When should a Percutaneous Endoscopic Gastrostomy (PEG) tube be removed?

When Should a PEG Tube Be Removed?

A PEG tube should be removed when the original indication for placement has resolved (such as recovery of swallowing function), the patient can maintain adequate oral nutrition independently, or when persistent complications cannot be managed conservatively—but never before 14 days post-insertion to ensure tract maturation and prevent peritoneal leakage. 1

Minimum Time Before Removal

• Never remove a PEG tube before 14 days after insertion, as this is the minimum time required to establish a fibrous gastrocutaneous tract that prevents intraperitoneal leakage 1
• Normal adherence of the stomach to the abdominal wall typically occurs within 7-14 days, with complete tract maturation usually established by 4-6 weeks 2
• By 4 weeks, the gastrocutaneous tract is generally considered mature enough for safe removal in most patients 2

Clinical Indications for PEG Removal

When Removal is Appropriate:

• Recovery of swallowing function after stroke or other neurologic conditions that have resolved 1
• Adequate oral intake restored such that the patient can meet nutritional requirements independently without supplementation 3
• Median duration before removal in patients who recover oral feeding is typically 4-6 months 4
• Approximately 21% of patients eventually have their PEG tubes removed after recovery of oral intake 5

When Removal is Necessary Due to Complications:

• Persistent peristomal infection that does not resolve despite appropriate antimicrobial treatment 3
• Stoma tract disruption or skin excoriation that cannot be managed conservatively 3
• Fungal infection with material deterioration and compromised structural integrity of the tube 3
• Tube dysfunction including breakage, occlusion, or dislodgement 3

Important Timing Considerations

Delayed Tract Maturation Risk Factors:

Patients with the following conditions may require longer than 4 weeks before safe removal 2:

• Malnutrition or poor wound healing
• Diabetes mellitus
• Immunosuppressive medications or corticosteroid treatment
• Ascites

Method of Removal

• Endoscopic removal using a snare to retrieve the internal fixation plate is the recommended approach, as this minimizes the risk of complications such as ileus 1
• The "cut and push" technique (cutting the tube at skin level and pushing the internal bumper into the intestinal lumen) should be avoided in patients with known or suspected intestinal strictures, previous bowel surgery, or risk factors for ileus 3, 1
• For tubes with balloon retention devices, deflate the balloon and apply gentle traction to remove 1

Post-Removal Management

• 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, and delayed gastric emptying 1
• If a persistent fistula develops after removal, endoscopic closure using over-the-scope clips or endoscopic suturing may be required 1, 6

Assessment Before Removal

Before removing a PEG tube, verify the following 3:

• Oral intake adequacy: Patient must be consuming >50% of energy requirements orally for at least 7 days
• Nutritional status: Weight should be stable or improving on oral intake alone
• Swallowing function: If dysphagia was the original indication, confirm resolution through clinical assessment or swallow study
• No ongoing need: Ensure no anticipated future need for enteral access (e.g., upcoming surgery or treatment that may impair oral intake)

Common Pitfalls to Avoid

• Do not remove before 14 days under any circumstances due to peritoneal leakage risk 1
• Do not use the "cut and push" method in patients with intestinal strictures or previous bowel surgery, as this has caused bowel obstruction requiring laparotomy 7
• Do not assume all patients will recover oral intake: only about 21% of patients eventually have tubes removed, with one-third dying within 60 days and half within 6 months of placement 5
• Ensure alternative feeding methods are established before removal if the patient will still require enteral nutrition 2

Long-Term PEG Management Alternative

If the patient requires ongoing enteral nutrition, there is no need for routine replacement based on time alone—PEG tubes can remain in place for many years (exceeding 10 years) with proper care and handling 4. Replacement should only occur when complications arise such as tube dysfunction, occlusion, or material fatigue 3, 4.