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SUPPLEMENTATION TO THE ENCYCLOPEDIA
Percutaneous Endoscopic Gastrostomy
Tube Replacement
$
Shou-jiang Tang
n
Division of Digestive Diseases, Department of Medicine, University of Mississippi Medical Center,
2500 North State Street, Jackson, MS 39216, USA
Received 19 December 2013; received in revised form 23 January 2014; accepted 24 January 2014
KEYWORDS
Percutaneous
endoscopic
gastrostomy;
Endoscopy;
Low-profile feeding
tube;
PEG replacement
tube;
Enteral feeding;
Video
Abstract
Background: Enteral feeding should be considered for patients with an intact and functional
gastrointestinal tract. Percutaneous endoscopic gastrostomy (PEG) tube placement is indicated
in patients requiring medium to long term enteral feeding (430 days) and with impaired
swallowing. Previously placed PEG tube can dislodge or be inadvertently removed, blocked, or
damaged. Gastrostomy tube replacement is not infrequently performed.
Patients and methods: In this video manuscript, the author demonstrates step-by-step PEG
tube replacement in several clinical scenarios: standard gastrostomy feeding tube (with
internal retention balloon or with internal collapsible bumper) removal and replacement;
low-profile feeding tube replacement; and feeding tube replacement over a wire guide.
Conclusions: PEG tube replacement can be easily replaced at bed-side in most cases.
Occasionally, in difficult cases gastrostomy feeding tube replacement needs endoscopic guidance
and assistance.
&2014 The Author. Published by Elsevier GmbH. This is an open access article under the CC BY
license (http://creativecommons.org/licenses/by/3.0/).
Video related to this article
Video related to this article can be found online at http://
dx.doi.org/10.1016/j.vjgien.2014.01.002.
1. Background
These patients had percutaneous endoscopic gastrostomy
(PEG) feeding tube placement for enteral feeding [1–4].
http://dx.doi.org/10.1016/j.vjgien.2014.01.002
2212-0971/&2014 The Author. Published by Elsevier GmbH. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/3.0/).
☆
The terms of this license also apply to the corresponding video.
n
Tel.: +1 601 984 4540; fax: +1 601 984 4548.
E-mail address: stang@umc.edu
Video Journal and Encyclopedia of GI Endoscopy (]]]])],]]]–]]]
Please cite this article as: Tang S-j. Percutaneous Endoscopic Gastrostomy Tube Replacement. Video Journal and Encyclopedia of GI
Endoscopy (2014), http://dx.doi.org/10.1016/j.vjgien.2014.01.002
Not infrequently, the existing gastrostomy feeding tube
becomes blocked, damaged, inadvertently removed.
Occasionally, the patient requests a low-profile gastro-
stomy feeding tube to be placed.
The patient and/or patient's family consented with PEG
replacement.
Before PEG tube removal or replacement, health care
providers need to discuss with the patient/patient family
about the need for continued enteral feeding and the
type of replacement feeding tubes (Figure 1).
Percutaneous PEG removal or replacement can be safely
performed after the PEG tract is matured, which usually
matures over several weeks (average 4 weeks) after
initial PEG procedure.
Infrequently, the PEG tube is advertently removed or
prematurely blocked within weeks after initial PEG tube
placement. The decision to replace the feeding tube
through the existing PEG tract is based on clinical
presentation, physical examination, laboratory results,
and consulting physicians. Replacement through the
existing tract can be attempted if there is no evidence
of leak or perforation. Replacement under endoscopy is
recommended in this setting.
Abdominal examination revealed no peritoneal signs.
Unlike in initial PEG placement, a dose of parental
antibiotics is not needed before the procedure for
prophylaxis.
The patient is placed on supine position for the
procedure.
After feeding tube replacement, enteral feeding can be
started immediately.
2. Materials
Diagnostic gastroscope (Olympus GIF-Q180, Olympus
America, Center Valley, PA).
Gastrostomy feeding tube (PEG-PULL-S, Cook Medical,
Winston-Salem, NC).
MIC-KEY
s
low-profile gastrostomy feeding tube (Kim-
berly-Clark, Rosewell, GA).
3. Endoscopic procedure
3.1. PEG replacement feeding tube placement
through the existing PEG tract
If the PEG tube is not replaced by another tube, the
PEG tract will shrink in several hours and close within
days. A new PEG tube should be replaced quickly.
Otherwise, a Foley catheter should be placed through
the PEG tract to keep it open.
Select the size of replacement feeding tube based on
the size of old PEG tube. If the old PEG tube is loose
and gastric juice leakage around the tube is an issue, a
slightly larger new tube can be tried.
