PEG Tube Insertion Depth into the Stomach
A PEG tube should be advanced into the stomach for a minimum of 2-3 cm, but ideally 5-10 cm during weekly mobilization to prevent buried bumper syndrome, with the external fixation plate positioned 0.5-1 cm away from the skin after the tract has healed. 1
Initial Placement and External Fixation
- Immediately after PEG placement, the external fixation plate should be subjected to very low traction, without tension. 1
- The external bolster should not compress the tissue excessively, as this is the most important risk factor for buried bumper syndrome. 1
- An adequate incision size of at least 8mm at the puncture site prevents pressure-related lesions. 1
Post-Healing Mobilization Protocol
- Once the gastrostomy tract has healed (after approximately one week), the tube must be rotated daily and moved inward at least once weekly. 1
- During weekly mobilization, advance the tube at least 2 cm into the stomach, though movements up to 5-10 cm are ideal to ensure you're actually moving the tube and not just displacing the abdominal wall. 1
- After mobilization, return the tube to its initial position with 0.5-1 cm of free distance between the skin and the external bolster. 1
Critical Anatomical Considerations
- The optimal gastric puncture point is the body of the stomach near the angularis, equidistant from the greater and lesser curves. 2
- The puncture location varies significantly: right upper quadrant in 31% of patients, left upper quadrant in 59%, left lower quadrant in 5%, and right lower quadrant in 5%. 2
Special Tube Types
- If the device is a gastrojejunostomy or gastrostomy with jejunal extension, it should NOT be rotated—only pushed in and out weekly. 1
- Rotation of jejunal extension tubes can cause malposition or damage to the jejunal component. 1
Common Pitfalls and Prevention
- Buried bumper syndrome occurs when excessive compression between internal and external fixation devices causes the internal bumper to migrate through the gastric wall. 1
- Alarming signs include difficulty mobilizing the tube, leakage around the insertion site when flushing, frequent feeding pump alarms, abdominal pain, chronic site infections, or resistance when administering feeds. 1
- A PEG can become embedded in gastric mucosa even if rotation is still possible, when a gastric mucosa "pocket" grows over and around the bumper. 1
- When gastropexy sutures are present (stomach fixed to abdominal wall), delay mobilization until sutures are removed, usually after two weeks. 1