Percutaneous Endoscopic Gastrostomy 
Gady Barutwanayo and Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
 
Percutaneous endoscopic gastrostomy tube 
has the same role as open gastrostomy tube; both 
allow administration of feeds directly to the stomach 
in patients with conditions which make oral intake 
difficult or even impossible such as:  
● Neurologic injury 
● Ischemic or hemorrhagic stroke  
● Motor neuron disease 
● Head and neck malignancy 
● Palliative gastric decompression for malignant 
bowel obstruction 
The only differences between open and 
endoscopic 
gastrostomy 
are 
technical 
skills, 
equipment and indication of the procedure.  
Obstructing tumors of the esophagus are a 
contraindication for endoscopic tube placement- 
open gastrostomy is indicated. (See Stamm 
Gastrostomy.) 
Gastrostomy tube placement should never be 
done in patients with gastric outlet obstruction. In 
such cases, a gastrojejunostomy anastomosis or 
jejunostomy feeding tube will be suitable, though 
their management are quite difficult compared to a 
simple gastrostomy, and are associated with 
technical or post operative complications.  
Endoscopic gastrostomy requires a special 
dedicated gastrostomy tube and equipment which 
make the procedure more expensive and difficult to 
access compared to open gastrostomy. Other 
varieties of tubes such as Foley catheters, often used 
in resource limited settings, cannot be used in this 
procedure.  
 
Typical percutaneous endoscopic gastrostomy kit containing 
the cannula, the tube, the guidewire, the snare for endoscopic 
retrieval, and various other equipment. Source: Wei M, Ho E, 
Hegde P. J Thorac Dis 2021;13(8):5277-5296. doi: 
10.21037/jtd-19-3728 
 
Post-operative management of the tube is the 
same as for open gastrostomy as detailed in the 
Stamm gastrostomy chapter.  
A two-person technique is the most preferred, 
one person to the endoscopy and the other person to 
insert and secure the tube. With some practice both 
duties can be performed by one person.  
In general, the steps of endoscopic gastrostomy 
tube placement are:  
● Flexible upper endoscopy 
● Localization of the gastrostomy site 
● Introduction of the guidewire through the 
abdominal wall to the stomach 
● Retrieval of the guidewire through the scope by 
a biopsy forceps 
● Pulling the guidewire out through the esophagus 
and mouth 
● Connection of the gastrostomy tube to the 
guidewire 
● Placement of the tube by pulling it back through 
the abdominal wall  
● Fixation of the tube to the skin  
 
Steps: 
1. General anesthesia is preferred if there is no 
contraindication. If the generation condition of 
the patient or his/her comorbidity doesn’t allow 
Percutaneous Endoscopic Gastrostomy 
Gady Barutwanayo and Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
it or puts the patient at high risk, the procedure 
can be done under light sedation, topical 
anesthesia sprayed in the throat, and local 
anesthesia injected during the procedure as 
described further below.  
2. The patient lies supine, abdomen prepared and 
draped from the inframammary line to the 
umbilicus. 
3. The scope is inserted through the mouth down 
through the esophagus to the stomach. An 
assistant provides jaw thrust as the scope is 
passed gently into the hypopharynx and cervical 
esophagus. We do this “by feel” rather than 
watching the tip of the scope on the screen.  
 
Assistant provides jaw thrust by pushing forward at the angle 
of the mandible bilaterally while the scope is gently inserted 
and passed into the esophagus. 
 
4. The stomach is insufflated to allow good 
visualization of the gastrostomy site with finger 
pressure. 
5. Pass the scope into the duodenum to make sure 
the pylorus is patent. Patients who are ill enough 
to need a gastrostomy tube may have a duodenal 
ulcer, so inspect the first and second portions of 
the duodenum carefully.  
 
View of the first portion of the duodenum immediately after 
passing through the pylorus. The posterior bulb, seen on the 
right side of the screen (Black arrow) should be examined 
closely as an ulcer here can erode into the gastroduodenal 
artery and cause life-threatening hemorrhage.  
 
