Percutaneous endoscopic gastrostomy tube replacement: A simple procedure?

Abstract

Replacement of gastrostomy tube in patients undergoing percutaneous endoscopic gastrostomy (PEG) is generally considered as a safe and simple procedure. However, it could be associated with serious complications, such as gastrocutaneous tract disruption and intraperitoneal tube placement, which may lead to chemical peritonitis and even death. When PEG tube needs a replacement (e.g., occlusion or breakage of the tube), clinicians must realize that the gastrocutaneous tract of PEG is more friable than that of surgical gastrostomy because there is no suture fixation between gastric wall and abdominal wall in PEG. In general, the tract of PEG begins to mature in 1-2 wk after placement and it is well formed in 4-6 wk. However, this process could take a longer period of time in some patients. Accordingly, this article describes three major principles of a safe PEG tube replacement: (1) good control of the replacement tube along the well-formed gastrocutaneous tract; (2) minimal insertion force during the replacement, and, most importantly; and (3) reliable methods for the confirmation of intragastric tube insertion. In addition, the management of patients with suspected intraperitoneal tube placement (e.g., patients having abdominal pain or signs of peritonitis immediately after PEG tube replacement or shortly after tube feeding was resumed) is discussed. If prompt investigation confirms the intraperitoneal tube placement, surgical intervention is usually required. This article also highlights the fact that each institute should have an optimal protocol for PEG tube replacement to prevent, or to minimize, such serious complications. Meanwhile, clinicians should be aware of these potential complications, particularly if there are any difficulties during the gastrostomy tube replacement.

Keywords: Complication; Gastrostomy tube exchange; Gastrostomy tube reinsertion; Gastrostomy tube replacement; Management; Percutaneous endoscopic gastrostomy; Peritonitis; Prevention.

Figure 1

Patient (A 60-year-old woman) developed sudden abdominal pain immediately after percutaneous endoscopic gastrostomy tube replacement. Fluoroscopy of the upper abdomen demonstrated the leakage of water-soluble contrast from a disc-tip gastrostomy tube into the peritoneal cavity (figure courtesy of Dr. Asada Methasate and Dr. Cherdsak Iramaneerat).

Figure 2

Intraoperative findings of the aforementioned patient showed an intraperitoneal gastrostomy tube, and the separation of mature gastrocutaneous tract close to the stomach (figure courtesy of Dr. Asada Methasate and Dr. Cherdsak Iramaneerat).