‘Cut and push’ as an alternative to endoscopic retrieval of PEG type gastrostomy tubes

‘Cut and push’ as an alternative to endoscopic retrieval of PEG type gastrostomy tubes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article ‘Cut and push’ as an alternative to endoscopic retrieval of PEG type gastrostomy tubes Harry Claxton, Karen Dick, Rhoda Taylor, Maddie Allam, Francesca Stedman, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2381897/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Jan, 2023 Read the published version in Pediatric Surgery International → Version 1 posted 7 You are reading this latest preprint version Abstract Purpose: Percutaneous Endoscopically placed Gastrostomy (PEG) tubes are frequently used in children. The traditional endoscopic method to remove/change the PEG device requires general anaesthesia in children. A minimally invasive alternative is the ‘Cut and Push’ method (C&P): avoiding the risks/wait times of general anaesthesia and reducing resource burden. Data regarding safety/effectiveness of C&P in children are lacking with concerns raised about the possibility of gastrointestinal obstruction. Methods: We retrospectively reviewed all cases of PEG removal / change to button in children (<18yrs) between December 2020 and January 2022. Cases were identified from a prospectively maintained database and all cases of C&P included. Parents/carers were asked if the child had suffered any complications following C&P and if flange was visualised in stools. Results: During the time period, 27 PEGs were either removed or changed to button via C&P. The average waiting time for C&P was 14.29 days, significantly shorter than the minimum 6 month waiting time for elective endoscopy. Our evaluation revealed no complications of C&P at median 70 days (range 25-301). In three cases the flange was visualised in the stool, at 2 days, 3 days and 5 weeksfollowing C&P respectively. Discussion: These data support the available literature suggesting C&P is an effective means to facilitate minimally invasive and prompt PEG removal / change to button in children. We recommend minimum weight and age parameters for this procedure and further evaluation of the safety and resource implications of this technique. Paediatric surgery Upper gastrointestinal Cut and Push Percutaneous Endoscopically placed Gastrostomy PEG Button gastrostomy. Figures Figure 1 Introduction Percutaneous Endoscopically placed Gastrostomy (PEG) tubes are frequently used in children for a variety of reasons including nutritional supplementation, exclusive route of nutrition and medication administration. Within the stomach the PEG is held in place with a ‘flange’, a flexible disk held against the internal stomach wall [1]. Most PEG tubes require either removal or replacement as a matter of course [2] either due to tube deterioration or patient choice and traditionally this is achieved by accessing the flange via endoscopy. Since endoscopy in most children is poorly tolerated without either general anaesthesia (GA) or sedation [3] a GA is usually required. While GA is never without risk, there may be additional considerations and hence desire to avoid GA in children with significant co-morbidities and the population of children requiring PEG access has a high incidence of co-morbidities [4]. For these reasons a safe alternative to GA for PEG removals would be attractive. One alternative to endoscopic removal is the ‘Cut and Push’ method (C&P). The cut and push method refers to the process of cutting the PEG tube externally, flush with the skin and advancing it into the stomach thereby releasing the internal flange. Following this the intention is that the flange passes through the gastrointestinal (GI) tract of the patient [5]. This method has been used in adult patients for over 20 years [5]. There is limited available literature regarding safety and effectiveness of C&P in children. Historically our practice has been to remove all PEG tubes via endoscopy under GA and avoid C&P due to anecdotal reports of complications related to a retained flange. However, we reconsidered this approach during the SARS-CoV-2 pandemic in light of limited capacity for endoscopic PEG removal under GA resulting in extremely long wait times. We were also aware that this approach was being utilised at other specialist Children’s centres. Our motivation to introduce this service was therefore primarily to relieve pressure on our GA endoscopy service as well as to reduce waiting times for patients (and their families), but we were also mindful of the potential benefit of avoiding GA. Given the limited data available regarding outcomes of children who have undergone C&P PEG removal we report our experience. Methods Development of a Cut and Push service: A C&P service was started in December 2020. Prior to offering our service we developed some inclusion / exclusion criteria following discussion with colleagues at other institutions but not based on any firm evidence. Inclusion criteria were a minimum age of 36 months and minimum weight of 14kg. These limits were intended to reduce the chance of