Gastrostomy Tube Placement Procedure
Percutaneous endoscopic gastrostomy (PEG) is the preferred procedure for G-tube placement due to its lower complication rates, cost-effectiveness, and shorter operating time compared to surgical gastrostomy. 1
Indications for G-tube Placement
- Patients requiring enteral feeding for >4-6 weeks 2
- Common conditions:
- Neurological disorders affecting swallowing (stroke, MS, ALS, Parkinson's)
- Mechanical obstruction (head/neck or esophageal cancer)
- Long-term partial intestinal failure requiring supplementary intake
- Prolonged coma or cognitive impairment 1
Contraindications
Absolute Contraindications
- Mechanical obstruction of GI tract (unless for decompression)
- Active peritonitis
- Uncorrectable coagulopathy
- Bowel ischemia 1
Relative Contraindications
- Recent GI bleeding
- Hemodynamic instability
- Ascites (requires drainage before procedure)
- Interposition of colon between abdominal wall and stomach
- Severe respiratory compromise 1
Pre-Procedure Assessment
- Laboratory assessment: platelet count >50,000/mL and INR <1.5 1
- Anticoagulation management:
- Antibiotic prophylaxis: Single dose 30 minutes before procedure (e.g., 2.2g co-amoxiclav) 1
PEG Placement Procedure
Standard Pull Technique
- Insufflate stomach to appose it to abdominal wall
- Identify proper placement site (typically 2cm below costal margin at point of maximal transillumination)
- Perform "one-to-one" finger indentation to ensure appropriate placement without overlying bowel or liver
- Perform "safe track technique" - pass small-bore needle with anesthetic while pulling back on plunger to ensure no interposed bowel loops
- Apply local anesthetic and create small incision (8mm) at skin entry site
- Place trocar needle into stomach
- Pass guide wire through trocar, endoscopically snare it, and pull out through mouth
- Secure gastrostomy tube to guide wire
- Pull tube from skin entry site through anterior abdominal wall 1
Alternative Techniques
- Transabdominal (Russell/introducer) technique: Preferred for head/neck cancer patients to minimize cancer seeding risk 1
- Radiologically-guided gastrostomy (RIG/PRG): Alternative when endoscopic placement isn't possible 1
- Laparoscopic-assisted gastrostomy: Option when PEG or PRG not feasible 3
Post-Procedure Care
Immediate Care
- First dressing change should be performed the morning after PEG placement
- Until granulation of stoma canal (usually days 1-7), change sterile dressing daily with local disinfection
- Push tube 2-3cm ventrally and pull back to resistance of internal fixation flange to avoid adhesions
- Apply Y-compress under tube and secure external fixation plate with free movement of at least 5mm 1
Ongoing Care
- After initial wound healing, clean wound every 2-3 days
- Washing with soap and water or showering possible after initial wound healing (1-2 weeks)
- Flush tube with 40ml water after feed or medication administration 1
- Do not remove tube for at least 14 days after insertion to ensure fibrous tract establishment 1
Complications and Management
Major Complications (0.5-4% of cases)
- Aspiration (0.3-1.0%)
- Hemorrhage (0-2.5%)
- Peritonitis (0.5-1.3%)
- Death (0-2.1%) 1
Minor Complications
- Peristomal infection (5.4-30%) - most common complication
- Stomal leakage (1-2%)
- Buried bumper (0.3-2.4%)
- Inadvertent removal (1.6-4.4%) 1
Special Considerations
- In patients with ascites, drain fluid via paracentesis before procedure 1
- For obese patients or those with abnormal anatomy, CT scan can help mark stomach for safe insertion 1
- For high-risk patients, consider:
- Abdominal plain film after gastric insufflation with 500ml air before procedure
- CT-guided placement when difficulty insufflating stomach or anatomical problems exist 4
- Recent evidence shows PEG is associated with significantly lower risk of inpatient adverse events, mortality, and readmission rates compared to radiological or surgical gastrostomy 5