The old PEG feeding tube has either an internal
retention balloon or an internal collapsible bumper.
The external bumper is loosened and the old PEG tube
should move easily to and fro within the PEG tract.
Open the new replacement tube package, check the
intactness of internal retention balloon by injecting
water using a prefilled syringe as directed in the
package insert, and apply lubricant to the tip and
external tubing of the new PEG replacement tube.
Old PEG removal can be achieved with one of the
following options [1]:
○Gentle manual traction of the external tubing
and removal of the PEG tube with its internal
bumper (collapsible version) through the
matured PEG stoma. For PEG tube with an
internal retention balloon, the balloon is fully
deflated before tube removal. This is performed
without sedation or endoscopy, and is the most
frequently utilized technique.
○Cutting the tubing close to the skin and pushing
the internal bumper into the stomach.
–Spontaneous passage of the internal bumper
through the gastrointestinal (GI) tract.
–Small risk (2–3%) of bowel obstruction by the
migrating bumper.
○
Endoscopic removal of the internal bumper after
cutting the feeding tube close to the skin. This
technique involves endoscopy and sedation.
Insert the replacement tube gently through the exiting
PEG tract into the stomach and inflate the internal
retention balloon with the prefilled syringe.
Check the position of the replaced tube by aspiration
of gastric content (Figure 2).
If there are any concerns about the location of the
replaced tube, a water soluble radiologic contrast
should be obtained to confirm the placement before
feeding is resumed.
Infrequently, the old PEG can be changed over a
standard wire guide.
Not done as a routine, a contrast study through the
replaced PEG tube can be performed to confirm its
intraluminal position.
Figure 1 Image showing two standard replacement gastro-
stomy feeding tubes (A and B), a low-profile feeding tube (C),
and two types of extension sets (D and E) associated with the
low-profile button. D is for bolus feeding.
S.-j. Tang2
Please cite this article as: Tang S-j. Percutaneous Endoscopic Gastrostomy Tube Replacement. Video Journal and Encyclopedia of GI
Endoscopy (2014), http://dx.doi.org/10.1016/j.vjgien.2014.01.002
3.2. Low-profile button placement through the
existing PEG tract
Some young and physically active patients prefer
wearing a low-profile feeding tube (Figure 3). A low-
profile button can be placed after the initial PEG tract
is matured.
The selection of the low-profile feeding tube is based
on the size of the old PEG tube and by measuring the
PEG tract length using the old PEG tube before
removal.
Features of these low-profile gastrostomy feeding tubes
include:
○Unobtrusive, easy to conceal, and ease of care
○Some tubes have a proximal anti-reflux valve and
tapered distal tip
○MIC-KEY
s
package provides two sets of extension
tubes
3.3. Buried bumper syndrome
Endoscopic findings: sunken internal bumper or absence
of the internal bumper in the gastric lumen, fistulous
opening or ulceration at the PEG site.
For externally removable PEG tube, the PEG can be
removed by external traction. If the internal bumper is
non-collapsible, the PEG tube can be removed after
endoscopic dissection of the PEG tract using a coagula-
tion device (such as needle knife or snare).
Insert a wire guide through the existing PEG tube.
Secure the wire guide with an endoscopic snare.
Remove the old PEG tube over the wire guide using
external traction.
Insert a new PEG tube through the old tract over the
secured wire guide.
PEG replacement should be performed under endoscopic
guidance to avoid false track formation during unguided
tube insertion.
4. Key learning points and tips and tricks
Percutaneous PEG removal or replacement can be safely
performed after the PEG tract is matured, usually over
several weeks (average 4 weeks) after initial PEG
placement.
Before PEG tube removal or replacement, health care
providers need to discuss the need for continued enteral
feeding and the type of replacement tubes with the
patients and their family.
If the PEG tube is not replaced by another tube, the PEG
tract will shrink in several hours and close within days. A
new PEG tube should be replaced quickly. Otherwise, a
Foley catheter should be placed through the PEG tract to
keep it open Select the size of replacement feeding tube
based on the size of old PEG tube.
If the old PEG tube is loose and gastric juice leakage around
the tube is an issue, a slightly larger new tube can be tried.
If there are concerns about the location of the replaced
tube, a water soluble radiologic contrast study should be
obtained to confirm the placement before feeding is
resumed.
5. Complications and risk factors
(if applicable)
Hemorrhage (local stoma bleeding, hematoma, gastro-
intestinal bleeding).
PEG tube tract rupture.
Infections (peri-stomal cellulitis, abdominal wall abscess,
peritonitis, and necrotizing fasciitis).