complications, most notably gastrointestinal obstruction due to the physical size of the flange in relation to the child. We excluded patients with any previous abdominal surgery or gastrointestinal comorbidities which may increase the risk of intestinal stricture or adhesions. The C&P is performed by (or under the guidance of) our Specialist Paediatric Surgical nursing team. The final decision for suitability for C&P versus endoscopic retrieval is made by the responsible consultant in conjunction with parental/patient preference. The majority of PEG tubes inserted in our institution are made by Freka (Fresenius Kabi) and size 15Fr. Cases that did not meet the criteria for C&P or in whom parents did not wish to proceed were placed on a waiting list for removal under GA. Our institution does not currently offer an endoscopy service under sedation. Following C&P procedure, parents/carers are provided with an information sheet (Fig. 1 ) advising as to signs of obstruction and other concerning symptoms. Carers of children undergoing C + P were given strict safety-netting instructions to contact the specialist nursing team, or visit the emergency department, with any significant gastro-intestinal complaint in the months following the procedure. They were educated as to the theoretical complications of gastro-intestinal obstruction, vomiting and pain. Carers were given no prospective instruction to be vigilant for the flange, they were advised that not visualising the flange was not of concern as it was flexible and likely to pass undetected hidden in the stool. Initially all cases were performed in hospital by a member of the Specialist Paediatric Surgical nursing team. However more recently some cases have been performed in other hospitals within the region with guidance from our Specialist Paediatric Surgical nurses. Data collection We keep a departmental clinical database of all children who have undergone gastrostomy tube insertion to aid effective administration of our service. Since the inception of the C&P service, the specialist nursing team prospectively collected additional data within this database including indication for C&P and any complications. All cases undergoing C&P from December 2020 until January 2022 were extracted from this database and all cases are included in this report. For each case, patient case-notes were also reviewed to identify any hospital attendances or admissions following the C&P procedure aiming to identify any complication or adverse event that may be related to C&P. A single member of the team (HC) undertook a follow-up phone-call with the primary carer for each case, at a minimum of one-month post C + P procedure, and asked a standardised set of follow-up questions: Did the carer have any concern about the C&P procedure? Did the child demonstrate any new complaints or symptoms in the months following the C&P procedure? Specifically did the child demonstrate any vomiting, constipation or change in bowel habit in the months following the C&P procedure? Did the carer visualise the flange in the stool? If so, how long after the C&P procedure? Service evaluation permission The project was approved as a service evaluation by our institution. Results During the study time period, 27 PEG’s were removed via C&P. Patient demographics are shown in Table 1. During our review, 4 cases were identified that did not meet the pre-planned inclusion/exclusion criteria for our clinical service. Details of these cases, which are included in this report and shown in Table 2. Twenty two of the 27 cases were performed as elective or planned procedures for the following indications: damaged PEG tube requiring change to button device (n=5), elective change to button gastrostomy device for parent/patient choice (n=14), and gastrostomy no longer required (n=3). All 22 elective cases were performed by the specialist nursing team during a hospital attendance but without hospital admission. The average waiting time for these elective procedures was 14 days following initial request for change, markedly shorter than waiting time for elective endoscopy under GA which ranged from 6-8 months during the study period. The remaining 5 procedures were performed on an urgent or unplanned basis, all because the PEG tube was damaged and could no longer be used. Of these cases, 3 were performed by emergency department doctors, 1 by a regional physician guided remotely by our specialist nurse team and the remaining case by the specialist nursing team. Review of case notes and data regarding follow-up extracted from our departmental database revealed no instance of emergency department or hospital attendance related to complication of C&P procedure. Follow-up phone calls with parents were performed at median 70 days (range 35 – 517) after C&P procedure. No complications were reported by parents, no case of regurgitation was reported. The flange was visualised in the stool in 3 cases by carers, at 2 days, 3 days and 5 weeks following C&P. Parent feedback about the service has been very positive, with many commenting that they appreciated avoiding the waiting time for endoscopy and