Transnasal Percutaneous Endoscopic Gastrostomy (T-PEG): A Case Series of Push and Pull-through T-PEGs in High-Risk Groups

Transnasal Percutaneous Endoscopic Gastrostomy (T-PEG): A Case Series of Push and Pull-through T-PEGs in High-Risk Groups | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Transnasal Percutaneous Endoscopic Gastrostomy (T-PEG): A Case Series of Push and Pull-through T-PEGs in High-Risk Groups Muhammad Saad, John Frost, Neil C Fisher This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7224383/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background: Percutaneous Endoscopy Gastrostomy (PEG) insertion is a long-established intervention in neurodegenerative diseases and aerodigestive malignancies where enteral feeding is required. Transnasal PEG (T-PEG) has been advocated as a safer alternative compared with conventional transoral PEGs for selected patients, although large case series are lacking in the literature. ( 1 , 2 ) This case series illustrates technique and outcomes for two types of T-PEG procedures; firstly, the using a modified ‘pull-through’ technique and secondly using a gastropexy-assisted ‘push’ technique Methods: Our practice is to use pull-through T-PEGs predominantly for high-risk patients with neurodegenerative disease, and push T-PEGs for patients with aerodigestive malignancies. Patient selection is carried out by a clinical nutrition multidisciplinary team (MDT). The techniques used for both pull-through T-PEG techniques are described. A prospective database of T-PEG cases was analyzed to evaluate outcomes. Results: A total of 55 T-PEG procedures were completed between 2018 and 2024. There were 27 cases of primary neurodegenerative diseases and 21 cases of aerodigestive cancer (remaining 7 cases, miscellaneous). All but one T-PEG was successful at first attempt and with no serious procedural complications. There was one readmission with self-limiting insertion site pain, and 30-day mortality was 1/55 (a cancer case). Conclusions: In our case series of T-PEGs, we have demonstrated a high procedural success rate and low complication and mortality rates. T-PEG can be considered a viable alternative for patients who are not suitable candidates for traditional PEG and a valid alternative to other options such as radiological or surgical gastrostomy. Figures Figure 1 Figure 2 Figure 3 Introduction PEG tube placement is generally safe and effective for enteral access in appropriately selected patients, but there are specific patient groups where conventional PEG placement may not be suitable or may present higher risks. ( 3 ) For instance, in patients with distorted pharyngeal or oesophageal anatomy consequent on aerodigestive malignancy, it may be difficult to navigate a gastroscope into the stomach, and risk of aspiration pneumonia are a concern. To mitigate this risk, alternative techniques for percutaneous feeding tube placement, such as radiologically inserted gastrostomy (RIG) are commonly employed. ( 2 ) Performing RIGs needs radiology support and local expertise. Another group of high-risk patients are those with neurodegenerative disease such as motor neuron disease (MND) with relatively high risk of aspiration associated with intravenous sedation and lying supine during conventional per-oral PEG insertion. Transnasal endoscopy has become more widely used as an alternative to per-oral gastroscopy in recent years ( 4 ) , and some case reports and case series have highlighted a role for transnasal endoscopy in placement of PEGs, referred to hereafter as transnasal PEGs (T-PEGs) ( 1 , 2 , 7 ) . However, yet the T-PEG does not feature prominently in The British Society of Gastroenterology (BSG) or European Society of Gastrointestinal Endoscopy (ESGE) guidelines on enteral feeding tube placement. ( 5 , 6 ) Promising results for T-PEGs regarding sedation safety, efficacy, and patient outcomes have been demonstrated in some published studies, although to date there is limited evidence with which to optimize the choice of T-PEG technique (push or pull-through) for given patient groups. Our practice encompasses a modified pull-through technique using Freka disk-retained PEG kits for high-risk patients with neurodegenerative disease, and a push technique using the Pexact 'push-PEG' gastropexy device for patients with aerodigestive (pharyngeal or oesophageal) malignancy ( 3 ). The aim of this case series and review is to highlight options for such patients with aerodigestive malignancy and neurodegenerative disease. We describe patient selection criteria, procedural techniques, and outcomes. Methods We used our prospectively maintained spreadsheet of T-PEG cases to review all cases, which were separated into ‘pull-through’ PEGs using the Freka disk-retained PEG tubes, and ‘push’ PEGs using the Pexact 'push-PEG' gastropexy kit (which involves placement of a balloon gastrostomy tube, BGT). Outcomes were reviewed using endoscopy reports and electronic patient record analysis. Patient groups Selected patients with neurodegenerative diseases and aerodigestive malignancies underwent T-PEG procedures between 2018 and 2024, following approval of the technique from our Trust’s New Interventions Committee. Initially T-PEGs were restricted to push-PEGs in patients with head and neck cancer, but the case mix was later expanded to include a modified pull-through technique in patients with neurodegenerative disease. Informed consent was obtained from all participants. Most PEG referrals were from our own institution, but we later incorporated tertiary referrals for patients with MND from a regional MND network. Head and neck cancer and oesophageal cancer cases were referred after discussion at their respective MDTs. The decision to opt for T-PEG instead of conventional PEG was made by the supervising enteral access specialists (NCF, JF) after review of clinical details within a multidisciplinary nutrition team MDT