Back to 2011 Program

INTRODUCTION
Since its introduction in 1980, the Percutaneous Endoscopic Gastrostomy (PEG) has become an efficient means of providing long-term enteral access for nutrition. Conveniently, the soft inner bumper allows PEG removal with relatively minimal external traction. Consequently, a major complication is early accidental dislodgement, from which significant morbidity may occur. We have perhaps underestimated and underappreciated the burden to the healthcare system due to this issue--- not only in the acute setting but over the lifetime of the PEG.
METHODS
A retrospective analysis of PEG placements was conducted at our institution, identifying all PEG tubes placed between July 1, 2007 and July 1, 2010 by one faculty surgeon. Patient charts were reviewed for 30-day mortality, major and minor complications, including early dislodgement, and subsequent management. Patients were reviewed until intentional removal of the PEG, cessation of records, or patient mortality.
RESULTS
A total of 563 PEGs were placed during our defined time period. The 30-day mortality rate was 7.8% (44/563), 7-day early accidental dislodgement was 4.1% (23/563), and the total lifetime accidental PEG dislodgement rate was 12.8% (72/563). Of those early dislodgements, 11 were replaced directly with a replacement gastrostomy tube, 6 were replaced with a second endoscopic PEG following several days of gastric decompression and antimicrobials, 5 by an open gastrostomy, and 1 was not replaced at all. An additional 49 PEGs dislodged following discharge while at rehabilitation facilities and nursing homes. The vast majority required an emergency department visit, level 1 surgical consultation, replacement gastrostomy tube, and radiographic confirmation of position, totaling an average of $3535 in hospital charges.
CONCLUSION
Many large PEG reviews report an early accidental dislodgement rate between 0.6% and 4.0%. The most clinically significant accidental removals occur in the first 7 days following placement, in which the stomach may fall away from the abdominal wall and open gastrostomy may cause obvious morbidity. Our early dislodgement rate (4.1%) is consistent with current reports. However, if followed longitudinally, a significantly higher rate of late dislodgement is seen (12.8%). Frequently placed into neurologically impaired or elderly patients, the PEGs that dislodge months and years later require expensive transportation, emergency room visits, surgical consultations, and fluoroscopic confirmation of replacement. The late removal complication, and its associated costs, are overlooked and underestimated. These data also suggest a need for improvement in the design of the soft inner bumper or a novel mechanism to secure a PEG in light of this significant burden to the healthcare system.