also avoiding the stress of GA. Discussion Here we report our recent experience with C&P removal of PEG tubes. Our intention in making this report is to increase the body of evidence available to clinicians who may wish to use the C&P technique for removal of PEG tubes in children. Whilst based on a relatively small number of cases, we have found C&P to be an effective technique and found no evidence of harm in the series we report. Endoscopic retrieval of a non-collapsible PEG flange usually requires GA in children. Logistics and waiting times for GA can be impractical and GA is not without risk [4]. Additional complications related to endoscopic removal of PEG tubes have been reported, not least airway compromise and oesophageal trauma [6]. Given the complete avoidance of these complications and avoidance of waiting for GA, C&P - a minimally invasive alternative to endoscopic retrieval, appears a favourable alternative. This alternative is only acceptable however if it is not associated with patient harm. We have not identified any evidence of harm in our series but acknowledge that it is a relatively small cohort. It will be important to further actively monitor for any evidence of harm and report larger patient numbers in due course. This is of particular importance since on discussion with colleagues at other centres, we are aware of a small number of cases involving impaction of the retained flange in the oesophagus in children following C&P, presumably following reflux / regurgitation from the stomach. Full details of these are not available but we are aware that they have been the cause of significant patient morbidity. Such a complication has been reported in the literature by Haanstra and colleagues but details are limited since the article is in Dutch [7]. Given the rare risk of significant complications we recommend that cases are actively reviewed following C&P to identify any evidence of harms and that these be reported for the benefit of all clinicians. A greater literature is available regarding safety and effectiveness of C&P in adults. This suggests complications following C&P are uncommon. In a systematic review including 5 cohort studies and 22 case studies with a total of 373 cases of C&P, a complication rate of less than 1% was identified [1]. The most frequent complication was gastrointestinal obstruction. While often resolving spontaneously, these complications sometimes require intervention such as laparotomy or endoscopy [1]. A small number of case studies report significant complications following C&P in adults including peritonitis, bleeding and even mortality [8–11]. Extrapolating the incidence of these complications is not possible however due to lack of reported denominators. When gastrointestinal obstruction does occur, it has been reported in various sites, from the oesophagus and stomach through the intestine and at ileostomy sites. Time until obstruction ranged up to almost 2 years following C&P in adults, most frequently occurring at around 9 weeks post procedure [1]. Overall, in the adult literature, the majority of complications are seen in patients who have either undergone previous abdominal surgery or who have comorbidities increasing risk of decreased intestinal motility or intestinal stricture [1]. Literature that is specific to paediatric populations is limited. In an update to the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition position paper from 2015, Homan et al recommends that C&P should be avoided in paediatric populations [12]. Homan et al draw this conclusion from Thomas et al 2018, who compared C&P to the ‘traction’ technique in a paediatric cohort, where 94 cases underwent C&P and 33 cases underwent ‘Traction’ technique [13]. The traction technique refers to pulling collapsible type PEG flanges through the abdominal wall with an outward pulling force [13]. Their findings suggest the C&P technique significantly reduces the need for procedural sedation compared to the traction technique but they did identify a higher rate of complications with C&P. Most notably, given the anecdotal experience reported above, flange impaction in the oesophagus requiring endoscopic retrieval occurred in 3.2%. They also report more minor complications associated with C&P occurring in 6.4% of their cohort; these included vomiting PEG remnants and aspiration pneumonia. Complications following C&P correlated strongly with lower patient body weight (mean weight in those with a complication was 9kg and all complications occurred in children under 12kg), and patient age (mean age in those with a complication was 26 months and all complications occurred in children under 5 years). Thomas et al specifically comment that younger children appear to be more likely to vomit the residual bumper [13]. A small number of paediatric case reports highlight complications, some significant, following C&P although most again, do not allow an understanding of the incidence of this problem. Kliener and colleagues report a case of asymptomatic flange remaining in the oesophagus of a two year old [14]. Mollitt and colleagues report an incidence of