Complications related to percutaneous endoscopic gastrostomy J Gastrointestin Liver Dis December 2007 Vol.16 No 4, 407-418 Address for correspondence: S.P.Stawicki, MD OPUS 12 Foundation 304 Monroe Boulevard King of Prussia, PA 10406, USA E-mail: stawicki_ace@yahoo.com Complications Related to Percutaneous Endoscopic Gastrostomy (PEG) Tubes. A Comprehensive Clinical Review Sherwin P. Schrag 1 , Rohit Sharma 2 , Nikhil P. Jaik 3 , Mark J. Seamon 4 , John J. Lukaszczyk 3 , Niels D. Martin 5 , Brian A. Hoey 5,6 , S. Peter Stawicki 7 1) Department of Surgery, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN. 2) Department of Surgery, Easton Hospital, Easton. 3) Department of Surgery, St Luke’s Hospital and Health Network, Bethlehem. 4) Department of Surgery, Division of Trauma and Surgical Critical Care, Temple University School of Medicine, Philadelphia. 5) Department of Surgery, Division of Traumatology and Surgical Critical Care, University of Pennsylvania School of Medicine, Philadelphia. 6) Department of Surgery, St Luke’s Hospital and Health Network, BethlehemSt. Luke’s Trauma Center, Bethlehem. 7) OPUS 12 Foundation, King of Prussia, PA, USA Abstract Percutaneous endoscopic gastrostomy (PEG) has become the modality of choice for providing enteral access to patients who require long-term enteral nutrition. Although generally considered safe, PEG tube placement can be associated with many potential complications. This review describes a variety of PEG tube related complications as well as strategies for complication avoidance. In addition, the reader is presented with a brief discussion of procedures, techniques, alternatives to PEG tubes, and related issues. Special topics covered in this review include PEG tube placement following previous surgery and PEG tube use in pregnancy. Key words Percutaneous endoscopic gastrostomy – PEG – complications - endoscopy - management Introduction Percutaneous endoscopic gastrostomy (PEG), the modality of choice for long-term enteral access, was first described in 1980 by Ponsky and Gauderer (1,2). Several modifications of the original procedure have been described (3-6). Although generally safe, PEG tube placement is associated with many potential complications. To date, there have been no comprehensive reviews of PEG tube related complications. In an attempt to fill this void, we present a review that describes the most commonly encountered PEG complications as well as strategies for their avoidance. Methods A literature review was performed via the PubMed TM search engine from 1976 to 2007, using the search terms “PEG tube”, “PEG”, “complications”, “technique”, and “morbidity”. Relevant cross-referenced non-PubMed TM listed articles were also included. Three hundred thirty-two articles were found including randomized controlled trials, retrospective studies, case series, case reports, editorials, letters and abstracts. These sources were evaluated for relevance to current medical practices and goals of this review. PEG: indications and contraindications Indications PEG tubes have two main indications – feeding access and gut decompression (7). In patients who are unable to maintain sufficient oral intake, PEG tubes provide long-term enteral access. This commonly includes patients with temporary/chronic neurological dysfunction, including those with brain injuries, strokes, cerebral palsy, neuromuscular and metabolic disorders, and impaired swallowing. Significant head/neck trauma and upper aerodigestive surgery that preclude oral nutrition also constitute important indications. In patients with advanced abdominal malignancies causing chronic obstruction/ileus, a PEG tube can be used to decompress the intestinal tract. PEG tubes may also be useful in the setting of severe bowel motility disorders (8). Contraindications Absolute contraindications to PEG placement include pharyngeal or esophageal obstruction, active coagulopathy and any other general contraindication to endoscopy. Of the three principal safety tenets of PEG placement, endoscopic gastric distension, endoscopically visible focal finger invagination, and transillumination, only the latter has been successfully challenged. Stewart et al. placed 62