Proper Procedure for Removing a Percutaneous Endoscopic Gastrostomy (PEG) Tube
The recommended procedure for removing a PEG tube is endoscopic removal using a snare to catch the internal fixation plate, as this method prevents potential complications such as ileus that can occur with the cut-and-push technique. 1
Methods of PEG Tube Removal
There are two main approaches to PEG tube removal:
1. Endoscopic Removal (Preferred Method)
- Perform endoscopy to visualize the internal bumper
- Use a snare to catch the internal fixation plate
- Remove the entire PEG tube through the mouth
- Benefits: Prevents risk of intestinal obstruction and allows visual confirmation of complete removal
2. External Removal Options
Cut-and-Push Technique:
- Cut the external portion of the tube and allow the internal bumper to pass naturally through the GI tract
- While studies have shown this can be done without complications in adults, it is NOT recommended due to several reports of subsequent ileus 1
Newer PEG Systems with Releasable Internal Fixation:
- Some modern PEG tubes have internal fixation plates that can be released from outside
- These can be removed percutaneously without endoscopy
- Particularly suitable for patients with temporary feeding needs (e.g., during chemotherapy or radiation therapy) 1
Complications of PEG Tube Removal
Potential Complications
- Retained bumper (5.5% of cases) 2
- Intraperitoneal placement of replacement device (3.17%) 2
- Gastrocutaneous fistula (0.78%) 2
- Inability to remove the tube (1.57%) 2
Risk Factors for Complications
- Longer duration of PEG placement (retained bumpers associated with average 29 months in situ) 2
- Immature gastrocutaneous tract (particularly if removed within 4-6 weeks of placement) 3
Special Considerations
For Early Accidental Dislodgement
- If PEG dislodges within hours/days of placement:
- Monitor for signs of peritonitis or sepsis
- Consider endoscopic closure of the gastric wall defect and PEG replacement at an adjacent site 4
- This approach can allow earlier resumption of enteral feeding
For PEG Replacement
- Ensure the gastrocutaneous tract is mature (typically 4-6 weeks after initial placement) 3
- Use minimal insertion force during replacement
- Confirm intragastric tube position after replacement
- Monitor for signs of complications (abdominal pain, peritonitis) after replacement 3
Post-Removal Care
If the stoma site is to be closed:
- Apply sterile dressing over the site
- Monitor for leakage from the stoma site
- Stoma typically closes within 24-72 hours
If replacing with another device:
- Ensure proper positioning
- Confirm placement before resuming feeds
- Maintain proper care of the new device
Pitfalls to Avoid
- Removing PEG tubes too early after initial placement (before tract maturation)
- Using excessive force during removal
- Failing to confirm complete removal of all components
- Neglecting to monitor for complications after removal
By following these guidelines, the risk of complications associated with PEG tube removal can be minimized, ensuring patient safety and optimal outcomes.