What are the guidelines for percutaneous endoscopic gastrostomy (PEG) placement?

Guidelines for Percutaneous Endoscopic Gastrostomy (PEG) Placement

PEG placement should be considered when nutritional intake is expected to be inadequate for more than 2-3 weeks, with early placement recommended before significant weight loss occurs, as patients typically lose approximately 12 kg in the 3 months before PEG is finally considered. 1

Primary Indications

Neurological Disorders

• Stroke and neurological dysphagia represent the most common indication for PEG placement. 2
• Early PEG feeding in stroke patients with dysphagia is highly effective and superior to nasogastric tube feeding, allowing parallel swallowing rehabilitation training. 2
• PEG can be removed when swallowing ability recovers. 2

Amyotrophic Lateral Sclerosis (ALS)

• PEG placement must be performed early in the disease course before pulmonary function deteriorates. 2
• Recommended pulmonary parameters: vital capacity >50% of predicted, though experienced operators can place PEG with VC ≥1L and PCO2 <45 mmHg. 2
• Critical sedation management is required, with active gastric desufflation post-procedure as patients cannot lower the diaphragm independently. 2

Dementia

• PEG placement in advanced dementia requires an individualized but critical and restrictive approach, as no published evidence demonstrates achievement of stated goals (improved function, comfort, prevention of aspiration, or reduced pressure sores). 2
• This represents the most controversial indication for PEG placement. 2

Other Neurological Conditions

• Cerebral tumors, bulbar paralysis, cerebral palsy, Parkinson's disease, persistent vegetative state, and craniocerebral trauma are established indications. 1

Oncological Indications

• Stenosing tumors of the ear, nose, throat region, and upper gastrointestinal tract warrant PEG placement. 1
• Patients undergoing chemotherapy or radiotherapy with poor nutritional status benefit from early PEG placement. 2, 1
• Early PEG placement is more effective than oral nutrition alone during cancer treatment. 2

Gastrointestinal and Metabolic Disorders

Crohn's Disease

• PEG insertion should be performed early in the disease course. 2
• Despite historical concerns, PEG placement is safe with no higher complication rates in Crohn's disease patients. 2
• Supplementary PEG feeding is highly effective for children with severe growth retardation when nutritional drinks fail. 2

Cystic Fibrosis

• Nocturnal PEG feeding improves nutritional status, stabilizes lung function, and is superior to nasogastric tubes. 2
• Long-term benefit depends on pre-gastrostomy pulmonary function; earlier placement yields better outcomes. 2

Other Conditions

• HIV/AIDS with wasting syndrome, short bowel syndrome, chronic renal failure are indications. 2, 1

Pediatric Indications

• PEG tubes can be safely placed in low-weight infants and neonates, even those weighing <3 kg, in experienced hands. 2
• Mentally and physically retarded children benefit substantially with improved nutritional status and quality of life. 2
• Severe kyphoscoliosis may complicate placement; consider general anesthesia with minilaparotomy backup if endoscopic positioning fails. 2

Critical Care Indications

• Major head trauma, persistent vegetative state, or prolonged intensive care stay warrant early PEG consideration to prevent complications of prolonged nasogastric tube feeding. 2, 1

Absolute Contraindications

The following are absolute contraindications to PEG placement: 2

• Serious coagulation disorders: INR >1.5, Quick <50%, platelets <50,000/mm³, PTT >450s
• Interposed organs (liver, colon) between abdominal wall and stomach
• Marked peritoneal carcinomatosis
• Severe ascites
• Peritonitis
• Anorexia nervosa
• Severe psychosis
• Clearly limited life expectancy

Relative Contraindications and Special Considerations

No Longer Contraindications

• Mild to moderate ascites is not a contraindication. 2
• Ventriculoperitoneal shunt systems do not increase complication rates. 2
• Peritoneal dialysis treatment is not a contraindication. 2
• Previous gastrointestinal surgery (Billroth I/II, total gastrectomy) is not a contraindication, though success rates are slightly lower. 2, 3
• Pregnancy does not preclude PEG placement. 2
• Lack of diaphanoscopy (transillumination) is no longer a contraindication if negative needle aspiration test is achieved. 2

Anticoagulation Management

• Low-dose aspirin is not an established contraindication for PEG placement, though clinical studies are lacking. 2
• Aspirin can be stopped 5 days prior, but clinical practice suggests PEG can be placed safely without stopping low-dose aspirin. 2

Local Contraindications

• Severe erosive gastritis or ulcers should be healed before PEG insertion. 2
• Extensive tumor infiltration at the puncture site is a local contraindication. 2
• Esophageal stenoses are not contraindications if passable by thin endoscope or treatable with dilation. 2

Pre-Procedure Requirements

Patient Preparation

• Fasting for at least 8 hours prior to procedure. 2
• Coagulation parameters must meet criteria: INR <1.5, Quick >50%, PTT <50s, platelets >50,000/mm³. 2
• Prophylactic antibiotics to prevent wound infection. 4, 5
• Indwelling venous catheter for sedation (midazolam 3-5 mg IV). 2
• Shave epigastric region if excessive hair growth present. 2

Safety Technique

• Gastroscopy is routinely conducted prior to PEG insertion to exclude local contraindications. 2
• Negative needle aspiration test is required: use syringe with 5 ml saline, puncture under continuous aspiration toward air-filled stomach without prior air aspiration. 2
• This technique is safer than diaphanoscopy alone. 2

Decision-Making Algorithm

1. Assess duration of anticipated inadequate oral intake: If expected >2-3 weeks, proceed to step 2. 1

2. Trial of conservative measures: Attempt oral supplementation, special nutritional drinks, and swallowing therapy first. 1

3. Evaluate prognosis and quality of life: PEG should be for medical reasons, not administrative convenience or as substitute for good nursing care. 1

4. Consider timing: Early placement is critical—do not wait for 12 kg weight loss that typically occurs before PEG consideration. 2, 1

5. Screen for contraindications: Check coagulation parameters, exclude interposed organs, assess for peritonitis or severe ascites. 2

6. Obtain informed consent: Legally valid consent is essential; for patients with reduced legal capacity without guardians, obtain consent from local magistrates court per local regulations. 2

Critical Pitfalls to Avoid

• Do not delay PEG placement until significant weight loss has occurred—patients typically lose 12 kg before PEG is considered, and this weight is rarely fully regained even in benign diseases. 2, 1

• Do not place PEG in advanced dementia without careful consideration—no evidence supports improved outcomes. 2

• Do not place PEG in ALS patients with severely compromised pulmonary function—placement becomes increasingly difficult and dangerous as vital capacity declines. 2

• Do not remove PEG tubes before 14 days post-insertion—risk of peritoneal leakage before fibrous tract establishment. 6

• Do not assume previous abdominal surgery is a contraindication—use safe tract technique with needle aspiration test. 2, 3