Over the past 25 years, since the introduction of percutaneous endoscopie gastrostqmy (PEG), the number of tubes placed yearly in this country has increased exponentially. Records from the United States Department of Veteran Affairs Medical Centers and a recent review of Medicare beneficiaries showed that the number of PEGs placed yearly over a 4-year period from 1988 to 1991 increased by 26%-33%.1>2 Over the next 4-year span, from 1991 to 1995, the number of PEGs placed increased even more (by 49%-56%). If this rate of growth continues, a conservative estimate suggests that over a quarter of a million PEG tubes will be placed in the US this year.3
The long-term care and maintenance of a PEG tube by the nutrition support specialist is thwarted by the fact that there are often multiple physicians of different specialties involved, using wide variations in placement techniques, type of tube, and site or positioning of the device within the gastrointestinal (GI) tract. Although the endoscopist has a well-defined and established skill set for techniques in tube placement, he or she is not always knowledgeable about the factors that contribute to subsequent complications. It is unusual for endoscopists placing the original PEG either to have the opportunity for extensive follow-up or to have the volume of cases necessary to obtain a working knowledge of management strategies that minimize the chance for developing later problems. Although acute specific procedure-related complications do occur infrequently (aspiration, hemorrhage, puncture of the colon, laceration of the gastric or small bowel mucosa, and stridor in <4% of cases),1,4 the majority of problems develop over a longer time period in 10%-11% of cases.1,4-6 Thus, the success of the primary medical care provider, efficacy of delivery of enterai nutrition, and prevention of long-term complications by default fall under the purview of the nutrition support specialist and the wound-care ostomy nurse. Fortunately, adherence to basic principles of routine wound care and a thorough daily physical examination of the PEG site is usually sufficient to identify problems early on and prevent interruption in the delivery of feedings or the need to replace the tube altogether. If the nutrition support specialist is fortunate enough to have the situation where the majority of PEG tubes are placed by the same endoscopist or group of endoscopists, or a radiologist, an ongoing relationship and active communication with these physicians immeasurably enhance the opportunity for success of nutrition therapy and the minimization of complications.
Upon the initial physical examination, a healthy wound site after PEG placement should be clean and dry, with no erythema, no exudate, and virtually no drainage (Figures 1, 2). The PEG tube should be able to be pushed in and out 1 cm if the external bolster has been placed properly. A hemostat facilitates moving the bolster back to examine the skin around the tract. A single layer of gauze tissue under the bolster helps absorb any moisture that might collect (Figure 1). Increasing the number of layers of gauze pads may increase tension between the bolsters and is discouraged. External bolsters should not be sutured to the skin. If sutures are present, they should be removed to allow cleaning underneath the bolster. Sutures securing the gastrostomy tube to the skin, seen usually with surgical placement, should not be removed for at least 4 weeks or until the gastrostomy tract has matured.
Delivery of enterai nutrition with infusion of formula should be initiated within 4 hours of tube placement.7 Studies have shown that early initiation of feedings is well tolerated and minimizes the duration of ileus after PEG placement.7 Feedings should be advanced quickly to goal over the first 24-48 hours. Usually, feedings are started at 25 mL/h and advanced by 25 mL/h every 6-8 hours until goal rate is achieved. For patients with a percutaneous endoscopie gastrojejunostomy (PEG/J) tube who are being fed through the jejunal tube, the gastric port may be placed to intermittent suction for a brief period of time as postprocedure gastroparesis may be present. Appropriate tube flushes with water should be instigated immediately with feeding. At any time after reaching target goal rate, the patient may be changed to cycled feedings, infusing formula through the night and coming off feedings for the daytime hours.
In any group of patients post-PEG placement, especially in a population at increased risk for infection (patients with diabetes, obesity, malnutrition, or chronic treatment with corticosteroids), it is important to know whether or not antibiotic prophylaxis was delivered at the time of the procedure. Failure to provide antibiotic prophylaxis increases the risk for PEG site infection in the immediate postplacement period.8-10 Patients already receiving antibiotics for other reasons do not require additional antibiotic prophylaxis.
