PEGSINS & OUTS

Denni Arrup, BA, RN, CGRN, CFERNovember 8, 2014

Learning Objectives

• History• Uses• Contraindications• Procedure• Complications• Equipment

What is a PEG?

• Definition: Percutaneous Endoscopic Gastrostomy Tube• Medical device used to provide nutrition and

medications• Temporary or permanent • Patients unable to obtain nutrition by mouth,

swallow safely or need supplementation

Composition

• Made of polyurethane or silicone• Diameter is measured in French units (each

French unit = 0.33 millimeters). Most common for adults is 20 Fr.

• Classified by site of insertion and intended use

History of Feeding Tubes

• 3500 years ago to Greek and Egyptian civilizations

• Papyrus writings: Egyptian physicians used reed and animal bladders to rectally feed patients things like milk, broth, wine, whey to treat different complaints

• Rectal feeding – method of choice for thousands of years

History – cont’d

• Difficulty accessing upper GI tract without killing the patient. Some things remain important to this day: not killing the patient

• 1598: Capivacceus used a hollow tube with a bladder attached to one end, filled with nutrient solution, down as far as patient’s esophagus

• 1617: Aquapendente (Italian professor of anatomy and surgery) used silver tube as a nasopharyngeal tube

History – cont’d

• 1646: Von Helmont devised flexible leather tube for feeding into the top of esophagus

• 1710: Tubing might be used to reach all the way to the stomach

• 1790: Oro-gastric feeding developed by John Hunter, used a whale bone covered by eel skin attached to a bladder pump.

History – cont’d

• 18th and 19th centuries: difficult and uncomfortable to keep tube down a person’s throat – rectal feeding was more accepted. (you thought colonoscopies were messy)

• 1870: Tube was placed in mouth back toward pharynx and mixtures of thick custards, mashed mutton, warm milk, beef broth, eggs and medications were given.

History – 1881

• US President James Garfield was shot and kept alive 79 days by being rectally fed a blend of beef broth and whisky.

• Rectal feeding (nutrient enemas) was popular in the early 1900’s – gone out of fashion (thankfully).

• Some medical students have re-discovered that colonic absorption is a very fast way to get drunk. Not a very clean method. . .

1st PEG

• June 12, 1979 at the Rainbow Babies and Children’s Hospital, University Hospitals of Cleveland

• Performed by:– Dr. Michael W.L. Gauderer, pediatric surgeon– Dr. Jeffrey Ponsky, endoscopist– Dr. James Bekeny, surgical resident

1st PEG

• Patient: 4 ½ month old child with inadequate oral intake

• Technique was first published in 1980 – gold gold standard for PEG placement

Uses

Naso-pharyngeal feeding

• ‘Fasting girls and spoilt children who refused food’

• Device that looked like a tea pot with a very long spout were used to force-feed patients in mental institutions – mixtures of egg, milk, beef tea and wine thickened with arrowroot

Delivery of enteral nutrition

• Dysphagia due to stroke• Pre-op - for oral/esophageal cancer surgery• ALS• Anatomical: cleft lip and palate during the

process of correction• Failure to thrive: premies to adults• Persistent N/V during pregnancy

Decompression

• Gastric decompression – major trauma or intestinal obstruction

• Provide gastric or post-surgical drainage

Delivery of Medication

• Liquid form of medication (elixir)• Carafate slurry• Administer medications as per guidelines

CONTRAINDICATIONS

Absolute contraindications

• Inability to perform an EGD• Peritonitis• Massive ascites (untreatable)• Uncorrected coagulopathy• Bowel obstruction (unless PEG is to be used

for drainage)

Relative Contraindications

• Gastric mucosal abnormalities: large gastric varicies, portal hypertensive gastropathy

• Previous abdominal surgery

• Morbid obesity

• Gastric wall neoplasm

Procedure

Collects all supplies needed for PEG

• PEG kit• Sterile gloves for GI tech and MD• Sterile bowl for collecting sharps• Sterile 4x4’s• Marking Pen• Gowns• Consents for procedure and sedation• Antibiotics and tubing, if required

Pre-op patient for procedure

• Consent

• Advance directives

• Obtain current set of vital signs, weight (kg), height (cm)

Pre-op

• Patient assessment

• Medications

• Labs

• NPO

Procedure Room

• Explain procedure to patient

• Take patient to room

• Insert bite block

• Drape patient

In the Room

• Perform time out

• Sedation

• Endoscopy performed

Procedure - 1• Open PEG Kit

• Scrub

• Mark

• Medicate

• Trocar

Procedure - 2

• Stylet

• Snare

• Retrieve

• Insert guidewire

Procedure - 3

• Grab guidewire

• Scope withdrawn

• Guidewire threaded into insertion tube

Procedure - 4

• MD will pull guidewire – insertion tube comes through skin

• MD pulls insertion tube

• MD positions PEG in place

Procedure - 5

• GI tech places external bumper and clamp on tube

• MD confirms placement of PEG

• GI tech inserts adapter on tube

• Measurement of tube given to RN for record

Procedure - 6

• Assess patient – abdominal binder?

