Neurological dysphagia (along with cancer-related reasons) is one of the most common reasons for referral for PEG tube insertion. Dysphagia is a common finding after a stroke and it’s incidence is reported to be as high as 45% among those admitted to hospital[15]. Some experts recommend that patients who are not able to meet their nutritional needs by oral intake, should be started on nasogastric (NG) tube feeding in the first 24 h after their stroke[16]. Nasogastric tube feeding alone may be enough in patients who need nutritional support for less than 4 wk, but PEG tube placement needs to be considered for longer periods[17]. PEG feeding provides a safe and reliable means of nutrition in stroke patients and its superior long-term results over NG tube feeding have been demonstrated[18,19]. Early PEG nutrition is also desirable in stroke patients, but the decision must be weighed up in patients with temporary dysphagia or those with short life expectancy due to underlying diseases. At least a two-week wait time for PEG insertion is clinically appropriate to evaluate its medical necessity. After insertion of the PEG tube, routine follow-up of patients should be carried out to evaluate regaining their swallowing ability. PEG tubes can be removed at any time if patients regain spontaneous swallowing.

PEG is a standard method of feeding in patients with amyotrophic lateral sclerosis (ALS). In some patients the PEG tube placement technique should be modified in view of associated anatomic deformity. Also gastric insufflation during and after the procedure should be minimized due to the inability of these patients to spontaneously lower their raised diaphragm[20]. Although there are some concerns about the safety of PEG tube placement in patients with restricted pulmonary function, Czell et al[21] showed that PEG can be performed in these patients under procedural non-invasive ventilation with minimal peri- and post-procedural complications. In addition their data showed no significant difference in long-term survival rate among patients with high (> 50%) and low (< 50%) forced vital capacity (FVC). This finding was in contrast to the results of other studies showing a lower survival rate after PEG tube placement in patients with ALS who had low FVC (< 50%)[22].

The role of the PEG tube has also been described in the nutritional support of other motor neuron and dysfunctional motor diseases such as cerebral palsy and bulbar palsy[23-25]. These patients frequently have feeding and swallowing problems that may lead to poor nutritional status, growth failure, chronic pulmonary aspiration and infection. The Epidemiologic Oxford Feeding Study reported a significant correlation between the severity of motor impairments and the need for gastrostomy feeding[26].

Most patients with advanced dementia are dependent on others in their daily living activities including eating. In a prospective study of nursing home residents, 86% of patients with advanced dementia had eating problems[27]. There are several mechanisms that are responsible for impaired self-feeding in this population: altered smell and anorexia resulting in a lack of interest in food; apraxia interfering with the task of eating, and dysphagia and loss of airway protective mechanisms leading to choking episodes and eating avoidance[28-30]. Feeding problems are usually considered one of the ominous symptoms of advanced dementia with a 6 mo mortality rate of 25%[27], a similar life expectancy to some generally considered poor prognosis diseases such as stage 4 congestive heart failure[31]. This is consistent with the finding that independent of age, patients with dementia undergoing PEG have a worse prognosis than other patient subgroups with a mortality rate of 54% after 1 mo and 90% after 1 year of tube insertion[32]. In another study cited elsewhere, PEG has a higher mortality rate in demented patients who are at least 80 years old[11]. The need for more aggressive palliative measures to prevent malnutrition in patients with advanced dementia is an important issue, however to date, there is no published evidence showing that PEG feeding can prolong survival or provide palliation in this patient population[33-36]. In a recent study designed to assess the effect of PEG feeding on pressure ulcer healing in patients with advanced dementia, patients with PEG were less likely to heal and more likely to develop new ulcers[37]. Given all these findings, PEG may not provide any clinical benefit to this patient population and simple efforts like hand feeding can be a viable alternative[38]. In one study, PEG tube insertion in nursing home residents with advanced dementia was associated with a significant increase in annual inpatient health care costs as well as in hospital and intensive care unit stay[39].

Patients with psychomotor retardation are prone to malnourishment and gastroesophageal reflux due to pathophysiologic causes inherent in this condition. The long-term efficacy of PEG tube feeding in improving nutritional status of severely disabled and mentally retarded adults and children has been shown. However, the use of PEG in those with aspiration and gastroesophageal reflux is not recommended[40].

The decision to start enteral nutrition in some patients with severe cerebral injury is challenging, as their recovery time and the final outcome is not clear. Generally, in order to prevent nutrition depletion, enteral feeding should be started as early as possible to restore physiological function of the GI system. Some authors advocate that PEG tube nutrition should be started in severe cerebral injury patients if they do not recover in 14 d[41].

