A percutaneous endoscopic gastrostomy (PEG) tube is a medical device inserted through the abdominal wall directly into the stomach for long-term nutrition, fluids, or medication. It is held securely by an internal retention disc, commonly referred to as a “bumper” or bolster, which rests against the inside stomach wall. Unlike simple tubes secured by a deflatable balloon, the internal bumper makes removal complex, requiring maneuvering by trained medical professionals, typically a gastroenterologist or surgeon.
Deciding When the Tube Must Be Removed
The decision to remove a PEG tube is based on clinical evidence that the patient no longer requires artificial enteral support. The primary criterion is the sustained ability to consume adequate nutrition and hydration orally. This means the patient has safely met their full nutritional needs by mouth for a stable period, often 8 to 12 consecutive weeks, without weight loss or deterioration of nutritional status. The original condition that necessitated the tube placement must have fully resolved or significantly improved. Removal may also be necessary if the device malfunctions (e.g., severe clogging or breakage) or due to complications like a persistent insertion site infection or the development of “buried bumper” syndrome.
Pre-Removal Assessment and Patient Preparation
Before removal, a thorough assessment ensures patient safety and determines the appropriate extraction technique. A primary step involves confirming the exact type of tube, as bumper-style tubes require a different procedure than those secured by a water-filled balloon. The maturity of the tract (the channel connecting the stomach to the skin) is also evaluated. The tract must have been in place for a minimum of four to six weeks to ensure the stomach is securely adhered to the abdominal wall, preventing leakage of stomach contents.
The physician checks for signs of buried bumper syndrome (BBS), a complication where the internal retention disc migrates and becomes embedded in the stomach wall. BBS symptoms include pain, leakage, or an inability to move the tube inward or outward. Patients are instructed to fast (NPO, nothing by mouth) for a specified duration, typically four to six hours before the procedure, to ensure the stomach is empty.
Methods for Bumper Tube Extraction
The internal bumper’s design dictates the extraction method, with the two primary approaches being traction removal and endoscopic removal. The traction, or “pull,” method is often used for PEG tubes in place for a long time, allowing the internal bumper to soften and become pliable. The external portion of the tube is cut, and a firm, steady force pulls the tube and its deformable bumper directly out through the stoma tract.
While simple and requiring no sedation, this method is only appropriate when the bumper is small and flexible enough to pass without significant trauma. A small amount of tearing is often expected, but the complication rate is low for appropriate candidates. If the tube is newer or the bumper is rigid, forcible traction risks serious complications, including tearing the stomach wall or causing peritonitis, necessitating an endoscopic approach.
Endoscopic removal is the preferred and safer method for tubes with rigid or large bumpers, those in place for a shorter period, or in cases of buried bumper syndrome. This procedure requires a gastroscope (a flexible tube with a camera) passed through the mouth and esophagus into the stomach, allowing the physician to directly visualize the internal bumper.
One technique uses the endoscope to grasp the bumper with specialized devices like a snare or forceps and pull the entire tube out through the mouth. The “cut-and-push” method is another common endoscopic technique used when the bumper cannot be easily retrieved orally. Here, the external tube is cut near the skin, and the remaining tube and bumper are pushed completely into the stomach. The bumper then passes naturally through the gastrointestinal tract and is eliminated in the stool, which is typically painless.
Immediate Care Following Tube Removal
Once the PEG tube is removed, the stoma site requires immediate attention to promote healing and prevent infection. A sterile dressing is applied, and the patient may experience a small amount of gastric fluid leakage from the opening. This mild drainage is normal for the first 24 to 72 hours as the body begins closing the tract.
The patient or caregiver is instructed to change the dressing daily or whenever it becomes wet or soiled, ensuring the skin around the site is kept clean and dry. The gastrocutaneous fistula (the channel from the stomach to the skin) usually begins to close within a few hours and seals completely within 24 to 72 hours. Patients should avoid activities that submerge the wound, such as swimming or tub bathing, until the site is fully healed, which can take up to two weeks.
Oral intake can usually be resumed shortly after the procedure, often within two hours, to help reduce initial leakage from the stomach. The physician provides guidance on resuming normal activities and when to contact the healthcare provider for signs of complications, such as increased redness, fever, or persistent, unusual drainage.