I'm Naina Coelho, nice to meet you all. So what I'm going to talk to you about today is a brief overview of feeding tubes. This talk will only cover percutaneous endoscopic gastrostomy or PEG tubes. But remember that you can do jejunostomy tubes as well. Those are called PEGs and then there are various types of PEGs. But today let's talk about just the basics of how to put a PEG in, what you should be thinking about. Oh, let's go back. My disclosures are a consultant for Boston Scientific and Alexian. So when you're asked to put a PEG in, you want to think about what the indications might be. And obviously the most common indication is that someone can't eat. These might be patients that you need to provide nutrition to because they've had a stroke or other cerebral injuries. It may be someone that is going to have significant radiation or has for an esophageal cancer, something like that. And you want to preemptively put that in. But you want to think about how the patient requires nutrition and hydration and that they would need it for longer than three or four days or a short period. So at least 30 days. Your track requires four to six weeks to mature. And so you want to make sure that the patient has that requirement for a longer time. Otherwise you can just be feeding them with a nasal tube for a shorter term. The other indication is for gastric decompression. So that might be patients who have some sort of gastric outlet obstruction, either structural or more of a chronic functional motility issue. If they have a bowel obstruction, you want to make sure that you're not putting a PEG in because someone has a small bowel obstruction with the idea of feeding them because you still have an obstruction distal to that site. Sometimes if you have a gastric outlet obstruction from a malignancy, you can put a PEG in and then feed distal to it with an extension called a jejunal extension tube past that obstruction into the small bowel. Okay. So think about why you want to put that in. And then before you're asked, or you maybe just refer the patient to put it in. And then you're going to think about what you have to assess before you start. So medications are important primarily in terms of the blood thinner status. So are they on anticoagulants of any kind? Because then you have to think about how you're going to handle that. And then if they're inpatient, are they already on antibiotics because they need a course of prophylactic antibiotics before, during the procedure, we'll talk about that. And so you want to know if they're already on something that has skin flora coverage, you don't need another dose. Anatomy is important. If a patient has a Roux-en-Y anatomy, for example, you're not going to have any real estate in the stomach to put that tube in. And so then you're thinking more about a jejunal tube. If they have a Bilrath 2 anatomy or some sort of gastric resection, again, a little harder. If they're post liver transplant, especially a living donor, they might have a lot of scarring in that area, which again makes it hard to do. So it's important to record if they've had prior surgery. The other important part of that is any abdominal hernia mesh placement. Because the newer meshes are not that much of an issue. But older meshes, you can't really go through a mesh to put a PEG tube in because you'll end up with a chronic fistula. So that's something to remember. The nutritional status is important, but oftentimes these patients are already malnourished, which is why you're putting them in. And so the important thing is, are they so bad that they're not going to have any wound healing? And that's most likely not the case. But you want to think about that. And we'll talk about comorbidities that might pose a risk, but you can almost always work around them. There's no absolute contraindication to putting these in, but you can think about that. And then informed consent is very important for these patients. Most often, especially for patients who've had a stroke or patients who are very ill, they're not going to be able to give you consent themselves. And so remember to document informed consent with the appropriate person that gives you power of attorney for this. So the ASGE has guidelines, and this is an older reference. But in 2021 last year, there was an update on management of anticoagulation for procedures. And the thing to remember for PEGS is that they are a high-risk procedure, because you are creating an artificial aperture, and so you have to make sure that you think about whether the patient then is either low-risk or high-risk. And so low-risk patients, and I refer you to that 2021 guideline that was published in ASGE, because that has specific instructions on what to do for which antithrombotic. But if they're low-risk patients, you can hold the antithrombotic. You don't need to bridge. If they're high-risk patients, you will bridge with low-molecular weight heparin. And remember, you can treat bleeding, so that's okay, but the risk of embolism is more important. If you have any concern, you can use... There's no long-term limit to how long you can use nasal feeding. I mean, obviously, you don't want to keep a patient for six months on nasal feeding, but if it's a couple of weeks until you can sort these issues out, that's okay. And again, these guidelines, the latest guidelines are the most important to look at. But if you're using antithrombotics, you want to hold your Coumadin. And that is really what... I shoot for an INR about 2.0 or less. Some institutions will want you to have 1.5 or less, but you can hold the Coumadin, and then you can bridge