retained internal crossbar (SILASTIC” (Dow Coming, Midland, MI) bolster) in 2.1% (5 of 234 cases) following C&P. This consisted of oesophageal impaction in 3 cases, and failure of passage beyond the stomach in 2 cases (including 1 which was asymptomatic). Of note one case was as young as 6 months. Their report from 1998, reporting C&P in the context of the ‘crossbar’ predecessor to the current flange in modern PEG devices [15]. Pitersen-Oberndorff [16] report 3 complications following C&P including one fatal case of oesophageal impaction, one case of asymptomatic gastric retention and one case of distal ileal obstruction amongst small bowel adhesions in a child who had a ventriculo-peritoneal shunt. To our knowledge this is the only case of obstruction distal to the pylorus reported in the paediatric literature, a fact which supports the use of some inclusion criteria based on age or weight. We theorise that weight should correlate with the size of pyloric outlet; a larger pyloric outlet should reduce risk of pre-pyloric complications. Parallels can be drawn between a PEG flange pushed into the stomach and ingested gastric foreign bodies. Data regarding ingested foreign bodies is more available in the paediatric literature, with up to 90% of cases presenting to hospital passing spontaneously [17–19]. We would therefore anticipate that a PEG flange should pass spontaneously. We took these factors into account when introducing our service and took measures to minimise incidence of harms. These include a minimum weight limit and absence of previous gastrointestinal surgery. We reasoned that with the majority of complications in children occurring proximal to the gastric outlet, a small pyloric lumen in small patients would likely be the key mechanism underlying increased risk of complications in children [13]. Whether there are additional co-morbidities such as known gastro-oesophageal reflux, hiatus hernia, neurological disability, and kypho-scoliosis that further increase the risk of complications is not clear. Haanstra and colleague’s report opens the possibility of specific co-morbidities increasing the risk of pre-pyloric complications of C&P in older children [7]. Over the 18 months for which our service has been running, we have encountered a few patients who did not fulfil our original inclusion criteria yet who have been included in this report (Table 2 ). Most of these (3 of 4) have been unplanned cases due to accidental severing of the PEG tube. This was replaced with a button gastrostomy device and the flange allowed to pass as has been previously reported. Similarly, some of these cases have been managed remotely under the guidance of our specialist nursing team, thereby avoiding transfer or admission to our regional specialist centre. These are additional indications for which C&P may carry advantages. During this time period, patient feedback has been positive. Although we have not formally measured patient satisfaction, particular benefits reported by parents are reducing time to PEG removal and avoiding a GA. The principal limitation to our report is the relatively limited sample size, yet it is one of the largest reported series in the paediatric literature. A strength is that we have included ALL children who had a C&P procedure, with no exceptions, even some cases which did not meet our ongoing criteria. A further strength is that we have contacted the patients’ parents following C&P to determine any evidence of adverse events related to C&P procedure. The duration following C&P is limited and it will be important to monitor this cohort for a longer period of time to ensure any later complications are captured. We acknowledge we have not formally assessed patient/parent satisfaction, nor the impact of introducing this technique on resource utilisation and costs. These are important considerations and worthy of further investigation. Conclusion In conclusion these data suggest C&P is an effective means to facilitate minimally invasive and prompt PEG removal / change in children. Whilst the absence of any adverse events in our series is reassuring it is important to continue to monitor for these in a larger population and for a longer period of time to confirm the safety of this approach. The literature suggests that the flange not passing through the pyloric sphincter is the primary mechanism leading to complications in children. We therefore recommend minimum age and weight criteria for C&P and routine follow-up following C&P. Further investigation should include measures of patient / parent satisfaction and impact of resource utilisation and cost savings. Refinement of inclusion/exclusion criteria may be warranted as we gather greater experience. Abbreviations PEG = Percutaneous Endoscopically placed Gastrostomy C&P = Cut and Push’ method GA = General anaesthesia Declarations Authorship Contribution and Conflict of interest statement Each author has participated sufficiently in the project and takes public responsibility for appropriate portions of the manuscript contents. No individual other than the authors listed have contributed substantially to