Management of Chronic PEG Tube Leakage
A purse-string suture is not recommended for correcting chronic leakage around a long-standing PEG tube—instead, focus on correcting mechanical causes, optimizing skin protection, and considering tube replacement strategies. 1, 2, 3
Why Purse-String Sutures Are Not the Solution
The evidence does not support purse-string suturing as a treatment for chronic PEG leakage. 1 The underlying problem in chronic leakage is typically an enlarged stoma tract from prolonged irritation, infection, or mechanical factors—not a simple gap that can be sutured closed. 2, 3 Endoscopic suturing techniques have been reported only for persistent gastrocutaneous fistulas after PEG removal, not for leakage around an in-situ tube. 4
Systematic Approach to Chronic PEG Leakage
Step 1: Assess and Correct Mechanical Causes
Check external bolster tension immediately: Ensure 0.5-1 cm of free distance between the external bolster and skin—excessive compression is the leading cause of tissue necrosis and tract enlargement. 1, 2, 3
Verify tube mobility: The tube should move inward at least 2 cm (ideally 5-10 cm) without resistance—difficulty mobilizing suggests buried bumper syndrome requiring urgent evaluation. 1, 3
Inspect for side torsion: Lateral tube movement causes ulceration and progressive tract enlargement, creating pathways for leakage. 2, 3
For balloon-type tubes: Check balloon volume weekly against manufacturer specifications—deflation allows migration and leakage. 3
Step 2: Immediate Skin Protection
Apply zinc oxide-containing barrier products (films, pastes, or creams) to all exposed skin to prevent acid-induced breakdown. 1, 2, 3
Use foam dressings instead of gauze—foam lifts drainage away from skin while gauze contributes to maceration. 1, 2
Step 3: Medical Management
Start proton pump inhibitors to decrease gastric acid secretion and minimize leakage volume—review regularly if used long-term. 1, 2, 3
Consider prokinetic agents if gastroparesis is contributing to increased gastric residuals and overflow. 3
Address constipation aggressively to reduce intra-abdominal pressure forcing contents around the tube. 3
Step 4: Treat Contributing Factors
Excessive granulation tissue: Apply topical corticosteroid cream for 7-10 days with foam dressing compression. 2
Local fungal infection: Treat with topical antifungal agents—chronic moisture creates a vicious cycle. 1, 2, 3
Peristomal infection: Take swab for culture and treat with appropriate antibiotics if persistent despite antiseptic measures. 1
Step 5: Tube Replacement Strategy for Refractory Cases
Critical: Do NOT upsize to a larger-diameter tube—this worsens leakage by further enlarging the tract. 2, 3
Instead, consider removing the tube for 24-48 hours to permit slight spontaneous closure of the tract, then replace with a tube that fits more closely. 2, 5 This approach has been successful in allowing stomal closure until a tight cutaneous seal is achieved. 5
Special Considerations for This Patient
Given the patient's diabetes, malnutrition, and dementia:
Hyperglycemia impairs wound healing—optimize glucose control to facilitate tract healing. 1
Malnutrition itself hinders tissue repair—paradoxically, successful enteral nutrition may cause weight gain that contributes to buried bumper syndrome. 3
Cognitive impairment increases risk of tube manipulation—secure the tube carefully and consider protective garments if the patient pulls at it. 6
Critical Pitfalls to Avoid
Never ignore difficulty mobilizing the tube—this is an alarming signal for buried bumper syndrome requiring immediate endoscopic evaluation. 1, 3
Avoid routine gastric residual checks—this increases tube occlusion risk 10-fold and can worsen overflow problems. 3
Do not use hydrogen peroxide after the first week—it irritates skin and contributes to stomal leaks. 3
Small peristomal drainage in the first week is normal—but chronic leakage in a long-standing tube indicates tract pathology requiring intervention. 1