The module covers:

1. Two different types of Balloon PEG- Button PEG (Low profile balloon gastrostomy tube)  and replacement balloon PEG
2. When to use which one and how

Low profile balloon gastrostomy tube (also called button PEG)

1. This is for the individual who is ambulatory and feels the long PEG tube is socially inconvenient (not to be confused with Replacement balloon PEG which also has got a balloon as a retaining device)
2. Once the tract is formed – remove the old PEG
   
   Picture1: The measuring device
3. Use the measuring device to measure the length of the tract
   
   Picture2: 16 French 3cm Corflo cuBBy PEG- low profile gastrostomy tube
4. Choose your balloon PEG – length and the French gauge- and get customized low profile balloon PEG for that particular patient
5. Accurate length is important as there is no sliding outer retaining device (in contrast to the Replacement balloon gastrostomy PEG) – so if the tube is longer than necessary it can bob up and down and  stoma will leak.
6. Introduce the lubricated tip of the Low profile balloon gastrostomy tube  gently into the tract
7. Inflate the balloon with the required amount of water
   
   Picture3: The extension tube to be attached just before feed
8. Before the feed- the attachment tube needs to be fixed – the blue mark on the attachment tube needs to be aligned with the blue mark on the button PEG and turned by 90 degrees
9. Once feed is over the extension tube is turned in the opposite direction and removed
10. Because of the extension tube needs to be repeatedly connected and disconnected -button PEG tends to wear out and needs replacement on a regular basis

Replacement balloon gastrostomy tube

1. This tube is placed if an old PEG has fallen/pulled out and there is a well formed and matured tract
2. Disadvantage over endoscopically inserted PEG is that it’s life is much shorter compared to the former.
3. Once the PEG falls out -the tract may close as early as 4 hours -so quick replacement (with balloon PEG or Foley’s catheter) is needed
4. Clean the stoma
   
   Picture4: The replacement balloon gastrostomy tube (not to be confused with button PEG or low profile device which also has got a balloon as a retaining device)
5. Insert the lubricated balloon PEG into the stoma gently and it should pass freely without much resistance
6. Inflate the balloon with water – 5-6ml
7. Pull the tube out until the balloon stops it- slide the outer fixation bumper snugly to the skin


Picture5: The extension tube with the Y connector

8. Attach the extension tube with the Y connector- one takes bladder wash syringe and the other- Luer lock syringe
9. After care- the patient or the carer to check the water amount in the balloon and top up as and when necessary

Here are the links for button PEG and replacement balloon PEG insertion video’s respectively:

Button PEG

http://www.youtube.com/watch?v=hSv4FOwZ9kQ&feature=related

Acknowledgement/Bibliography:

1. Guidelines for enteral feeding in adult hospital patients : BSG 2003
2. Novotny NM et al. Percutaneous endoscopic gastrostomy buttons in children: superior to tubes. J Pediatr Surg. 2009;44(6):1193-6
3. Heiser M et al. Balloon-type versus non-balloon-type replacement percutaneous endoscopic gastrostomy: which is better? Gastroenterol Nurs. 2001 Mar-Apr;24(2):58-63
4. Product guide of the respective companies- Merck Serono and Flocare

http://www.youtube.com/watch?v=hqsaWOTG2ZQ

1. Different types of NJT
2. How to do it
3. Aftercare

Different types of NJT

1. Freka Endolumina- is 8Fr and it is placed through the biopsy channel of the scope (TTS- through the scope)
2. Corflo- is 10F and is placed over a guide wire and it does not go through the biopsy channel
3. Flocare Bengmark Naso-Intestinal tube- inserted non-endoscopically using normal peristalsis-see the video link below

How to do it

TTS type ( Freka Endolumina)

1. It comes with a length of 270cm and 8Fr (2.6mm outer diameter) and so is compatible with the instrument channel of the endoscope ( >=2.8mm)
   
   Picture1: The Freka NJT
2. Insert the scope orally and advance it as far as possible through the stomach towards the intestine
   
   Picture2-4: Freka NJT going through the biopsy channel and the endoscope being removed subsequently keeping the NJT in
   
3. Once the desired position has been reached, advance the intestinal tube (NJT) through the instrument channel of the scope to reach under observation a position distal to the ligament of Treitz. The distal tip of the tube may be moistened with sterile water to assist insertion.
4. Approx 100-105cm mark should be at the incisor level when the tip is in jejunum.
5. Withdraw the scope with rotating /jiggling motion otherwise the friction between the scope and the NJT will pull the tube out
6. Feed more NJT as the scope comes out
7. Assistant holds the end of the scope as it comes out of the mouth and then holds the NJT at lips while the scope is removed
8. So now the NJT is placed but coming out through the mouth which needs to be re-routed through the nostril.
   
