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Journal of Pediatric Surgery (2013) 48, 1810–1812

Operative Techniques

A simple method for percutaneous endoscopic gastrostomytube removal: “Tie and retrograde pull”Suleyman Cuneyt Karakus a,⁎, Coskun Celtik b, Naim Kokua, Idris Ertaskına

aGaziantep Children Hospital, Department of Pediatric Surgery, Gaziantep, TurkeybGaziantep Children Hospital, Department of Pediatric Gastroenterology, Gaziantep, Turkey

Received 1 October 2012; revised 29 March 2013; accepted 30 March 2013

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Key words:Percutaneous endoscopicgastrostomy;

Epidermolysis bullosa;Percutaneous endoscopicgastrostomy catheterremoval, buriedbumper syndrome

AbstractBackground/Purpose: Various techniques have been presented to remove the percutaneousendoscopically placed gastrostomy tube in children, but tubes with semi-rigid internal retaining discsare difficult or impossible to remove by external traction. We describe a simple and effective endoscopicremoval technique that should be applicable to any type of percutaneous endoscopic gastrostomy tube.Methods: Percutaneous endoscopic gastrostomy tube removal was performed with the “tie and retrogradepull” technique. After a polypropylene suture was placed and tied 1 cm over the skin level, the percutaneousendoscopic gastrostomy tube was cut 0.5 cm over the knot. The suture was cut from the connection pointbetween the needle and the suture. The distal end of the suture was pushed through the stoma into thestomach. Then a forceps was inserted through the gastroscope. The suture was caught, and the residualpercutaneous endoscopic gastrostomy portion was retrieved via retrograde traction on the suture.Results: The causes of exchange were determined to be planned tube replacement in 9, buried bumpersyndrome in 1, and tube occlusion in 3 patients. The mean tube dwell time was 10.8 ± 3.9 months.Esophageal mucosal tear developed in 1 patient with epidermolysis bullosa during removal. No othercomplications occurred during PEG tube exchanges.Conclusion: This is a rapid and useful technique that does not require any complex endoscopic devices.© 2013 Elsevier Inc. All rights reserved.

Percutaneous endoscopic gastrostomy (PEG) is theprocedure of choice for long-term enteral feedings of patientswith a functioning gut who cannot ingest nutrients. Removalof the PEG tube is recommended when it is no longerrequired or when there is persistent gastrostomy leakage,deterioration of the PEG tube, or the internal bumper isburied [1,2]. Although the “cut and push” method is usually

⁎ Corresponding author. Gaziantep Children Hospital, Department ofediatric Surgery, Gaziantep, Turkey. Tel.: +90 505 7769416; fax: +90 342600290.E-mail address: sckarakus@yahoo.com (S.C. Karakus).

022-3468/$ – see front matter © 2013 Elsevier Inc. All rights reserved.ttp://dx.doi.org/10.1016/j.jpedsurg.2013.03.077

used to remove the PEG tube in adults, there have beenreports of serious complications in children, such as smallbowel perforation, bronchoesophageal fistula and oesopha-geal, gastric outlet, and small bowel obstruction owing toretained internal bumper [3–5]. We describe a simpleendoscopic removal technique.

1. Methods

A polyurethane tube with a silicone 2.5-cm-diameterinternal retention disc was used for PEG insertion. This tube

Fig. 2 The distal end of the suture is pushed through the stomainto the stomach, where it is grasped by the forceps in the flexibleendoscope. The inset shows details.

1811“Tie and retrograde pull” for PEG tube removal

can even be used in children with a body weight of less than3 kg. 10-Fr, 14-Fr and 18-Fr tubes were used in 30 (51,3%),19 (43,6%) and 2 (5,1%) insertions, respectively. The tubesdescribed were used for initial PEG placement andreplacement. The causes of replacement were planned tubereplacement in 9 patients, buried bumper syndrome in 1patient, and tube occlusion in 3 patients.