if you need to up to the morning of the procedure with your low-molecular weight heparin. If you're using Plavix, that is considered high-risk, so we recommend stopping for five days prior to elective placement of a PEG tube. If you're using Doax, three days is what we use, 72 hours, so you can use anywhere from three to five days in order to place that. If they've had a recent stent, if they've got other comorbidities, then it's a question of balancing their need and then the risks, and you have that all documented in your informed consent, and that's okay. And when you restart, I start Coumadin, you can start either the evening after or the same day off. It doesn't matter. If you've treated the bleeding... If you have intraprocedural bleeding, you'd have treated it, and the chances of delayed bleeding are quite low. So when would you not do a PEG? Well, if it's medically futile. And you might have situations where you're asked to put PEGs in and you really don't think it's a good idea, and it's important to document what you're thinking and have a discussion with the people that are referring you, with the patient, to understand why you're doing this, especially with patients with severe dementia. If they're not institutionalized, they can pull the tube out pretty easily, and so that's important to discuss with your referring team about whether you definitely want it. What is the strategy that they're going to have, at least in the first few days, to make sure that the patient doesn't reach that tube and pull it out? And what you're going to encounter more often, though, are technical issues. So you might have a patient with a large intrathoracic stomach, for example, and a fixed hernia, and you can't find any spot in the stomach to put the PEG in, and that's important. If you have a large wound, so the patient is quite close to being post-op and they have a large scar, then you're not going to be able to get very close to that scar, or they have a secondary, a wound that's closing by secondary intention, and they're really not able to eat or malnourish from it. But a PEG is not a great idea in that site, because you don't want to put it very close to a wound that's not completely healed. An inability to advance the endoscope into the esophagus can be overcome. You can dilate a stricture if you need to get there, and now you can do what is known as a direct PEG. So if you can just get a scope in, and we'll talk about the procedure in a few minutes, which will make sense, but you kind of have to pull a bumper through the esophagus. So if you have a tight stricture, you're not going to be able to do that. Even if you get your scope through, you want to maybe stretch that out if it's a dilatable lesion, but if it's not, you can consider doing what we call a direct PEG, which is directly placing it in the stomach with the use of T fasteners. So I said earlier that these were only relative contraindications. You can think about massive ascites is not a situation where you want to put a PEG tube in without draining that first, and that's because you can get secondary fungal ascites. But patients with massive ascites are often, sometimes they have from cirrhosis, which is less common, and cirrhosis is actually a higher risk lesion to put this in, only because they're going to need, they'll reaccumulate that. But in patients who you're putting it in for palliation because they have, you know, peritoneal carcinomatosis and large ascites, you send the patient for a tap just before you put your PEG in, and if you put the bumper tight enough, then you should be okay. So that's not really a complete contraindication. Gastric varices to me is more concerning. Again, cirrhotic patients, if you have the capacity to do EUS and make sure there's no varices in the wall, that's a good idea. Usually they're not on the anterior wall of the stomach anyway, so you're a little bit protected, but that's not 100%. So if you have a CT scan that the patient has had that shows varices throughout the stomach, it's probably someone you want to think again about whether you definitely want to put that PEG in. They're harder to control, too, if they do bleed. Peritoneal dialysis, again, a question of whether you definitely want to put that tube in. What is the patient's, what are you doing it for? Can you avoid it in any way? That's a big one. And then the others, hiatal hernia is, again, a technical issue. Obesity is not really a contraindication. Some of the techniques we show you are harder to do, like transillumination or seeing a light on the outside if the patient is very obese, but you can still do these tests, place the tube. And we talked about mesh. If the mesh has been removed and your surgeon tells you, you know, there's no mesh that I see, or you can always get either an ultrasound for that left upper quadrant, which is where you're going to put the tube in, and if they don't see anything, or you get a CT scan. And if your mesh is in the right lower quadrant or an inguinal hernia mesh, for example, that's okay. You just can't have it in the field that you're going to put the tube in. There we go. So while the video is playing, PEG tubes come in various types, but essentially every tube will have the contents as you're seeing. Remember that it's a sterile procedure, so the kit is sterile. So once you open up the kit, the contents should be removed only once you're gowned and gloved. What you're seeing there is the angiocath, that one, this was the finder needle. This is a scissors as well as a little mosquito that come in every kit. Some of these you don't use for every routine PEG