Intestinal passage of the PEG end-piece: is it safe?

Replacing gastrostomy tubes with collapsible bumpers in pediatric patients: Is it safe to "cut" the tube and allow the bumper to pass enterally?

PURPOSE

The "cut and push" technique for removal of percutaneous endoscopic gastrostomy (PEG) tubes with collapsible bumpers offers an alternative to the standard traction method of removal. This study compared the outcomes of these techniques.

METHODS

We completed a research ethics board-approved retrospective cohort study, identifying all patients less than 18years of age who underwent PEG tube removal at a children's hospital between December 2013 and December 2016. Outcomes included need for sedation and complications.

RESULTS

We identified 127 children who had PEG tubes removed. Significantly fewer children required sedation with the cut and push group (1.1% vs. 60.6%, p≤0.001). Ten complications occurred, including 9 in the cut and push group (9.6% vs. 3%, p=0.23). Mean age at time of complication was significantly younger in the cut and push group (2.2 vs. 6.3years p=0.004).

CONCLUSION

This is the largest reported series comparing the cut and push vs. traction removal methods. The cut and push technique significantly reduced the need for procedural sedation but was associated with increased risk of complications. While these data suggest that the technique is safe in older children, caution should be taken in younger children who appear to be more likely to vomit the residual bumper.

LEVELS OF EVIDENCE

Level III-Treatment study, Retrospective comparative study.

A simple method for percutaneous endoscopic gastrostomy tube removal: "tie and retrograde pull"

BACKGROUND/PURPOSE

Various techniques have been presented to remove the percutaneous endoscopically placed gastrostomy tube in children, but tubes with semi-rigid internal retaining discs are difficult or impossible to remove by external traction. We describe a simple and effective endoscopic removal technique that should be applicable to any type of percutaneous endoscopic gastrostomy tube.

METHODS

Percutaneous endoscopic gastrostomy tube removal was performed with the "tie and retrograde pull" technique. After a polypropylene suture was placed and tied 1cm over the skin level, the percutaneous endoscopic gastrostomy tube was cut 0.5 cm over the knot. The suture was cut from the connection point between the needle and the suture. The distal end of the suture was pushed through the stoma into the stomach. Then a forceps was inserted through the gastroscope. The suture was caught, and the residual percutaneous endoscopic gastrostomy portion was retrieved via retrograde traction on the suture.

RESULTS

The causes of exchange were determined to be planned tube replacement in 9, buried bumper syndrome in 1, and tube occlusion in 3 patients. The mean tube dwell time was 10.8 ± 3.9 months. Esophageal mucosal tear developed in 1 patient with epidermolysis bullosa during removal. No other complications occurred during PEG tube exchanges.

CONCLUSION

This is a rapid and useful technique that does not require any complex endoscopic devices.

[The value of percutaneous endoscopic gastrostomy in ENT tumor patients]

Many patients with advanced head and neck cancer are already in a poor nutritional status and need supportive nutritional therapy at the time of initial diagnosis. Malnutrition is associated with delayed recovery, prolonged hospital stay and unfavorable prognosis. By using percutaneous endoscopic gastrostomy (PEG), the social stigmatization for the patient resulting from the conspicuous nasal feeding tube is avoided. The PEG can be easily implemented at the time of diagnosis by head and neck surgeons in patients suffering from massive tumor-associated weight loss, when definitive or adjuvant radiochemotherapy is anticipated, or prior to tumor surgery likely to be followed by prolonged significant dysphagia and protracted swallowing rehabilitation. Analgesics can be administered via the PEG tube, thus simplifying adequate pain management, which plays a central role in the care of head and neck cancer patients.

Intestinal obstruction after PEG tube replacement: implications to daily clinical practice

One method commonly employed to remove percutaneous endoscopic gastrostomy (PEG) tubes is to disconnect the internal flange from the rest of the tube at skin level. The internal segment is then allowed to pass spontaneously through the gastrointestinal tract. This report describes a case in which the internal flange resulted in intestinal obstruction in a patient with underlying Crohn disease, necessitating surgical removal. The limited published literature relating to risks of retained PEG flanges is reviewed. This suggests that in patients with underlying gastrointestinal disease and other risk groups, disconnected internal PEG flanges should be retrieved endoscopically in preference to allow spontaneous passage.

Small bowel obstruction caused by intraluminal migration of retained percutaneous endoscopic gastrostomy internal bumper

INTRODUCTION

Early complications associated with percutaneous endoscopic gastrostomy are well documented. Late complications associated with retained gastrostomy flange are rare. It is unclear why some patients with retained gastrostomy flange (internal bumper) develop mechanical obstruction and others do not. We report a case of mechanical obstruction with perforation occurring 6 months after the tube was cut.

PATIENT AND METHODS

A 76-year-old hemiplegic patient with no swallowing reflex and who previously was on long-term percutaneous gastrostomy feeding tube underwent removal of the feeding tube but the internal bumper was left in situ due to encrustation.

RESULTS

Due to migration of the retained flange, the patient developed small bowel obstruction.

CONCLUSIONS

Retained internal bumper is potentially dangerous and we recommend endoscopic retrieval of such flange.

The 'cut and push' method of percutaneous endoscopic gastrostomy tube removal

BACKGROUND AND AIMS

The standard method of removing percutaneous endoscopic gastrostomy tubes is by gastroscopy. This has implications for endoscopy time and resources, and we believe is not always necessary. Depending on the type of percutaneous endoscopic gastrostomy tube used we often used the 'cut and push' method. This involves cutting the catheter at skin level and allowing the tube and internal bumper to spontaneously pass. The cut and push method also represents a considerable resource saving compared to the endoscopic method that we think warrants further discussion.

METHOD

We reviewed all the files of the percutaneous endoscopic gastrostomy tubes removed in our unit over the last 4 years.

RESULTS

During the period of July 1995 to July 1999, we have inserted 384 percutaneous endoscopic gastrostomy tubes. Seven tubes have been removed endoscopically and 73 tubes have been removed with the cut and push method. Only two possible complications have been recorded (2.7%).

CONCLUSIONS

We believe that we have provided further evidence that percutaneous endoscopic gastrostomy tubes can be removed safely using the cut and push method. Patients who are often frail and who have multiple medical problems are saved an often-long journey to the endoscopy unit as well as the hazards of an endoscopy. The saving in resources in what is already an overworked system by not performing endoscopies is also considerable.

Nonendoscopic removal of percutaneous endoscopic gastrostomy tubes: morbidity and mortality in children

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) tubes are often removed by cutting the tubing at skin level and allowing the internal components to pass through the gastrointestinal tract. This technique is commonly used in adults, but little information is available concerning its safety in younger patients.

METHODS

To assess the safety of this approach in children, the clinical courses of all patients who had undergone PEG tube removal in our pediatric gastroenterology unit over a 3-year period were reviewed.

RESULTS

Five of 11 patients in whom the internal components were allowed to pass developed significant complications. Three required subsequent endoscopic removal of the internal component due to persistent vomiting, one died from complications of esophageal perforation caused by the retained internal component, and one developed a gastrocutaneous fistula containing the retained bumper 2 years after PEG tube removal. Significant complications occurred more often in the younger and smaller patients.

CONCLUSIONS

Small children are at greater risk than adults for developing serious complications associated with unremoved PEG tube internal components. If passage of the internal components cannot be confirmed after 2 weeks, chest and abdominal radiographs should be obtained.