More than 40% of patients with head and neck malignancy have some degree of malnutrition[42]. The underlying mechanisms of this malnutrition include the obstructive effect of the tumor, oropharyngeal mucositis due to aggressive treatment with high dose radiotherapy and/or chemotherapy and reduced appetite. The PEG tube can be inserted either prophylactically or therapeutically in this setting[43-45]. In a recent study, PEG tubes inserted prophylactically resulted in a lower complication rate compared to tubes inserted therapeutically[46]. Recently a modified transnasal technique was introduced in patients with oropharyngeal cancer, when the routine method was unsuccessful[47].

In chronic unresolved gastrointestinal stenosis or ileus, PEG can be used to drain gastric secretions and resolve persistent nausea and vomiting[48,49].

PEG tube nutrition in human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) patients with wasting syndrome results in significant improvement in body weight and nutritional serum markers such as albumin and transferrin[50]. In another study, children with AIDS who were fed chronically by gastrostomy tube gained more weight and had a shorter length of hospital stay when enteral feeding was started early[51].

In patients with cystic fibrosis, better nutritional status is associated with superior survival[52]. The role of PEG tube feeding in improving nutritional status and baseline pulmonary functional status in these patients has already been described[53-55]. Therefore, some experts recommend PEG tube insertion as an early intervention rather than as a last resort in malnourished patients with cystic fibrosis[55].

Enteral nutrition is an important part of the treatment in patients with Crohn’s disease, especially in children who require elemental diet. This type of nutrition not only reversed malnutrition and improved weight gain and linear growth, but also reduced steroid requirements[56]. The concern of fistula formation has resulted in many physicians refraining from considering PEG tube insertion in this population, however, over time its safety during usage and after removal has been reliably demonstrated[57,58]. However, considering the large number of oral nutritional supplements and other nutritional alternatives available, it is currently uncommon to insert a PEG tube for enteral feeding in patients with Crohn’s disease.

In patients with prior abdominal surgery, a PEG tube can be inserted after confirming a “safe tract” with no interposed bowel[59]. In obese patients, PEG can be safely performed with minor modifications, even in patients with an extreme body mass index (> 60 kg/m²)[60,61].

During pregnancy, PEG tube insertion may be complicated by potential risks of uterine and fetal injury. However, tube insertion has been reported in pregnant women up to 29-wk gestation with no major complication after applying special precautions[62-65].

Generally, ascites is considered a relative contraindication for PEG tube placement due to concerns regarding ascitic fluid leakage. There are some case reports of successful tube insertion, after paracentesis or modifications of the placement technique, even in patients with massive ascites[66-68]. However, in a case series of patients with cirrhosis, the patient group with ascites had a higher mortality rate. Therefore, experts have concluded that the risks of PEG tube insertion in cirrhotic patients with ascites outweigh its overall benefits[69].

When medically indicated, there is no age or weight limit in PEG tube placement. The safety of PEG insertion even in very small (3 kg) and medically complex infants has been determined[70].

Bleeding from the PEG tract, gastric artery, splenic or mesenteric vein injuries (massive retroperitoneal bleeding) and rectus sheath hematoma have been reported[72-74]. In hemodynamically unstable cases, fluid support should be started immediately with close monitoring of vital signs. Bleeding can usually be controlled with simple pressure over the abdominal wound, however, endoscopic or surgical exploration of the bleeding source may be needed in some cases. Using a standard technique with consideration of anatomical structures and correcting coagulation disorders before PEG tube insertion can be helpful in the prevention of bleeding.

Aspiration pneumonia is a serious and potentially fatal complication of PEG tube feeding. Although a PEG tube is usually preferred over a NG tube in high-risk patients, there is little data available on the comparable risk of aspiration between these two routes of feeding[75]. In fact, despite its widespread usage, insertion of a PEG tube in patients with neurologic dysphagia failed to reduce the risk of aspiration pneumonia[76]. In a study of stroke patients, 18% suffered from aspiration pneumonia which was higher than the rate of PEG site infection in the same study[77]. Aspiration pneumonia is quite common in this patient population and its risk increases with high-volume feeds and the prone position[78]. A jejunal extension can be considered in patients with significant risk of aspiration, but its usage has been associated with more tube dysfunction and dislocation rates[79].

Any intra-abdominal organ, more likely colon[80] and small bowel[81] and rarely liver[82] and spleen[73], is at risk of injury during PEG tube placement. Also few cases of complete laceration of the stomach following tube insertion have been reported in the literature[83]. Iatrogenic perforation of the bowels during PEG tube insertion is more common among elderly patients due to laxity of the colonic mesentery[84]. Patients with bowel injury may develop the classic signs of peritoneal irritation. However, in some instances, the diagnosis is challenging since candidates for PEG tube nutrition do not always communicate easily due to their underlying altered mental status. In addition, the persistence of transient subclinical pneumoperitoneum occurring during PEG[85] limits the utility of plain films in the diagnosis of suspected visceral perforation. A watchful follow-up is important after any PEG tube insertion and there should be a low threshold for further investigation. Performing a computed tomography (CT) scan with water-soluble contrast, or fluoroscopy in the case of hemodynamic instability, is a useful alternative to confirm gastrointestinal integrity in this setting. Any evidence of active leakage of contrast into the peritoneal cavity in the presence of the signs of peritonitis warrants emergent surgical intervention.