placement. That's a sterile drape that comes within the kit. So once you've cleaned the patient, you put the drape on surrounding the site that you want to put the tube in at, and that way you can keep your instruments on a sterile field while you're doing the procedure. It's gauze and betadine to clean. And these are the clips that you'll put on the end of the tube when you're all done. That's the bumper that's going to be on the outside. Another cleaning supplies. Again, every kit will look different. So the kit I use, for example, nowadays doesn't look exactly like this, but it has the same contents. And that's the tube. So you can see here, and I'm just going to stop, oops, I restarted that. See right there. So that's the bumper, that white bumper that you see, that's going to be on the inside of the stomach. And then the tube is going to come out, and the hard plastic bumper you saw will be on the outside to hold it in place. And that's the snare that comes with the kit to use to grasp the wire, and we'll go through that procedure again. So how do you put a peg in? It's ideal to have the patient on their back for this rather than on their side, which you normally have patients for. And so you have to be really careful about airway protection, especially if you're doing this for a patient who has gastroparesis, and they're going to have a stomach full of food, or they've been in the hospital for a while and getting narcotics. We usually recommend endotracheal intubation so that you're protecting the airway when you're doing this. When you're in that position, you can see where the stomach is right there, and we used to restrain the hands. If they're getting general anesthesia, you don't usually need to do that. But if they're demented patients, you want to make sure that when they wake up, their instinct is not to just pull that. And so you have to be careful about that. And the antibiotics are given intra-procedure. So one dose, we use Ancepha unless you're penicillin allergic. And you give that dose once you start. And so what you want to do is place it to the left of the midline. I don't know that my, oh, there it is, okay. There. Below the ribs, and that's why if you have a large hiatal hernia, you can see how that's not going to work. But you want to be two finger widths below the rib margin that you feel, away from the central midline, and somewhere in this area with insufflation, you should be able to find this spot. So identify your midline, identify where you want to go. Sometimes the stomach sits in a different position, so really you'll find the eventual position based on transillumination. Try to avoid close to the right rib margin, because the liver is there. And in the lower two quadrants, there's A, you have the colon, much more overlying small bowel, which you might inadvertently puncture. And B, you're going to have, the stomach very rarely is there. So you want to make sure that you do this. The rib reason is so that the bumper doesn't irritate the ribs when the patient sits up. Because eventually when they sit up, there's going to be more abdominal contraction. So the technique is you'll go into the stomach and insufflate, lots of air so that you oppose the stomach to the anterior abdominal wall. And then you can see the light in thin patients. And wherever you see the light, you want to indent your finger so that you can see it. And when you push from the outside, you'll see a bulge on the inside. And that's how you know that you have pretty good, what we call one is to one. So if you're pushing really hard, you should see a pretty good indentation. If you don't see that, or you see both walls of the stomach collapsing, then that's not really a direct apposition to the anterior abdominal wall. And that would be a site that you probably don't want to use. If you get really good light, the chances are that you have a really good apposition already. But remember that colon transmits light too. So if you have an overlying loop of colon, you can sometimes get that. And that's where the finger indentation really helps. You can see here the scope in the bottom left is in the stomach. We're putting a lot of air in, and you're pressing down. And you can see that indentation right there. What's important to remember is the angle at which you press. Sometimes in patients, especially with altered anatomy, you might have to actually press poking upwards towards the rib. And if you do that, and that's where you're getting really good pressure, then your find a needle, and eventually your other needle should go in that same direction. Ideal to go up and down straight away, but sometimes you have to angle that track. And you should put your pressure in the same direction that your needle's going to go. And then you know that you're less likely to trap something on the way. And that's what transillumination looks like. So you want to turn your room lights down. We turn off all lights. Sometimes we turn off our ancillary monitors as well, so that you can really see, especially in overweight patients. And then you're going to do the safe track technique. So what you do is you're holding the needle a little different. This one's showing you the thumb pushing down. You actually want to be aspirating the entire time. So again, insert your needle. You have a find a needle, and we'll go through the steps while we're watching this. But when you insert your find a needle, you're pulling back on the plunger the entire time. And then when you hit the stomach, you'll get air bubbles into the syringe, and your endoscopist should tell you at the same time, I see the needle. Unlikely