the preparation and revision of the manuscript. All authors declare that they do not have any conflicts of interest. All authors declare that they do not have any financial and/or personal relationships with other people or organizations that could inappropriately influence (bias) their work to disclose. No financial support has been given/sort for the completion of this study. Authorship Contribution Form and Statement Each author has participated sufficiently in the project and takes public responsibility for appropriate portions of the manuscript contents. No individual other than the authors listed have contributed substantially to the preparation and revision of the manuscript. Study conception and design: H Claxton, N Hall. Data acquisition: H Claxton, K Dick, R Taylor, M Allam, F Stedman, C Keys, N Hall. Analysis and data interpretation: H Claxton, N Hall. Drafting of the manuscript: H Claxton, K Dick, R Taylor, M Allam, F Stedman, C Keys, N Hall. Critical revision: H Claxton, F Stedman, C Keys, N Hall. References Pratt J, Green S (2017) Removal of percutaneous endoscopic gastrostomy tubes in adults using the “cut and push” method: A systematic review. Clin Nutr ESPEN 21:59–65. https://doi.org/10.1016/j.clnesp.2017.05.004 Lohsiriwat V (2013) Percutaneous endoscopic gastrostomy tube replacement: A simple procedure? World J Gastrointest Endosc 5:14–18. https://doi.org/10.4253/wjge.v5.i1.14 Isoldi S, Cucchiara S, Repici A, et al (2021) Gastrointestinal endoscopy in children and adults: How do they differ? Dig Liver Dis 53:697–705. https://doi.org/10.1016/j.dld.2021.02.016 Hansen TG, Engelhardt T, Weiss M (2019) Outcomes after paediatric anaesthesia: which ones should have the priority? Curr Opin Anaesthesiol 32:392–397. https://doi.org/10.1097/ACO.0000000000000720 Pearce CB, Goggin PM, Collett J, et al (2000) The “cut and push” method of percutaneous endoscopic gastrostomy tube removal. Clin Nutr Edinb Scotl 19:133–135. https://doi.org/10.1054/clnu.2000.0100 Palmer GM, Frawley GP, Heine RG, Oliver MR (2006) Complications Associated with Endoscopic Removal of Percutaneous Endoscopic Gastrostomy (PEG) Tubes in Children. J Pediatr Gastroenterol Nutr 42:443–445. https://doi.org/10.1097/01.mpg.0000189361.61298.9f Haanstra H B, Vastert Sj, Vos Gd, Pelleboer Ra (2007) [Two children with severe complications following incomplete removal of a percutaneous endoscopic gastrostomy (PEG) catheter]. Ned Tijdschr Geneeskd 151: Burdick JS, Venu R,, Hogan W (1993) Replacement of the percutaneous gastrostomy tube is the indrect non-endoscopic visualization technique safe. Gastrointest Endosc Vol. 39:249–249 Peacock O, Singh R, Cole A, Speake W (2012) The “cut and push” technique: is it really safe? BMJ Case Rep 2012:bcr2012006607. https://doi.org/10.1136/bcr-2012-006607 Weston AP, Campbell DR (1995) Distal small bowel obstruction by a severed PEG tube: Successful endoscopic management by ileoscopic retrieval. Gastrointest Endosc 42:269–271. https://doi.org/10.1016/S0016-5107(95)70106-0 Harrison E, Dillon J, Leslie FC (2011) Complications of the cut-and-push technique for percutaneous endoscopic gastrostomy tube removal. Nutr Clin Pract Off Publ Am Soc Parenter Enter Nutr 26:230–231. https://doi.org/10.1177/0884533611405533 Homan M, Hauser B, Romano C, et al (2021) Percutaneous Endoscopic Gastrostomy in Children: An Update to the ESPGHAN Position Paper. J Pediatr Gastroenterol Nutr 73:415–426. https://doi.org/10.1097/MPG.0000000000003207 Thomas H, Yole J, Livingston MH, et al (2018) Replacing gastrostomy tubes with collapsible bumpers in pediatric patients: Is it safe to “cut” the tube and allow the bumper to pass enterally? J Pediatr Surg 53:942–945. https://doi.org/10.1016/j.jpedsurg.2018.02.020 Kleiner GI, Vergara TM (1998) Esophageal obstruction after incomplete removal of a percutaneous endoscopic gastrostomy tube. Pediatr Emerg Care 14:133–135. https://doi.org/10.1097/00006565-199804000-00011 Mollitt DL, Dokler ML, Evans JS, et al (1998) Complications of retained internal bolster after pediatric percutaneous endoscopic gastrostomy. J Pediatr Surg 33:271–273. https://doi.org/10.1016/s0022-3468(98)90445-6 Pietersen-Oberndorff KM, Vos GD, Baeten CG (1999) Serious complications after incomplete removal of percutaneous endoscopic gastrostomy catheter. J Pediatr Gastroenterol Nutr 28:230–232. https://doi.org/10.1097/00005176-199902000-00030 Wright CC, Closson FT (2013) Updates in pediatric gastrointestinal foreign bodies. Pediatr Clin North Am 60:1221–1239. https://doi.org/10.1016/j.pcl.2013.06.007 Lee JH, Lee JS, Kim MJ, Choe YH (2011) Initial location determines spontaneous passage of foreign bodies from the gastrointestinal tract in children. Pediatr Emerg Care 27:284–289. https://doi.org/10.1097/PEC.0b013e318213131a ASGE Standards of Practice Committee, Ikenberry SO, Jue TL, et al (2011) Management of ingested foreign bodies and food impactions. Gastrointest Endosc 73:1085–1091. https://doi.org/10.1016/j.gie.2010.11.010 Cuschieri S (2019) The STROBE guidelines. Saudi J Anaesth 13:S31–S34. https://doi.org/10.4103/sja.SJA_543_18 Tables Table 1 - Demographics of the cases included in this report. Cases outside the inclusion criteria are justified in table 2. Demographic Cases (Total 27) Gender 19 male, 8 female Age Median: 6 Years 138 Days (range 1y86d - 18y82d) Weight Median: 17kg (range 9-48kg) Table 2 - Description of four cases outside of the original inclusion criteria for the C&P service. The weight or age outside the intended range is marked with a ‘*’. Case number Weight and Age Details 11 4 years 156 days 13kg* Unplanned case, PEG tube snapped in the community and was replaced by a ‘button gastrostomy’ out of hours in the emergency department. 