peg, rig or surgical gastrostomy? a why, where, when & how ... · peg, rig or surgical...
TRANSCRIPT
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PEG, RIG or Surgical Gastrostomy? A why, where, when & how guide to
gastric tube placement
Alison YoungConsultant Nurse in Nutrition
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• Brief over view of decision making• Via the safest route.• With minimal risk and complications.• Achieving effective outcome
Aims of this session
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Why a Gastrostomy Tube?
• Diagnosis - if they have one• Reason for enteral nutrition• Assessments and/or imaging studies• Can the patient swallow their own saliva?• Dietetic input, what’s been tried/failed?• Screening for contraindications.• What is the patients’ long term prognosis?• Ethical guidelines. Is a case conference required?
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What is the device being used for?
• Feed, fluids and/or medication • Venting• Type or size of the device• Who is going to manage the device?• Implications on lifestyle?• Replacement and repair
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Gastrostomy Tubes
• Which one do you choose?• Placement techniques• Risk, benefit and alternative• Clear management/post placement
guidelines• Trouble shooting
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Options• PEG
Percutaneous endoscopic gastrostomy– Quick – good tubes
• RIGRadiologically inserted gastrostomy– No endoscope – avoids mouth
• Surgical placement- No endoscope – avoids mouth – But which tubes can we use
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How do you decide on placement techniques?
• Depends on why they need the tube• Is it safe to do a pull through PEG• Is it safer to do a direct puncture• Is endoscopy safe, sedation or GA• Is there capacity in radiology?• Do theatres have the correct equipment?
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Pull-Through PEG
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Advantages• Simple technique• Range of devices available
• Size• Material• Internal fixator• External fixation
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DisadvantagesØRequires endoscopy
• Difficult in advanced tumours• Mouthguard• Airway management
ØPEG bumper pulled through mouth• Site infection• Tumour seeding
ØPEG removal / retrieval
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Russell Introducer Method
(AKA Direct Puncture or Push PEG)
• Balloon-retained tube
• Inserted directly through abdo wall
• Seldinger technique – dilators• Large “cutting” trocar needle
• Split introducer – peel away
• Gastropexy
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PEXACT (Endoscopic “Direct Puncture” PEG)
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MIC Introducer
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Kimberly-Clark MIC - Endoscopic Placement
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Advantages• Aseptic technique• Well tolerated• Direct placement of “Button”• Endoscope provides view only• Ultrathin (nasal) endoscope
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Disadvantages
• Less familiar technique
• More complicated procedure
• Still needs endoscopy
• Difficult if “target” restricted
• Balloon-retained device
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Radiologically Inserted Gastrostomy (RIG)
• Have you got a dedicated and skilled interventional radiologist available?
• Timing and ease of access to this service provision?
• Types of devices available
• Who do they contact if problems?
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Small-bore RIG: Problems• (Gastropexy)
• Re-intervention rate ~30%
– Blockage
– Displacement
• No replacement
• (No jejunal extension)
Laasch, Lawrance et al. Clin Radiol 2003;58(5)
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Seeding to PEG site
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Gastro-Colo-Cutaneous Fistula
http://webmm.ahrq.gov/case.aspx?caseID=277
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Summary• Why we doing it?• Who is going to look after it?• What does the patient think?• Can the patient get replacement devices
locally?• What capacity do we have?• Planning and effective safe care
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For more details please contact:
Royal Liverpool and Broadgreen University Hospitals NHS Trust
T:
M:
E:
Thank you.
0151 706 3650
07717808585
Alison Young
Consultant Nurse in Nutrition