PEG Removal

This is only advisable for cases where a well-defined tract has been formed. Indications and Contraindications

Indications ■ The PEG tube is no longer needed (reversal of original indication)

■ Blocked tube that cannot be cleared by flushing Percutaneous Removal

STEPS Identify the type of PEG tube first: a mushroom type will only have one lumen in the tube while a balloon type will have two lumens on sectioning the tube. "Mushroom" type:

Clean the PEG site and apply lidocaine ointment.

A sustained pull at 90 degrees to the anterior abdominal wall will result in a sudden folding and collapse of the mushroom and the tube "pops" out of the stoma.

Bleeding is uncommon and the stoma closes in 8-48h. Balloon type:

Deflate the balloon by using a syringe for the balloon port or by cutting the tube, allowing the water to leak out of the balloon.

Once the balloon is deflated, the tube can be pulled out with no resistance.

Endoscopic Removal Indication

When percutaneous removal is not possible, e. g., when the balloon cannot be deflated or the "mushroom" PEG tube cannot be pulled out.

STEPS Upper endoscopy is performed. The PEG tube is snared using a polypectomy snare inside the stomach. (The balloon may need to be deflated using a sclerotherapy needle.) The tube is cut from the outside using a pair of scissors or scalpel. The snared end is pulled out along with the endoscope.

Reinsertion

A new balloon-type PEG tube is inserted through the existing stoma and inflated with water. The balloon end is pulled up to the stomach wall and a rubber stopper is applied on the outside to position it snugly against the anterior abdominal wall.

Standard Postoperative Investigations

■ Daily check for an adequate approximation of the gastric wall to the abdominal wall to prevent dislocation and peritonitis

Postoperative Complications

■ Perforation of esophagus, stomach, transverse colon

■ Hemorrhage

■ Sepsis: usually detected in 2-3 days

■ Clogging of the tube

■ Gastrocutaneous fistula

■ Gastric ulcer

■ Peritonitis

■ "Buried bumper syndrome" when the bumper gets buried in the stomach wall

■ Distal migration of the tube resulting in gastric outlet obstruction

■ An agitated patient may pull the tube out

Tricks of the Senior Surgeon

■ Care has to be taken for a necrosis of the gastric wall in case of a too strong approximation by the "mushroom."

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