13 3 years 281 days 9kg* Unplanned case, PEG tube snapped in the community and was replaced by a ‘button gastrostomy’ out of hours in the emergency department. 19 4 years 192 days 13kg* Elective removal of PEG tube as child no longer needed a feeding gastrostomy. Anxiety from parents at unused PEG appearing damaged resulted in pressure for urgent removal, this was at the time of the most significant delays due to the COVID pandemic. Consultant consented to the carers to the theoretical increased risk of obstruction increased by low weight of child, they chose to proceed. 21 1 year 83 days* 16kg Unplanned case, PEG snapped in the community and was replaced by a ‘button gastrostomy’ out of hours in the emergency department. Additional Declarations No competing interests reported. Supplementary Files STROBEChecklist.docx Cite Share Download PDF Status: Published Journal Publication published 30 Jan, 2023 Read the published version in Pediatric Surgery International → Version 1 posted Editorial decision: Major revision 04 Jan, 2023 Reviews received at journal 02 Jan, 2023 Reviewers agreed at journal 01 Jan, 2023 Reviewers invited by journal 01 Jan, 2023 Editor assigned by journal 17 Dec, 2022 Submission checks completed at journal 16 Dec, 2022 First submitted to journal 15 Dec, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2381897","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":160553627,"identity":"54a34135-9cec-48e8-b7f9-1dd1bcd2608c","order_by":0,"name":"Harry Claxton","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7UlEQVRIiWNgGAWjYBACgwMQWgbKtWEwIFYLDwMDM5AqSINqSSBay4fDRGg5fvbZZx4GOx7+GfkHHxcYnM8z5z/A9uDjD9xa7M+kG8/mYUjmkThzmNl4hsHtYssZCeyGM/A6LI2ZmYfhAA/D8WY2aR6D24kbbjAAGfi0nH8G0SJ/mBmk5VzihvMH2KT/4NNyA2qLAcSWA4kbDiSwSeP1/o1nzIxzDJJ5DM8cNjbmMUgGOiyxTbInDZ/D0pgZ3lTYycndSHz4mOePHdBhh49J/LDBrQUEmHhQY5yxAb96kBI8kTAKRsEoGAWjgIEBAIEtTDLMyw4FAAAAAElFTkSuQmCC","orcid":"","institution":"Southampton Children’s Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Harry","middleName":"","lastName":"Claxton","suffix":""},{"id":160553629,"identity":"a5d69a26-86ce-43b9-b814-d28636ddce5a","order_by":1,"name":"Karen Dick","email":"","orcid":"","institution":"Southampton Children’s Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Karen","middleName":"","lastName":"Dick","suffix":""},{"id":160553632,"identity":"59e0572d-175b-428e-b611-07a47d1142db","order_by":2,"name":"Rhoda Taylor","email":"","orcid":"","institution":"Southampton Children’s Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Rhoda","middleName":"","lastName":"Taylor","suffix":""},{"id":160553634,"identity":"5d7fd33c-e2f8-48e2-bae2-5133b9e6ca19","order_by":3,"name":"Maddie Allam","email":"","orcid":"","institution":"Southampton Children’s Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Maddie","middleName":"","lastName":"Allam","suffix":""},{"id":160553635,"identity":"c4cf28c0-5f2b-4370-b501-c98fd37b45cf","order_by":4,"name":"Francesca Stedman","email":"","orcid":"","institution":"Southampton Children’s Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Francesca","middleName":"","lastName":"Stedman","suffix":""},{"id":160553638,"identity":"ae0a2aa2-f72b-46c4-98e0-b0601589bc42","order_by":5,"name":"Charlie Keys","email":"","orcid":"","institution":"Southampton Children’s Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Charlie","middleName":"","lastName":"Keys","suffix":""},{"id":160553640,"identity":"0ebf4839-1a75-435b-8747-dee1812506c1","order_by":6,"name":"Nigel J Hall","email":"","orcid":"","institution":"Southampton Children’s Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Nigel","middleName":"J","lastName":"Hall","suffix":""}],"badges":[],"createdAt":"2022-12-15 13:29:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2381897/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2381897/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00383-023-05382-5","type":"published","date":"2023-01-30T18:39:55+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":30571371,"identity":"965d8722-1617-4183-a384-945ede7986ce","added_by":"auto","created_at":"2022-12-20 14:50:30","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":332013,"visible":true,"origin":"","legend":"\u003cp\u003eDemonstrates the information sheet that parents / carers are provided with either when considering or following the C\u0026amp;P procedure. The document both explains the risks and benefits of the procedure.