   Picture5 and 6: The NJT is being re-routed through the nose: Courtesy Fresenius Kabi
9. Pass a NG  tube (16 size) / blue re-routing catheter  through the nostril
   
   Picture 7: Re-routing catheter, silicone oil, adhesive dressing and Magill’s forceps
10. Grab it from oropharynx with a Magill’s forceps ( +/-  using laryngoscope) and pull out through mouth
11. Ensure that the tube is in position against the rear wall of the pharynx without any loops.
12. Cut the end of the NG tube with a scissors/ No cutting if it is a re-routing catheter
    
    Picture 8: The NJT is passes easily through the re-routing catheter when lubricated with silicone oil
13. Thread the NJ tube  into the lumen of the NG  tube or the opening of the re-routing catheter
14. Pull out the NG tube from the nostril and at the same time looking inside the mouth (+/- with the help of a  laryngoscope and of the Magill’s forceps). Make sure the NJ tube is not slipping out of the oesophagus upwards.
15. The NJT is now in trans-nasal position
16. Cut the NJT to desired length and advance the fastening screw over the NJT
    
    Picture 9 and 10: The fixing of the Luerlock connector: Courtesy Fresenius Kabi
17. Insert the metal pin of the Luerlock connector as far as possible into the NJT and screw the fastening screw tightly to the stop.
18. Thread in the connectors
19. Tape the NJ tube at nostril with a y shaped Elastoplasts (stem of the Y on bridge of the nose limbs surround the NJT) and also at the side of the cheek and also behind the ear.
20. Record the length of the tube at nostril and document in the tube care plan.

Corflo PEJ

1. This is a bigger tube and has to guided over a guide wire
2. Insert the scope orally and advance it as far as possible through the stomach towards the intestine
3. Once the desired position has been reached, advance the guide wire through the instrument channel of the scope to reach under observation a position distal to the ligament of Treitz.
4. Approx 100-105cm mark should be at the incisor level when the tip is in jejunum.
5. Withdraw the scope keeping the guide wire in
6. Feed more guide wire as the scope comes out
7. Assistant holds the end of the scope as it comes out of the mouth and then holds the guide wire at lips while the scope is removed
8. So now the guide wire  is placed but coming out through the mouth which needs to be re-routed through the nostril.
   
   Picture 11: Re-routing catheter
9. Pass a supplied re-routing catheter  through the nostril
10. Grab it from oropharynx with a Magill’s forceps ( +/-  using laryngoscope) and pull out through mouth
11. Ensure that the tube is in position against the rear wall of the pharynx without any loops.
12. Thread the guide wire  into the lumen of the re-routing catheter
13. Pull out the re-routing catheter  from the nostril and at the same time looking inside the mouth (+/- with the help of a  laryngoscope and of the Magill’s forceps). Make sure the guide wire  is not slipping out of the oesophagus upwards.
    
    Picture 12: The Corflo NJT with pre-fitted connector
14. Next thread the NJT over the guide wire. Before threading the NJT over the guidewire, flush the tube with 20 ml of water, using a syringe inserted into the access port. Also dip the distal end of NJT in water. These steps are crucial as this flushing and dipping activates the C-19 lubricant to facilitate tube passage over the guidewire.
15. It comes ready with the attachment. So just fix it with adhesive dressings.

Aftercare

1. AXR to confirm the position- the NJT should be free of tension and straight i.e. without loops, in a position distal to the ligament of Treitz.
2. Remember to flush the NJT with 30ml of cool boiled water before and after the feed or at least once a day.
3. It can remain in position for up to four weeks if the tube and the nose are carefully cared for. If enteral feeding is needed after this a PEG-J is recommended.