approach. T-PEG was generally favoured over RIG due to logistical considerations and local expertise. Procedure details All cases are done in our endoscopy suite with or without conscious sedation with midazolam and/ or pethidine, and topical lignocaine anaesthesia sprayed into the nostrils. If the patient is not already hospitalized, then procedures are done as day cases and the patient is discharged if stable after 1–2 hours of observation. Transnasal Push-PEGs with the Pexact gastropexy device for patients with aerodigestive malignancies For this procedure we use the Freka Pexact device, involving gastropexy followed by advancement of a balloon gastrostomy tube [figure 1 ]. Push-PEGs may be done using the conventional transoral endoscopic approach, but we selected the transnasal route where there was pharyngeal or oesophageal stricturing due to malignancy or post-surgical or radiotherapy-induced fibrosis. The patient lies in a supine position on the endoscope trolley with conventional oximetry and pulse monitoring. The transnasal Pexact push-PEG procedure involves inflating the stomach once the naso-endoscope is in place. After a suitable site for needle entry is found (using finger indentation with or without transillumination), a finder needle with local anaesthetic is advanced using the ‘safe track’ technique (counter-traction on the syringe plunger to help ensure there is no other loop of bowel between the abdominal wall and the stomach lumen). Thereafter, gastropexy sutures are done with endoscopic vision of the intragastric steps [figure 2]. The gastropexy suture results in safe fixation of the gastric wall to the abdominal wall; some clinicians will do a ‘2-point’ gastropexy with sutures at two points, but our preference is to do a ‘3-point’ gastropexy with the 3 sutures in a triangular configuration. After the gastropexy sutures are done, a large trocar is advanced into the stomach in the middle of the ‘triangle’ made by the sutures, then a balloon gastrostomy tube is placed, and its retaining balloon inflated. The gastropexy sutures are removed after 10–14 days Transnasal Pull-through PEGs with Freka disk-retained PEG kits for patients with neurodegenerative diseases The Freka PEG kit consists of a gastrostomy tube with a firm 2cm diameter plastic internal retaining disk, which prevents the tube from becoming dislodged. For this procedure, the patient is lying in a supine or semi-upright position on the endoscope trolley with conventional oximetry and pulse monitoring. The naso-endoscope is advanced into the stomach and an appropriate point for PEG entry is identified as above. The abdominal wall is punctured with the PEG trocar and the traction thread advanced into the stomach. The thread is captured in the stomach using paediatric biopsy forceps and then removed through the nostril. This is followed by naso-oral transfer of the traction thread from the nose to the mouth with the help of a laryngoscope and Magill’s forceps (a technique described previously) ( 8 ) [figure 3 ]. The PEG may then be completed using a conventional pull-through technique. Outcomes Between 2018 and 2024, 55 T-PEG procedures were completed. Indications were neurodegenerative diseases (29 cases), aerodigestive cancer (20 cases, head & neck cancer 9, upper GI cancer 11), stroke (4), trachea-oesophageal fistula (1) and PEG exchange (1). The neurodegenerative cases were predominantly MND cases (26/29). The aerodigestive malignancy cases had PEG insertions either before or after definitive therapy for their malignancy, according to clinical need. Within this timeframe, one attempted T-PEG failed in a patient with head & neck cancer, owing to hiatus hernia with intrathoracic stomach and inability to find a safe spot for abdominal wall puncture. Distribution of Indications for T-PEG Procedures Table 1 Etiology Number of Cases Neurodegenerative Disease (predominantly MND) 1 29 Oesophageal Cancer 11 Head and Neck Cancer 9 Stroke 4 PEG Exchange (Pull Through) 2 Tracheo-oesophageal fistula 1 1 1 MND: Motor Neuron Disease 2 Exchange (Pull Through): Case where an existing gastrostomy tube was exchanged using the modified pull-through technique. Sedation Practices Overview Table 2 Patient Group Sedation Method Number of Cases Median Dose Neurodegenerative Disease Midazolam only 16 1 mg Pethidine 1 25mg No sedation 12 N/A Aerodigestive cancer Midazolam and Pethidine 20 2 mg (Midazolam), 25 mg (Pethidine) N/A: Not applicable Midazolam: A short-acting benzodiazepine used for sedation Pethidine: An opioid analgesic used for pain relief and mild sedation, All procedures were day cases with no procedural complications. One patient was readmitted due to peritonism around the PEG site after a pull-through PEG, but CT scanning did not demonstrate any complication and the symptoms settled with antibiotic therapy and analgesia, allowing discharge home with PEG feeding after 6 days. Three patients had delayed positive PEG-site swabs (2 Pexact push-PEGs and 1 Freka pull-through PEG. Two had mixed growth and one had Staph Aureus grown from swabs, all were managed with topical antimicrobials and none required PEG removal. The 30-day mortality rate was 1 out of 55 (2%) in a patient with advanced head and neck cancer. Discussion The high technical success rate with minimal complications observed with both push and pull-through transnasal PEGs in our case series highlights the potential of T-PEGs as a safe alternative to conventional methods for percutaneous tube feeding. The patient groups most likely to benefit from this alternative are those with neurodegenerative diseases (for example MND) and aerodigestive malignancies, who are often at higher risk of aspiration pneumonia or failed endoscope passage due to luminal stricturing. In 2014, Lin published a case series of transnasal percutaneous endoscopic gastrostomy in patients considered high-risk ( 1 ) Lin's study concluded that T-PEG techniques were