Complications of the Cut‐and‐Push Technique for Percutaneous Endoscopic Gastrostomy Tube Removal

Abstract

The use of the "cut-and-push" technique for percutaneous endoscopic gastrostomy (PEG) removal has been recognized since 1991. This technique is used in patients who are thought to have no risk of distal adhesions or strictures. Its use in selected patients is supported by current British Society of Gastorenterology guidelines. However, the risk of complications has long been debated. This report describes a patient who developed complications as a result of PEG removal using the cut-and-push technique. The patient had undergone previous abdominal surgery, and removal of the PEG endoscopically was not possible. A barium follow-through was performed in light of the history, and it excluded any mechanical blockage. Follow-up x-ray showed passage of the remnant beyond the pylorus. Despite this, the remnant became lodged in the small bowel, eventually resulting in perforation and death. This case highlights the fact that impaction of the remnant can occur in patients without evidence of mechanical obstruction on investigation. This raises a question about the need for serial x-rays to ensure passage of the remnant if the patient cannot confirm this visually.

Feasibility of the Cut‐and‐Push Method for Removing Large‐Caliber Soft Percutaneous Endoscopic Gastrostomy Devices

“…Although 5 remnants were not collected from feces, no cases of intestinal obstruction were noted (abdominal pain, absolute constipation, abdominal tenderness, nausea, or vomiting) during the study. Some alarming cases reported obstruction or perforation due to the inner flange embedded within the intestinal wall several months after the procedure 8 – 12 . Therefore, we recognize that a follow‐up period of 1 month might underestimate the real hazards of the cut‐and‐push technique.…”

“…So far, few studies have been conducted demonstrating the safety of the cut‐and‐push method of PEG removal up to 15 French (Fr) caliber 5 – 7 . However, concerns with this method arose from reports of severe complications 8 – 12 . Many queries with the technique are pending, and well‐established indications and limits are far from being defined.…”

The ‘cut and push’ technique: is it really safe?

“…5 6 There are also reported cases of small bowel perforations secondary to the retained flange in patients with a history of abdominal surgery. 7 Barium studies cannot be used to accurately predict those patients with a history of abdominal surgery that will encounter difficulties passing the PEG remnant. 7 This method should therefore be avoided in patients with previous abdominal surgery.…”

“…7 Barium studies cannot be used to accurately predict those patients with a history of abdominal surgery that will encounter difficulties passing the PEG remnant. 7 This method should therefore be avoided in patients with previous abdominal surgery. It is important that the PEG flange is retrieved endoscopically or an alternative PEG tube (designed to be completely removed through the skin) is used to prevent these complications occurring in such individuals.…”

Removal of percutaneous endoscopic gastrostomy tubes in adults using the “cut and push” method: A systematic review

“…Three of the four cohort studies published have been from the UK ( [5][6][7], which may be reflective of the healthcare system. There are, however, case reports in the literature that report bowel perforation post CP where the inner remnant of the PEG tube has become lodged in the bowel causing obstruction or perforation ( [9][10][11][12]. In some instances this had been fatal ( 13 ).…”