Here is the link for Naso-jejunal tube insertion video:
No video found so far. One good link is given below for non-endoscopic naso-jejunal tube insertion. http://www.youtube.com/watch?v=HUv13Xy0GwE

Acknowledgement/Bibliography:

1. Guidelines for enteral feeding in adult hospital patients : BSG 2003
2. Niv E et al. Post-pyloric feeding. World J Gastroenterol. 2009 Mar 21;15(11):1281-8.
3. DiSario JA. Endoscopic approaches to enteral nutritional support. Best Pract Res Clin Gastroenterol. 2006;20(3):605-30.
4. Product guide of the respective companies- Fresenius Kabi, Merck Serono and Nutricia

The module covers:

1. Indication of PEG-J tube
2. Contra-indications
3. How to insert a PEG-J tube
4. Aftercare
5. What are the complications

Indication of PEG-J tube

1. Patients with Gastroparesis requiring long term feeding
2. Gastric outlet obstruction as long as obstruction is not impassable
3. Recurrent aspiration pneumonia (although aspiration can still occur from reflux of stomach contents)

Contraindications:

1. Gross ascites
2. Ongoing chest infection
3. Coagulopathy
4. Dementia/Persistent vegetative state

How to insert a PEG-J tube

1. A PEG tube is first placed as usual
   • Just after the PEG is inserted and before the intestinal tube goes through the PEG tube – slide the outer retaining device of the PEG tube, then the pinch valve and then the blue white ring which holds the PEG Y connector over the PEG tube. Do not connect the PEG Y connector at this stage
2. After putting few drops of silicone oil inside of the PEG tube the Intestinal catheter is introduced through the PEG tube and once the tip (weighted bolus) is seen in the stomach, it is grasped with a snare
3. Endoscope is advanced into the pylorus and then into the duodenum
4. If enterosocpe is used the intestinal catheter can be passed into the jejunum but use of enteroscope is  not necessary routinely as the snare can be pushed into jejunum.
5. A forceps can be used as an alternative  to guide the intestinal tube and some might prefer a forceps over a snare as deep inside the jejunum when you are releasing the tip of the intestinal tube you are better assured that the device ( snare/forceps) is properly detached from the tip and not pulling out the intestinal tube on it’s way out.
6. Once the snare is released the assistant can  feed in more intestinal tube by simply pushing more tube in
7. Withdraw the endoscope from the duodenum  taking care that the intestinal tube is not dislodged
8. Once the endoscope is in the stomach remove any loops in the intestinal tube by withdrawing it and then the endoscope  can be withdrawn completely.
9. Next step are the connections of all the adaptors in proper order which can be confusing if not seen before
10. For a Freka PEG-J
    
    Picture1: In order from left: Outer retaining device:2 quick release clamp: 3 blue white ring
    • As mentioned before  ( this step has already been executed before the intestinal tube went in )-Just after the PEG is inserted and before the intestinal tube goes through the PEG tube – slide the outer retaining device ( item no 1 in the above picture) of the PEG tube, then the quick release clamp ( item no 2 in the above picture)  and then the blue white ring  ( item no 3 in the above picture) which holds the PEG Y connector over the PEG tube. Do not connect the PEG Y connector at this stage as this increase the friction while the jejunal tube is being passed.
      
      Picture2 : In order from top:1 intestinal luer lock:2 click adaptor:3 PEG  Y connector:4 blue white ring which holds the PEG Y connector
    • After the intestinal tube is positioned and the endoscope is withdrawn – slide the PEG  Y connector ( Item no 3 in above picture ) OVER THE  intestinal tube and fit with the locking device ( Item no 4 in above picture-blue white ring ) already in place on the PEG tube by twisting. The outer white plastic ring would break off leaving the blue ring behind
    • Next slide the click adaptor ( Item no 2 in above picture)  over the intestinal tube and press hard onto the PEG Y connector – you will hear a click
    • Then cut the intestinal tube to desired length and push in the metal pin of the intestinal luer lock ( Item no 1 in above picture)  into the cut end of the intestinal tube.
    • Next advance the intestinal luer lock into the click adaptor and then screw in the click adaptor into it by turning  the PEG tube – AND NOT BY TURNING THE INTESTINAL TUBE – which if done might  dislodge the intestinal tube from the jejunum
11. If using a CORFLO     PEG-J
    
    Picture3: Inner bumper, outer retaining device and quick release clamp Picture4: CORLOCK TWOOMEY Y adaptor Picture5: Not to use CORLOCK-CORPORT Y adaptor
    • As mentioned before  ( this step has already been executed before the intestinal tube went in )-Just after the PEG is inserted and before the intestinal tube goes through the PEG tube – slide the outer retaining device of the PEG tube, then the quick release clamp and then the PEG Y connector ( called CORLOCK TWOOMEY Y ADAPTOR)  over the PEG tube. Normal PEG comes with a CORLOCK-CORPORT Y ADAPTOR which  should not be used with a jejunal tube.
      