• Patient moved to recovery

• Call report to floor or nursing home

COMPLICATIONS

Complications of procedure

• Hemorrhage• Cellulitis• Gastric ulcer• Perforation of bowel• Puncture of left lobe of liver• Gastrocolic fistula• Diarrhea

Clogged tube

• Flush PEG tube

• Use brush to create opening in clogged tube

• Instill grapefruit juice or lemon-lime soda and let sit 10 minutes

• Much easier to keep the lumen flushed

Infection

• SKIP

• Wash PEG site with soap and water as part of daily cleansing routine

• Check VS – temperature

• Check labs - WBC

Infection, cont’d

• Turn the PEG tube – 360 with feedings/flush

• Check for PEG tube measurement

“Buried Bumper Syndrome”

• Occurs – when the gastric bumper migrates into the

gastric wall– when the external bumper is too tight on the

outside, causing pressure on the gastric bumper, eroding into the stomach wall at site of stoma

• Abdominal pain, crepitus around stoma, purulent drainage

REMOVAL OF PEG

Indications

• PEG tube no longer needed

• Persistent infection at the PEG site

• “Buried Bumper Syndrome”

• Failure, breakage or deterioration of PEG tube

Procedure – removal of PEG: 1

• PEG tubes with rigid, fixed internal bumpers are to be removed endoscopically.

• Bumper removed

• Cut tube pushed into stoma

• Insert snare

Procedure – Removal of PEG: 2

• Pull snare with scope

• Place endoclip

• Dress skin

NEW USES

ASPIRE

• Low risk method of weight loss

• Developed by 3 physicians:– Dr. Sam Klein – Director of the Center for Human

Nutrition at Washington University School of Medicine in St. Louis, Missouri

- Dr. Moshe Shike – Attending Physician andDirector of Clinical Nutrition at Memorial Sloan Kettering Cancer Center in New York

- Dr. Stephen Solomon – Attending Physician andChief of IR at Memorial Sloan Kettering

Aspire Bariatrics founded in 2005 by Drs. Klein, Shike and Solomon• These 3 physicians combined their expertise

in the areas of nutrition, obesity, gastroenterology, interventional radiology, percutaneous endoscopic gastrostomy (PEG) tubes and medical device discovery

• Modified and adapted the PEG tube to help patients lose weight

New Approach to Weight Loss

• Minimally invasive• Reversible• ‘AspireAssist’ available in Europe• Clinical trials in the United States• Dramatic results – patients have lost an

average of 46 pounds during the first year

Procedure

• During an outpatient procedure in an endoscopy center or surgi-center, the patient would meet all the requirements for an endoscopy: NPO for 8 hours, labs and EKG, sleep study if needed, heart and blood pressure medications taken with a sip of water prior to arrival, ride home verified before procedure

Procedure – cont’d

• Consent obtained by anesthesia and endoscopist

• Procedure explained to patient with possible complications

• Discharge instructions reviewed with patient so he/she able to care for the fresh PEG

• Diet – normal food, drink and amounts• Follow up visit scheduled for 10 days

Procedure – cont’d

• No diet change needed to begin• Patient to learn healthier eating habits over

time• Relatively inexpensive – cost of AspireAssist

device, PEG tube insertion with anesthesia • Bariatric surgery very expensive

Aspire Assist

•After a meal, the patient can attach the Aspire Assist device to the skin port on the outside of the abdomen. The valve on the skin port is opened to remove 30% of stomach contents into the toilet

Aspire Assist - 2

• This ‘aspiration’ takes place 20 minutes after consumption of a meal.

• Time needed to perform procedure – 5 to 10 minutes

• Weight loss is attained because 30% of stomach contents removed 3 times/day (with each meal), resulting in less caloric intake in small intestines

ASPIRE

• New way to reduce portion size

• Vitamins will be prescribed to keep healthy

• Counseling sessions

• Important to drink plenty of fluids to assist with aspiration

Caring for skin-port

• Care is similar to PEG care –

• Activity is encouraged, no deep-water diving

Removal of Skin-Port

• Reversible if not needed or wantedWeight loss achievedChanged mind

Removal is same as for PEG removal Procedure under sedation to remove device Clip the opening on the inside of the stomach Steristrips on the outside of the opening Closes within 2-3 days.

EquipmentBy Vendors

Boston Scientific

• 20 Fr PUSH PEG• 20 Fr PULL PEG• 24 Fr PUSH PEG• 24 Fr PULL PEG

Cook Medical

• Flow 20 Pull Method• Flow 20 Push Method• Peg 20 Jejunal tube• Peg 24 Jejunal tube

Corpak

• CORFLO feeding tubes

Today’s Overview

Today’s Overview

Summary

• INS

– History

– Procedure

– Contraindications

– Uses

Summary – cont’d

• OUTS– Removal

– Procedure

References Aadhaar (2012, March 14). You start with a tube…: Tubefeeding – a brief history [Web log post]. Retrieved from http:// youstartwithatube.blogspot.com/2012/03/tubefeeding-brief- history.html

Phillips, N. (2006). Nasogastric tubes: An historical context. Medsurg Nursing, 15(2), 84-88.

Ponsky, J. (2011). The development of PEG: How it was. J Interv Gastroenterology, 1(2), 88-89

References (cont’d) Ponsky, J. & Gauderer, M. (1981). Percutaneous endoscopic gastrostomy: a nonoperative technique for feeding gastrostomy. Gastrointestinal Endoscopy, 27(1), 9-11.

Sullivan, S., Stein, R., Jonnalagadda, S., Mullady, D., & Edmundowicz, S. (2013). Aspiration therapy leads to weight loss in obese subjects: A pilot study. Gastroenterology, 145(6), 1245-1252.

QUESTIONS?