PEG Tube Removal in a Surgical Setting
PEG tubes should be removed endoscopically by catching the internal fixation plate with a snare, as this is the recommended method to prevent potential complications such as ileus. 1
Safe Removal Methods for PEG Tubes
The approach to PEG tube removal depends on the type of tube and how long it has been in place:
Standard Bumper-Type PEG Tubes
- Endoscopic removal is the safest method for standard PEG tubes with internal bumpers 1
- Although studies have shown that cutting the tube at skin level and allowing the internal bumper to pass naturally ("cut and push" technique) can be done without complications in many adults, this is not recommended as the primary approach 1
- The endoscopic retrieval method involves:
- Using a snare to catch the internal fixation plate
- Removing it through the mouth to prevent potential complications 1
Special Considerations
- Endoscopic retrieval is especially important in patients with:
- Previous bowel surgery
- Risk of strictures
- Risk of ileus that could prevent spontaneous migration of the cut bumper 1
Alternative PEG Systems
- Some newer PEG systems have internal fixation plates that can be released from the outside
- These systems can be removed percutaneously without endoscopy 1
- These are particularly suitable for patients requiring only temporary enteral nutrition 1
Complications of Improper Removal
Improper PEG tube removal can lead to serious complications:
- Gastrocutaneous tract disruption - can occur if the tract is not mature 2
- Intraperitoneal tube placement during replacement attempts 2
- Chemical peritonitis - if gastric contents leak into the peritoneal cavity 2
- Ileus - if the internal bumper becomes lodged in the intestines 1
Post-Removal Care
After PEG tube removal:
- Monitor the site for proper healing
- The gastrocutaneous fistula typically closes spontaneously within 4 days 3
- Watch for signs of infection or leakage
Special Situations
Emergency Removal
- If a PEG tube must be removed emergently and endoscopy is not immediately available, surgical consultation should be obtained
- Never attempt to forcefully remove a PEG tube that has been in place for less than 4 weeks, as the tract may not be mature 4
Replacement After Removal
- If replacement is needed after removal, it should be performed before the tract closes completely
- A mature fibrous tract is necessary for safe replacement, which typically forms after 4 weeks 1
Common Pitfalls to Avoid
- Do not attempt "cut and push" technique in patients with history of bowel surgery or known intestinal strictures
- Do not apply excessive traction force to remove tubes unless they are specifically designed for external removal
- Do not attempt bedside removal of tubes that have been in place for less than 4 weeks 4
By following these guidelines, PEG tube removal can be performed safely in a surgical setting, minimizing the risk of complications and ensuring the best outcomes for patients.