      Picture6: Sequence of attachments: Courtesy Merck Serono
    • Seat the silicone plug in the straight limb of the Y connector gently  and introduce the jejunal tube through this
    • After the intestinal tube is positioned and the endoscope is withdrawn  seat the silicone plug firmly into the  Y connector
    • Slide the Adjust-a-Sleeve cap over the jejunal tube and screw it to the Y connector
      
      Picture7: The pink stylet is next to be removed after flushing the side port
    • Remove the stylet from the jejunal tube after flushing the side port with 10ml water.
    • Then cut the intestinal tube to desired length and attach the administration set to the end of the jejunal tube.

Aftercare

1. Aftercare is exactly similar to PEG except that the jejunal tube must not be rotated because of the risk of dislodgement of the intestinal tube from jejunum.
2. Another difference is that AXR is needed to verify position of the tip.
3. The jejunal tube will last up to 6 months and then it needs to be replaced. The PEG should last for as long as it remains functional.
4. Hygiene is of utmost importance as there is no acid barrier in the jejunum as in the stomach
5. To prevent buried bumper syndrome PEG tube aftercare advise include rotation of the tube regularly – for PEG-J however that is contraindicated- instead just push the bumper in and pull back.
6. Additional aftercare is in common with aftercare of PEG
7. Observe the stoma for leakage, inflammation
8. Remove keyhole dressing after 24hours if any applied
9. Clean the skin around the tube with saline water
10. Feeding is usually commenced after 6-12 hours starting with sterile water (refer to local dietician’s protocol)
11. Commence 4 hourly flushing with 20mls of sterile water using a 50ml syringe
12. Flush with 20ml of sterile water before, during and after medication and enteral feed
13. Flush the gastric port with 20ml of sterile water once daily if no contraindication (e.g. gastric outlet obstruction)

Complications:

1. Intraabdominal wall abscess
2. Necrotising fasciitis
3. Peritonitis
4. Colonic perforation
5. Haemorrhage
6. Localised infection
7. Leakage or blockage of the tube
8. Pressure necrosis
9. Mucosal overgrowth around the gastric retaining device
10. Misplacement of the jejunal tube

PEG-J insertion video:
Nothing available online but an excellent DVD available from St Marks/ Fresenius Kabi ( Freka ) which also demonstrate all other enteral feeding access

Acknowledgement/Bibliography:

1. Guidelines for enteral feeding in adult hospital patients : BSG 2003
2. Adler DG et al. Percutaneous transgastric placement of jejunal feeding tubes with an ultrathin endoscope. Gastrointest Endosc 2002; 55: 106-110
3. Sibille A et al. An easier method for percutaneous endoscopic gastrojejunostomy tube placement. Gastrointest Endosc 1998;48(5):514-7.
4. Bumpers HL et al. A simple technique for insertion of PEJ via PEG. Surg Endosc1994 Feb;8(2):121-3.
5. Product guide of the respective companies- Fresenius Kabi and Merck Serono

1. Before you even start
2. Different types of PEG tubes
3. How to do it
4. Aftercare
5. How to remove a PEG tube
6. What to do when PEG tube falls out

Before you even start

1. Patient must have seen a dietician, SALT team and a gastroenterologist –all of whom along with the patient/carer must concur that PEG insertion would be in the best interests of the patient
2. Take consent- use form 4 if unable to consent and the placement is felt to be in the best interests of the patient
3. The patient should be NPO for at least 4 hours
4. Antibiotic prophylaxis with a single shot IV antibiotic an hour before the procedure
5. IV sedation if needed

Different types of PEG tubes

1. The main difference between types of tubes are the type of the gastric retaining devices- collapsible e.g. Corflo  and non collapsible e.g. Freka. The non collapsible PEG  is removed with help of endoscopy whereas the collapsible ones are removed transcutaneously.
2. Size of the tube- French or Charriere- CH 12/14/16/18/20. The narrower the gauge the better is the patient tolerance ( 1F=0.3mm eg 12F=3.6mm)

