PEG Tube Placement in Patients with Abdominal Wall Mesh

Assessment and Placement Considerations

Pre-procedure imaging is essential to evaluate the location of the mesh and identify a safe puncture site, according to the American Gastroenterological Association 1
The "safe track technique" should be used to provide information about the depth and angle of the puncture tract, as recommended by the American Gastroenterological Association 1
Proper site selection is critical, choosing a site at least 2 cm below the costal margin at a point of maximal transillumination, as suggested by the American Gastroenterological Association 1
Perform "one-to-one" finger indentation to ensure appropriate placement without overlying bowel loops or mesh, as recommended by the American Gastroenterological Association 1

Large midline wounds, abdominal mesh, and ostomies make finding a safe window challenging but should not necessarily preclude PEG placement, according to the American Gastroenterological Association 1
Synthetic meshes in contaminated fields are not recommended by guidelines in emergency abdominal wall reconstruction, as stated by the World Society of Emergency Surgery 2, 3

Risk of entero-atmospheric fistula formation is increased with direct application of synthetic prosthesis over bowel loops, as reported by the World Society of Emergency Surgery 2, 3
Complications may include tube blockage, dislodgement, and infection, as noted by the American Gastroenterological Association 4

Verify proper tube position after placement, especially important with altered anatomy, as recommended by the American Gastroenterological Association 6
A water-soluble contrast study is the most reliable radiographic method to confirm proper PEG tube position, as suggested by the American Gastroenterological Association 6
Implement routine water flushing after each feeding and medication administration to prevent blockage, as recommended by the American Gastroenterological Association 7
Regular tube maintenance, such as pushing the tube in and out weekly (2-10 cm) helps prevent buried bumper syndrome, as noted by the American Gastroenterological Association 7

If safe PEG placement cannot be achieved due to mesh location, consider alternative enteral access methods, such as radiologically-placed gastrostomy tubes, surgical gastrostomy or jejunostomy, or nasogastric/nasojejunal tubes for short-term feeding, as recommended by the American Gastroenterological Association 4