6. Return the scope into the stomach and pass the 
tip towards the anterior stomach wall. When the 
scope is at the gastroesophageal junction, the 
anterior stomach is on the left side of the screen. 
The stomach must be fully insufflated for this 
maneuver to succeed. Inspect the anterior 
abdominal wall for transillumination. Turn out 
the lights in the operating room if necessary.  
 
In this very thin cachectic patient, the light of the scope can be 
well seen in the epigastrium. In obese patients this visualization 
can be more difficult.  
 
Percutaneous Endoscopic Gastrostomy 
Gady Barutwanayo and Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
7. A finger is pressed against the abdominal wall 
where the light is located. The indentation from 
the surgeon’s fingers can be seen through the 
endoscope. The tube should be placed in the 
anterior distal stomach body or antrum.  
 
Press on the area where the light was previously seen while 
watching on the screen to further confirm the area where the 
tube will be placed. 
 
 
When finger pressure is applied, an indentation in the anterior 
stomach wall is seen. This should be in the center of the 
stomach, not to the cranial (lesser curve) or caudal (greater 
curve) sides.  
 
8. Localize the site and inject local anesthetic. A 
21G needle is inserted while pulling back on the 
plunger to make sure no blood, air, or stool 
returns before the needle reaches the stomach. 
Inject the skin and the fascia. 
9. The large needle provided in the gastrostomy kit 
is inserted with the same direction and angle as 
the local anesthetic. On the endoscope monitor, 
its tip is seen to enter into the stomach.  
 
Insert the large cannula provided in the kit through the skin and 
muscle of the anterior abdominal wall.  
 
 
The cannula is seen to enter into the stomach.  
 
10. The inner cannula is removed. The guidewire is 
passed through the cannula into the stomach. 
Waste no time doing this, if the cannula comes 
out during this stage, a hole is left in the stomach. 
11. Once the guidewire is in the stomach, it is 
grasped through the scope by a biopsy forceps. 
Percutaneous Endoscopic Gastrostomy 
Gady Barutwanayo and Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Using a biopsy forceps, grasp the guidewire 
 
12. Maintaining a tight grasp on the guidewire, the 
scope is withdrawn up through the esophagus 
with the guidewire  
13. The gastrostomy tube is connected to the 
guidewire. 
 
Pass the guidewire through the wire loop on the end of the 
gastrostomy tube. Then pass the other end of the gastrostomy 
tube through the loop of the guidewire, resulting in a “square 
knot” holding the gastrostomy tube’s wire to the guidewire.  
The gastrostomy tube’s wire and the guidewire will be 
connected 
in 
this 
configuration. 
Source: 
Image:SquareKnot.png by PAR, Public Domain 
 https://commons.wikimedia.org/w/index.php?curid=2269260  
 
14. Grasp the guidewire where it emerges from the 
abdominal wall and pull firmly, causing the 
gastrostomy tube to enter the patient’s mouth and 
pass down the esophagus into position. Be 
careful to pull in a controlled manner, it is 
possible to pull the tube completely through the 
abdominal wall. If this occurs, perform 
laparotomy 
and 
open 
gastrostomy 
tube 
placement through the hole in the stomach, 
otherwise this hole will leak freely into the 
peritoneum.  
15. When the tip of the gastrostomy tube begins to 
emerge through the skin, cut the skin with a #11 
blade to allow it to pass.  
 
At the abdominal wall, the guidewire is pulled until the tube 
starts to emerge. Cut the skin to allow the tube to pass and 
continue pulling until it is in position.  
 
16. The scope is reintroduced following the 
gastrostomy tube revealing the internal view of 
the bumper in the correct position. 
 
Percutaneous Endoscopic Gastrostomy 
Gady Barutwanayo and Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Confirm that the tube is positioned and seated well.  
 
