This information will help you prepare for your percutaneous endoscopic gastrostomy (PEG) placement at Memorial Sloan Kettering Cancer Center (MSKCC). A PEG is a tube that is inserted into the stomach to drain stomach juices and fluid. This will help relieve the nausea and vomiting caused by a blockage in your stomach or bowel and will make you feel more comfortable. A PEG will also allow you to drink and eat soft foods. If the tube can't be placed in your stomach, you may have a percutaneous endoscopic jejunostomy (PEJ) placed instead. In this case, the tube is placed in your jejunum, which is a part of your small intestine. The tube is placed during a procedure called an endoscopy. All the instructions in this booklet apply to both a PEG and a PEJ.
Having a PEG may let you enjoy eating and drinking and being with your family at mealtimes. If you have a nasogastric tube through your nose to prevent you from vomiting, it will be removed.
You will be able to drink liquids and eat soft foods or foods that have been mixed in the blender. However, these fluids and foods will only give you a small amount of nutrition. This is because they will mostly drain through the tube into a drainage bag.
A Week Before Your Procedure
Ask about your medications
You may need to stop taking some of your medication before your procedure. We have included some common examples below.
- If you take medication to thin your blood, ask the doctor who prescribes it for you when to stop taking it. Some examples are warfarin (Coumadin®), dalteparin (Fragmin®), heparin, tinzaparin (Innophep®), enoxaparin (Lovenox®), clopidogrel (Plavix®), and cilostazol (Pletal®).
- If you take insulin or other medications for diabetes, you may need to change the dose. Ask the doctor who prescribes your diabetes medications what you should do the morning of your procedure.
Get a letter from your doctor, if necessary
If you have an automatic implantable cardioverter-defibrillator (AICD), you will need to get a clearance letter from your cardiologist before your procedure.
Arrange for someone to take you home
You must have someone 18 years or older take you home after your procedure. Please call one of the agencies below if you do not have someone who can do this. They will help find someone to take you home.
Partners in Care (888) 735-8913
Caring People (877) 227-4649
3 Days Before Your Procedure
You will receive a telephone call from an endoscopy nurse. He or she will review the instructions in this guide with you and ask you questions about your medical history. The nurse will also review your medications and tell you which to take the morning of your procedure. Use the space below to write them down.
The Day Before Your Procedure
A clerk from the Admitting Office will call you after 2:00 pm the day before your procedure. He or she will tell you what time you should arrive at the hospital for your procedure. If you are scheduled for your procedure on a Monday, you will be called on the Friday before. If you do not receive a call by 7:00 pm, please call (212) 639-5014.
If you need to cancel your procedure for any reason please call the doctor who scheduled it for you.
Do not eat or drink anything after midnight the night before your surgery. This includes water, gum, and hard candy.
The Day of Your Procedure
Things to remember
- Do not eat or drink anything the morning of your surgery. This includes water, gum, and hard candy.
- Take only the medicines your doctor told you to take the morning of your procedure. You may have written them down above. Take them with a few sips of water.
- Do not put on any lotion, cream, powder, deodorant, make-up, or perfume.
- Remove jewelry, including body piercings.
- Leave all valuables such as credit cards and jewelry at home.
- If you wear contacts wear your glasses instead.
What to bring with you
- A list of the medications you take at home
- Medications for breathing problems (such as inhalers), medicines for chest pain, or both
- A case for your glasses
- Your Health Care Proxy form, if you have completed one
Where to Park
Parking at MSKCC is available in the garage on East 66th Street between York and First Avenues. To reach the garage, enter East 66th Street from York Avenue. The garage is located about a quarter of a block in from York Avenue, on the right-hand (north) side of the street. There is a tunnel that goes from the garage into the hospital. There are also commercial garages nearby: 4 on East 69th Street between First and Second Avenues and 3 on East 65th Street between First and Second Avenues. For questions about prices, call (212) 639-2338.
Where to go
Please arrive at the Surgical Day Hospital (SDH) at 1275 York Avenue. This is the main building of MSKCC. Take the M elevator to the 2nd floor.
