Deconstructing the steps of full-type percutaneous endoscopic gastrostomy tube insertion. Percutaneous endoscopic gastrostomy, or PEG, is the preferred feeding route for patients requiring medium to long-term enteral nutrition. It is the better alternative to surgical methods since it is safer and more cost-effective, with lower procedure-related mortality and complication. There are three different methods of PEG tube insertion, the pull technique, push technique, and introducer technique. Pull technique is the standard method used, however, it is contraindicated in patients with head and neck or esophageal cancer due to the risk of tumor seeding. The main indications of PEG insertion are enteral feeding in patients with inadequate oral intake, neurologic conditions, or head and neck tumors, as well as decompression in patients with bowel obstruction. On the contrary, contraindications for PEG include recent GI bleeding, coagulopathy, sepsis, severe ascites, peritoneal carcinomatosis, hepatomegaly, gastric viruses, and bowel ischemia. This is the case of a 69-year-old male who stroked with dysphagia. He was referred for PEG tube insertion to sustain his nutritional status. Here are some of the pull-type PEG kits available in the market. A pull-type PEG kit is comprised of a drape, scalpel, cannula with needle, looped wire, a snare, the desired feeding tube, tube clamp, external bolster, twist lock, and the feeding port adapter. Illustrated here is the recommended endoscopy unit setup for performing PEG insertion. The procedure involves two proceduralists. One is the endoscopist and an assistant who performs the sterile PEG procedure. Ensure that all accessories are adequately prepared and the nurse assistant is positioned on the right side of the proceduralist. With the patient in the supine position, the first and most critical step is finding the area of the PEG site. Apply adequate stomach insufflation to bring the gastric wall in contact with the abdomen. Direct the tip of the gastroscope toward the anterior wall and activate the transillumination function on the endoscope processor. Look for an externally visible bright red or orange light on the abdominal wall. If necessary, you may need to dim the room light for better visualization. Apply digital pressure at the point of maximal transillumination and look for an indentation in the gastric wall through the endoscopic view. Mark the selected PEG site, which is typically two centimeters below the left costal margin. Avoid areas near the syphoid process or any previous surgery scar. After marking, clean the area thoroughly and drape the entire abdomen, leaving the PEG site exposed. Implementing a sterile procedure and administering prophylactic antibiotic are important measures to prevent both immediate and post-procedure infections. Typically, a penicillin or a cephalosporin-based antibiotic is administered, but the choice may vary based on the institution's established guidelines or the patient's allergy status. Once the abdomen is draped, confirm the marked PEG site with finger indentation using a sterile glove. Then, infiltrate the skin and its deeper layers with the local anesthetic. Apply constant negative pressure on the syringe while advancing the needle into the stomach. Observe for air bubbles, stool, or blood as you push the needle. If you see air bubbles in the syringe before puncturing through the gastric lumen, an interposed viscose may have been punctured apart from the stomach. In such cases, look for an alternative entry track. In the absence of air bubbles, further advance the needle until it reaches the gastric lumen as confirmed through the endoscopic view. Withdraw the needle and continuously inject anesthesia. Next, make a one-centimeter transverse abdominal ball incision. Then, insert the cannula with needle under endoscopic visualization. Once inside the gastric lumen, withdraw the needle and leave the cannula in place. Advance the looped wire through the cannula while the endoscopist waits for the wire to exit and grabs it using an endoscopic snare. Upon securing, withdraw the gastroscope along with the looped wire. Once the scope is out, open the snare and release the wire. Secure the PEG tube to the oral end of the looped wire by creating a knot. To do this, insert the wire tip through the loop at the tapered end of the feeding tube. Then, open the looped wire and pass the internal bumper of the PEG tube through it to create a square knot. Lubricate the PEG tube adequately from the knot to the internal bumper. Then, pull the wire from the abdominal wall end to extract the PEG tube. Continue pulling the wire until you feel a resistance. This resistance is due to the tapered end of the PEG tube against the anterior wall of the stomach. Next, anchor the wrist of your other hand in the patient's abdomen. Support the incision and apply a firm, steady upward traction to pull the tube. If there is substantial resistance, you may extend the incision to allow tube passage. Once the tapered end exits, continuously pull the tube until the internal bumper is against the gastric wall. Reinsert the gastroscope to confirm correct placement. Once confirmed, detach the looped wire from the PEG tube. Insert the external bumper and slide it down near the skin. Then, attach the twist lock to secure the bumper. Insert and advance the tube clamp near the bumper. Leave at least one centimeter gap between the external bumper and the skin to avoid tension. Cut the excess tube at the X mark and lock the tube clamp to prevent air leakage. Finally, connect the feeding port and clean the PEG site. While PEG tube insertion is generally considered a safe procedure, periprocedural complications such as aspiration, perforation, peritonitis, and bleeding may still occur. Transient subclinical pneumoperitoneum is frequently observed but is typically not considered significant. These complications may not manifest immediately. Therefore, it is important to closely monitor the patient's vital signs, particularly within the first two hours after the procedure. On the other hand, the most common post-procedure complication is infection at the PEG site. Wound infections are mainly caused by contamination of the internal bumper by bacteria. Unlike the push or introducer PEG, in pull technique, there is a risk of introducing oral bacteria into the peristomal site as the tube is pulled. Pre-procedural oral care and administration of prophylactic antibiotic 30 minutes before the procedure can minimize this risk. In our case, the patient did not develop any complication. After PEG tube insertion, enteral feeding and medication administration may be started within three to four hours if with no complications. Flush the tube with adequate amount of water before and after feeding and medication administration. The peristomal area should be cleaned daily and kept sterile. In the event of inadvertent tube dislodgement, seek prompt assessment at the hospital, particularly if the tube is less than four weeks old. In conclusion, pull technique is the standard method for PEG tube insertion. The procedure is safe, straightforward, and can be easily replicated without the need of special equipment and accessories. Our video has deconstructed and provided stepwise instructions on the performance of pull-type PEG insertion. This will enhance understanding, retention, and promote safety and consistency in the learning process.

percutaneous endoscopic gastrostomy tube insertion

PEG tube insertion methods

pull technique

sterile technique

post-procedure care