favoured due to their minimal invasiveness and lower complication rates. Our study aligns with this conclusion, demonstrating high success rates and minimal complications in both patient groups. One reasonable alternative to T-PEGs is the RIG which is favoured by many units and endorsed in society guidelines. However, a recent meta-analysis and systematic review by Ahmed et al ( 9 ) concluded that RIGs have higher post-procedural mortality and tube complication rate compared with conventional PEGs. We suggest from our case series that it is reasonable to extrapolate that T-PEGs may likewise have a lower complication rate compared with RIGs and this was supported in one published case series ( 10 ) Another case series from McCulloch A and colleagues evaluated T-PEG placements using Pexact push-PEGs in a large MND patient cohort, without sedation, and found good tolerance in most patients. ( 2 ) . One patient developed a respiratory infection, and two patients had PEG displacements, with one unrelated death in the medium term. The T-PEG technique was deemed safe and well-tolerated, leading to its adoption in preference to other options and recommendation for other high-risk patients. We adapted this technique in our practice by adopting nasal-oral transfer of the traction thread and switching to the pull-through technique as described, thus avoiding the gastropexy steps and allowing for a much faster procedural completion time. Collectively, these studies, along with ours, testify to the relative safety and tolerability of the T-PEG technique. It is important to acknowledge the limitations of this study. This was an observational case series rather than a controlled study. The procedures were done by experienced operators and the technical success rates may not be transferable to all practitioners. Furthermore, our practice is restricted to two PEG devices, namely, the Freka disk-retained PEG kits and the Pexact 'push-PEG' gastropexy device. Other PEG and gastropexy devices are available and may also deserve evaluation. Future research could explore a broader range of T-PEG techniques to provide a more comprehensive understanding of their safety and efficacy. ( 11 ) In conclusion, our case series highlights high success rates for both push and pull-through PEGs using transnasal endoscopy, with very low complication rates. T-PEG methods emerge as a promising alternative to traditional techniques for percutaneous enteral tube feeding in high-risk patient groups. ( 11 ) Declarations Corresponding Author Dr. Muhammad Saad [email protected] Funding No Funding Author Contribution Author Contributions:M.S. wrote the main manuscript text and prepared the first draft. J.F. and N.C.F. contributed to case selection, data acquisition, and manuscript revisions. All authors reviewed and approved the final manuscript.Corresponding AuthorDR Muhammad Saad [email protected] Acknowledgements: we are grateful for the support of our wider Clinical Nutrition team and Endoscopy Department colleagues in developing our T-PEG service References Lin LF, Shen HC. Unsedated transnasal percutaneous endoscopic gastrostomy carried out by a single physician. Dig Endosc. 2013; 25(2):130-5. doi : 10 . 1111/j. 1443-1661.2012.01350 . x. Epub 2012 Jul 10. PMID: 23362930. DOI: 10.1111/j.1443-1661.2012.01350.x McCulloch A, Roy O, Massey D, Hedges R, Skerratt S, Wilson N, Woodward J. Nasal unsedated seated percutaneous endoscopic gastrostomy (nuPEG): a safe and effective technique for percutaneous endoscopic gastrostomy placement in high-risk candidates. Frontline Gastroenterol. 2018; 9(2):105–109. doi: 10.1136/flgastro-2017-100894. Epub 2017 Dec 5. PMID: 29588837. PMC5868436 DOI: 10.1136/flgastro-2017-100894 Sarkar P, Cole A, Scolding NJ, Rice CM. Percutaneous Endoscopic Gastrostomy Tube Insertion in Neurodegenerative Disease: A Retrospective Study and Literature Review. Clin Endosc. 2017; 50(3):270–278. doi: 10.5946/ce.2016.106. Epub 2016 Oct 13. PMID: 27737522; PMCID: PMC5475517DOI: 10.5946/ce.2016.106 Parker C, Alexandridis E, Plevris J, O'Hara J, Panter S. Transnasal endoscopy: no gagging no panic! Frontline Gastroenterol. 2016; 7(4):246–256. doi: 10.1136/flgastro-2015-100589. Epub 2015 Jul 2. PMID: 28839865; PMCID: PMC5369487, DOI: 10.1136/flgastro-2015-100589 Westaby D, Young A, O'Toole P, et al. The provision of a percutaneously placed enteral tube feeding service. Gut 2010;59:1592–605. DOI: 10.1136/gut.2009.204982 https://www.esge.com/assets/downloads/pdfs/guidelines/2020_a_1303_7449.pdf Arvanitakis Marianna et al. Endoscopic management of … Endoscopy 2021; 53 | © 2020.European Society of Gastrointestinal Endoscopy. Nevah MI, Lamberth JR, Dekovich AA. Transnasal PEG tube placement in patients with head and neck cancer. Endoscopy 2014, vol 79 (4), 599–604 DOI: 10.1016/j.gie.2013.08.019 Gauderer MWL. Conversion of a transnasal PEG to the transoral route . Gastrointest Endosc 2004; 60 DOI: 10.1016/S0016-5107(04)01547-0 Ahmed Z, Iqbal U, Aziz M et al. Outcomes and Complications of Radiological Gastrostomy vs. Percutaneous Endoscopic Gastrostomy for Enteral Feeding: An Updated Systematic Review and Meta-Analysis. Gastroenterology Research. Volume 16, Number 2, April 2023, pages 79–91. PMCID: PMC10181338, DOI: 10.14740/gr1593 O Roy1, J Woodward1, S Skerratt2, A Datta3, N Johnston2OC-112 Nupeg (nasal unsedated seated peg) is safer and better tolerated than rig (radiologically-inserted gastrostomy) in very high risk gastrostomy candidates https://doi.org/10.1136/gutjnl-2015-309861.112 Fisher N, Frost JP216 Transnasal percutaneous endoscopic gastrostomy (T-PEG): improving and expanding the indications for PEG insertion Gut 2022;71:A146-A147 . DOI: 10.1136/gutjnl-2022-BSG.270 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 24 Aug, 2025 Reviews received at journal 08 Aug, 2025 Reviewers agreed at journal 08 Aug, 2025 Reviewers invited by journal 07 Aug, 2025 Editor assigned by journal 30 Jul, 