Obtaining a routine abdominal film postplacement is neither required nor encouraged. The procedure of PEG placement is a controlled perforation. Abdominal films will show a large, fairly significant pneumoperitoneum in up to 56% of cases.11'12 In the absence of peritoneal signs (rebound tenderness), this finding is of no consequence and should be expected. Likewise, routine contrast studies to evaluate a leak post-PEG placement are discouraged as well. Such studies are appropriate only if there is rebound tenderness and evidence of peritoneal inflammation. In this situation, a contrast study would change management as the presence of a leak with peritoneal signs would indicate the need for surgical intervention. With evidence of peritonitis only, in the absence of a leak, broad-spectrum antibiotics and good wound care should be sufficient.
The most important information to be obtained from the endoscopist involves positioning of the external bolster. The endoscopist initially placing the PEG should be encouraged after every procedure to provide a diagram of exactly where the external bolster should be placed, allowing 1-cm movement in and out between the skin and the external bolster. Whether a diagram has been provided or not, the number on the PEG tubing, presumably indicating the correct position set by the endoscopist for the external bolster, should be noted and recorded. Such practice provides a valuable reference point for any healthcare providers who will be manipulating the device and the bolster as part of nursing care thereafter. Excessive tension, with compression of the tissue between the internal and external bolsters, is the most critical factor in development of mucosal pressure necrosis, buried bumper syndrome, and the breakdown of the PEG tract. A prospective study by Chung and Schertzer13 compared one group of PEG patients in whom there was tight placement of the external bolster (resulting in a mean PEG tube tract length of 4.9
Dressings over the wound site should be changed daily after initial PEG placement. The skin should remain dry with no erythema. Surprisingly, even the day of or the day after initial placement, there should be no abdominal wall rebound tenderness or signs of peritoneal inflammation. Although hydrogen peroxide is very effective at reducing bacterial colonization and wound infection, the agent is corrosive to the skin, causes excessive drying of the tissue, and is therefore discouraged. A mild antibacterial soap, or simply mild soap and water, used daily is sufficient to keep the site clean. Soaps with fragrance should be avoided as the fragrance usually indicates that alcohol is contained in the preparation, which, like the hydrogen peroxide, can lead to drying and cracking of the skin.
Soon after receiving the patient postplacement, the nutrition support specialist should take the opportunity to identify the type of tube that has been placed (Figure 3). A good understanding of what lies under the skin prevents mishaps in handling the device and provides clues as to where problems arise should the tube malfunction. Most routine PEG tubes will have an external bolster and a main infusion port for delivery of enterai formula, with a second smaller side port for delivery of fluids and medications. The infusion cap or plug is removable and may be changed easily without removing the PEG tube. The length of tubing can be easily trimmed back with scissors to optimize patient convenience. A Foley catheter or a replacement PEG tube will, in addition, have a separate port for inflation of a balloon on the distal tip which functions as the internal bolster. On these tubes, the infusion cap or plug is fused with the rest of the tube. The lumen for the inflatable balloon bolster prevents trimming or altering the length of the tube. Care must be taken not to inject water, tube feedings, or medications into the balloon port. This will lead to balloon rupture and replacement PEG-tube dislodgment.
A Malencot tube, typically used for surgical placement, will have a single large infusion port with no external bolster and no side port for delivery of fluids and medications. These tubes, which may be trimmed in length, are usually secured in place by suturing to the skin (in the absence of an external bolster).
