From the Guidelines
The transition from a nasogastric (NG) tube to a percutaneous endoscopic gastrostomy (PEG) tube requires a surgical procedure performed by a gastroenterologist or surgeon, and should be considered for patients with long-term enteral feeding needs exceeding 4-6 weeks, as recommended by the most recent guidelines 1.
Procedure Overview
The procedure is typically performed under moderate sedation and involves passing an endoscope through the mouth into the stomach, identifying an appropriate insertion site, and creating a small incision in the abdominal wall.
- The tube is then pulled through this opening and secured with internal and external bumpers.
- Before the procedure, patients should fast for 6-8 hours, and blood tests to assess coagulation status are typically required.
- Antibiotics (often a single dose of cefazolin 1-2g IV) are administered 30-60 minutes before the procedure to prevent infection, as suggested by previous studies 1.
Post-Procedure Care
After placement, the insertion site should be monitored for signs of infection, leakage, or displacement.
- Feeding can usually begin 4-24 hours post-procedure, starting with water flushes and advancing to formula as tolerated.
- PEG tubes are preferred over long-term NG tubes because they are more comfortable, reduce risks of sinusitis and aspiration pneumonia, allow for better mobility, and can remain in place for months to years with proper care, as noted in the guidelines 1.
Patient Selection
Patients selected for gastrostomy should be at high risk of malnutrition and unlikely to recover their ability to feed orally in the short term, with the concept of gastrostomy feeding being acceptable to the patient and their family or carers, as emphasized in the guidelines 1.
- The prognosis of any swallowing difficulty should be assessed by a specialist.
- The patient’s gastrointestinal function must be adequate to absorb and tolerate the proposed feeding.
From the Research
Procedure for Converting from a Nasogastric (NG) Tube to a Percutaneous Endoscopic Gastrostomy (PEG) Tube
The procedure for converting from a Nasogastric (NG) tube to a Percutaneous Endoscopic Gastrostomy (PEG) tube involves several steps:
- The patient is first assessed for suitability for PEG tube placement, considering indications such as the need for long-term enteral nutrition and contraindications such as distal enteral obstruction or severe uncorrectable coagulopathy 2.
- The PEG tube placement procedure involves performing an upper endoscopy, followed by the insertion of a plastic catheter percutaneously into the stomach under direct endoscopic view 3.
- A guidewire is introduced through the lumen of the catheter and is grasped by a polypectomy snare passed through the working channel of the endoscope, utilizing the guidewire to tie the distal portion of the feeding tube, which is then pulled to its final position 3.
- The "pull" technique is the most common method of PEG tube placement, although other methods have been described in the literature 2.
Indications for PEG Tube Placement
PEG tube placement is indicated for patients who require long-term enteral nutrition, such as those with difficulty swallowing due to medical conditions 4, 5.
- The procedure is preferred over parenteral nutrition and offers superior access to the gastrointestinal system over surgical methods 2.
- PEG tube placement is also indicated for stomach decompression and can be used in patients with a functional gastrointestinal system 2.
Comparison of PEG and NG Tubes
Studies have compared the complications, blood biochemical indexes, and outcomes of patients with swallowing disturbances receiving NGT feeding and PEG 6.
- While both techniques are safe and effective in the short term, PEG is shown to be superior to NGT feeding in improving nutrition and preventing common complications on a longer-term basis 6.
- PEG tube placement can reduce the risk of complications such as aspiration pneumonia, gastrointestinal bleeding, and reflux esophagitis compared to NGT feeding 6.