2025 Submission checks completed at journal 30 Jul, 2025 First submitted to journal 27 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7224383","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":497552892,"identity":"1b643a69-cb28-4e14-ab8c-9a38048c5eb6","order_by":0,"name":"Muhammad Saad","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9UlEQVRIiWNgGAWjYBACgwM8YJqxAUTy/LBhMCCkxRJFC29PGlRLAm4t9qi2sB0mrMXsRu7BTzdz7GQb+A8//PCG53yeOf8Btgcff+DTkpcsnbst2bhBIs1Yco7F7WLLGQnshjPw2pJjANTCnNggwWAgzcNzO3HDDQY2aR48Wgxu5Bj/zt1Wn9jAf/zzbx62c4kbzh9gk/6DX4sZ0JbDiQ0MQAYP24HEDQcS2KTxed/gzBsz69xtx43bJHLKLOf2JAMdltgmCQxs3FqO5xjfzt1WLdvPf3zzjTc/7IAOO3xMAhilhAEbggmJo1EwCkbBKBgFFAAABZRXygtbipIAAAAASUVORK5CYII=","orcid":"","institution":"Dudley Group NHS Foundation Trust","correspondingAuthor":true,"prefix":"","firstName":"Muhammad","middleName":"","lastName":"Saad","suffix":""},{"id":497552893,"identity":"0e6a10e4-12c0-4d8b-a3b8-935ace10819a","order_by":1,"name":"John Frost","email":"","orcid":"","institution":"Dudley Group NHS Foundation Trust","correspondingAuthor":false,"prefix":"","firstName":"John","middleName":"","lastName":"Frost","suffix":""},{"id":497552894,"identity":"7328d1ad-00cc-4db2-ad35-46acb0d110ee","order_by":2,"name":"Neil C Fisher","email":"","orcid":"","institution":"Dudley Group NHS Foundation Trust","correspondingAuthor":false,"prefix":"","firstName":"Neil","middleName":"C","lastName":"Fisher","suffix":""}],"badges":[],"createdAt":"2025-07-27 06:16:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7224383/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7224383/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89069074,"identity":"d32cd646-1ff4-4000-9f0e-a36a6de29c59","added_by":"auto","created_at":"2025-08-14 10:50:20","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":59267,"visible":true,"origin":"","legend":"\u003cp\u003eFreka Pexact device, involving gastropexy followed by advancement of a balloon gastrostomy tube \u003ca href=\"https://www.fresenius-kabi.com/pl/produkty/freka-pexact-gastric-fr-15\"\u003e\u003cstrong\u003ehttps://www.fresenius-kabi.com/pl/produkty/freka-pexact-gastric-fr-15\u003c/strong\u003e\u003c/a\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7224383/v1/59889c4315fe881b664f23e9.jpg"},{"id":89065948,"identity":"d628db9c-c51e-4ab9-93c6-97462c970c92","added_by":"auto","created_at":"2025-08-14 10:42:27","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":179537,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e[A to D]\u003c/strong\u003e \u003cstrong\u003eSteps in the Gastropexy and Push-PEG Procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e[A] The naso-endoscope is positioned, and a suitable site for the first gastropexy suture is identified using finger indentation. Local anesthetic is injected, and the gastropexy needles are advanced. [B] The first suture has been placed, and the process is repeated for the second gastropexy suture. [C] Three gastropexy sutures are completed in a triangular configuration. \u0026nbsp;[D] The balloon gastrostomy tube has been 'pushed' into place within the triangle formed by the gastropexy sutures.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7224383/v1/ff2e04b35f42b9d9c6d50f66.jpg"},{"id":89065933,"identity":"40db02c1-ec03-484a-8621-5a82e2aa2931","added_by":"auto","created_at":"2025-08-14 10:42:26","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":164438,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e[A to C]. Nasal-Oral Transfer of the PEG Traction Thread\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e[A] The traction thread has been captured within the stomach using pediatric biopsy forceps and pulled out through the nose with the naso-endoscope. A laryngoscope and Magill forceps are then used to retrieve the thread from the pharynx. [B] The thread is grasped with the forceps and pulled through the mouth. The shorter end of the thread, protruding from the nostril, will automatically be extracted first. [C] The thread has now been fully retrieved through the mouth, allowing completion of a conventional transoral pull-through PEG placement.\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7224383/v1/a310fa41897d9a049478cf29.jpg"},{"id":89070174,"identity":"e77a7239-378f-45f0-acff-99d6187189a0","added_by":"auto","created_at":"2025-08-14 10:58:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":920515,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7224383/v1/1c53bebe-1fa7-4bc2-a168-cc1445bb9b20.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Transnasal Percutaneous Endoscopic Gastrostomy (T-PEG): A Case Series of Push and Pull-through T-PEGs in High-Risk Groups","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePEG tube placement is generally safe and effective for enteral access in appropriately selected patients, but there are specific patient groups where conventional PEG placement may not be suitable or may present higher risks. \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e For instance, in patients with distorted pharyngeal or oesophageal anatomy consequent on aerodigestive malignancy, it may be difficult to navigate a gastroscope into the stomach, and risk of aspiration pneumonia are a concern. To mitigate this risk, alternative techniques for percutaneous feeding tube placement, such as radiologically inserted gastrostomy (RIG) are commonly employed. \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e Performing RIGs needs radiology support and local expertise. Another group of high-risk patients are those with neurodegenerative disease such as motor neuron disease (MND) with relatively high risk of aspiration associated with intravenous sedation and lying supine during conventional per-oral PEG insertion.