What to expect
Once you arrive at the hospital, doctors, nurses, and other staff members will ask you to state and spell your name and date of birth many times. This is for your safety. Patients with the same or similar names may be having procedures on the same day.
Your doctor will explain the procedure to you and answer any questions you may have. He or she will ask you to sign a consent form.
When it's time for your procedure, you will be brought into the procedure room and helped onto an exam table. You will be attached to equipment to monitor your heart, breathing, and blood pressure. You will also receive oxygen through your nose. A mouth guard will be placed over your teeth to protect them.
You will receive anesthesia through your IV, which will make you fall asleep. Once you are asleep, your doctor will pass the endoscope through your mouth, down your esophagus (food pipe), into your stomach, and into the first part of your small intestine.
A tiny incision (surgical cut) will be made on the skin of your abdominal wall and a feeding tube will be passed through your incision. The feeding tube will extend 8 to 12 inches outside your body and will be covered by a small bandage to keep in place. When the doctor has completed the procedure the endoscope will slowly be removed. The end of the PEG tube wil be connected to a bag into which your stomach fluids will drain.
After Your Procedure
You will be taken Post Anesthesia Care Unit (PACU), where a nurse will monitor your temperature, pulse, breathing, and blood pressure. He or she will also check the bandage around your tube. You will stay in the PACU until you are fully awake.
When you are fully awake, the nutrition nurse will show you and your caregiver how to use the feeding tube, how to handle the PEG or PEJ and how to give yourself the feeding solutions. It is very important that you have your caregiver with you during the teaching session.
You may feel some soreness in your throat. This is normal and will get better in a day or two.
You may have some discomfort at your incision site for the first 24 to 48 hours. If needed, you will be prescribed pain medication for discomfort. Use the medication as instructed.
You can shower 48 hours after your procedure. Do not take tub baths or swim for 1 week after your procedure.
Rest on the day of the procedure, but you can resume your usual activities the next day.
Your nurse and dietitian will tell you about the types of foods you can eat. Your nurse will also tell you where to get supplies and show you how to
- Clean the skin around your PEG or PEJ
- Flush the tube
- Fix the tube if it gets clogged
- Take care of and change the drainage bag
- Take medications
- Clamp or cap the tube
Before you are discharged from the hospital, your nurse will give you the following supplies to take home:
- One box of 4 x 4 gauze
- One roll of 1-inch tape
- One irrigation (flushing) kit
- Two drainage bags
- Two caps
You can obtain more supplies from a surgical supply store in your area.
If you have any questions about the PEG or PEJ, ask your nurse.
Caring for the Skin Around Your PEG or PEJ
- Inspect the skin around your tube daily for any redness, pus, or swelling. Tell your doctor if you have any of these symptoms.
- Clean the skin around the tube with iodine (Betadine®) swab sticks once a day for 2 days. Cover the tube with a clean, 4 x 4 piece of gauze and paper tape.
- On the third day after your procedure, begin a daily routine of caring for the skin around your tube while showering. Wash it with a mild soap such as Dove® or Neutrogena® and water. Dry your skin well, cover it with a bandage, and secure it with tape or use a Cath-Secure® tab to hold the tube in place.
- When you remove the old dressing, it will probably be stained with fluid or mucus. There may also be old blood or crusting around the tube. Don't be afraid to remove this while you are cleaning the site. Call your doctor or nurse if you must change the bandage more than 3 times a day because it is soaked or if there is constant leakage.
- If the tube should accidentally become dislodged or fall out, cover the opening with a thick bandage. Use several 4 x 4 gauzes. Then, call your doctor immediately. Don't eat or drink anything.
Caring for Your Drainage Bag
- When the drainage bag is disconnected, it should be cleaned with cool water and a mild detergent. If you feel nausea or any discomfort when the PEG is capped during the time it takes to clean and dry the bag, attach a second bag.