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-2381897/v1/6165a2ef781c661b26cf6062.png"},{"id":44718425,"identity":"2eef32b6-6afd-41b8-a266-7bfb0b830fb6","added_by":"auto","created_at":"2023-10-16 18:46:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":613673,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2381897/v1/3d412adc-b97b-434a-b2e4-1292a1c9f658.pdf"},{"id":30571370,"identity":"024f3338-b977-42b8-9767-52d58cf181e7","added_by":"auto","created_at":"2022-12-20 14:50:30","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":23313,"visible":true,"origin":"","legend":"","description":"","filename":"STROBEChecklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-2381897/v1/759519bdc510ee57167edb67.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"‘Cut and push’ as an alternative to endoscopic retrieval of PEG type gastrostomy tubes","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePercutaneous Endoscopically placed Gastrostomy (PEG) tubes are frequently used in children for a variety of reasons including nutritional supplementation, exclusive route of nutrition and medication administration. Within the stomach the PEG is held in place with a ‘flange’, a flexible disk held against the internal stomach wall [1]. Most PEG tubes require either removal or replacement as a matter of course [2] either due to tube deterioration or patient choice and traditionally this is achieved by accessing the flange via endoscopy. Since endoscopy in most children is poorly tolerated without either general anaesthesia (GA) or sedation [3] a GA is usually required. While GA is never without risk, there may be additional considerations and hence desire to avoid GA in children with significant co-morbidities and the population of children requiring PEG access has a high incidence of co-morbidities [4]. For these reasons a safe alternative to GA for PEG removals would be attractive.\u003c/p\u003e \u003cp\u003eOne alternative to endoscopic removal is the ‘Cut and Push’ method (C\u0026amp;P). The cut and push method refers to the process of cutting the PEG tube externally, flush with the skin and advancing it into the stomach thereby releasing the internal flange. Following this the intention is that the flange passes through the gastrointestinal (GI) tract of the patient [5]. This method has been used in adult patients for over 20 years [5]. There is limited available literature regarding safety and effectiveness of C\u0026amp;P in children.\u003c/p\u003e \u003cp\u003eHistorically our practice has been to remove all PEG tubes via endoscopy under GA and avoid C\u0026amp;P due to anecdotal reports of complications related to a retained flange. However, we reconsidered this approach during the SARS-CoV-2 pandemic in light of limited capacity for endoscopic PEG removal under GA resulting in extremely long wait times. We were also aware that this approach was being utilised at other specialist Children’s centres. Our motivation to introduce this service was therefore primarily to relieve pressure on our GA endoscopy service as well as to reduce waiting times for patients (and their families), but we were also mindful of the potential benefit of avoiding GA. Given the limited data available regarding outcomes of children who have undergone C\u0026amp;P PEG removal we report our experience.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eDevelopment of a Cut and Push service:\u003c/h2\u003e\u003cp\u003eA C\u0026amp;P service was started in December 2020. Prior to offering our service we developed some inclusion / exclusion criteria following discussion with colleagues at other institutions but not based on any firm evidence. Inclusion criteria were a minimum age of 36 months and minimum weight of 14kg. These limits were intended to reduce the chance of complications, most notably gastrointestinal obstruction due to the physical size of the flange in relation to the child. We excluded patients with any previous abdominal surgery or gastrointestinal comorbidities which may increase the risk of intestinal stricture or adhesions. The C\u0026amp;P is performed by (or under the guidance of) our Specialist Paediatric Surgical nursing team. The final decision for suitability for C\u0026amp;P versus endoscopic retrieval is made by the responsible consultant in conjunction with parental/patient preference. The majority of PEG tubes inserted in our institution are made by Freka (Fresenius Kabi) and size 15Fr. Cases that did not meet the criteria for C\u0026amp;P or in whom parents did not wish to proceed were placed on a waiting list for removal under GA. Our institution does not currently offer an endoscopy service under sedation.\u003c/p\u003e\u003cp\u003eFollowing C\u0026amp;P procedure, parents/carers are provided with an information sheet (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e) advising as to signs of obstruction and other concerning symptoms. Carers of children undergoing C + P were given strict safety-netting instructions to contact the specialist nursing team, or visit the emergency department, with any significant gastro-intestinal complaint in the months following the procedure. They were educated as to the theoretical complications of gastro-intestinal obstruction, vomiting and pain. Carers were given no prospective instruction to be vigilant for the flange, they were advised that not visualising the flange was not of concern as it was flexible and likely to pass undetected hidden in the stool.