that you're going to be doing both. So you might have a nurse doing the skin part of it, or you might be doing this. But you want to make sure that when you see the needle in the stomach, that's when you see air. If you have a loop of colon in between, you'll see air and no needle. And that's when you know that there's something else that's causing the air to come in, and you want to change your sight and try again. You can see here the person holding the needle will say air, and you say, yeah, I see the needle. And now we confirm that we're in the right spot. So some people require skin incisions. They're not always done. But especially in thin patients, you don't require a skin incision. Making an incision can sometimes increase your risk of drainage around the tube site. But if you do, it's just a very small one, a five millimeter small incision. But in super young muscular patients or patients who have really thick skin, you sometimes have to make a little bit of an incision so that you can allow the tube to come through without too much difficulty. Our own practice has moved away from incisions. So unless the patient, you know, we're doing something that very obese patient, but we don't tend to do that only because it increases the leakage rate. And so after you've done your finder needle, you've identified this is the right track. In the same spot with the same direction of your needle, you're going to put in an angiocatheter. So this is a hollow catheter with this sharp needle in the middle. And that's what you're going to use to do that. You can't safe track it. So you're not going to be able to aspirate back on this. You're just going to pass it straight down. Takes a little bit of pressure to get that catheter and the needle through. And you can see it with the scope. So that's the angiocatheter that you're seeing. And what you do is once you pass it in, you'll then remove the inner needle and be left with the outer white sheath. And through that white sheath from the skin, you'll pass your wire in, pull it out through the mouth, and then pull the tube back down. That catheter is flexible and they're showing you how you're going to, through the skin From the outside, pass the wire in. Snare that with the snare that you got in the kit. And then take that out through the mouth. That can be a little tough to get through. Now in our practice, with the needle in place, we snare the catheter because you don't want to lose that. If that falls back out, then you're going to have a small perforation there. So you snare it, close around the catheter. In this video, they're not closing. They pass the needle out and pass the wire back in. In my practice, we close, and then all you do is you open it a little bit, slide it back up, and grab the wire. And now you have the wire in there, and you're going to come all the way out through the mouth and get your tube ready to go. So your tube is already out and ready to go. You put the big loop through the little loop and the bumper through the big loop. You might have a nurse that does that, and if you don't, you can watch the video again. We have dedicated PEG nurses, but you pass that out, and then you just tie it like a little sailor's knot that you're going to have. The big loop through the little, bumper through the big loop, and then what you're going to do is pull. So you can see up here, you've got basically you have a wire that's traversing the entire patient here. And so now when you pull from here, you're going to drag that tube all the way back down and up into the stomach. Big loop through the little, bumper through the big. You want to make sure that you lube. So you lube that knot, because that can sometimes be a little rough to get through. And then you pull upward. So directly up, they're feeding the other end through the patient's mouth, and you're just going to pull up. When you pull, it's helpful to splint around the site so that you're not pulling the whole anterior abdominal wall with you. Splint with your two fingers and pull, and that'll help you. One thing in the video there is that they're wrapping their hands directly around the cord. I would advise against that when you're doing it, because it's very sharp wire and will cut your hands. So if you wrap a little piece of gauze around the palm of your hand, and then wrap that wire around, it's pretty brute strength to pull this through. So you're going to pull there. But the trick there is once the bumper enters, because it's a long wire, and then you have a long tube at the end of it. But once the bumper enters the mouth, slow down your pulling, because if you're feeling really strong that day, there have been instances where it just gets pulled all the way out. So slow down your pull there. You'd have had the knot come through. You'd have had the white bump, the conical tip part come through, and then slow down until you can feel the bumper underneath. Then all you have to do is you cut the tube at the length that you want to do it at, and then you advance the bumper. So current bumpers look different. Again, this is an older video. This is a T-shaped bumper. Most of them are round now, and the kit you saw earlier had a round bumper. You slide the bumper over this, and you would get it closer to the skin. Now what you don't want to do here is pull too hard, because you can pull that bumper again. And once you place it down there, you should have a little bit of give, just like the video showing you. It should be able to go left to right. It shouldn't be loose, but it shouldn't be super tight either. A good way to know if you're doing, if you have