How to do it

1. Percutaneous endoscopic gastrostomy is performed in a supine position and requires two operators, one for endoscopy and one for tube insertion
2. After the endoscope has been passed into the stomach turn the patient on the back
3. Locate the position for insertion of the PEG tube on the anterior abdominal wall by: a. Transabdominal impulse- endoscopically visible bulging when assistant presses the wall. b. Diaphanoscopy i.e.transillumination of the endoscopic light through the abdominal wall at the puncture area. However, lack of diaphanoscopy is no longer a contraindication for PEG tube insertion. c. Negative needle aspiration test (using a syringe containing 5ml saline solution, puncture under continuous aspiration towards the air-filled stomach without prior air aspiration) is safer than an adequate diaphanoscopy
4. A mark is made on the abdominal wall once a site is chosen by firmly pressing a needle cap.
5. The assistant can stand on either site with the  instrument trolley next to him/her.
6. The  chosen puncture site is cleaned extensively using aseptic technique
7. Inject local anaesthetic through all layers of the abdominal wall, slowly advancing the syringe into the gastric lumen- air is aspirated from stomach lumen
8. Make a stab incision of approximately 3 mm for tube size  CH 9, 4-5 mm for tube size CH 15 ( blue) or 6-7 mm for tube size CH 20 into the skin
   
   Picture1 and 2: The trolley and the actual kit for Freka PEG
9. Advance the puncture cannula into the stomach under direct endoscopic view
10. Then remove puncture needle from the cannula
11. The safety air valve automatically closes the lumen of the cannula as soon as the needle is taken out
    
    Picture 3 and 4: The different pieces inside the kit: Courtesy Fresenius Kabi
12. By this time the endoscopist has introduced the endoscope into the stomach and introduced a snare through the biopsy channel.
13. Attach the blue introducer device to the plastic cannula and advance placement wire (double thread)  into the stomach quickly and remove the introducer device immediately, otherwise stomach will deflate
    
    Picture 5: The snare over the plastic sheath- has to be repositioned so that it catches only the placement wire leaving the plastic sheath
14. As soon as the placement wire (double thread)  is visible in the stomach catch it with a snare
15. Steady the snare/biopsy forceps with respect to the endoscope and pull out everything through the mouth Picture 6: Looping the loop
16. Fix the loop the PEG tube with the loop of the placement wire (double thread)  in an interlocking fashion and smear the PEG tube with liberal amount of KY jelly before introduction ( first put placement wire through PEG tip wire loop and then pass the PEG bumper through the placement wire loop and pull the bumper out to lock the two loops together)
17. Now pull the guiding thread through the puncture cannula with your left hand, and at the same time guiding the lubricated PEG tube through the mouth with the right hand
18. When the tip of the PEG tube reaches the puncture cannula, a resistance will be felt. At this point, remove the puncture cannula and further pull will bring out the conical end of the PEG tube through the incision
19. Pull the PEG tube through the abdominal wall until the inner retention plate abuts the inner gastric wall
20. Pull on the tube until  elastic resistance is felt and keep under tension
21. The inner retention plate should be able to be rotated freely and there is no need to check  the retention plate by reintroducing the endoscope
22. Cut the guiding thread of the PEG tube close to the cone
23. Pass the conical end of the PEG tube through the hole of the fixation plate and then through the tube clamp
    
    Picture 7: Fixation of the outer retaining device and rest: Courtesy Fresenius Kabi
24. Close the tube clamp and then cut off the cone of the tube
25. Push the end of the tube through the fixing screw and then push the pin of the Luer-Lock connector as far onto the tube as possible and secure it by turning the fixing screw
26. Pull off the screwing aid (outer white ring) in a downward direction and discard the white ring.
27. Clean and dry the puncture site, fixation plate and tube thoroughly
28. The fixation plate should be snugly fitted to the abdominal wall and should remain under moderate tension for 24 hours to promote good adaptation of the stomach wall to the abdomen the wall. Keep a record of the mark at abdominal wall ( normally 3-4cm)
29. After 24hours, the tube should be loosened. Leave 5 mm free play between the skin and the fixation plate.
30. For intra-gastric feeding a fasting period after peg placement of at least 1-2 hours is recommended. Some authorities suggest fasting period of 6-8hours to prevent chance of peritonitis.

The variation for a Corflo PEG

Picture 8: Inner retaining plate of the Corflo PEG: Other end with the loop
1. The retaining device for a Corflo PEG is collapsible so that it can be pulled out after cutting the tube few cm outside of the abdominal wall.
   