A PEG/J tube will have a Y configuration with 2 ports of similar size, one representing the gastric port for aspiration and the other representing the jejunal port for infusion of the enterai formula. This Y-port connector is in fact a separate plug or cap inserted into the PEG tube. However, disengaging the cap may displace the jejunal tube (to which it is fused) from the small bowel. A small skin-level device, which has the appearance of a valve on a beach ball, is a button PEG. This device has a fixed stem length and only a single port for infusion of formula; it is 1 fused piece that cannot be trimmed. The external bolster is created by the flaps on the valve, and the freedom of movement in and out is determined by the stem length (and cannot be adjusted; Figure 3). If the PEG fistula tract length is not measured correctly, the skin-level device that is placed may be too "short." This will result in compression of the abdominal wall between the internal and external bolster of the skin level device, with resultant peritubular infection, fistula breakdown, and peritubular leakage.
Subsequent Surveillance and Monitoring
Routine examination of the PEG tract and the access device itself is important to identify problems early on before they progress to a complication necessitating cessation of feedings or surgical intervention. For the PEG site with a mature tract, correct positioning of the external bolster is still important to prevent complications later. The bolster should be set to allow 1 cm of movement to and fro. A more loosely set bolster allowing greater movement may cause subtle breakdown of the PEG tract.
The tubing of the PEG should be examined for splits or cracks that would cause leakage. Most tubes are composed of either silicone or polyurethane. The advantage of polyurethane is its structural strength, allowing for a thinner wall and a wider lumen (which correlates to less chance for clogging). Its relative stiffness compared with silicone, however, may make it harder on the surrounding tissue, increasing the chances for breakdown of the tract. Although silicone is softer, more pliable, and thus easier on the tissue, its reduced structural strength necessitates a thicker wall of tubing and a reduction in the lumenal diameter. Also, the silicone tube is subject to fungal colonization, which is evidenced by breakdown of the integrity of the material, with discoloration and an irregular beading of the tube (Figure 4).15 This complication represents actual colonization of the lumenal surface and ingestion of the polycarbons in the silicone by a variety of yeast (various species of Candida and Torulopsis).15 Although there is little risk to the patient, further degradation of the PEG tube can lead to cracks, leaks, or occlusion, requiring the PEG tube to be replaced.
The infusion plug for the tube should be examined for cracks or breaks, which again can lead to leakage (Figure 5). As mentioned earlier, for most PEG tubes, the plug can be replaced without changing out the entire tube (Figure 5a). For replacement PEG tubes, the plug is fused with the rest of the tubing (Figure 56). A crack or a break would indicate the need for replacement of the entire PEG tube, which can be done easily at the bedside without endoscopie or fluoroscopic guidance. Hospitals with a high volume of PEG patients should keep a surplus supply of extra plugs and external bolsters and a variety of commercial replacement PEG kits. Correcting a leaking PEG tube is important as it is a source of moisture against the skin and the opportunity for infection, inflammation, or breakdown of the tissue.
One of the most common problems that develop in the follow-up of patients with a long-term access device is deterioration of the PEG site. With varying degrees of severity, deterioration may present as a range of findings from an increase in drainage, leakage, or maceration of the skin to an enlarging tract diameter or complete breakdown of the tissue around the PEG (Figure 6). When the wound postplacement is healthy and intact, the skin should be dry, with little exudate. There should be a natural tendency for the wound to close down around the PEG tube. Increased drainage or an enlarging hole around the tube is indicative of some problem that will ultimately lead to breakdown of the tract if not corrected (Figure 6). A wide differential of clinical factors and pathologic mechanisms exists that may contribute in combination to the deterioration of the tissue and the integrity of the PEG tract. A physical examination of the site is critical and often may identify the prevailing etiology for the problem. Endoscopy to view the gastric mucosa and the internal bolster should be performed if there is evidence of bleeding, fixation of the PEG tube (cannot be rotated within or pushed in and out of the PEG tube tract), or breakdown of the tissue.