enough, is you should be able to spin the tube in your hands, and it shouldn't give you too much tension. But it shouldn't just spin really easily either, because you want to have, what's going to oppose the stomach to the wall is that tension that you create. Should you repeat an endoscopy? I do, only because I want to make sure that I document that the bumper is not buried and it's not too tight. So after that bumper is secured on the outside, I go in to look at the internal bumper, get a picture, and I also take a picture of the outer limit, because you want to mark every peg tube that you put in, you want to put in the number at the skin disc. And convention is the top of the skin disc that you had, so that when, if the patient says it fell out, or the patient says it's gone in and it's moved, you know where you ended your procedure at. So we take pictures of the inside and then the bumper as well, and that's a good way to document where you're at. So when do you use it? You can use, if you're using it for decompression, you can use it immediately, otherwise feeding is usually just wait for four hours and then feed. In case there is immediate post-procedural bleeding and you need to go in and take care of it, then you have that option. What are potential adverse events? So the commonest adverse event actually is aspiration. And so we talked about the fact that patients on their back, they can't really protect their own airway. So you have to be very cognizant of why you're doing it and make sure you suction and watch the airway carefully. The other is bleeding, up to 2.5% risk of bleeding in the most recent large study done. And so you want to make sure when you're doing these that you've thought about the anticoagulants like we talked about. When you transilluminate, you'll sometimes see vessels. And so we'll take a little Sharpie and mark those out so we know when we're poking. Because when you're poking, you don't have transillumination. Your lights are all on in the room, everyone's watching. And so if you draw those vessels out, you'll make sure not to get those. And then pneumoperitoneum is really what, I mean, you're creating that, right? Because you're going right through. So I don't worry about that, but it was more of an issue when you used air and not CO2. Post-procedure, the commonest is dislodgement of the tube. That's the commonest complication that you'll see. The other is impingement of a loop of colon there. So you develop a gastrocolic fistula. Nothing to worry about. You don't have to do surgery. When the patient comes back, you can just change that out and close it. And then neoplastic seeding is another one. So you have to think about patients who have new oropharyngeal cancers and where they are in their stage of treatment. So if they have an untreated oropharyngeal cancer, you don't want to do a pull-through bumper peg because that has the increased potential to seed the tract. If they've already had some radiation and you're doing it now because they can't eat, then that's okay, but you don't want to do it in a fresh, especially now that you have the option to do direct pegs and you don't have to pull anything through. That's a better option. And then the bedded bumper syndrome is sort of a peg emergency, if you will, and we'll talk about that. We talked about aspiration, again, commonest complication of peg placement. You can elevate the head of the bed when you're getting the scope in and to empty the stomach. I would recommend against having the head up when you're putting the peg in because you want to have the abdomen as flat as you can. And then later once, if the patient has chronic narcotics or they've got some kind of distal obstruction, then you do have the increased risk of aspiration. Remember that people think that because you're not swallowing, your risk of aspiration has gone away, but it actually can happen from reflux as well, so that's important. Aspiration is commonly skin-level flora. The use of that one single dose of prophylactic antibiotic has been shown to significantly decrease this. So if you just do that, you're okay. If they continue to have an abscess at the site, you can use antibiotics. Sometimes very rarely you have to do a local drainage. You might have someone who excitedly does an X-ray and calls you to tell you there's air under the diaphragm after you did a peg tube, and you tell them, don't worry about it, it's supposed to be there. Okay? The pneumoperitoneum is very frequent. It's supposed to be there. You don't need to do anything about it unless the patient has peritonitis, in which case if you did multiple sticks, you either had another loop of bowel in between that developed a perforation or there's something that's caught. Pain after the peg tube should be mostly musculoskeletal pain, but if you have severe pain, then you might have a torsion of a loop of small bowel that got caught, and in that case you want some cross-sectional imaging. Leakage is actually very common in patients. It's reported at one to two percent, but most of the time patients don't talk about this. It can be just a little bit of leakage, or sometimes it can be quite significant. If you've made a large cut, the body has to heal around that, and if these patients have poor nutritional status, that's going to be harder, so you want to avoid that. That's why if you can avoid making an incision, that's the idea. It's almost always gastric contents, but they'll tell you the food is coming back out. Well, you're feeding right there, right, because you're feeding right inside the bumper, so if you're going to leak, you're going to leak