Percutaneous endoscopic gastrostomy

Percutaneous endoscopic gastrostomy

Anesthesia type	MAC
Airway	Natural airway
Lines and access	PIV x1
Monitors	Standard
Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative
Article quality
Editor rating	Unrated
User likes	0

A gastrostomy is a surgical procedure where a tube is placed through the abdominal wall and into the stomach. Though there are several ways to insert a gastrostomy tube, the most common technique is a percutaneous endoscopic gastrostomy (PEG). With this method, the stomach is accessed via endoscopy. The abdominal wall and stomach are then punctured under endoscopic guidance. The gastrostomy tube (G-tube) is passed through the mouth, into the stomach, and then through the stomach and abdominal wall through the puncture. The gastrostomy tube balloon in the stomach is then inflated to keep the tube in place and the retention disk on the skin side is adjusted to endure the tube remains at the correct depth.

A gastrostomy tube may also be placed directly via a laparotomy as is the case in a Stam or Janeway gastrostomy. As these procedures are more technically involved and typically require general anesthesia, PEG tube placements are the preferred method for most patients.

G-tubes are typically placed for permanent or temporary gastric access that is needed for greater than 30 day, making a nasogastric tube unsustainable. A G-tube is usually placed for enteral access for nutrition and medication or, less often, gastric decompression. Long-term enteral access is needed when there is a neurologic impairment or mechanical impediment that prevents patients from managing oral secretions or increases aspiration risk. These conditions can include, but are not limited to dysphagia from stoke or neurologic disorders, head and neck cancers, trauma, and failure to thrive. In the case of gastric decompression, a patient may have an chronic ileus, poor bowel motility, or obstruction causing nausea, vomiting, or abdominal discomfort.

Preoperative management

Patient evaluation

System	Considerations
Airway	Aspiration risk
Neurologic	Ability to cooperate with MAC sedation
Cardiovascular	Hypovolemia due to N/V or poor PO intake
Pulmonary
Gastrointestinal	Nutritional status
Hematologic
Renal	Electrolyte abnormalities due to GI fluid loss
Endocrine
Other

Labs and studies

• CMP
• Other labs per H&P

Operating room setup

Endoscope

Patient preparation and premedication

Patient dependent. Consider IV acetaminophen for pre-operative pain control

Intraoperative management

Monitoring and access

Standard monitoring

PIV x1

Induction and airway management

Typically done under MAC sedation

Positioning

Supine

Maintenance and surgical considerations

For MAC, titrate sedatives (propofol infusion), and analgesics (fentanyl) for appropriate depth of anesthesia

Emergence

If GETA used, ensure return of laryngeal reflexes prior to extubation.

Postoperative management

Disposition

PACU

Pain management

IV Tylenol, NSAIDS, opiates as indicated

Potential complications

• Leakage of gastric contents around tube
• Tube dislodgement
• Clogged tube
• Periosteal wound infection

Procedure variants

	Variant 1
Unique considerations	Previous gastric procedures can affect difficulty
Position	Supine
Surgical time	30-60 minutes
EBL	Minimal
Postoperative disposition	PACU
Pain management	IV pain medication
Potential complications	Periostimal leakage, local skin infection