Increased erythema, marked tenderness, and exudate at the site may indicate infection of the tissue surrounding the PEG (Figure 7). Although a specific PEG-site infection is difficult to diagnose, such a complication is estimated to occur in up to 30% of cases.8,16 Culturing the wound site or aspirating from the surrounding tissue with a needle or syringe is unnecessary. Issues related to the patient (diabetes, obesity, malnutrition, chronic use of steroids), the initial placement technique (introducer us push/pull, small incision, failure to provide antibiotic prophylaxis), and nursing care (excessive traction) are all risk factors for infection at the site. Fortunately, 70% of these PEGsite infections are minor and respond to local wound care and the addition of systemic antibiotics.8 Progression to peritonitis, which is infrequent (occurring in <1.6% of cases), is heralded by development of rebound tenderness and signs of peritoneal inflammation.8·17 As mentioned earlier, systemic antibiotics and good wound care should be sufficient to correct this problem, unless a peritoneal leak is found on contrast studies and surgical intervention is required. The development of necrotizing fasciitis is a potentially lethal complication of PEG-site infection. In this situation, edema, erythema, and bullae formation indicate necrosis of the tissue, and the patient often progresses to clinical sepsis. Broad-spectrum antibiotics are required, as is surgical intervention with wide debridement of the tissue surrounding the PEG.
Fungal colonization of the PEG site can lead to breakdown of the skin and continued irritation (Figure 8). Fungal colonization of a body surface occurs anywhere there is prolonged moisture (Figure 86). Failure to displace the bumper for cleaning, an overgrowth of skin folds around the PEG due to weight gain from tube feedings, and infrequent dressing changes contribute to fungal colonization. Keeping the area dry and clean and adding an antifungal agent is usually successful in clearing this irritant effect (Figure 8c).
Torsion of the tube against the side wall of the tract occurs frequently as a result of tension on the tube created when the tube is caught under a bedrail, bedding, or the patient's own body (Figure 9). Lateral torsion against one side of the tract leads to ulceration and enlarging of the fistula opening on the abdominal wall. This problem might be averted or corrected by placement of a clipping device, which stabilizes the tube and prevents side-to-side torsion (Figure 10). A homemade version of the device may be constructed with a Styrofoam cup or bowl cut to form around the tube and then taped down to prevent lateral motion.
Granulation tissue often forms within the tract in long-term cases and can actually grow out onto the surface of the skin (Figure 11). Although this does not usually cause excessive exudate and drainage, it is a source of moisture underneath the bolster, which can lead to breakdown of the skin. The hypergranulation tissue may be trimmed with scissors and cauterized with silver nitrate sticks or some other cautery device.
Unrestricted motion in and out through the PEG tract will cause deterioration of the tissue at the site. This situation is usually caused by 1 of 2 different mechanisms: a surgical PEG in which the sutures holding the tube to the skin have been inadvertently pulled out or intentionally removed, or any tube for which there has been failure to place an external bolster. The motion of the tube to and fro within the tract leads to breakdown of the tract and an enlarging hole. Simply replacing the tube with a new one of larger diameter (to fit the enlarging hole) will worsen the situation and lead to further deterioration of the site. Again, an external clipping device can stabilize the tube and prevent this motion, or replacement of the tube with a new tube for which an external bolster has been configured will also prevent this problem. Foley catheters are frequently used as replacement tubes, but caregivers frequently place these tubes without an external bolster. An external bolster can be easily constructed and placed over the Foley catheter before initial placement.
Probably the most common reason for increased drainage and breakdown of the site is buried bumper syndrome.18-20 Extensive tension between the bolsters compresses the tissue, increases inflammation, and leads to breakdown of the tract. Factors that increase the risk for buried bumper syndrome, besides excess tension, include stiff (polyurethane) tubes, malnutrition, poor tissue healing (due to diabetes or irradiation), or excessive weight gain. The range in severity of this complication is wide, from simple ulceration beneath the bolster to complete erosion and penetration of the tube out through the abdominal wall. Suspicion for buried bumper syndrome should arise if the physical examination of the site indicates that the tube is fixed and efforts to push the tube in and out are unsuccessful. Additional findings as a result of this complication may include abdominal pain, tenderness, increased drainage, peristomal infection, or breakdown of the site or the inability to infuse water, tube feedings, or medications through the tube. With these findings, endoscopy is required and the tube usually needs to be replaced.
