Endoscopic Direct-PEG Placement in Patients Unable to Undergo Pull-PEG Procedure

Introduction Percutaneous endoscopic gastrostomy (PEG) tube placement is a frequently performed procedure to provide enteral nutrition in patients with dysphagia. Two methods are used for placing a PEG tube via the mouth: The "Pull" method and the "Push" method(1). In the "Pull" technique, the feeding tube is pulled from the mouth, through the esophagus and stomach to the outside. In the introducer-style "Direct" technique, the feeding tube is pushed from the outside to inside the stomach. Both these techniques are considered safe, effective, and have their own advantages and disadvantages(2).

Limitations of Pull PEG technique The "Pull" PEG technique is challenging in patients with head and neck malignancies, obstructing esophageal cancers, and laryngeal malignancies. The severe stenosis often precludes the passage of the adult endoscope as well as the large internal bumper of the feeding tube which must be pulled through the stenotic upper gastrointestinal tract. Further, microorganisms and malignant cells from the oropharynx/ esophagus can be pulled by the feeding tube leading to peristomal infections as well as metastatic deposits at the site of the gastrostomy(3,4). A prospective evaluation of "Pull" PEGs placed in patients with oropharyngeal and esophageal tumors revealed metastatic deposits of malignant cells in 9.5% of patients, 16 weeks after the PEG(5). Retrospective assessment of PEG placement for oropharyngeal cancer demonstrated abdominal wall metastasis of 0.64%(6).

Direct PEG technique The endoscopic Direct PEG (D-PEG) uses the Russel introducer technique which obviates the passage of the gastrostomy tube through the oropharynx. Further, it can also be performed with an ultrathin endoscope which is easy to navigate through stenotic or malignant upper gastrointestinal tract obstructions. The D-PEG requires performance of gastropexy (attachment of gastric wall to the abdominal wall using sutures) with anchor-like T-fasteners for easy and safe placement of the PEG tube(2).

The D-PEG is performed under endoscopic visualization of the gastric wall which facilitates greater control and allows safe selection of gastrostomy site. It also obviates the need for ionizing radiation. Further, the endoscope enables transillumination to confirm the absence of intervening abdominal viscera between the abdominal wall and stomach. These advantages are lacking in IR-guided PEG which does not offer endoscopic visualization of the gastric lumen.

Currently, patients who fail a per-oral Pull PEG tube placement are typically referred for IR-guided PEG placement(3). Thus, patients who fail a "pull" PEG procedure, are referred to IR for a second invasive procedure. However, with the availability of the D-PEG, patients failing a "Pull" PEG can undergo a PEG placement during the index procedure.