Gastrostomy

Percutaneous endoscopic gastrostomy

• Preoperative preparation

  • Confirm indication (e.g., dysphagia, need for long-term enteral nutrition)
  • Assess for contraindications: coagulopathy, ascites, gastric outlet obstruction, severe obesity, or peritonitis
  • Obtain consent, including risks of bleeding, perforation, infection, and visceral injury
  • Nil by mouth for 6 hours prior
  • Prophylactic antibiotics typically given (e.g., co-amoxiclav or cefazolin)

• Patient positioning and anaesthesia

  • Supine position
  • Conscious sedation or general anaesthesia depending on patient condition
  • Pulse oximetry and cardiac monitoring

• Endoscopic assessment

  • Insert gastroscope and examine upper GI tract
  • Insufflate the stomach fully with air to oppose it against the abdominal wall
  • Identify appropriate site in anterior gastric wall—usually mid-body or high greater curvature
  • Perform transillumination (bright light visible externally)
  • Confirm site by indentation test (apply pressure externally and see it endoscopically)

• Abdominal site preparation

  • Mark the site where transillumination and indentation are strongest
  • Sterilise and drape the abdominal wall
  • Infiltrate local anaesthetic at the selected point

• Needle puncture and guidewire placement

  • Make a small skin incision
  • Insert a needle with cannula into the stomach under endoscopic guidance
  • Pass a guidewire through the needle and grasp it with a snare or forceps endoscopically
  • Withdraw the endoscope, pulling the guidewire out of the mouth

• Tube preparation and pull-through

  • Attach the PEG tube to the guidewire at the mouth
  • Pull the guidewire back through the oesophagus and stomach until the PEG is through the abdominal wall
  • Apply traction until the internal bumper rests against the gastric wall

• Secure the external bumper

  • Attach the external fixation plate
  • Position the external fixation plate snug but not tight (1–2 mm clearance)
  • Cut the tube to appropriate length and place cap or feeding adapter

• Confirm position and flush

  • Check for free movement of the tube and absence of leakage
  • Flush the tube with water or saline to confirm patency
  • Dress the site with sterile gauze

• Postoperative care

  • Avoid feeding for 4–6 hours; then start with water, then build to feeds if tolerated
  • Monitor for signs of bleeding, peritonitis, or tube dislodgement
  • Routine site care and education on tube use and maintenance

• PEG Complications

  1. Bleeding
  2. Infection of the site
  3. Erosion of the tube
  4. Skin erosion/necrosis
  5. Feeding into the abdo cavity
  6. Occasionally necrotizing fasciitis
  7. Peri-tube leak of ascites
  8. Gastric or gastrocolic fistula

• How to Avoid Complications

  • Complications minimized by careful placement techniques and avoidance of excessive pressure at initial tube adjustment
  • In the first 24 hrs after insertion, the PEG must be snug against the gastric mucosa but not too tight
  • If it is not snug, it may leak around the tube and if too tight, it may lead to gastric or skin necrosis
  • Evidence supports enteral nutrition can be commenced 4 hrs after PEG insertion
  • Antibiotics are often used at the time of insertion and the site needs daily inspection for 5-7 days

• Circumstances when PEG insertion is not possible

  • May be impossible after major gastric surgery, multiple adhesions and in the presence of a large hiatus hernia as the stomach may be intrathoracic.
  • In some cases, e.g. hiatus hernia, a laparoscopically assisted gastrostomy insertion has been described.
  • An alternative technique is to place a tube inside the stomach under radiological guidance.

Open Gastrostomy

• Preoperative preparation
  • Confirm indication for long-term enteral access
  • Nil by mouth for 6 hours
  • Prophylactic antibiotics (e.g., co-amoxiclav)
  • Consent including risks of infection, leak, visceral injury, and bleeding
• Anaesthesia and positioning
  • General anaesthesia
  • Supine position with arms tucked or abducted
  • Abdominal skin prepared and draped widely
• Incision and exposure
  • Upper midline incision
  • LUQ tube site - small incision and bring tube through abdominal wall
• Identify and select gastrostomy site
  • Choose a site on the anterior wall of the stomach, usually in the mid-body or high greater curvature
  • Apply gentle traction on stomach with Babcock forceps or stay sutures
• Bring stomach to the abdominal wall
  • Place purse-string suture (2–0 PDS) around the selected site
  • Make a small gastrotomy (0.5–1 cm) within the purse-string
  • Insert a Foley catheter or mushroom-tipped tube through the gastrotomy (this is already coming through your abdominal incision)
  • Inflate the balloon
• Secure the tube
  • Tie down the purse-string suture to seal the tube in place
  • Place 4 quadrant anchoring sutures (gastropexy) between stomach and peritoneum of anterior abdominal wall
  • These prevent leakage and internal migration
• Check position and patency
  • Flush the tube with saline to confirm patency
  • Aspirate to confirm intragastric placement
  • Ensure the stomach sits flush against the abdominal wall
• Closure
  • Close peritoneum and fascia in layers
  • Skin closed with absorbable or interrupted sutures
  • Apply sterile dressing around the tube
• Postoperative care
  • Usually keep NPO for 4–6 hours, then start water or clear fluids via tube
  • Gradually increase to full enteral feeds
  • Daily cleaning and rotation of the tube to avoid skin breakdown or buried bumper
  • Monitor for signs of infection, leak, tube dislodgement, or peritonitis