Warmth, tenderness, and a swelling or mass effect at the PEG site indicate excessive inflammation (with or without infection). Although this may be progression of PEG site infection with development of a small peristomal abscess, a rare complication occurring upon initial placement that may present similarly is laceration of the left lobe of the liver caused by the PEG tube penetrating the organ (Figure 12). This usually leads to poor opposition of the stomach wall to the abdominal wall, persistent inflammation, and a breakdown of tissue at the PEG site. A CT scan is required to make this diagnosis, and management usually requires pulling the PEG and replacing in a different location at a later time. Surgery is required only if the site fails to heal after removal of the PEG.
A number of etiologic factors can lead to corrosive injury of the tissue around the PEG site (Figure 13). Excessive acid may be present in the stomach and leak around the tube due to endogenous acid secretion (because of failure to use proton-pump inhibitors or automatic stop orders for such drugs by the pharmacy) or to exogenous provision of ascorbic acid (vitamin C given to promote wound healing). Reduced gastric emptying may occur as a result of gastroparesis from opioid narcotics, sedatives, or clinical sepsis or as a result of mechanical obstruction from migration of an internal balloon bolster on a PEG tube caudad to the level of the pylorus. Delayed gastric emptying for any reason contributes to the volume of potentially corrosive agents retained in the stomach and increases the likelihood for drainage out through the tract. Prolonged use of hydrogen peroxide at the PEG site for antisepsis also contributes to corrosive injury of the tissue.
In some patients, breakdown of the tract for whatever reason is so severe that the site must be abandoned, the PEG tube removed, and the wound allowed to seal. Placement of a nasojejunal tube alone may allow healing of the site while enteral feedings continue. The larger the defect and the greater the volume of effluent out through the ostomy site, the less likely the stoma will close. Feeding directly into the stomach via a nasogastric tube only increases output through the fistula and will delay healing. Infrequently, a permanent ostomy or gastrocutaneous fistula remains, and the wound does not progress to spontaneous closure (Figure 14). This problem can lead to continued breakdown and irritation of the skin, with excessive fluid and electrolyte losses, furthering the debilitation of the patient. Placement of an ostomy bag over the defect may improve irritation somewhat by collecting the effluent and reducing the amount of moisture on the skin of the abdominal wall. Usually, this defect cannot be corrected without placement of a nasoenteric tube into the jejunum, with the tip of the tube well below the ligament of Treitz. High-dose proton-pump inhibitors to reduce gastric secretion and even placement of a nasogastric Salem-sump tube (down the other nares) to decompress the stomach may be required to ultimately close the tract. If these measures fail to correct the complication, surgical intervention may be required.
Nodular growth around the PEG site in a patient with a history of an oropharyngeal, esophageal, or gastric carcinoma may indicate the complication of tumor implantation at the PEG site.21-23 Although this complication is rare in occurrence, 1 report estimated that it may occur in up to 3% of patients with such cancers in whom the PEG tube was pulled down on initial placement through the oropharynx and esophagus into position in the stomach.22 Although feedings may continue as management options are reviewed, the patients may live long enough to require local irradiation of the site or surgical resection. 23
The odd complaint of stool around the PEG site or the observation that the rectal effluent from diarrhea has the same appearance of the formula being infused into the PEG may indicate the occurrence of the rare complication of a gastrocolocutaneous fistula.24,25 This complication develops either acutely by perforation of the transverse colon with initial placement of the PEG into the stomach or by erosion over time into the colon by a tube that was initially placed properly. Although this complication may present acutely as an infection at the PEG site, the more common presentation is chronic and may not even be apparent until the PEG tube is actually removed. Management is surprisingly simple. The PEG tube may be pulled, a bandage placed over the site, and the fistula allowed to close on its own. A nasoenteric tube is placed down into the small bowel to continue enterai feedings, and a new PEG may be placed within 7-10 days. Only if the fistula fails to close is surgical intervention required.
