostomy tube) tubes?

Gastrostomy Tube Placement: Specialists and Techniques

Gastrostomy tubes are primarily placed by gastroenterologists, interventional radiologists, and surgeons, with the method of placement depending on patient characteristics and institutional expertise. 1

Specialists Who Place Gastrostomy Tubes

• Gastroenterologists: Most commonly place percutaneous endoscopic gastrostomy (PEG) tubes using the Ponsky ("pull") technique with endoscopic guidance 1
• Interventional Radiologists: Place tubes using fluoroscopic or ultrasound guidance, particularly beneficial for patients with:
  • Severe narrowing of the upper GI tract
  • Morbid obesity where endoscopic transillumination is difficult
  • Head and neck cancers (to avoid tumor seeding through the oral route) 1
• Surgeons:
  • General surgeons can place gastrostomy tubes surgically or endoscopically
  • Head and neck surgeons are increasingly performing PEG placement, especially for their cancer patients 2
  • Surgical placement may be done during other abdominal procedures or laparoscopically 1

Placement Techniques

1. Transoral (Endoscopic) Approach

• Most common method using the Ponsky ("pull") technique
• Procedure steps:
  • Stomach insufflation with air
  • Identification of optimal site via transillumination
  • Abdominal wall puncture with confirmation of safe track
  • Guide wire passage and tube pull-through 1

2. Transabdominal Approach

• Radiologically guided:
  • Stomach insufflation via NG tube or direct needle
  • Gastropexy devices deployment (1-4) to secure stomach to abdominal wall
  • Needle access, guide wire placement, tract dilation
  • Placement of 10-20F gastrostomy tube 1
• Endoscopically guided:
  • Similar to radiological approach but with endoscopic visualization
  • Particularly useful for patients with head and neck cancer to avoid tumor seeding 1

Patient Selection Considerations

Gastrostomy placement should be considered for patients:

• With enteral feeding needs likely to exceed 4-6 weeks
• At high risk of malnutrition
• Unlikely to recover oral feeding ability in the short term
• With adequate gastrointestinal function to absorb and tolerate feeding 1

Common Indications

• Neurological disorders affecting swallowing (stroke, MS, ALS, Parkinson's)
• Cognitive impairment and depressed consciousness (head injury)
• Mechanical obstruction to swallowing (oropharyngeal/esophageal cancer)
• Long-term partial intestinal failure requiring supplementary intake 1

Relative Contraindications

• Gastroesophageal reflux
• Previous gastric surgery
• Ascites
• Extensive gastric ulceration
• Neoplastic/infiltrative disease of the stomach
• Gastric outlet obstruction
• Coagulopathy
• Hepatomegaly or gastric varices 1

Advantages of Different Approaches

• Endoscopic advantages:

  • Can be performed at bedside
  • No radiation exposure
  • Allows simultaneous diagnostic/therapeutic endoscopy 1

• Radiological advantages:

  • Suitable for patients with upper GI tract narrowing
  • Better for morbidly obese patients
  • Avoids tumor seeding in head and neck cancer patients 1

Important Considerations

• Prophylactic antibiotics (e.g., 2.2g co-amoxiclav) should be administered 30 minutes before insertion to reduce peristomal infections 1
• Tubes should not be removed for at least 14 days after insertion to ensure tract formation 1
• The external bumper should be placed approximately 1cm or more from the abdominal wall 1

Proper patient selection and technique choice are crucial for reducing complications and ensuring optimal outcomes for patients requiring long-term enteral access.