\u003c/p\u003e\u003cp\u003eTransnasal endoscopy has become more widely used as an alternative to per-oral gastroscopy in recent years \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e, and some case reports and case series have highlighted a role for transnasal endoscopy in placement of PEGs, referred to hereafter as transnasal PEGs (T-PEGs) \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e. However, yet the T-PEG does not feature prominently in The British Society of Gastroenterology (BSG) or European Society of Gastrointestinal Endoscopy (ESGE) guidelines on enteral feeding tube placement. \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003ePromising results for T-PEGs regarding sedation safety, efficacy, and patient outcomes have been demonstrated in some published studies, although to date there is limited evidence with which to optimize the choice of T-PEG technique (push or pull-through) for given patient groups. Our practice encompasses a modified pull-through technique using Freka disk-retained PEG kits for high-risk patients with neurodegenerative disease, and a push technique using the Pexact 'push-PEG' gastropexy device for patients with aerodigestive (pharyngeal or oesophageal) malignancy\u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/b\u003e\u003c/sup\u003eThe aim of this case series and review is to highlight options for such patients with aerodigestive malignancy and neurodegenerative disease. We describe patient selection criteria, procedural techniques, and outcomes.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe used our prospectively maintained spreadsheet of T-PEG cases to review all cases, which were separated into \u0026lsquo;pull-through\u0026rsquo; PEGs using the Freka disk-retained PEG tubes, and \u0026lsquo;push\u0026rsquo; PEGs using the Pexact \u0026apos;push-PEG\u0026apos; gastropexy kit (which involves placement of a balloon gastrostomy tube, BGT). Outcomes were reviewed using endoscopy reports and electronic patient record analysis.\u003c/p\u003e\n\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003ePatient groups\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eSelected patients with neurodegenerative diseases and aerodigestive malignancies underwent T-PEG procedures between 2018 and 2024, following approval of the technique from our Trust\u0026rsquo;s New Interventions Committee. Initially T-PEGs were restricted to push-PEGs in patients with head and neck cancer, but the case mix was later expanded to include a modified pull-through technique in patients with neurodegenerative disease. Informed consent was obtained from all participants. Most PEG referrals were from our own institution, but we later incorporated tertiary referrals for patients with MND from a regional MND network. Head and neck cancer and oesophageal cancer cases were referred after discussion at their respective MDTs. The decision to opt for T-PEG instead of conventional PEG was made by the supervising enteral access specialists (NCF, JF) after review of clinical details within a multidisciplinary nutrition team MDT approach. T-PEG was generally favoured over RIG due to logistical considerations and local expertise.\u003c/p\u003e\n\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eProcedure details\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eAll cases are done in our endoscopy suite with or without conscious sedation with midazolam and/ or pethidine, and topical lignocaine anaesthesia sprayed into the nostrils. If the patient is not already hospitalized, then procedures are done as day cases and the patient is discharged if stable after 1\u0026ndash;2 hours of observation.\u003c/p\u003e\n\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eTransnasal Push-PEGs with the Pexact gastropexy device for patients with aerodigestive malignancies\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eFor this procedure we use the Freka Pexact device, involving gastropexy followed by advancement of a balloon gastrostomy tube [figure \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e]. Push-PEGs may be done using the conventional transoral endoscopic approach, but we selected the transnasal route where there was pharyngeal or oesophageal stricturing due to malignancy or post-surgical or radiotherapy-induced fibrosis.\u003c/p\u003e\n\u003cp\u003eThe patient lies in a supine position on the endoscope trolley with conventional oximetry and pulse monitoring. The transnasal Pexact push-PEG procedure involves inflating the stomach once the naso-endoscope is in place. After a suitable site for needle entry is found (using finger indentation with or without transillumination), a finder needle with local anaesthetic is advanced using the \u0026lsquo;safe track\u0026rsquo; technique (counter-traction on the syringe plunger to help ensure there is no other loop of bowel between the abdominal wall and the stomach lumen). Thereafter, gastropexy sutures are done with endoscopic vision of the intragastric steps [figure 2]. The gastropexy suture results in safe fixation of the gastric wall to the abdominal wall; some clinicians will do a \u0026lsquo;2-point\u0026rsquo; gastropexy with sutures at two points, but our preference is to do a \u0026lsquo;3-point\u0026rsquo; gastropexy with the 3 sutures in a triangular configuration. After the gastropexy sutures are done, a large trocar is advanced into the stomach in the middle of the \u0026lsquo;triangle\u0026rsquo; made by the sutures, then a balloon gastrostomy tube is placed, and its retaining balloon inflated. The gastropexy sutures are removed after 10\u0026ndash;14 days\u003c/p\u003e\n\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eTransnasal Pull-through PEGs with Freka disk-retained PEG kits for patients with neurodegenerative diseases\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eThe Freka PEG kit consists of a gastrostomy tube with a firm 2cm diameter plastic internal retaining disk, which prevents the tube from becoming dislodged. For this procedure, the patient is lying in a supine or semi-upright position on the endoscope trolley with conventional oximetry and pulse monitoring. The naso-endoscope is advanced into the stomach and an appropriate point for PEG entry is identified as above. The abdominal wall is punctured with the PEG trocar and the traction thread advanced into the stomach. The thread is captured in the stomach using paediatric biopsy forceps and then removed through the nostril. This is followed by naso-oral transfer of the traction thread from the nose to the mouth with the help of a laryngoscope and Magill\u0026rsquo;s forceps (a technique described previously) \u003csup\u003e\u003cstrong\u003e(\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/strong\u003e\u003c/sup\u003e[figure \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e]. The PEG may then be completed using a conventional pull-through technique.