Evidence of GI bleeding in patients with long-term PEG tubes occurs in up to 2.5% of cases and may present as melena, hematochezia, or hematemesis.4,26,27 Most commonly, such bleeding occurs as a result of erosion and ulceration on the posterior wall of the stomach, opposite from the internal bolster of the PEG tube. Presumably caused by trauma from the bolster itself, this complication is more prevalent in thinner patients. Erosion and ulceration may also occur underneath the internal bolster as a manifestation of buried bumper syndrome and may be a source of upper GI bleeding. Any number of causes of GI bleeding may occur unrelated to the presence of the PEG tube, such as peptic ulcer disease, angiodysplasias, or erosive esophagitis. Evidence of GI bleeding needs to be evaluated by endoscopy, but it is unusual for this complication to require cessation of feedings or removal of the PEG tube.
Interruptions to Delivery of Enteral Nutrition
A number of clinical scenarios may lead appropriately or inappropriately to interruptions in the delivery of enteral nutrition. Vigilant surveillance, strict protocols for the regulation of infusion of the formulas, and prompt attention to any problems that do arise minimize the time period of cessation from tube feeding. The most common factors that impede enterai nutrition support include high gastric residual volumes, making the patient NPO for diagnostic tests and procedures, intolerance to gastric feedings (due to ileus, gastroparesis, nausea, vomiting), tube displacement, or tube clogging.28 Besides monitoring for development of such problems, the nutrition support specialist is encouraged to identify high-risk patients, anticipate which problems will arise given certain circumstances, and communicate effectively with the medical team caring for the patient and the endoscopist before procedural intervention.
A clogged feeding tube is a frequent complication involving particularly the jejunal portion of PEG/J tubes. Clogging occurs in up to 20% of cases, with the likelihood for occurrence exacerbated by increasing tube length, decreasing tube diameter, infrequent flushes, use of medications through the tube, continuous as opposed to bolus infusion, and the practice of obtaining residual volumes through the tube.29,30 Frequent flushing with 100-300 mL of water per shift helps reduce this complication. The most effective declogging agent has been shown to be a Viokase (Axcan Pharma, Birmingham, AL) pancreatic enzyme tablet crushed with a 650-mg bicarbonate tablet, mixed in warm water, and then infused back and forth with a 10-mL syringe. If this fails to unclog the tube, then mechanical devices such as a cytology brush (obtained from the endoscopy suite) or commercial corkscrew device may be required to break through the clog.29,30
Inadvertent displacement of the PEG tube is a concern in any patient with altered mental status, dementia, or delirium. Even in stable coherent patients, accidents occur, leading to inadvertent removal of the tube. Although this complication occurs in up to 4.4% of cases, a variety of simple measures may be used in the high-risk patient to prevent its occurrence.6,26,27 Placing mittens on the patient's hands, wrist restraints, or a clipping device around the PEG reduce chances for displacement. Use of an abdominal binder is discouraged as a pressure effect is created, applying side torsion on the tube (which promotes ulceration and enlargement of the tract). Communication with the endoscopist identifying the high-risk patient beforehand allows for additional strategies at the time of the initial procedure. Placing T-fasteners to secure the stomach against the abdominal wall at the time of endoscopie or radiologie gastrostomy tube placement, or choosing to place a Stamm surgical gastrostomy instead, keeps the stomach from falling away from the abdominal wall and facilitates easy replacement should dislodgement occur. A third option at the time of the initial procedure is to place a skin-level button PEG. The design of this device is such that if the patient inadvertently pulls on their tubing, they simply disengage the connecting tube, leaving the button PEG in place.