All procedures were done under general anesthesia.Prophylactic antibiotic was administered and maintainedfor 48 hours after the procedure. The PEG tube (Flocare PEGSet; Nutricia, Schiphol Airport, The Netherlands) with a disctype bumper was inserted by the standard pull-throughendoscopic-guided method previously described by Gau-derer et al [6]. A simple technique was performed for theremoval of the PEG tube, which is described as follows: A40 mm reverse cutting needle on a 0-polypropylene suture(Prolene; Ethicon, Inc., Johnson and Johnson, USA) waspassed approximately 1 cm over the skin through the PEGtube and tied, the PEG tube was cut 0.5 cm over the knot(Fig. 1). The suture was cut from the connection pointbetween the needle and the suture. The distal end of thepolypropylene suture was inserted into the stomach (Fig. 2).Then a forceps was inserted through a gastroscope. Thesuture was caught and then pulled out of the mouth (Fig. 3).In the presence of buried bumper syndrome, the polypro-pylene suture was inserted into the stomach from the tubelumen. A gentle manipulation of the PEG tube was appliedby pulling the suture under endoscopic view where thebumper could easily be dislodged from the mucosa. Finally,the bumper was pulled up into the oesophagus and removedthrough the mouth without a snare.

If the removed gastrostomy tube is to be replaced by anew one (at the time of the procedure), both suture ends arekept long. Thus, after the cut catheter exits through themouth, a guiding tract suture remains. After the old tube isremoved, the oral end of the suture is attached to the newgastrostomy tube, which is then guided into place as in atypical pull-PEG.

Fig. 1 After the polypropylene suture is placed and tied 1 cmabove the skin level, the tube is cut 0.5 cm above the knot.

2. Results

Fifty-one consecutive PEG procedures were performed on38 patients (38 insertions and 13 tube exchanges) betweenAugust 2009 and June 2012 at Gaziantep Children's Hospitalin Gaziantep, Turkey. Twenty (52,6%) of the patients weremale and 18 (47,4%)were female. Themean age of the patientswho underwent PEGwas 4,9 ± 3,6 years (range, 1–14 years).

The mean operating time of PEG tube replacement was11.8 ± 2.6 minutes (range, 8–15 minutes). The mean tubedwell time was 10.8 ± 3.9 months (range, 6–18 months).An esophageal mucosal tear occurred during removal in 1patient with epidermolysis bullosa and was managed with

ig. 3 The residual PEG portion is retrieved via retrogradeaction on the suture.

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1812 S.C. Karakus et al.

conservative treatment. No other complications occurredduring PEG tube exchanges.

3. Discussion

PEG has gained widespread acceptance because of itssafety, short operating time, and low complication rate. Inrecent years, laparoscopic gastrostomy with an initialinsertion of a skin-level device is reported to be a goodalternative to the PEG in children [7].

The main indications for replacing the tube wereirreversible clogging of the tube, buried bumper syndrome,deterioration of the catheter, and accidental dislodgement.Although PEG tubes with a collapsible bumper can be gentlypulled out by external traction, PEG tubes with rigid bumpersshould be removed endoscopically. An endoscopy snare isnecessary for the removal of PEG tube. However, sometimesthe snare does not grasp the bumper and leaves the bumper inthe stomachwhile the bumper is pulled up into the esophagus.The “cut and push” method, characterized by the removal ofthe PEG tube by cutting the tube at skin level and allowing theinternal bumper to be excreted with stools, is unsafe and maylead to intestinal obstruction, especially in children [8].

Only two cases of a longitudinal esophageal tear and apneumomediastinum caused by a tear at the upper esophagealsphincter were reported during PEG insertion in children[9,10]. About one quarter of patients with epidermolysisbullosa require gastrostomy tube placement because of highnutritional demands, esophageal strictures, and dysphagia[11]. In our case, an esophageal tear at the lower esophagealsphincter may be caused by the fragility of the mucousmembranes and an inappropriate size match between the tubeand esophagus. Esophageal stricture was not detected.

The “tie and retrograde pull”method is simply the reverseof PEG insertion. The most important point in this procedureis to use a thick suture such as 0-polypropylene, as a thin

suture may be detached at the time of PEG tube removal. The“tie and retrograde pull” method is a rapid, safe, and usefultechnique which reduces the mean time of the PEG tuberemoval and does not require the use of any complexendoscopic devices. It can be performed by any endoscopist.

References

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[3] Colleti RB, Herbert JC. Esophageal obstruction after incompleteremoval of a PEG tube. Gastrointest Endosc 1991;2:211-2.

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[11] Stehr W, Farrell MK, Lucky AW, et al. Non-endoscopic percutaneousgastrostomy placement in children with recessive dystrophic epider-molysis bullosa. Pediatr Surg Int 2008;24:349-54.