Matthew Mayuiers, MD, Charles E Lucas, MD, Choichi Sugawa, MD. Wayne State University, Department of Surgery
Introduction: Since 1980, the preferred method of enteral access has been the percutaneous endoscopic gastrostomy tube (PEG). Accidental removal is a common complication associated with excessive cost and possible significant morbidity.
Removal prior to 14 days is considered "early removal." Early removal has more significant risk associated with it, and can necessitate emergent operation to prevent peritonitis and sepsis. Some patients, who do not exhibit signs of peritonitis, may be simply observed. For these patients, PEG replacement would typically be delayed 5-10 days to ensure closure. This delay results in prolonged NPO status and worsened nutritional status. Presented below is a case of early accidental removal followed by endoscopic clip closure, and immediate PEG replacement.
Case Report: A 43-year-old male presented after a large left middle cerebral artery infarct. A PEG placement was completed without complication. Eleven hours after the procedure the patient had pulled the PEG tube out of the abdominal wall. At this time the patient appeared to have no abdominal pain and no signs of peritonitis. Twelve hours following the accidental removal of his PEG tube, the patient was taken back to the endoscopy suite, and an EGD was performed. The previous PEG site was identified and appeared closed and ulcerated. The mucosal defect was closed with two endoscopic metallic clips. A PEG tube was then placed at an adjacent site.
The following day, the patient was restarted on trickle feeds and advanced to regular tube feeding over a period of 24 hours. Since that time, his PEG has been functioning well.
Discussion: We propose that in the case of early accidental PEG removal, the patient should be examined first for evidence of peritonitis. If initial physical exam and radiographic investigation do not reveal peritonitis or significant pneumoperitoneum, the patient should undergo urgent repeat endoscopy. At this time, the gastrotomy can be closed endoscopically via metallic clips and PEG can be replaced immediately. Tube feeds can be initiated after a 12-24 hour period of dependent drainage with serial abdominal exams.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 85664
Program Number: P376
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster