Percutaneous Endoscopic Stomas for Enteral Feeding and Drainage
Percutaneous Endoscopic Stomas for Enteral Feeding and Drainage
The idea that nutrients can be introduced into the gastrointestinal
(GI) tract through a route other than the mouth is not new. This
practice was started by the ancient Egyptians, who used nutrient
enemas for preservation of general health. Greek physicians prescribed
enemas containing milk and wine for treatment of diarrhea .
The introduction of nutrients into the rectum continued in Western
medicine until its inadequacies were outlined at the beginning
of this century .
Attempts to fashion tubes for placement in the upper GI tract
originated in Venice in the 16th century, with the use of tubes
made from animal bladder that were placed in the esophagus. A
major development occurred at the end of the 18th century when
a tube made of eel skin was used for 5 weeks to feed a patient
with neurogenic dysphagia . The use of nasogastric tubes for
feeding or emptying the stomach became widespread in the 19th
century. Thereafter, surgical gastrostomies and jejunostomies
along with nasogastric tubes were used for these purposes.
The introduction of endoscopic techniques for the placement of
tubes in the GI tract in the last 15 years has revolutionized
the approach to enteral feeding and presented opportunities to
improve the quality of life of patients, particularly those with
impairment of GI function because of cancer. Although gastrostomy
and jejunostomy tubes have been placed for many years by surgical
techniques, the relatively high morbidity and mortality [3-5],
and the requirement for an operating room have limited their use.
In the last decade, there has been a marked increase in utilization
of long-term enteral feedings. The Oley Foundation estimated that
in 1992, 148,000 patients across the United States received long-term
enteral feeding outside hospitals; 43% of these patients had cancer
. This increase can be attributed mainly to the development
of simple, safe, and cost-effective endoscopic techniques for
placement of tubes in the GI tract, and to the availability of
a wide range of low-cost commercial enteral feeding solutions.
Gauderer and Ponsky  introduced the technique for placement
of a percutaneous endoscopic gastrostomy (PEG) in 1980. This method
has become so popular that, in 1990, it was reported to be the
second most common indication for upper GI endoscopy in hospitalized
patients . Various modifications of the original technique
have been reported, along with techniques for placement of tubes
directly into the jejunum . The majority of tubes placed in
the upper GI tract endoscopically are used for enteral feeding.
However, this technique can also be used to place wide tubes for
drainage of an obstructed GI tract . The technique involves
the introduction of a thread or a guide-wire into the stomach
or jejunum, which is used either to pull or push a tube through
the mouth, esophagus, stomach, and abdominal wall.
Pull and Push Methods
The method of placement of a percutaneous endoscopic gastrostomy
has been described in numerous reports [7,11-14]. The patient
first undergoes a routine upper GI endoscopy. The stomach is then
inflated, pushing the gastric wall against the abdominal wall.
When the lights in the endoscopy room are dimmed, the light from
the tip of the scope in the stomach can be seen transilluminating
the abdominal wall. The transillumination identifies the part
of the anterior gastric wall that is positioned directly against
the abdominal wall. This is a safe area for the placement of the
gastrostomy tube. After application of a local anesthetic, a 5-mm
incision is made in the skin. A 16-gauge, smoothly tapered Medicut
catheter is inserted through the incision into the stomach. The
metal guiding stylet is removed, and a thread (pull method) or
guide-wire (push method) is passed through the catheter.
Pull Method--In the pull method, the thread is grasped
by a biopsy forceps or a snare (passed through the scope), and
the endoscope is withdrawn, pulling the thread with it through
the mouth. Thus, the thread passes through the abdominal wall,
stomach, esophagus, and pharynx, and exits through the mouth.
The gastrostomy tube may range in size from 15 F to 28 F. One
end of the tube has a widened mushroom shape, and the other end
is attached to a tapered plastic or rubber dilator, the tip of
which is hooked to a thread or wire. The thread exiting through
the mouth is tied to the thread on the tapered end of the tube.
The end of the thread exiting through the abdominal wall is pulled,
moving the tube through the mouth into the stomach. The tapered
dilator of the tube is then pulled through the abdominal wall,
creating the channel through which the tube exits.
The endoscope is reintroduced, and, under endoscopic visualization,
the tube is pulled out further until the mushroom end is positioned
firmly against the gastric wall. The gastric and abdominal walls
are secured firmly against each other by placing a bumper on the
tube at the point where it exits from the abdominal wall.
The Push Method--In the push method , instead of a
thread, a guide-wire is brought out of the patient's mouth. A
Sachs-Vine tube is pushed over the guide-wire until the dilator
tip exits through the abdominal wall.
The performance of percutaneous endoscopic gastrostomies has been
found to be safe, with a morbidity rate of 3% to 15% and mortality
of 0.3% to 1% [11-15]. The tubes function well in the long-term,
with very few complications .
Indications for Placement
Table 1 shows the indications for placement of a feeding gastrostomy
tube. Among cancer patients, the most common indications are cancer
of the head and neck with obstruction and or severe dysphagia.
Originally, prior abdominal surgery was considered a contraindication
for the placement of percutaneous endoscopic tubes. However, it
is clear now that the procedure can be performed effectively and
safely in patients who have undergone major abdominal operations,
as well as in those with disseminated abdominal carcinomatosis
and ascites [9,10,15,16].
Successful long-term enteral feeding requires that the patient
and a family member be trained thoroughly to perform the feeding
safely and avoid complications, particularly aspiration. It is
also essential to establish an orderly medical follow-up program,
to ensure that the patient is adequately nourished and that problems
arising from the feeding are appropriately addressed. Feeding
through a gastrostomy tube can be accomplished by infusing boluses
of 300 cc to 500 cc, three to four times a day. In this system,
up to 3,000 calories can be provided safely.
With the increase in survival in patients on long-term enteral
nutrition, issues of quality of life, comfort, and esthetics have
become important. Although a percutaneous endoscopic gastrostomy
offers these patients a simple and convenient access for feeding,
the protruding tube can get caught in clothes, is esthetically
unappealing, and interferes with sexual activity and body image.
The skin level button gastrostomy (Figure 1) offers an advantage
by eliminating the protruding tube [17-19]. This device is particularly
advantageous in cancer patients with good performance status who
have severe dysphagia and require long-term enteral feeding .
Placement of a button gastrostomy requires a mature gastrocutaneous
or jejunocutaneous fistula and is usually performed 4 to 6 weeks
after the initial placement of a percutaneous endoscopic gastrostomy
or jejunostomy tube. Technically, the button is placed by stretching
it over a metal stylet, which is then pushed through the fistula
into the stomach. Safety considerations require that an upper
GI endoscopy be performed so that the stomach can be distended
prior to insertion. The endoscopy also ascertains that the button
is appropriately placed inside the stomach . The device functions
well long-term, and requires replacement on average only after
1½ to 2 years .