16. The flange is cinched down on the skin to prevent 
leakage and secure the tube 
 
The flange slides over the gastrostomy tube with some difficulty. 
Be careful to cinch it down but not to over tighten it.  
 
Pitfalls 
● Early dislodgement of the tube may result in a 
hole in the stomach that drains freely into the 
peritoneal cavity. The surgeon must be aware of 
this possibility. It is generally acceptable for an 
experienced hand to try to replace any dislodged 
tube, but a contrast study is mandatory before 
using a tube that has fallen out and been replaced 
within two weeks of its placement.  
● Commercially available open and percutaneous 
gastrostomy tubes include a flange that is cinched 
down on the skin to prevent leakage and secure 
the tube. If this flange is too loose, leakage will 
occur. If it is too tight, necrosis of the skin or 
even the full thickness abdominal wall can occur. 
Our practice is to cinch it down until it is tight, 
then release it 1cm. Full thickness necrosis of the 
abdominal wall leads to gastrocutaneous fistula. 
This is a devastating complication that is best 
avoided by erring on the side of “too loose” 
rather than “too tight.”  
● All gastrostomy tubes will allow some degree of 
leakage around the tube. Proper care of the tube 
includes keeping the skin clean including under 
the flange, assuring proper tightness of the 
flange, and protecting the skin with zinc barrier 
cream if irritation starts to occur. Most skin 
complications will occur after discharge, so the 
patient and family should be taught proper care 
of the tube. Other solutions to persistent leakage 
around the tube include changing the tube to a 
larger size, increasing frequency of feeds while 
decreasing volume, assessing gastric emptying 
function and treating with prokinetics if 
appropriate. In extreme cases the patient may 
need closure and placement of the tube in another 
part of the stomach, or conversion to Janeway 
gastrostomy.  
● Buried bumper syndrome is a rare but difficult 
complication: the wide end of the tube becomes 
encased in the stomach wall. The risk factors for 
this complication include poor nutrition and 
excess pressure on the tube flange. Management 
depends on the condition of the patient: for frail 
patients with poor long-term prognosis, the tube 
can be cut at the skin, left in place, and another 
placed at a different site in the stomach. If there 
is associated infection or abscess, the tube must 
be surgically removed by wedge resection of the 
involved stomach and abdominal wall.  
Percutaneous Endoscopic Gastrostomy 
Gady Barutwanayo and Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Buried bumper syndrome. The tube is embedded in the gastric 
wall and covered with mucosa (Black arrow.) Source: 
Boeykens K, Duysburgh I BMJ Open  
Gastroenterology 2021;8:e000628. doi: 10.1136/bmjgast-
2021-000628 
 
 
Specimen after wedge resection of the abdominal wall and 
stomach 
for 
buried 
bumper 
syndrome. 
Source: 
Boeykens K, Duysburgh I BMJ Open  
Gastroenterology 2021;8:e000628. doi: 10.1136/bmjgast-
2021-000628  
 
● When gastrostomy tubes are no longer needed 
and 
removed, 
the 
tract 
usually 
closes 
spontaneously within 2-5 days at most. When it 
does not close, a gastrocutaneous fistula is 
present. The most common causes of this are 
poor nutrition or distal obstruction. This 
complication can make nutrition difficult, as the 
patient will often voluntarily restrict feeds to 
decrease fistula output, leading to a “vicious 
cycle” in an already malnourished patient. If 
measures to improve the patient’s nutrition do 
not lead to fistula closure, laparotomy and 
closure of the fistula may be required. Assess the 
patient’s nutritional status carefully before 
attempting operation (See Chapter, Nutritional 
Assessment.)  
 
Gady Barutwanayo MBBS 
AIC Kijabe Hospital 
Kenya 
 
Richard Davis MD FACS FCS(ECSA) 
AIC Kijabe Hospital  
Kenya 
 
June 2022 
