Percutaneous Endoscopic Pharyngostomy (PEP) Tube Placement for Gastrointestinal Diversion: A PEP in Your Palliative Step

Background Need for chronic gastrointestinal diversion (GID) due to advanced malignancy or prolonged gastrointestinal discontinuity can pose a challenge for patients in which gastrostomy tube placement is not a feasible option. Nasogastric (NG) tubes carry a risk of multiple complications and can impact quality of life. Need for long-term GID can increase length of stay, delay discharge to post-acute care, and result in readmissions. We discuss the procedural steps to percutaneous endoscopic pharyngostomy (PEP) tube placement utilizing common endoscopic, ultrasound imaging, and percutaneous access skills. Methods We conducted a single-center retrospective review of 10 patients who required long-term GID and underwent PEP performed by acute care surgeons between May 2019 and August 2025. Results Patients ranged from ages 39 to 81. Nine patients required palliation due to malignant obstruction from advanced malignancy. One patient required decompression of an esophageal pouch after gastrectomy for ischemia without reconstruction. Three dislodged tubes were replaced, resulting in a total of 13 operations performed. Complications included the dislodgement of five PEP tubes, ranging from post-op day 12 to 42. Nine of the patients were discharged home with an average discharge of 3.4 days post-op. Three patients were lost to follow-up, but all three were discharged to home hospice as per the patient’s preoperative goals of care. Discussion Percutaneous endoscopic pharyngostomy is a useful skill for acute care surgeons to provide access for GID in selected patients. Challenges include a high dislodgement rate requiring reintervention.