PEG application is the process of inserting a tube into the stomach through endoscopy and feeding from there in patients who cannot eat orally. It is generally applied to the elderly, patients with neurological diseases (such as paralysis, stroke, dementia, Alzheimer's, Parkinson's) or patients who cannot swallow due to brain tumors or head and neck tumors. It is sometimes applied in chronic neurological diseases such as ALS and Multiple sclerosis. Patients may be in nursing homes or hospital intensive care units. Sometimes he may be a home care patient. In some cases, PEG can also be applied to patients who can do their daily activities on an ambulatory basis but cannot only swallow.
Everything You Want to Know About Percutaneous Endoscopic Gastrostomy (PEG)
PEG is a pathway opened from the abdominal area to the stomach to provide daily food to patients who cannot feed orally. Unlike similar methods opened by surgery and radiology, it is an easier and more sustainable method. It was first described in 1980 and has evolved and become more practical since then. Its use has become widespread in the last two decades. It is a frequently preferred long-term enteral nutrition method because it is well tolerated by patients, does not require operating room conditions during the procedure and can be performed with superficial anesthesia, is relatively easy to apply, has a short procedure time and has a low risk of complications.
Why is PEG opening necessary?
In fact, nutritional support is absolutely necessary in patients who cannot feed orally. It is much better to give nutrients orally or to the gastrointestinal tract than to be fed intravenously. This type of nutrition keeps the patient's immune system alive and makes it easier to protect against vascular infections and other problems. Generally, nasal feeding tubes are placed in patients who will be fed for less than 4-6 weeks. But as can be expected, these tubes cause discomfort to the patient in the long term. For this reason, it is more comfortable for the patient and their relatives to undergo a PEG from the beginning for a patient whose nutrition does not improve or will not improve after about 1 month.
To whom will PEG be performed?
It is available to all patients who cannot take adequate nutrition orally and whose condition is expected to last longer than 1 month. knows. To give examples of these diseases:
Brain and nervous system diseases
• Confusion, loss of consciousness after stroke, paralysis, head trauma
• Inability to swallow as a result of damage to the nerves that provide swallowing function
• Eating tube tumors
• Head and neck tumors
• Amyotrophic lateral sclerosis
• Myasthenia gravis
• Dementia
• Such as advanced stages of Alzheimer's and Parkinson's disease
Apart from the diseases listed above, PEG can also be opened in many rare cases.
Are there situations where opening PEG is not possible?
Generally, it is necessary to be more careful in patients who have had surgery in the abdominal area. Because organs such as the large intestine may be stuck under the scar in the stitch area of the surgery. These organs (such as the large intestine) may be damaged while performing PEG. However, your doctor decides whether it is safe to open PEG using various methods. PEGmay be opened when deemed safe. Again, in overweight patients, the fat layer in the abdominal area may make it difficult or even impossible to insert a PEG. All of these are carefully reviewed by the doctor who will install the PEG. Naturally, if the patient has problems with bleeding or uses blood thinning medication or aspirin, this will prevent the procedure.
Is PEG insertion a difficult procedure for the patient?
The procedure It is performed under anesthesia. It is entered into the stomach with a small needle through the skin. Local anesthesia is also applied to this area. Therefore, it is not considered a painful procedure. In conscious patients, painkillers can be given for 1 day after the procedure. To prevent infections, patients are given a single dose of antibiotics before the procedure. Processing time is around 15-20 minutes, if everything goes well. After the procedure, patients can stay in the hospital for one night, or if they are in a controlled environment such as a nursing home, they can be monitored for 4-6 hours and sent away after the first feeding.
What benefits does PEG opening bring to the patient, what happens if PEG is not opened?
The answer to this question is different in different diseases. For examplein patients with dementia, PEG placement is sometimes Studies show that it improves the patient's quality of life. In addition, the situation becomes easier for caregivers. Placing PEG in patients suffering from stroke or brain hemorrhage provides protection from many infections in intensive care. PEG is a superior treatment approach in terms of faster recovery of patients and prevention of complications such as sinusitis seen in nasal feeding tubes. In neurological diseases such as ALS, PEG is a treatment that prolongs life and positively affects the quality of life. In cancer patients, PEG application is generally performed for esophageal cancer and brain tumors.