both of those. And then it does lead to poor wound healing, so that's important to remember as well. If your patient presents with leakage, you want to think about, A, do they have an infection? B, do they have a buried bumper? So you want to look at where the bumper level is, because if you have a buried bumper and you've gone from four to two centimeters on the outside, then that track has now widened in the subcutaneous tissue, and that's why you're leaking. And then is it really super tight, in which case you want to loosen it. And again, a pure PEG tube, you can always rotate. If patients have jejunal extensions, you cannot rotate those PEG tubes. But if they're just a PEG tube, you can always spin it to see how it's doing. What you don't want to do, and the natural tendency is if it's leaking, just go ahead and tighten the bumper, because if you have a buried bumper, you're going to make that worse. If it's already tight, that's going to be worse. And you want to avoid, in general, putting in a larger diameter tube right off the bat, only because you can only go to 26 French with these tubes, and you're going to end up getting a larger and larger hole. It's more important to address why it's happening. Maybe their albumin is really low. Maybe they need some supplemental nutrition to allow that track to heal. So this is the buried bumper syndrome, and you can see up here how your bumper should sit. Oh, boy. Let's see. There it is. Your bumper should sit, should be fully visible, and you should be able to almost push it in and look underneath the bumper at the tube. If you cannot, that is because this is almost epithelialized there. This is, again, in a track that's forming. It's pulling right through there. This one is on the outside. The bumpers come all the way through here. And you can see on CT up here, the bumper is in the wall of the stomach, if not in that track already. OK, so you can manage these. If they're not all the way, something like this, you can grasp with a small rat tooth forcep if you want and pull it in gently by jiggling and wiggling and pull it in, loosen the bumper, and watch how they do. This one, of course, is too far gone. You just take it out and let the site heal before you feed again. This one, too, you can try and get it out, but it's probably going to be harder to do, in which you might have to grab it with a rat tooth and really tug and dislodge that granulation that's formed. Gastrocolic fistulas do happen. They happen because a loop of colon got stuck in between. Most patients are asymptomatic. They don't present with obstruction because their stool will just go around that site. And all you need to do is when you exchange the tube, you'll go back in. And the way sometimes how you find it is you go in to pull the bumper out. You don't see the bumper. That's if it's sitting in the colon. Those patients usually present sooner with diarrhea. But if you go in and you see the bumper and you snare it out, and now when you put the balloon in, it doesn't go directly into the track. There's probably a second lumen in there and the colon is trapped. You can just close that colonics, put the balloon into the colon, and the second site will close down on its own if the nutrition is reasonable. Very, very rarely do you have to send these patients to surgery. So patient has put the tube in. Three days later, they say, oh, I pulled the tube out by mistake. That does happen. What you want to do is put patients, you get this proflex net that they can wear that's not as involved as a binder if they're compus mentis. If they're demented, a binder is a better idea so that they really can't get to the tube. And then what you want to do is if it's really early, you want to get the tube in if you can. Ideally, once you get it in, get a fluoro shot so that you can see that it's actually in the stomach and not in another track. And if it's peritoneal signs, of course, they go to surgery. You can prevent that by doing T fasteners. That's not routinely done. So these are little needles with a T tube at the end that you can put in. And we use that when we do direct pegs. So you fasten the stomach at multiple points to the anterior abdominal wall, and then you can push a direct peg in. But that's one way to prevent it. Really, what you want to do is always put some sort of netting or binding on the patient. Also, even if you have a completely normal patient who requires a tube for some reason, initially, the tube will drag and hang down. And that will alter the direction of the track. And then you have more leakage. So try and wear a bind at least until the track is completely formed for the first six weeks. And then you can let the tube hang free if you need to. If you get a call about a fallen out peg, you want to put something in that hole to keep the track open if you can. So if you're in an ER, you can put in a Foley tube or anything else that you might have. If it's starting to, these tubes will close down within, start to close down within 24 hours. And sometimes by 48 or 72, it's just a pinhole. And if that's the case, you can try and pass a, we use, I use flexible jag wires, 0.035s, and I'll see if I can jimmy that into the hole under fluoroscopy, make sure that it's coiling in the stomach, and then pass something over it, maybe just a pediatric feeding tube to begin with. And then you can upsize it with dilation over time. You can, if it's an old track and it's a well-matured epithelialized track, you can dilate at that same session. This is something you don't want to see. It's metastasis. So you can see how it's, you know, looks just like a tumor