   Picture 9: Fixing the outer retaining device of the Corflo PEG
2. The first piece of the outer retaining device has got a 90 degree bend and the PEG tubing is pressed into the groove of it the second piece is pushed into the first piece
   
   Picture 10: The sequence of different pieces for the Corflo PEG
3. The sequence of the inner retaining device, two piece outer retaining device and quick release clamp
   
   Picture11: The CORLOCK-CORPORT Y Adaptor : Courtesy Merck Serono
4. Untwist the skirt from the Y adaptor (CORLOCK-CORPORT Y adaptor )and pass the PEG tube through the narrow end of the skirt
5. Push the PEG tube onto the barbed end of the Y-adaptor
6. Push the skirt onto the Y-adaptor

Aftercare

1. Ideally before the first feed is started the patient should be seen by the dietician who explains it to the patient or the carer.
2. For daily cleaning -loosen the clamp device of the outer fixation plate and pull back the fixation plate
3. Carefully clean the puncture site, the tube and the underside of the fixation plate and let the puncture site dry properly
4. Push the tube carefully 3-4 cm into the stoma and rotate through 180 degrees every time the dressing is changed. At least once a week but no more than once a day. It is important for the tube to move freely in the stoma to prevent the retention plate becoming embedded(buried bumper syndrome)
5. Then pull and that you gently until resistance is felt, and  push the fixation plate back to snugly fit to the skin with a free play of 5mm.
6. During  the first wound healing phase, the dressing should be changed daily; after that, the frequency of dressing changes will depend on the condition of the site in question (approximately every 2-3 days)
7. The puncture site should rechecked by a health care professional  at least once a day in the first week after the tube has been positioned.
8. In any case, the dosage of the feed should be increased gradually. For pump controlled continuous tube feeding, which is the preferred method, always use the enteral feeding pumps which are commercially available

How to remove a PEG tube

Notes on Freka PEG tube removal (needs endoscopic removal)

1. Insert the gastroscope into the stomach
2. The assistant cuts off the luerlock adapter and remove the tube clamp and the outer fixation plate
3. Advance the tube into the stomach slightly
4. Catch the inner retention plate with a snare and cut the tube off at level with the abdominal wall and pull the inner plate with rest of the tube out with the gastroscope
5. Then apply an adhesive dressing. Patient can eat immediately after removal of a PEG tube.
6. Some trusts cut the Freka PEG tube close to the skin and push it into the stomach (this method should not be used if there is any suscpicion of distal stricturing ) and expect the inner rigid retaining device to be passed per rectum in due course (not advised by the company)

Notes on Corflo  PEG tube removal (does not need endoscopy for removal)

1. Remove the fixation device
2. Make sure the inner bumper is rotating freely before pulling the tube
3. Cut the tube 4-5 inches away from the abdominal wound (this also cuts a small capillary tube inside the tube which deflates the inside bumper
4. Pull the tube out while stabilizing the exit site with fingers
5. The hole should close in 24hours

What to do when PEG falls out

1. The tract even it is established can close very fast (within 4 hours)- so to maintain the patency at least a similar French size Foley catheter needs to be inserted into the stomach.
2. Do not use anything more than mild pressure to insert a Foley’s catheter
3. Then later when available either change that to a replacement balloon PEG which can be inserted at bedside ( easy and quick but short lifespan and needs change) or endoscopic reinsertion of PEG (needs endoscopy but long life) or a RIG tube (radiologically inserted gastrostomy) can be placed without the need for screening ( advantage of non-balloon collapsible inner retaining device and no need for endoscopy and longer life compared to replacement balloon PEG)
4. Don’t confuse replacement balloon PEG with low profile button PEG ( which is normally used for cosmetic reason)
5. If there is a tract but uncertainty where that is leading up to – guidewire can be inserted with caution and a PEGogram obtained to confirm intragastric location.

Complications of PEG insertion:

1. Intraabdominal wall abscess
2. Necrotising fasciitis
3. Peritonitis
4. Colonic perforation
5. Haemorrhage
6. Localised infection
7. Leakage or blockage of the tube
8. Pressure necrosis
9. Mucosal overgrowth around the gastric retaining device

Here is the link for PEG insertion video:

Further reading: Indications, Insertion, Trouble shooting, Buried Bumper Syndrome and Patient information

Acknowledgement/Bibliography:

1. Guidelines for enteral feeding in adult hospital patients : BSG 2003
2. Angus F et al. The percutaneous endoscopic gastrostomy tube. Medical and ethical issues in placement. Am J Gastroenterol 2003; 98: 272-277
3. Korula J et al. A simple and inexpensive method of removal or replacement of gastrostomy tubes. JAMA 1991; 265:1426-28
4. Product guide of the respective companies- Fresenius Kabi and Merck Serono

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