When and how is a Percutaneous Endoscopic Gastrostomy (PEG) tube removed?

PEG Tube Removal: When and How

PEG tubes should be removed endoscopically by catching the internal fixation plate with a snare, as there are several reports of ileus following the "cut and push" method, despite studies showing this can be done without complications in adults. 1

When to Remove a PEG Tube

• PEG tubes are frequently used as prophylactic or temporary measures, with up to 20-30% of PEG tubes being removed in some centers 1
• A PEG tube should not be removed for at least 14 days after insertion to ensure a fibrous tract is established that will prevent intraperitoneal leakage 1
• Removal is appropriate when:
  • The patient has resumed adequate oral nutrition and no longer requires supplementary feeding 2
  • The original indication for PEG placement has resolved (e.g., recovery of swallowing function after stroke) 1
  • Younger patients (<65 years) and those with localized head and neck cancer are more likely to resume oral nutrition and have their PEG tubes removed 2

Methods of PEG Tube Removal

Endoscopic Removal (Preferred Method)

• The recommended approach is endoscopic removal of the internal fixation plate using a snare 1
• This method minimizes the risk of complications such as ileus that have been reported with other removal techniques 1

External Removal Options

• For tubes with balloon retention devices:
  • Deflate the balloon and apply gentle traction to remove 1
• For tubes with rigid fixation devices:
  • These typically require endoscopic removal 1
  • Some studies suggest cutting the tube close to the skin and pushing it through into the stomach to allow spontaneous passage, but this carries a 2% risk of non-passage and should not be used if there is any suspicion of distal stricturing 1

Newer PEG Systems

• Some commercially available PEG systems have internal fixation plates that can be released from the outside, allowing percutaneous removal without endoscopy 1
• These systems are particularly suitable for patients with anticipated temporary feeding needs, such as during planned chemotherapy or radiation therapy 1

Management After PEG Removal

• After permanent removal, the gastrocutaneous tract typically closes spontaneously within 72 hours 1
• Risk factors for persistent gastrocutaneous fistula include:
  • Immune suppression
  • Prior infection at the gastrostomy site
  • Malnutrition
  • Delayed gastric emptying 1
• If a persistent fistula develops, endoscopic closure using over-the-scope clips or endoscopic suturing may be required 1

Special Considerations

• If early accidental removal occurs (within 14 days of placement):
  • Assess for signs of peritonitis or sepsis
  • In stable patients without peritonitis, endoscopic closure of the gastric wall defect and PEG replacement at an adjacent site can be considered 3
• For patients who require long-term enteral access but desire improved cosmesis:
  • Consider conversion to a low-profile "button" system after a stable stoma has formed (at least 4 weeks after initial placement) 4

Pitfalls to Avoid

• Never remove a PEG tube before 14 days post-insertion due to risk of peritoneal leakage 1
• Avoid the "cut and push" technique in patients with known or suspected intestinal strictures 1
• Be aware that while PEG tubes can remain functional for many years (even exceeding 10 years), removal should be considered when the clinical indication has resolved 1
• Monitor for signs of persistent gastrocutaneous fistula after removal, particularly in high-risk patients 1