\u003c/p\u003e"},{"header":"Outcomes","content":"\u003cp\u003eBetween 2018 and 2024, 55 T-PEG procedures were completed. Indications were neurodegenerative diseases (29 cases), aerodigestive cancer (20 cases, head \u0026amp; neck cancer 9, upper GI cancer 11), stroke (4), trachea-oesophageal fistula (1) and PEG exchange (1). The neurodegenerative cases were predominantly MND cases (26/29). The aerodigestive malignancy cases had PEG insertions either before or after definitive therapy for their malignancy, according to clinical need.\u003c/p\u003e\n\u003cp\u003eWithin this timeframe, one attempted T-PEG failed in a patient with head \u0026amp; neck cancer, owing to hiatus hernia with intrathoracic stomach and inability to find a safe spot for abdominal wall puncture.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDistribution of Indications for T-PEG Procedures\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEtiology\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNumber of Cases\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeurodegenerative Disease (predominantly MND)\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOesophageal Cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHead and Neck Cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStroke\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePEG Exchange (Pull Through) \u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003eTracheo-oesophageal fistula\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e1 MND: Motor Neuron Disease 2 Exchange (Pull Through): Case where an existing gastrostomy tube was exchanged using the modified pull-through technique.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSedation Practices Overview\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePatient Group\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSedation Method\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNumber of Cases\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMedian Dose\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeurodegenerative Disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMidazolam only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 mg\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePethidine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25mg\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo sedation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAerodigestive cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMidazolam and Pethidine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 mg (Midazolam), 25 mg (Pethidine)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eN/A: Not applicable\u003c/p\u003e\n\u003cp\u003eMidazolam: A short-acting benzodiazepine used for sedation\u003c/p\u003e\n\u003cp\u003ePethidine: An opioid analgesic used for pain relief and mild sedation,\u003c/p\u003e\n\u003cp\u003eAll procedures were day cases with no procedural complications. One patient was readmitted due to peritonism around the PEG site after a pull-through PEG, but CT scanning did not demonstrate any complication and the symptoms settled with antibiotic therapy and analgesia, allowing discharge home with PEG feeding after 6 days. Three patients had delayed positive PEG-site swabs (2 Pexact push-PEGs and 1 Freka pull-through PEG. Two had mixed growth and one had Staph Aureus grown from swabs, all were managed with topical antimicrobials and none required PEG removal. The 30-day mortality rate was 1 out of 55 (2%) in a patient with advanced head and neck cancer.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe high technical success rate with minimal complications observed with both push and pull-through transnasal PEGs in our case series highlights the potential of T-PEGs as a safe alternative to conventional methods for percutaneous tube feeding. The patient groups most likely to benefit from this alternative are those with neurodegenerative diseases (for example MND) and aerodigestive malignancies, who are often at higher risk of aspiration pneumonia or failed endoscope passage due to luminal stricturing.\u003c/p\u003e\u003cp\u003eIn 2014, Lin published a case series of transnasal percutaneous endoscopic gastrostomy in patients considered high-risk \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e Lin's study concluded that T-PEG techniques were favoured due to their minimal invasiveness and lower complication rates. Our study aligns with this conclusion, demonstrating high success rates and minimal complications in both patient groups.