Complications of the cut-and-push technique for percutaneous endoscopic gastrostomy tube removal

The use of the "cut-and-push" technique for percutaneous endoscopic gastrostomy (PEG) removal has been recognized since 1991. This technique is used in patients who are thought to have no risk of distal adhesions or strictures. Its use in selected patients is supported by current British Society of Gastorenterology guidelines. However, the risk of complications has long been debated. This report describes a patient who developed complications as a result of PEG removal using the cut-and-push technique. The patient had undergone previous abdominal surgery, and removal of the PEG endoscopically was not possible. A barium follow-through was performed in light of the history, and it excluded any mechanical blockage. Follow-up x-ray showed passage of the remnant beyond the pylorus. Despite this, the remnant became lodged in the small bowel, eventually resulting in perforation and death. This case highlights the fact that impaction of the remnant can occur in patients without evidence of mechanical obstruction on investigation. This raises a question about the need for serial x-rays to ensure passage of the remnant if the patient cannot confirm this visually.