LOUISVILLE-The "feeding tube" that was removed Friday from Terri Schiavo was most likely a percutaneous endoscopic gastrostomy tube, or PEG - a cleverly designed device that can be initially inserted in about 10 to 15 minutes and reinserted in less than a minute.
So says Steve McClave, MD, who is director of clinical nutrition at the University of Louisville here. He says that about 250,000 PEGs are placed each year in America, with most of them going to stroke patients who have difficulty swallowing and maintaining adequate nutrition after a stroke. "For those patients, normal swallowing returns in about 6 to 8 weeks and the PEG is removed," he says.
Action Points
- Address questions that patients have about "feeding tubes" from reading about the Terri Schiavo case and review the science behind enteral nutrition.
- Understand the low risk of complications associated with feeding tube placement.
Dr. McClave is chairman of special interest group established by the American Society of Gastrointestinal Endoscopy to study total enteral nutrition, and he is a member of the board of trustees of the American Society for Parenteral and Enteral Nutrition.
He says that PEG technology was a major breakthrough because it eliminates the need for surgery to place feeding tubes into the stomach. "We go through the abdominal wall with a needle into the stomach," he says.
The needle placement is guided by an endoscope that is inserteded through the mouth and then lowered into the stomach. Once the needle is in the stomach, the feeding tube, which is a tapered tube about 2 feet long, is placed over it and is pulled through the abdominal wall to the outside along the track made by the needle.
Typically the PEG is held in place or anchored by a "bumper or inflatable mushroom shaped balloon," Dr. McClave says. "To remove the tube, you simply deflate the balloon with a syringe by sucking the air out with a syringe in the tube, and then you can pull the tube out."
The initial procedure is done using the benzodiazepine drug Valium, "so that we have conscious sedation," he says. "And if there is any potential for discomfort, conscious sedation would also be used for a reinsertion."
PEG placement is considered a safe procedure, with a complication rate of only 1.5% to 4%, he says. Moreover, complications are most likely to occur early. He noted that Ms. Schiavo, who has now had her feeding tube removed for a third time, probably has a "well established track, a sort of permanent opening where the tube rests," he said. He said that track endothelialization usually occurs within 7 to 10 days of PEG placement.
For patients with such permanent tracks or fistula, "re-insertion can be done very quickly if the track is still open - which is very likely. You just put a little Vaseline on the tube and you can guide it back in. It takes less than a minute."
He said, however, that if the patient is dehydrated, which is probable after several days without a PEG, "it may be necessary to hydrate by running normal saline or Ringers' solution before reinserting the PEG."