One-half of the cases of inadvertent removal occur in the acute setting in which the PEG tract is immature.6,26,27 In this situation, inadvertent displacement results in the stomach falling away from the anterior abdominal wall, and essentially the patient is left with an acute perforation. If this event is witnessed, the patient may be sent directly back to the endoscopy suite, and the tube may be replaced through the same hole in the abdomen. Although the new tube may not necessarily pass through the same hole in the gastric wall, the cinching of stomach by the PEG up against the anterior abdominal wall seals the previous hole in the stomach, and the situation is surprisingly well tolerated. If there is delay in identification of this problem and the tube has been out for a matter of hours, the management involves placement of a nasogastric tube, initiating intermittent suction, and giving the patient broad-spectrum antibiotics. Again, surprisingly, few of these cases require surgical intervention. Within a short period of time (usually 7-10 days), a new PEG can be placed (often at the same site).
In the other half of cases of inadvertent displacement, the tract is mature, and management of the displacement is simpler.6,26,27 Maturation of the tract should normally occur over 10-14 days. However, in elderly patients, patients who are malnourished, diabetic patients, or patients in whom radiation therapy may have altered tissue strength and healing, delays in maturation may occur for up to 4 weeks. In a chronic PEG patient with a mature tract, efforts should be made to replace the feeding tube quickly to avoid closure of the tract (which can occur in as little as 12-24 hours). If a commercial replacement tube is not available, a Foley catheter with the addition of a homemade external bolster can be placed through the tract and used effectively for continued feeding. Anytime a tube is placed blindly back into a PEG tract, a contrast study with an abdominal (flat plate) film to confirm positioning in the stomach is necessary.
At institutions where there is a high volume of PEG tubes being placed, problems with intolerance, delayed gastric emptying, or nausea and vomiting that may require conversion of the PEG to a PEGJ should be expected. Positioning of the PEG tube within the stomach is a key factor in the success with which a PEG tube can be converted to a PEGJ tube. Communication between the nutrition support specialist and the endoscopist helps anticipate these problem cases and may lead the endoscopists to shift their location of PEG placement from the left upper quadrant (where the tube usually ends up being placed in the upper body or lower fundus of the stomach) down toward the umbilicus and to the right of midline (which places the PEG lower in the antrum). Positioning of the tube in the antrum allows for a shorter, more direct route to the pylorus and on down into the small bowel. Most endoscopists are not aware that the position in the antrum is an area that provides the shortest tract for PEG placement and the greatest area with which the stomach approximates the anterior abdominal wall. Placement of PEG tubes in the left upper quadrant gives a much longer, more tangential route from the skin to the stomach. Such placement facilitates the process of conversion from PEG to PEGJ, should this be required.
Similar problems occur with surgical placement of gastrostomy tubes. The traditional Witzel gastrostomy involves a tunneling of the gastrostomy tract toward the fundus of the stomach. The angle of this tract toward the esophagogastric (EG) junction makes conversion to a PEGJ nearly impossible. A jejunal tube placed through such a gastrostomy will angle toward the EG junction with a large curve before bending down toward the pylorus. The long length of tube required to get the pylorus and the curved angle toward the EG junction promote displacement of the tube back into the stomach. Again, good communication with the surgeon may convince them to convert to using a Stamm gastrostomy, which instead leads to a more perpendicular, direct line of placement into the stomach, and a tube that is much more easily converted to a PEGJ should the need arise.
A better understanding of tube placement techniques, a careful physical examination of the site on a routine basis, and a keen eye for development of early problems all serve to maintain the health of the tissue around the PEG tube and prevent long-term complications. A close relationship and good communication between the nutrition support specialist or wound ostomy nurse and the endoscopist or radiologist who places these tubes helps with improvement in techniques on initial placement and the early identification and correction of problems as they arise. Surprisingly, often very simple management strategies can reverse problems before a serious complication develops. Dietitians, nurses, and other nutrition support specialists are encouraged to be knowledgeable and more proactive in the surveillance and management of patients receiving chronic enteral tube feeding as they may be the members of the healthcare team most capable of optimizing efficacy from nutrition support while minimizing risk to the individual patient.