\u003c/p\u003e\u003cp\u003eOne reasonable alternative to T-PEGs is the RIG which is favoured by many units and endorsed in society guidelines. However, a recent meta-analysis and systematic review by Ahmed et al \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e concluded that RIGs have higher post-procedural mortality and tube complication rate compared with conventional PEGs. We suggest from our case series that it is reasonable to extrapolate that T-PEGs may likewise have a lower complication rate compared with RIGs and this was supported in one published case series \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eAnother case series from McCulloch A and colleagues evaluated T-PEG placements using Pexact push-PEGs in a large MND patient cohort, without sedation, and found good tolerance in most patients. \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e. One patient developed a respiratory infection, and two patients had PEG displacements, with one unrelated death in the medium term. The T-PEG technique was deemed safe and well-tolerated, leading to its adoption in preference to other options and recommendation for other high-risk patients. We adapted this technique in our practice by adopting nasal-oral transfer of the traction thread and switching to the pull-through technique as described, thus avoiding the gastropexy steps and allowing for a much faster procedural completion time.\u003c/p\u003e\u003cp\u003eCollectively, these studies, along with ours, testify to the relative safety and tolerability of the T-PEG technique.\u003c/p\u003e\u003cp\u003eIt is important to acknowledge the limitations of this study. This was an observational case series rather than a controlled study. The procedures were done by experienced operators and the technical success rates may not be transferable to all practitioners. Furthermore, our practice is restricted to two PEG devices, namely, the Freka disk-retained PEG kits and the Pexact 'push-PEG' gastropexy device. Other PEG and gastropexy devices are available and may also deserve evaluation. Future research could explore a broader range of T-PEG techniques to provide a more comprehensive understanding of their safety and efficacy. \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn conclusion, our case series highlights high success rates for both push and pull-through PEGs using transnasal endoscopy, with very low complication rates. T-PEG methods emerge as a promising alternative to traditional techniques for percutaneous enteral tube feeding in high-risk patient groups. \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eCorresponding Author\u003c/h2\u003e\u003cp\u003eDr. Muhammad Saad\u003c/p\u003e\u003cp\[email protected]\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eNo Funding\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAuthor Contributions:M.S. wrote the main manuscript text and prepared the first draft. J.F. and N.C.F. contributed to case selection, data acquisition, and manuscript revisions. All authors reviewed and approved the final manuscript.Corresponding AuthorDR Muhammad Saad [email protected]\u003c/p\u003e\u003ch2\u003eAcknowledgements:\u003c/h2\u003e\u003cp\u003ewe are grateful for the support of our wider Clinical Nutrition team and Endoscopy Department colleagues in developing our T-PEG service\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLin LF, Shen HC. \u003cem\u003eUnsedated transnasal percutaneous endoscopic gastrostomy carried out by a single physician. Dig Endosc.\u003c/em\u003e 2013;\u003cem\u003e25(2):130-5. doi\u003c/em\u003e: \u003cdiv class=\"ExternalRefDOI\"\u003e10\u003c/div\u003e.\u003cem\u003e1111/j.\u003c/em\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e1443-1661.2012.01350\u003c/span\u003e\u003cspan address=\"http://1443-1661.2012.01350\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. \u003cem\u003ex. Epub 2012 Jul 10. PMID: 23362930.\u003c/em\u003e DOI: 10.1111/j.1443-1661.2012.01350.x\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcCulloch A, Roy O, Massey D, Hedges R, Skerratt S, Wilson N, Woodward J. \u003cem\u003eNasal unsedated seated percutaneous endoscopic gastrostomy (nuPEG): a safe and effective technique for percutaneous endoscopic gastrostomy placement in high-risk candidates. Frontline Gastroenterol.\u003c/em\u003e 2018;\u003cem\u003e9(2):105\u0026ndash;109. doi: 10.1136/flgastro-2017-100894. Epub 2017 Dec 5. PMID: 29588837.\u003c/em\u003e PMC5868436 DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/flgastro-2017-100894\u003c/span\u003e\u003cspan address=\"10.1136/flgastro-2017-100894\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSarkar P, Cole A, Scolding NJ, \u003cem\u003eRice CM. Percutaneous Endoscopic Gastrostomy Tube Insertion in Neurodegenerative Disease: A Retrospective Study and Literature Review. Clin Endosc.\u003c/em\u003e 2017;\u003cem\u003e50(3):270\u0026ndash;278. doi: 10.5946/ce.2016.106. Epub 2016 Oct 13. PMID: 27737522;\u003c/em\u003e PMCID: PMC5475517DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5946/ce.2016.106\u003c/span\u003e\u003cspan address=\"10.5946/ce.2016.106\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eParker C, Alexandridis E, Plevris J, O'Hara J, Panter S. \u003cem\u003eTransnasal endoscopy: no gagging no panic! Frontline Gastroenterol.\u003c/em\u003e 2016;\u003cem\u003e7(4):246\u0026ndash;256. doi: 10.1136/flgastro-2015-100589. Epub 2015 Jul 2. PMID: 28839865;\u003c/em\u003e PMCID: PMC5369487, DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/flgastro-2015-100589\u003c/span\u003e\u003cspan address=\"10.1136/flgastro-2015-100589\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWestaby D, Young A, O'Toole P, et al. The provision of a percutaneously placed enteral tube feeding service. Gut 2010;59:1592\u0026ndash;605. DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/gut.2009.204982\u003c/span\u003e\u003cspan address=\"10.1136/gut.2009.204982\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e\u003cem\u003ehttps://www.esge.com/assets/downloads/pdfs/guidelines/2020_a_1303_7449.pdf\u003c/em\u003e Arvanitakis Marianna et al. Endoscopic management of \u0026hellip; Endoscopy 2021; 53 | \u0026copy; 2020.European Society of Gastrointestinal Endoscopy.