Is it safe to remove a percutaneous endoscopic gastrostomy (PEG) tube by pulling?

PEG Tube Removal by Traction

While it is possible to remove a PEG tube by simply cutting the external portion and allowing the internal bumper to pass naturally, endoscopic removal is still recommended due to reports of complications such as ileus. 1

Safe Methods for PEG Tube Removal

Recommended Approaches:

1. Endoscopic Removal (Preferred Method)

   • The internal fixation plate is caught with an endoscopic snare
   • Provides direct visualization to ensure complete removal
   • Reduces risk of complications such as ileus 1

2. Specialized PEG Systems

   • Some modern PEG systems have internal fixation plates that can be released externally
   • These can be safely removed percutaneously without endoscopy
   • Particularly suitable for temporary feeding situations (e.g., during chemotherapy) 1

3. "Cut and Push" Method (Use with Caution)

   • Involves cutting the catheter at skin level and allowing internal bumper to pass naturally
   • While some studies show this can be done safely, it carries risks
   • Only appropriate for certain types of PEG tubes 2
   • Not recommended as first-line approach due to potential complications

Factors to Consider Before Removal:

• Tract Maturity: The gastrocutaneous tract typically matures in 1-2 weeks and is well-formed by 4-6 weeks, but may take longer in some patients 3
• Tube Type: Different PEG designs require different removal approaches
• Patient Condition: Consider overall health status and ability to tolerate complications

Potential Complications of PEG Removal

• Bleeding: Rare but can be severe, potentially requiring endoscopic intervention 4
• Tract Disruption: The gastrocutaneous tract can be damaged during removal
• Intraperitoneal Placement: If a replacement tube is needed, improper placement can lead to peritonitis 3
• Ileus: Several reports document intestinal obstruction after allowing internal bumpers to pass naturally 1

Alternative Removal Techniques

• "Tie and Retrograde Pull": For tubes with semi-rigid internal discs that resist external traction
  • A suture is placed and tied above skin level
  • The tube is cut above the knot
  • The suture is pushed into the stomach and retrieved endoscopically
  • Allows for controlled removal of difficult tubes 5

Post-Removal Care

• Wound Care: After removal, the stoma site typically closes within 24-48 hours
• Monitoring: Watch for signs of infection, bleeding, or peritonitis
• Dressing: Apply a sterile dressing until the site is healed

Important Precautions

• Never attempt removal by traction if the tube has been in place for less than 4 weeks
• Never forcefully pull if resistance is encountered
• If the PEG tube cannot be removed easily by the intended method, seek specialist assistance rather than using excessive force
• Always confirm the internal bumper is intact after removal

While simple traction removal is possible in some cases, the safest approach is endoscopic removal to minimize the risk of complications that could negatively impact patient morbidity and mortality.