Necrotizing fasciitis is a very rare, but potentially fatal complication of PEG[86-88]. This complication is an acute surgical emergency and is characterized by rapidly spreading infection along the fascial planes resulting in abdominal fascia necrosis. Traction and pressure on the PEG tube are two main factors which have been shown to increase the risk of abdominal wall necrotizing fasciitis following PEG tube placement[89]. Keeping the external bumper 1-2 cm away from the abdominal wall can take the pressure off the PEG wound and potentially prevent this complication. Treatment requires immediate wide surgical debridement, broad-spectrum empiric antibiotics and intensive care support.

Buried bumper syndrome can occur in tubes with an internal bumper as early as 3 wk after PEG tube insertion[90-93]. Excessive tension between the internal and external bumpers causes ischemic necrosis of the gastric wall and subsequently migration of the tube toward the abdominal wall. The tube becomes dislodged anywhere between the gastric wall and the skin along the PEG tract. This complication can present as feeding problems, periostomal leakage, or pain and swelling at the tube insertion site[94]. The tube should be removed as soon as the diagnosis is made, as grave complications such as perforation of the stomach, peritonitis and death may follow without appropriate management[95]. Depending on the tube type, a PEG tube can be removed by endoscopy[94,96], surgical incision[97] or simply by external traction of the tube[98,99]. This complication can be easily avoided by regular checking of the PEG tube position, leaving a small distance between the external bumper and the resident’s skin and daily 180-360 degree rotation of the tube.

This is a rare complication of PEG in patients with head and neck cancer. Generally, it is believed that seeding occurs during the “pull” or “push” method when the tube is in contact with oropharyngeal cancer during insertion[100-103]. However, some authors consider hematogenous or lymphatic spread of the tumor cells as the main mechanism of metastasis in some instances[104,105]. The diagnosis is usually delayed until the metastasis is large enough to be visible or local disorders such as bleeding or infection are seen. In the case of suspicion, diagnosis can be confirmed by biopsy and CT scan[106].

The development of hyper-granulation tissue around the gastrostomy tube is a common complication in patients with a PEG tube[107,108]. Although the exact mechanism of granuloma formation has not been described, factors such as friction from a poorly secured tube and excess moisture due to fluid leakage causing skin breakdown at the exit site seem to be responsible[107,109]. The presence of a granuloma is not a life-threatening complication, but its moist and highly vascularized surface results in patients being prone to wound infection, biofilm formation and bleeding. While a wide variety of treatment options from the application of topical antimicrobial agents and low dose steroids to cauterization by silver nitrate and surgical removal have been described in the literature, none have proved to be more effective than others[107,110].

Tube site infection is the most common minor complication following PEG placement. The prevalence varies between 5%-25% in different studies, and in some series it was reported to be as high as 65%[111,112]. Although mild redness around the stoma site is common due to tube movement, extension of the redness and addition of purulent discharge or other signs of systemic inflammation should raise suspicion regarding wound infection. Minor infections usually resolve with the application of local antiseptics and daily dressing changes, but in cases of persistent infection further investigation is warranted. Periostomal swabs, although considered to have restricted results, can be cultured to tailor the systemic or local antibiotic treatments. The effectiveness of prophylactic antibiotic administration in preventing systemic and local infection has been studied in several articles[112-119]. A systematic review of ten eligible randomized controlled trials (RCTs), which evaluated prophylactic antimicrobials in 1100 patients, showed a statistically significant reduction in the incidence of periostomal infection with prophylactic antibiotics (pooled OR = 0.31, 95%CI: 0.22-0.44)[120].

The current gold standard for antibiotic prophylaxis is the intravenous administration of a single dose of cephalosporins in the first hour before PEG tube insertion. Recent efforts in exploring other prophylactic alternatives, found co-trimoxazole administered immediately via a newly inserted PEG catheter just as effective in preventing periostomal infection[121,122].

The recent emergence of Methicillin-Resistant Staphylococcus aureus (MRSA) as a PEG-site infection pathogen, generally resistant to cephalosporins, has raised concerns over the use of prophylactic antimicrobials. Some studies showed benefits of pre-PEG MRSA screening and nasopharyngeal decolonization of MRSA in reducing periostomal wound infection rate[123,124].

