Percutaneous endoscopic gastrostomy (PEG) tubes are the tube of choice where long-term enteral feeding is warranted (Westaby et al, 2010). Unlike balloon-style gastrostomy tubes, PEG tubes are not regularly changed and can remain in situ for a number of years. However, when tube degradation, localised exit site problems, such as persistent overgranulation or infection is experienced, health professionals may recommend the PEG tube is replaced (Nishiwaki et al, 2011). PEG tubes may also need to be removed without replacement when the patient no longer requires artificial nutrition, such as when a patient has a PEG tube placed following a stroke and is later able to swallow again safely.
Research suggests that some PEG tubes are non-traction removable and can only be removed with an endoscope (Westaby et al, 2010). However, there are a number of traction-removable devices on the market. This is advantageous when shorter term enteral feeding is warranted or when further endoscopy is contraindicated, such as after head and neck surgery (Cass et al, 1999).
The PEG tube used at the Leeds Teaching Hospitals NHS Trust (LTHT) is the CORFLO PEG (Avanos Medical, Alpharetta, Georgia, USA), which is made from medical grade polyurethane. It is held in place by an internal retention bumper. The CORFLO PEG comes in a range of sizes, 12 French gauge (Fr), 16 Fr and 20 Fr, all of which can be removed with traction. The procedure is simple. The tube is removed at the bedside by removing or cutting off the feeding port, applying pressure to the peristomal area and pulling the tube to retrieve the internal bumper through the tract. Avanos recommends that this is not attempted until the tract is formed and suggest this is more than 2 weeks following placement. However, at LTHT, guidelines advise not to attempt traction pull until at least 12 weeks following initial insertion.
Staff involved in patient care
There are three enteral feeding specialist nurses at LTHT, two at Band 6 and one at Band 7. There were changes in the team over the period the data were collected; however, there was no correlation between experience and complication rate.
Method of removal
It is standard practice to offer a patient the choice regarding how they wish their PEG tube to be removed or replaced. The options are endoscopic removal or traction pull. The ‘cut and push’ method, whereby the tube is cut externally and the bumper allowed to pass through the gastrointestinal (GI) tract and excreted is not offered due to the risk of bowel obstruction and perforation from the retained bumper (Peacock et al, 2012).
The risks and benefits associated with these removal methods should be discussed with the patient so that they can make an informed choice. Traction removal of a PEG tube is associated with fast outpatient appointment turnaround, does not require medical support as it can be done by specialist nurses, does not require sedation and the associated post-procedural observation period in a recovery area, intravenous access or endoscopy. Entonox can be prescribed by the specialist nursing team, should a patient feel they need it. Also a lidocaine-containing lubricant is administered in and around the tract to aid removal and make the procedure more comfortable.
Endoscopic removal of a PEG tube, on the other hand, is largely carried out by doctors on scheduled endoscopy lists, potentially leading to delays to tube change/removal.
Patients must weigh up the levels of discomfort associated with both procedures, ie the distress related to intubation with the endoscope or the removal of the bumper through the tract. The process for gaining consent for endoscopic procedures, should include providing information about the procedure itself as well as the preparation, such as the fasting period, the risks, benefits and alternatives to the procedure (Everett et al, 2016). This would include risks such as damage to loose teeth, crowns or to dental bridgework. Respiration may be affected by the insertion of the endoscope and administration of sedation in some patients (Friedrich et al, 2014). For example, those with cystic fibrosis or motor neurone disease will be more likely to be negatively affected and likely encouraged to choose the traction removal method. Anaesthetic review should be sought prior to endoscopic procedures in patients with breathing difficulties (Westaby et al, 2010). This may contribute to a longer waiting period before removal of the tube. Additionally, findings from other studies have highlighted rare complications, such as infection or oesophageal perforation as a result of the withdrawal of the bumper via the oesophagus (Palmer et al, 2006).
The PEG removal referral forms received by the Enteral Feeding Nursing Service over an 8-year period were used to find the PEG tube insertion and removal reports within the hospital endoscopy database (the procedures take place in the endoscopy department). The reports were used to calculate the length of time the tube had been in place prior to traction removal, the size of the tube removed, if a replacement device was inserted and if any immediate complications ensued.
When collecting data, no patient-identifiable information was included in the study. Prior to the traction removal of patients' PEG tubes, potential risks were explained and informed consent gained, according to usual Trust practice.
In total, 127 patients underwent a traction removal of their PEG tube between 2013 and 2021 (Figure 1). No patients were omitted from the study. Of the 127 patients, 13 experienced complications:
- Seven of the 127 patients experienced a retained bumper (5.5%)
- Two patients experienced unsuccessful attempts at traction removal by the enteral feeding nurses (1.57%)
- Two replacement gastrostomy devices were inadvertently replaced into the peritoneal cavity—out of 63 patients who required a replacement (3.17%)
- One replacement device was inadvertently inserted into the colon following traction removal of the PEG (out of 63—1.59%)
- One patient (0.79%) developed a gastrocutaneous fistula, although the patient had been experiencing leakage before the traction pull.
Similar results are documented in the literature. Srinivasan et al (2010) also reported retained bumpers following traction removal of a PEG tube and one patient required a laparoscopy for suspected low profile button device misplacement following removal of a PEG tube. One patient experienced an enterocutaneous fistula, which required surgical closure. This complication was also reported in studies by Makris and Sheiman (2002) and Kobak et al (2000).
In the cases of a retained bumper, the average length of time the tube was in situ prior to traction removal was 2.7 years. The shortest was 4.5 months and the authors hypothesise that this was retained due to the physique of the patient. He was a small frame with extremely tight abdominal muscles and a well maintained exit site, therefore making it harder for the bumper to come through the tract, and it had thus detached from the tubing. The longest time a tube had been in situ before a retained bumper complication on removal was 4 years and 3 months. One may assume that the longer a tube is in situ, the greater the chance of a retained bumper due to tube degradation; however, the results identified a patient whose tube had been in situ for as long as 8 years 6 months without complication on removal.
