Can a Percutaneous Endoscopic Gastrostomy (PEG) tube be placed in a patient with a history of mesh from an abdominal wall reconstruction?

PEG Tube Placement in Patients with Abdominal Wall Mesh

PEG tube placement can be safely performed in patients with prior abdominal wall reconstruction using mesh, but requires careful planning and modified techniques to identify a safe puncture site away from the mesh.

Assessment Before PEG Placement

• Pre-procedure imaging is essential to evaluate the location of the mesh and identify a safe puncture site 1, 2
• Abdominal plain film after gastric insufflation with 500 mL of air can help identify optimal puncture points 2
• CT imaging provides detailed anatomy and orientation along the potential PEG tract, especially valuable in patients with prior abdominal surgery 2
• The optimal gastric puncture point should be in the body of the stomach near the angularis, equidistant from the greater and lesser curves 2

Modified Techniques for Safe Placement

• The "safe track technique" should be used to provide information about the depth and angle of the puncture tract 1, 3

  • This involves using an aspirating, lidocaine-filled syringe and needle before gastric puncture
  • Simultaneous air return in the aspirating syringe and endoscopic visualization of the intragastric needle confirms a safe tract

• Proper site selection is critical:

  • Choose a site at least 2 cm below the costal margin at a point of maximal transillumination 1
  • Perform "one-to-one" finger indentation to ensure appropriate placement without overlying bowel loops or mesh 1
  • Avoid placement through the linea alba (midline) to prevent incisional hernias 4

Special Considerations with Abdominal Mesh

• Large midline wounds, abdominal mesh, and ostomies make finding a safe window challenging but should not necessarily preclude PEG placement 1
• Synthetic meshes in contaminated fields are not recommended by guidelines in emergency abdominal wall reconstruction 1
• If there is difficulty with standard PEG placement due to mesh:
  • Consider laparoscopically-directed PEG placement as a safer alternative approach 5
  • CT-guided PEG tube placement may be used when there are anatomical problems or previous surgery 2

Potential Complications to Monitor

• Risk of entero-atmospheric fistula formation is increased with direct application of synthetic prosthesis over bowel loops 1
• Technical success rates are slightly lower in previously operated patients (88% vs 100%) 3
• Complications may include:
  • Tube blockage, dislodgement, and infection 1
  • Potential damage to the mesh or surrounding structures 6
  • Incisional hernia formation, especially if placed through the linea alba 4

Post-Procedure Management

• Verify proper tube position after placement, especially important with altered anatomy 7
• A water-soluble contrast study is the most reliable radiographic method to confirm proper PEG tube position 7
• Implement routine water flushing after each feeding and medication administration to prevent blockage 8
• Regular tube maintenance, such as pushing the tube in and out weekly (2-10 cm) helps prevent buried bumper syndrome 8, 6

When to Consider Alternative Approaches

• If safe PEG placement cannot be achieved due to mesh location, consider alternative enteral access methods:
  • Radiologically-placed gastrostomy tubes 1
  • Surgical gastrostomy or jejunostomy 1
  • Nasogastric/nasojejunal tubes for short-term feeding 1