How to remove a percutaneous endoscopic gastrostomy (PEG) tube with hypergranulation tissue?

Management of PEG Tube Removal with Hypergranulation Tissue

For PEG tubes with hypergranulation tissue, first treat the hypergranulation with silver nitrate cauterization or topical corticosteroids before removal, then remove the tube endoscopically by catching the internal fixation plate with a snare rather than using the cut-and-push technique. 1, 2

Treatment of Hypergranulation Tissue Before Removal

First-Line Options:

1. Silver Nitrate Application 2

   • Apply directly to hypergranulation tissue
   • Results typically seen within 1-2 applications
   • Provides chemical cauterization of excessive tissue
   • Clean site with antimicrobial cleanser before application

2. High-Potency Topical Corticosteroids 2, 3

   • Apply clobetasol 0.05% ointment directly to hypergranulation tissue
   • Use twice daily for 7-10 days
   • Particularly effective for inflamed granulation tissue with bleeding and exudation
   • In one case study, hypergranulation tissue almost completely disappeared after just 4 days of treatment 3

3. Combination Approach

   • For moderate to severe cases, combine silver nitrate with topical steroids between applications 2
   • Apply foam dressing over treatment site to provide compression 1

For Resistant Cases:

• Scoop shave removal followed by hyfrecation 2
• Intralesional triamcinolone acetonide injection 2
• Argon plasma coagulation 1
• Surgical removal 1, 2
• Consider changing to alternative brand or type of tube 1

PEG Tube Removal Procedure

Recommended Removal Method:

• Endoscopic removal is recommended over the cut-and-push technique 1
• Catch the internal fixation plate with an endoscopic snare 1
• This approach prevents potential complications such as ileus that have been reported with the cut-and-push method 1

Alternative Removal Options:

• For newer PEG systems with releasable internal fixation plates, removal can be done percutaneously without endoscopy 1
• These systems are particularly suitable for cases where temporary enteral nutrition was anticipated 1

Precautions During Removal

1. Bleeding Risk

   • Monitor for excessive bleeding during and after removal
   • In rare cases, massive bleeding can occur after PEG removal 4
   • Have hemostatic devices available (e.g., over-the-scope clip system for severe cases) 4

2. Special Considerations

   • For patients with previous bowel surgery or at risk of strictures/ileus, endoscopic retrieval is strongly advocated 1
   • These conditions could hinder spontaneous migration of the internal bumper if cut-and-push technique is used 1

Daily Care Before and After Removal

• Clean site daily with antimicrobial cleanser and water 2
• Dry thoroughly after cleaning 2
• Apply zinc oxide-based skin protectants to surrounding skin if leakage is present 2
• Ensure proper tube stabilization to minimize movement before removal 2
• Avoid excessive tube movement which can worsen hypergranulation 2
• Avoid hydrogen peroxide for cleaning after the first week post-placement 2
• Avoid occlusive dressings as they can lead to skin maceration 2

Pitfalls and Caveats

1. Avoid cut-and-push technique in patients with:

   • Previous bowel surgery
   • Risk of strictures
   • History of ileus
   • These patients require endoscopic removal to prevent complications 1

2. Monitor for infection

   • If site infection is suspected, apply topical antimicrobial agents 1
   • If infection persists despite topical and systemic antibiotics, tube removal may be necessary 1

3. Assess for buried bumper syndrome

   • This rare complication requires endoscopic removal using a needle knife sphincterotome 1
   • Can be avoided with adequate aftercare 1

4. Avoid prolonged corticosteroid use

   • Limit topical steroid application to 7-10 days to prevent skin atrophy 2, 3
   • Monitor for signs of skin erosion 5

By following this approach, hypergranulation tissue can be effectively managed before PEG tube removal, minimizing complications and ensuring safe removal of the device.