would or a polyp would in the colon or anywhere else. It's the same way. And so this is a metastasis. Like I said, if you have active cancer that's never been treated, you want to avoid pulling through this. You can do, IR is fine, they will put in a direct peg, but now you can do them endoscopically as well. And they're relatively easy to do, so I would recommend that. Another condition that you might consider doing it is if a patient's already on your table and you go in and you have a bunch of esophageal candidiasis. That used to be a contraindication to placement of, it still is a contraindication to a pull through peg because you can see that track with fungus, but that might be a case you could do a direct peg in. In contrast, this is granulation tissue. So it can look a little confusing if you're not sure, take a biopsy, but granulation tissue will be a small area right around where the peg tube comes out and it can bleed. Oftentimes patients will present with a little bit of oozing or bleeding at the site. You can treat it with these silver nitrate sticks. You just get a whole container. They tell me it's a couple of bucks and you can just use one stick and it burns that site. Sometimes we use APC as well. Patients are awake. They don't, doesn't, doesn't hurt to treat it. But that's the other thing you need to remember. And then all peg tubes that you currently have can be traction pulled. So you want to make sure that it's at least been there four to six weeks so that the track is mature. But if they've no longer a need for it, they can be pulled directly out. When you pull them out, most patients want a little sedation, but it's really very quick. So if you can talk them into doing it without, that's fine. Again, you want to splint around so that you don't pull the entire abdomen. And when it comes out, you want to make sure that the bumper is intact and part of it didn't fall out. The only contraindication to traction pulling is active anticoagulation. So if the patient is actively anticoagulated, you want to avoid traction pulling. If that's the case, you can do an, you do it with endoscopy. You go down with the scope, snare the bumper, cut it on the outside and bring that bumper out through the mouth. Replacement tubes are of all kinds, but the important thing to remember is most replacement tubes are balloons at the end, as you can see here. So you can replace with a bumper, but remember every time you put a bumper in and you put it back out, if the patient needs to be replaced, you need to have another endoscopy because you have to go and snare the bumper, pass another wire, repeat that process. Whereas a balloon can be a bedside exchange. And so ideally after the first year, you want to replace with a balloon. Ideally after the first year, most bumper tubes you can keep for nine to 12 months. Then you want to try and switch to a balloon tube so that the balloon can just be deflated and eventually you can teach long-term patients or their caregivers to do it for themselves. A low profile tube is one that ends right at the skin, the button right here, as you can see. This is not an ideal first replacement. In our practice, we don't do this as the first replacement only because the patient's still gaining weight or losing weight. That tube and that length is hard to identify. But once they've had it for a while, their weight is stable, then this is a really nice tube. It has nothing on the outside, just looks like a little button. And they have an attachment that they attach onto it and feed through that. Is that my bell or is that something else? OK. And I did tell you briefly, but there are other extensions. Jejunal tubes have got a long tail on them that you can trim as you need. You can get extensions that you can put through these. And you have gastrojejunal tubes that are all one piece. But that's too much for today's talk. So migration can occur if your bumper is really too loose on the outside. And now just with peristalsis, the balloon or the bumper is being dragged down. No tubes really have come without an external bumper anymore. So that's not as much of an issue. But if the patient tells you, every time I feed, I start vomiting, then you're thinking about, is this a gastric outlet obstruction? And you can see here on the CT, the bumper's sitting in the small intestine. And so that's something you want to think about. And it's very simple. You just get an image, and you can pull it back and tighten it. So you're called at 5 o'clock. The PEG tube is leaking or there's blood on the tube. What do you do? Always examine first. So if there's tenderness at the site, then you're worried about a buried bumper. Those are almost always painful. If there's a lot of leakage, you can always try and loosen it actually a little bit. Spin it, see how it does. What you want to avoid is putting too much gauze underneath that external bumper. Because if you do that, you're going to mask what's happening. And it causes the internal bumper to get really tight. If you've documented in your placement what that level was at, then you know where the patient is expected to be. Think about how long the patient has had the tube. If it's been a really long time, do they still need it? Always think about whether it's an original tube with a bumper or a balloon, because that's going to affect how you change it out. And then, like I said, you can spin it and see where you're at. And with that, I'll end. Any questions? OK, thank you.

feeding tubes

PEG tubes

indications for PEG insertion

nutritional requirement assessment

complications

tube replacement options

evaluation