The data showed that 6 of the 7 retained bumpers were from size 16 Fr PEG tubes and only 1 from a size 12 Fr. However, as LTHT routinely places size 16 Fr PEG tubes, the sample does not allow for a fair analysis of an association between retained bumpers and PEG tube size. Size 12 Fr are occasionally used in patients with a small build and size 20 Fr only in those who need to vent gastric content, and so are rarely used in comparison to the standard 16 Fr feeding tubes.
Replacement tubes placed into peritoneal cavity
Of the 127 tubes that were removed with traction, 63 were replaced with a gastrostomy tube; 2 of these 63 replacements resulted in the device entering the peritoneal cavity (3.17%). This was confirmed with a fluoroscopic investigation using contrast solution after failing to obtain a satisfactory gastric sample for pH testing. One PEG was 12 Fr and the other a 16 Fr. Both PEGs had only been in situ prior to removal for 3 and 5 months, respectively. Therefore it could be argued that tract disruption was likely due to tract immaturity. This may well be related to specific patient characteristics; however, the study also identified two other patients who underwent traction removal of their PEGs 3-5 months after insertion with reinsertion of a gastrostomy who did not experience this complication. A study by Cass et al (1999) of a similar sample size, also experienced a low complication rate, with only 1 in 87 resulting in peritoneal placement of the replacement device.
Intracolonic insertion of replacement device
This is almost a red-herring in the results, as the complication is not a result of the traction pull, but as a result of the initial insertion. In this case, the initial PEG tube was inadvertently placed via the colon and into the stomach. This meant that the replacement device followed the formed tract into the colon. This complication is rare and can be avoided by the use of a transillumination test, a finger indentation test and the ‘safe tract’ technique at the time of PEG insertion (Ben-Menachem et al, 2012). Research suggests that it often remains unrecognised until the gastrostomy is changed and the replacement tube ends up lying within the lumen of the interposed colon (Westaby et al, 2010).
This was seen in only one patient following traction pull. However, this patient had been experiencing leakage before the tube change. In hindsight, traction may not have been the best removal method as the resulting trauma may have impacted on the integrity of the skin in and around the tract.
Unable to remove tube
The tube was unable to be removed in two patients. In one case, despite the nurses referring to an experienced gastroenterology consultant the traction removal was abandoned and the patient went on to have it removed using endoscopy the same day. There was no obvious reason why the tube was unable to be pulled through the tract. It was not an obviously neat tight stoma tract; no reason could be concluded as to why this happened. The usual protocol had been employed. In the second patient, the stoma tract was particularly neat and tight and the patient had tight abdominal muscles, the authors hypothesise that these are the reasons why the bumper was unable to move through the tract.
When gaining consent from a patient before undertaking a procedure, the health professional must be able to explain the risks, benefits and alternatives to the procedure so that they can make an informed decision. Although complication rates are low, the consequences associated with them can be fatal. The data collection in this study found that no secondary complications ensued in this group of 127 patients. This is due to the undertaking of risk assessments and the awareness of the enteral feeding nurses about such consequences.
Although previous research has demonstrated that obstruction from a retained internal bumper is unlikely (Merrick et al, 2008; Srinivasan et al, 2010), it could be hypothesised that patients with Crohn's disease and/or previous abdominal surgery are at increased risk of such a complication. This is due to factors such as bowel wall thickening, the development of fat and fibrous tissue as a result of chronic bowel inflammation, hypertrophy of the muscular layer and strictures, all of which may make it more difficult for the retained bumper to pass out of the system naturally. Therefore advice is always sought from a consultant gastroenterologist in the cases of retained bumpers in those patients with risk factors. Although this was not deemed necessary, an endoscopic retrieval of the retained bumper could be undertaken.
Chemical peritonitis, due to feeding through a tube placed into the peritoneal cavity, was avoided because radiological investigation was undertaken when this complication was suspected.
In addition, feeding was not initiated in the case of the tube that entered the colon, because of the presence of what appeared to be faecal matter and a lack of gastric aspirate the nursing team instigated a radiological investigation.
One hundred and twenty of the 127 tubes were 16 Fr, three were 20 Fr and four were 12 Fr, which meant it was not possible to discover whether there was a correlation between size of tube and complication rate. Had the different sizes of tube been equally split between patients, this factor could have been more fairly explored.
This retrospective study looked at PEG tube removal reports in 127 patients in one hospital with the aim of identifying the types and rate of complications associated with traction removal of the PEG tube. Complication rates were low—problems occurred in only 13 patients. The authors hope this article will contribute to the relatively small pool of research relating specifically to complication rates following traction removal of PEG tubes.
- This retrospective study aimed to identify the complications associated with traction removal of percutaneous endoscopic gastrostomy (PEG) tubes in one hospital trust over an eight-year period
- Of the 127 patients studied, five types of complication were identified
- A retained bumper was the most common complication (occurring in seven patients)
- Complication rates were low (only 13 patients experienced problems). There was no clear correlation between length of time of the PEG tube in situ or tube size and complication rate
CPD reflective questions
- When preparing patients for enteral feeding-related procedures, do you feel confident to explain the risks, benefits and alternative options in full?
- When undertaking traction removal of a PEG tube, are you prepared for complications? For example, who could you contact for support? What would you do if you could not get the patient in for a radiological assessment immediately? Have you prepared a back-up plan?
- Do you have a thorough referral/vetting system in place to ensure appropriateness for traction removal? For example, how long has the tube been in place? What anticoagulation are they taking? What replacement device is deemed most appropriate?