The aim is to ensure that these patients receive nutrition without interrupting their treatment until the treatment of esophageal tumors is completed. In brain tumors, since the nerves that enable swallowing are paralyzed, the patient's nutrition depends entirely on the PEG tube. Feeding tubes placed through the nose in these patients are not comfortable and are not suitable for long-term use. Apart from these diseases, PEGcan be opened for unconscious patients in intensive care and if the possibility of eating is not considered possible within 4-6 weeks.
If PEG is not opened, the patients Since they cannot get enough calories and nutrients daily, there is a collapse in the immune system, a tendency to infections and a delay in the healing process. A shortening of life expectancy may be expected in some diseases.
Which tubes are suitable for PEG?
PEGtubes can be of different types and sizes. Generally, tubes with a diameter of 18, 20 or 22 French (6,7,8 mm) are used in adults. These tubes are made of polyurethane or silicone. The advantage of silicone tubes is that they are thinner, while polyurethane tubes are softer. Apart from these, Foley catheters and similar tubes should not be used for feeding purposes. New PEG tubes include low-profile PEG tubes. These are suitable for patients who continue their daily activities. Since these PEG tubes do not have feeding tubes, they do not cause discomfort under clothing. When feeding is applied, feeding is done through appropriate adapters.
Who can perform PEG and where?
PEG application can usually be performed by a gastroenterologist and general surgeon. Operating room conditions are not always required for PEG placement. PEG application can be easily performed in well-designed endoscopy units. Contrary to popular belief, PEG infections are caused by the patient's own flora, not by environmental conditions. As the PEG tube passes through the patient's throat during placement, it carries the bacterial flora of that area to the PEG insertion site in the abdomen. Most of the PEG infections occur for this reason. To prevent this, the patient is given antibiotics before and after the procedure.
Can patients with PEG be fed orally?
A misunderstood point PEGOral feeding of the affected patients is completely stopped. However, although some patients can eat orally, PEG can also be administered to patients who cannot take in enough calories. Therefore, there is no harm in these patients continuing to take liquid foods orally in terms of PEG.
Does PEG cause addiction?
Especially In patients who have had a stroke, paralysis, or have lost the ability to eat as a result of head trauma, PEG is placed temporarily. When the neurological status of these patients improves, PEG is removed and oral feeding is continued. In this respect, PEG does not cause addiction in the patient, that is, there is no such thing as a patient who has undergone PEG being dependent on the PEG tube for life. In patients who are conscious and even continue their daily activities, it may be easier for the patient to receive rare PEG nutrition after PEG insertion. In this case, the doctor will overcome the situation with suggestions that will facilitate the patient's swallowing reflex.
How is PEG opened?
After the decision to open PEG, The patient's routine blood tests are performed and approval is preferably obtained from the anesthesia department. If the patient has additional diseases that would make PEG surgery difficult, the relevant departments are consulted. Blood thinning drug or ace If he/she uses prin, these are discontinued. If he/she has a prosthetic heart valve, the necessary antibiotics are given to protect against infection. In many centers, the patient is given intravenous anti-infective antibiotics about 1 hour before the PEG is opened. The procedure can be performed in operating room conditions or in well-designed endoscopy units. The patient's PEG procedure takes approximately 10-15 minutes if everything goes well. Mortality rates due to PEG procedure are very rare, 1%. Other complications are anesthesia-related complications such as puncture and bleeding that occur during PEG placement. However, these complications are extremely rare. Late complications are primarily infection at the PEG site. The incidence of this may vary between 1-5%. It usually occurs as a result of the throat flora being removed and moved to the wound area in the abdomen during the PEG insertion. Leaking around the PEG tube is another complication after starting nutritional products. In this case, the patient's nutrition is slowed down and the scar tissue is waited to close and stop the leakage (about 1 week). Many cases improve with this measure. In cases that persistently do not improve, inserting a one size larger PEG tube through the same opening will solve the problem. The rarer situation where thePEG tube is buried in the stomach tissue is treated surgically.
What should I do as the patient's relative after the PEG is opened?
AfterPEG is opened, we can monitor the patients for 6-8 hours and send them to nursing homes. However, it may be appropriate for patients coming from home to stay overnight. Feeding can be started even after 4 hours. Many centers wait up to 8 hours. It is necessary to start nutrition at a low intensity, with a nutritional product recommended by your dietitian, and at a slow pace. What you need to do at this stage is to check whether there is a leak around the PEG tube and to strictly comply with the hygiene and recommendations.
In our country, many of the nutritional product companies offer freePEG tube and nutritional products. He comes to the homes of patients and their relatives and provides education. You will also be given a phone number for any questions you may have.
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