PEGS INS & OUTS

1. PEGSINS & OUTS Denni Arrup, BA, RN, CGRN, CFER November 8, 2014

2. Learning Objectives • History • Uses • Contraindications • Procedure • Complications • Equipment

3. 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

4. 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

5. 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

6. 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

7. 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.

8. 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.

9. 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. . .

10. 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

11. 1st PEG • Patient: 4 ½ month old child with inadequate oral intake • Technique was first published in 1980 – gold gold standard for PEG placement

12. Uses

13. 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

14. 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

15. Decompression • Gastric decompression – major trauma or intestinal obstruction • Provide gastric or post-surgical drainage

16. Delivery of Medication • Liquid form of medication (elixir) • Carafate slurry • Administer medications as per guidelines

17. Contraindications

18. Absolute contraindications • Inability to perform an EGD • Peritonitis • Massive ascites (untreatable) • Uncorrected coagulopathy • Bowel obstruction (unless PEG is to be used for drainage)

19. Relative Contraindications • Gastric mucosal abnormalities: large gastric varicies, portal hypertensive gastropathy • Previous abdominal surgery • Morbid obesity • Gastric wall neoplasm

20. Procedure

21. 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

22. Pre-op patient for procedure • Consent • Advance directives • Obtain current set of vital signs, weight (kg), height (cm)

23. Pre-op • Patient assessment • Medications • Labs • NPO

24. Procedure Room • Explain procedure to patient • Take patient to room • Insert bite block • Drape patient

25. In the Room • Perform time out • Sedation • Endoscopy performed

26. Procedure - 1 • Open PEG Kit • Scrub • Mark • Medicate • Trocar

27. Procedure - 2 • Stylet • Snare • Retrieve • Insert guidewire

28. Procedure - 3 • Grab guidewire • Scope withdrawn • Guidewire threaded into insertion tube

29. Procedure - 4 • MD will pull guidewire – insertion tube comes through skin • MD pulls insertion tube • MD positions PEG in place

30. 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

31. Procedure - 6 • Assess patient – abdominal binder? • Patient moved to recovery • Call report to floor or nursing home

32. Complications

33. Complications of procedure • Hemorrhage • Cellulitis • Gastric ulcer • Perforation of bowel • Puncture of left lobe of liver • Gastrocolic fistula • Diarrhea

34. 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

35. Infection • SKIP • Wash PEG site with soap and water as part of daily cleansing routine • Check VS – temperature • Check labs - WBC

36. Infection, cont’d • Turn the PEG tube – 360 with feedings/flush • Check for PEG tube measurement

37. “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

38. Removal of PEG

39. Indications • PEG tube no longer needed • Persistent infection at the PEG site • “Buried Bumper Syndrome” • Failure, breakage or deterioration of PEG tube

40. 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

41. Procedure – Removal of PEG: 2 • Pull snare with scope • Place endoclip • Dress skin

42. New Uses

43. 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 and Director of Clinical Nutrition at Memorial Sloan Kettering Cancer Center in New York • Dr. Stephen Solomon – Attending Physician and Chief of IR at Memorial Sloan Kettering

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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