- Mix 1 part white vinegar with 3 parts water. Soak the bag in this solution for 10 to 15 minutes. Allow the bag to dry.
- If you are eating, clean the drainage bag once a day. If you are not eating, the bag can be cleaned every 3 to 4 days. You will need to empty the bag when it is about one-third to one-half of the way full of stomach juices, or about every 8 hours.
Your nutritionist will give you the Oley Complication Chart to help you manage any major side effects you might have with tube feeding. To view the chart online, go to http://www.oley.org/charts/newHEN.pdf
Eating and Drinking With Your PEG or PEJ
You may drink clear liquids after your procedure. These include ginger ale, apple juice, coffee, tea, broth, flavored ice, and gelatin (Jell-O®).
Sit up when you drink or eat to allow the fluids or food to drain into the bag. For the same reason, you will need to sit up for about 20 to 30 minutes after you eat. If you don't, you may feel nauseous. If you feel nauseous, check to make sure the tube is not tangled and sit up to allow it to drain. This should make you feel better.
When you are drinking clear liquids without any problems, slowly increase your diet to full liquids. If you have not had any problems after 2 days, you can start eating soft or pureed foods. Puree foods in a blender. If you eat food that is not pureed, you must eat it in tiny pieces and chew it very well. Don't eat more than 4 cups of food or drink more than 1 liter (1,000 ml) of fluid in 24 hours. Have very small portions. Each time you eat or drink, you will lose some important nutrients. This is because they drain into the drainage bag with the food or liquid.
Most of what you eat will drain through the tube into the drainage bag. For example, if you eat red Jell-O®, the drainage in the bag will be red. Stomach juices will drain into the bag even if you have not eaten. The colors will range from green to dark yellow.
Most patients will need to have IV (given through a vein) liquids when they are at home so they do not become dehydrated. A Mediport® or PICC line will be used to deliver the fluids. Your doctors will insert 1 of these while you are in the hospital if you do not already have one.
Connecting the PEG or PEJ to the Drainage Bag
The PEG or PEJ tube should be connected to the drainage bag when you eat, drink, feel nauseous, and sleep. It does not have to be connected at other times. To connect the drainage bag to the PEG, remove the clear plastic cap from the tubing on the bag and twist the end into the PEG.
Flushing the PEG or PEJ
Once you are done eating, you or your caregiver may need to flush the PEG or PEJ. This is because the tube can get clogged with food. It may also need to be flushed if thick stomach juices or mucus clog it. If you feel nauseous or full and don't feel better after sitting up, flush the PEG or PEJ.
How to Flush the PEG or PEJ
- Gather the following:
- About 60 mL of water (normal saline or plain tap water)
- A 60 mL syringe
- A cap
- A clean drainage bag
- Paper towels
- Wash your hands well with soap and warm water.
- Place the paper towels under the PEG or PEJ to absorb any drainage
- Draw up the 60 mL of water into the syringe
- Clamp the tube
- Disconnect the PEG or PEJ from the drainage bag.
- Insert the syringe into the opening of the PEG or PEJ. Unclamp the tube and insert the water with a gentle push of the plunger.
- Remove the syringe, reconnect the PEG to the drainage bag, and allow it to drain.
- If the tube is still not draining anything, or if your nausea does not get better, call your nurse or doctor.
Taking Medication With Your PEG or PEJ
You may swallow medication tablets by mouth; however, you must cap the tube for at least 30 to 40 minutes after you take any medications.
You will be given a guide about tube feeding with your PEG or PEJ. This guide has important information about getting nutrition and taking medication with a feeding tube.
Call Your Nurse Or Doctor Immediately if You Develop
- A temperature of 101° F (38.3° C) or higher
- Shakes or chills
- Abdominal pain or cramps
- Any signs of bleeding
- Pain at your incision site that does not get better with the medication you were prescribed
- Nausea and vomiting
- Any signs of redness, swelling, oozing, or pus around the tube
- Need to change your bandages more than 3 times a day or have continual leakage
- Your tube becomes dislodged or falls out