title: Late accidental dislodgement of a percutaneous endoscopic gastrostomy tube: an underestimated burden on patients and the health care system.
abstract: BACKGROUND
  Since its introduction in 1980, the percutaneous endoscopic gastrostomy (PEG) tube has become an efficient means of providing long-term enteral access. Conveniently, the soft inner bumper allows PEG removal with relatively minimal external traction. Consequently, a major complication is accidental dislodgement, from which significant morbidity may occur. Clinicians have perhaps underestimated and underappreciated this complication, not only in the acute setting but over the lifetime of the PEG tube.
  
  
  METHODS
  A retrospective analysis of PEG placements conducted at the authors' institution identified all PEG tubes placed between July 1, 2007 and July 1, 2010 by one faculty surgeon. Patient charts were reviewed for 30-day mortality, complications, 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 identified. The 30-day mortality rate was 7.8% (44/563), and the 7-day early accidental dislodgement rate was 4.1% (23/563). The total lifetime accidental PEG dislodgement rate was 12.8% (72/563). Of the 72 dislodged PEGs, 49 occurred after discharge from rehabilitation or nursing facilities. The vast majority required an emergency department visit, a level 3 surgical consultation, a replacement gastrostomy tube, and a radiographic confirmation of tube positioning, resulting in charges totaling an average of $1,200.
  
  
  CONCLUSIONS
  Many large PEG reviews report an early accidental dislodgement rate of 0.6% to 4.0%. The most clinically significant accidental removals occur in the first 7 days after placement, and open gastrostomy may cause obvious morbidity. The early dislodgement rate in this study (4.1%) is consistent with those currently reported. However, if cases are followed longitudinally, a significantly higher rate of late dislodgement (12.8%) is seen. Frequently placed into neurologically impaired or elderly patients, the PEGs that dislodge months and years later require expensive management. The late removal complication and its associated costs are overlooked and underestimated.
authors.affiliation: Department of Surgery, University of Virginia Health System, Charlottesville, VA 22908, USA. LHR2M@virginia.edu
authors.forename: Laura H
authors.initials: LH
authors.lastname: Rosenberger
authors.forename: Timothy
authors.initials: T
authors.lastname: Newhook
authors.forename: Bruce
authors.initials: B
authors.lastname: Schirmer
authors.forename: Robert G
authors.initials: RG
authors.lastname: Sawyer
mesh_terms: D020878:Device Removal; D004750:Enteral Nutrition / Q000295:instrumentation*; D004868:Equipment Failure; D005260:Female; D005774:Gastrostomy / Q000295:instrumentation* / Q000401:mortality*; D017722:Hospital Charges; D006801:Humans; D008297:Male; D011183:Postoperative Complications / Q000401:mortality*; D012189:Retrospective Studies; D012307:Risk Factors