‘Re-PEGing’: an endoscopic approach to inadvertent early removal of PEG tube

Figures & data

Figure 1. Entake PEG safety system (Commed, Utica, NY). The tube dome is collapsible upon pulling allowing passage of the tube through the gastrocutaneous tract.

Figure 2. Gastric wall defect 6 hours after inadvertent removal of PEG tube (white arrow). Note partial sealing of the defect.

Figure 3. Endoscopic view of double-PEG, placed to improve the apposition and patching of the gastric and abdominal walls.

Table 1. Clinical data (*indicates time from attempted direct tube replacement [DTR]).

Patient #	Age, Sex	Indication for PEG	Comorbidities	Time from original placement to removal (days)	Time to “rePEG” from removal (hours)	Inadvertent intraperitoneal DTR?	Clinical findings after ERPT	Imaging findings	“Double PEG” done?	Clinical Course
1	65, M	Malnutrition	Alcohol and Tobacco abuse	10	24*	Yes	Asymptomatic	Extragastric tube position, intraperitoneal contrast (figure 4)	Yes	Received antibiotics. Discharged 3 days later. Second PEG tube removed a month later.
								Minimal pneumoperitoneum and peritoneal fluid
2	59, M	Aspiration	Developmental disability	25	20	No	Asymptomatic	Not done	No	No complications.
			Myocardial infarction							Discharged uneventfully to skilled nursing facility
3	72, M	Aspiration	Dementia	1	6	No	Hypotensive, Hypoxic Abdomen diffusely tender	Large pneumoperitoneum (figure 5)	Yes	Treated for septic shock in the ICU. Required vasopressors. No intra-abdominal source identified. Good recovery. Second PEG removed a month later.
4	87, F	Acute stroke	Atrial fibrillation	14	12*	Yes	Asymptomatic	Intraperitoneal position of replacement tube	No	Post-procedural CT abdomen with contrast showed no intraperitoneal leak.
			Dementia							Received antibiotics.
										Recovered uneventfully, and was discharged 3 days later.
5	68, M	Laryngeal cancer	Acute delirium	2	13	No	Initially asymptomatic	Minimal pneumoperitoneum and peritoneal fluid	No	Became septic 2 hours after PEG replacement.
							Septic picture after PEG placement			Required vasopressors and mechanical ventilation.
										Respiratory cultures positive for Klebsiella spp. Which was successfully treated with antibiotics.
										Chemoradiation for laryngeal cancer was started after recovery.
6	89, F	Aspiration	Dementia	12	10	No	Asymptomatic	Tube dome within the abdominal wall, with contrast spreading between muscle layers. Minimal pneumoperitoneum and peritoneal fluid (figure 6)	No	Received antibiotics. Discharged to nursing home 5 days later.
7	59, M	Aspiration	Developmental disability	1	5	No	Asymptomatic	Normal CT abdomen	No	Received antibiotics. Uneventful recovery