This complication is more common among debilitated patients, those with previous gastric surgery and in patients with underlying medical conditions that predispose them to delayed wound healing. Periostomal leakage usually occurs within the first few days after PEG tube placement, although it can occur even in patients with a mature PEG tract. Evaluation of the leakage should include examination of the patient for any evidence of infection, ulceration, buried bumper[83] or any other potential causes such as tube displacement, slowed gastric emptying, excessive gavage or residual, and enlarged gastric fistula. Intervention generally starts with meticulous prevention and continues with treatment of specific causes including underlying disease[125]. Inserting a larger tube through the same PEG tube tract will create more problems such as further tissue breakdown resulting in an even larger stoma. In patients with a mature PEG tract, the PEG tube can be completely removed, allowing the tract to close completely. When medically indicated, another PEG tube can then be placed in another location on the abdominal wall.

Tube dislodgment can occur when the gastrostomy tube either slides in or out of the gastrointestinal tract. If the tube slides too far into the gastrointestinal tract it can obstruct the gastric outlet. If the internal balloon deflates or the external bumper or disc is inadvertently removed, the gastrostomy tube can slide out. This is one of the common causes of emergency department presentation in patients with PEG tube and in some studies was reported to occur in up to 12.8% of patients[126,127]. In patients with a mature abdominal wall tract, e.g., dislodgment of the tube more than a month after placement, the PEG tube can be replaced safely through the same tract without endoscopy. In the case of doubt, a water-soluble contrast study can be performed to confirm the location of the replaced tube prior to feeding. The remaining cases should be managed by endoscopic placement of a new PEG tube either near or even through the dislodged tube site[110,128].

Although rare, PEG tube migration to the pyloric area can cause gastric outlet obstruction. Symptoms may include abdominal cramps and nausea and vomiting. This complication usually occurs when the external bolster migrates away from the abdominal wall, allowing the PEG tube to slide forward through the PEG tract into the duodenum[129,130]. Maintaining the position of the external bumper 1-2 cm from the skin is the key factor in preventing the tube from being pulled into the stomach.

Pneumoperitoneum is a common finding after PEG tube insertion and its prevalence is reported to be as high as 50% in some studies[110,131]. In fact, post-PEG pneumoperitoneum is not generally considered a complication, because it does not cause any unfavorable consequences. This condition is usually related to air insufflation associated with the endoscopic procedure and needle puncture of the abdominal wall. In the absence of peritoneal signs, the presence of pneumoperitoneum should not prevent initiation or continuation of PEG feeding. However, the potential for bowel injury should be considered when free air (no matter how small) persists after 72 h of PEG insertion[84,132-134].

Since its introduction by Gauderer et al[4], several different techniques have been developed to insert the PEG tube. Generally, all of these methods share a common concept of insertion of the gastrostomy tube through the abdominal wall at a point where the stomach and abdominal wall are in closest contact. Herein, we briefly describe the 3 most commonly used techniques in clinical practice: “pull” technique, “push” (guide wire) technique and introducer (Russell) method. Finding the tube insertion site on the abdominal wall by endoscopic trans-illumination and one to one indentation is the first critical step in all these techniques.

The “pull” technique is the method initially introduced by Gauderer et al[4] and is currently considered to be the most common technique utilized to insert the PEG tube. In this method a string is inserted through a needle in the abdominal wall into the stomach, grasped with endoscopic biopsy forceps and then taken out through the esophagus and mouth. Subsequently the string is fixed to the external end of the feeding tube and the tube is pulled from the mouth to the esophagus, stomach and then out though the abdominal wall.

The first section of the “push” technique is similar to the “pull” technique. A guide wire is inserted into the stomach and pulled out through the mouth with the endoscope. The feeding tube is pushed over the guide wire into the stomach and out the puncture site[138]. No significant differences in complication and efficacy rates between the pull and push methods have been reported[138,139].

Th introducer (Russell) technique[140] uses the Seldinger method to place a guide wire into the stomach under endoscopic view. Afterwards, a dilating catheter and sheath are passed over the guide wire and after removal of the guide wire the feeding tube is advanced through the peel-away sheath.

Long-term protruding gastrostomy tubes may not be favorable in some patients due to the risk of periostomal leakage, inadvertent catheter dislodgment and cosmetic issues. These regular tubes can be replaced by a skin level low profile button gastrostomy tube after maturation of the stoma canal upon request by selected patients[141-143]. Their higher cost and replacement, which is needed every 6 mo, limits their routine use and they are often reserved for adolescent patients for cosmetic reasons. Although one-step button gastrostomy tube insertion can be performed similar to the routine “pull technique” PEG tube placement, it is generally recommended that it is carried out following complete maturation of the stoma[144].