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNevah MI, Lamberth JR, Dekovich AA. \u003cem\u003eTransnasal PEG tube placement in patients with head and neck cancer. Endoscopy 2014, vol 79 (4), 599\u0026ndash;604\u003c/em\u003e DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.gie.2013.08.019\u003c/span\u003e\u003cspan address=\"10.1016/j.gie.2013.08.019\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGauderer MWL. \u003cem\u003eConversion of a transnasal PEG to the transoral route\u003c/em\u003e. \u003cem\u003eGastrointest Endosc\u003c/em\u003e 2004;\u003cem\u003e60\u003c/em\u003e DOI:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0016-5107(04)01547-0\u003c/span\u003e\u003cspan address=\"10.1016/S0016-5107(04)01547-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAhmed Z, Iqbal U, Aziz M \u003cem\u003eet al. Outcomes and Complications of Radiological Gastrostomy vs. Percutaneous Endoscopic Gastrostomy for Enteral Feeding: An Updated Systematic Review and Meta-Analysis. Gastroenterology Research. Volume 16, Number 2, April\u003c/em\u003e 2023, \u003cem\u003epages 79\u0026ndash;91.\u003c/em\u003e PMCID: PMC10181338, DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.14740/gr1593\u003c/span\u003e\u003cspan address=\"10.14740/gr1593\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eO Roy1, J Woodward1, S Skerratt2, A Datta3, N Johnston2OC-112 Nupeg (nasal unsedated seated peg) is safer and better tolerated than rig (radiologically-inserted gastrostomy) in very high risk gastrostomy candidates \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/gutjnl-2015-309861.112\u003c/span\u003e\u003cspan address=\"10.1136/gutjnl-2015-309861.112\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFisher N, \u003cem\u003eFrost JP216 Transnasal percutaneous endoscopic gastrostomy (T-PEG): improving and expanding the indications for PEG insertion Gut 2022;71:A146-A147\u003c/em\u003e. DOI:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/gutjnl-2022-BSG.270\u003c/span\u003e\u003cspan address=\"10.1136/gutjnl-2022-BSG.270\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"innovative-surgical-trends","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Innovative Surgical Trends](https://link.springer.com/journal/44414)","snPcode":"44414","submissionUrl":"https://submission.springernature.com/new-submission/44414/3?","title":"Innovative Surgical Trends","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7224383/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7224383/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003ePercutaneous Endoscopy Gastrostomy (PEG) insertion is a long-established intervention in neurodegenerative diseases and aerodigestive malignancies where enteral feeding is required. Transnasal PEG (T-PEG) has been advocated as a safer alternative compared with conventional transoral PEGs for selected patients, although large case series are lacking in the literature. \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e This case series illustrates technique and outcomes for two types of T-PEG procedures; firstly, the using a modified \u0026lsquo;pull-through\u0026rsquo; technique and secondly using a gastropexy-assisted \u0026lsquo;push\u0026rsquo; technique\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eOur practice is to use pull-through T-PEGs predominantly for high-risk patients with neurodegenerative disease, and push T-PEGs for patients with aerodigestive malignancies. Patient selection is carried out by a clinical nutrition multidisciplinary team (MDT). The techniques used for both pull-through T-PEG techniques are described. A prospective database of T-PEG cases was analyzed to evaluate outcomes.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eA total of 55 T-PEG procedures were completed between 2018 and 2024. There were 27 cases of primary neurodegenerative diseases and 21 cases of aerodigestive cancer (remaining 7 cases, miscellaneous). All but one T-PEG was successful at first attempt and with no serious procedural complications. There was one readmission with self-limiting insertion site pain, and 30-day mortality was 1/55 (a cancer case).\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e\u003cp\u003eIn our case series of T-PEGs, we have demonstrated a high procedural success rate and low complication and mortality rates. T-PEG can be considered a viable alternative for patients who are not suitable candidates for traditional PEG and a valid alternative to other options such as radiological or surgical gastrostomy.\u003c/p\u003e","manuscriptTitle":"Transnasal Percutaneous Endoscopic Gastrostomy (T-PEG): A Case Series of Push and Pull-through T-PEGs in High-Risk Groups","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-14 09:57:20","doi":"10.21203/rs.3.rs-7224383/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-24T16:50:13+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-08T07:41:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"105140425538207067560226067540157456292","date":"2025-08-08T07:29:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-07T17:46:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-30T10:30:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-30T10:29:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"Innovative Surgical Trends","date":"2025-07-27T06:06:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"innovative-surgical-trends","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Innovative Surgical Trends](https://link.springer.com/journal/44414)","snPcode":"44414","submissionUrl":"https://submission.springernature.com/new-submission/44414/3?","title":"Innovative Surgical Trends","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"99a2a5eb-e777-4ed0-b4ab-afaa88fae46a","owner":[],"postedDate":"August 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-04T21:38:18+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-14 09:57:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7224383","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7224383","identity":"rs-7224383","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}