Pressure necrosis, gastric ulcer.
Skin breakdown.
Hyper-granulation tissue.
6. Scripted voiceover
Voiceover text
No text.
No text.
Figure 2 Image showing the bile stained gastric content being
aspirated through the newly replaced gastrostomy feeding
tube, confirming the intragastric location of the feeding tube.
Figure 3 Image showing a low profile feeding button.
3Percutaneous Endoscopic Gastrostomy
Please cite this article as: Tang S-j. Percutaneous Endoscopic Gastrostomy Tube Replacement. Video Journal and Encyclopedia of GI
Endoscopy (2014), http://dx.doi.org/10.1016/j.vjgien.2014.01.002
Voiceover text
After percutaneous endoscopic gastrostomy, i.e. PEG
feeding tube placement, the PEG tube can become
blocked, damaged, or inadvertently removed.
If the PEG tube is not replaced by another tube, the PEG
tract will shrink in several hours and close within days. A
new PEG tube should be replaced quickly.
Otherwise, a Foley catheter should be placed through the
PEG tract to keep it open.
Size selection of the replacement feeding tube should be
based on the size of the old PEG tube.
If the old PEG tube is loose and gastric juice leakage around
the tube is an issue, a slightly larger new tube can be
tried.
The external bumper is loosened and the old PEG tube
should move easily to and fro within the PEG tract. This
old feeding tube has an internal retention balloon.
The balloon is being deflated with an empty syringe. Efforts
should be made to completely deflate the balloon before
tube withdrawal
Open the replacement tube package, check the intactness
of the internal retention balloon by injecting water
through a prefilled syringe as directed in the package
insert.
and apply lubricant to the tip and tubing of the new
replacement tube.
The old feeding tube should be easily withdrawn by applying
gentle traction on the tubing.
Insert the new feeding tube gently through the existing PEG
tract into the stomach.
Inflate the internal retention balloon with a prefilled syringe
Apply gentle traction on the tube to ensure the internal
balloon is fully inflated.
Then slide the external bolster over the tubing close to the
skin.
Check the intragastric location of the new feeding tube by
aspiration of gastric content.
In this patient, the old feeding tube is advertently removed
and a Foley catheter is place to keep the PEG tract open.
Before removing the catheter, the internal retention
balloon is being deflated.
The Foley catheter is easily removed.
After applying lubricant to the tip of the feeding tube, the
replacement tube is gently advanced through the PEG
tract into the stomach.
The spontaneous return of bile stained gastric juice within
the tube indicates optimal intragastric location of the
feeding tube.
We are inflating the internal rention balloon with a prefilled
syringe.
To minimize the risk of skin breakdown and ischemic gastric
ulcer development, the external bolster should not be
placed too tight over the skin.
After initial PEG tube placement, instead of having an
internal retention balloon, the original PEG tube has a
collapsable internal bumper.
Voiceover text
In this case, the PEG tube can be removed by applying firm
traction on the tubing.
Infrequently, the old PEG tube can be exchanged over a
standard wire guide.
In difficult cases, endoscopy can be utilized to guide and
assist feeding tube exchange.
Some young and physically active patients prefer wearing a
low-profile feeding tube. A low-profile button can be
placed after the initial PEG tract is matured.
We are testing the intactness and patency of the internal
rention balloon.
With an empty syringe, the internal retention balloon of the
old feeding tube is deflated.
The old low profile feeding tube is easily removed and the
new one is placed.
By injecting the prefilled syringe through the balloon port,
the internal retention balloon is inflated.
PEG tube removal or replacement can be safely performed
after the PEG tract is matured. If the PEG tube is not
replaced by another tube, the PEG tract will shrink in
several hours and close within days.
Size selection of the replacement feeding tube should be
based on the size of the old PEG tube. If there are
concerns about the location of the replaced tube, a water
soluble radiologic contrast should be obtained to confirm
the placement before feeding is resumed.
Conflict of interest
Shou Tang has nothing to declare and we have no conflict of
interests.
Funding source
No funding was available for this study and manuscript.
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[2] Fukami N, Anderson MA, Khan K, Harrison ME, Appalaneni V,
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[3] Kwon RS, Banerjee S, Desilets D, Diehl DL, Farraye FA, et al.
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[4] Tang SJ. Percutaneous endoscopic gastrostomy (pull method)
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2014. (in press).
S.-j. Tang4
Please cite this article as: Tang S-j. Percutaneous Endoscopic Gastrostomy Tube Replacement. Video Journal and Encyclopedia of GI
Endoscopy (2014), http://dx.doi.org/10.1016/j.vjgien.2014.01.002