\u003c/p\u003e\u003cp\u003eInitially all cases were performed in hospital by a member of the Specialist Paediatric Surgical nursing team. However more recently some cases have been performed in other hospitals within the region with guidance from our Specialist Paediatric Surgical nurses.\u003c/p\u003e\u003ch2\u003eData collection\u003c/h2\u003e\u003cp\u003eWe keep a departmental clinical database of all children who have undergone gastrostomy tube insertion to aid effective administration of our service. Since the inception of the C\u0026amp;P service, the specialist nursing team prospectively collected additional data within this database including indication for C\u0026amp;P and any complications. All cases undergoing C\u0026amp;P from December 2020 until January 2022 were extracted from this database and all cases are included in this report.\u003c/p\u003e\u003cp\u003eFor each case, patient case-notes were also reviewed to identify any hospital attendances or admissions following the C\u0026amp;P procedure aiming to identify any complication or adverse event that may be related to C\u0026amp;P.\u003c/p\u003e\u003cp\u003eA single member of the team (HC) undertook a follow-up phone-call with the primary carer for each case, at a minimum of one-month post C + P procedure, and asked a standardised set of follow-up questions:\u003c/p\u003e\u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDid the carer have any concern about the C\u0026amp;P procedure?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDid the child demonstrate any new complaints or symptoms in the months following the C\u0026amp;P procedure?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSpecifically did the child demonstrate any vomiting, constipation or change in bowel habit in the months following the C\u0026amp;P procedure?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDid the carer visualise the flange in the stool? If so, how long after the C\u0026amp;P procedure?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e\u003ch2\u003eService evaluation permission\u003c/h2\u003e\u003cp\u003e The project was approved as a service evaluation by our institution.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eDuring the study time period, 27 PEG\u0026rsquo;s were removed via C\u0026amp;P. Patient demographics are shown in Table 1. During our review, 4 cases were identified that did not meet the pre-planned inclusion/exclusion criteria for our clinical service. Details of these cases, which are included in this report and shown in Table 2.\u003c/p\u003e\n\u003cp\u003eTwenty two of the 27 cases were performed as elective or planned procedures for the following indications: damaged PEG tube requiring change to button device (n=5), elective change to button gastrostomy device for parent/patient choice (n=14), and gastrostomy no longer required (n=3). All 22 elective cases were performed by the specialist nursing team during a hospital attendance but without hospital admission. The average waiting time for these elective procedures was 14 days following initial request for change, markedly shorter than waiting time for elective endoscopy under GA which ranged from 6-8 months during the study period.\u003c/p\u003e\n\u003cp\u003eThe remaining 5 procedures were performed on an urgent or unplanned basis, all because the PEG tube was damaged and could no longer be used. Of these cases, 3 were performed by emergency department doctors, 1 by a regional physician guided remotely by our specialist nurse team and the remaining case by the specialist nursing team.\u003c/p\u003e\n\u003cp\u003eReview of case notes and data regarding follow-up extracted from our departmental database revealed no instance of emergency department or hospital attendance related to complication of C\u0026amp;P procedure.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFollow-up phone calls with parents were performed at median 70 days (range 35 \u0026ndash; 517) after C\u0026amp;P procedure. No complications were reported by parents, no case of regurgitation was reported. The flange was visualised in the stool in 3 cases by carers, at 2 days, 3 days and 5 weeks following C\u0026amp;P. Parent feedback about the service has been very positive, with many commenting that they appreciated avoiding the waiting time for endoscopy and also avoiding the stress of GA.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eHere we report our recent experience with C\u0026amp;P removal of PEG tubes. Our intention in making this report is to increase the body of evidence available to clinicians who may wish to use the C\u0026amp;P technique for removal of PEG tubes in children. Whilst based on a relatively small number of cases, we have found C\u0026amp;P to be an effective technique and found no evidence of harm in the series we report.\u003c/p\u003e \u003cp\u003eEndoscopic retrieval of a non-collapsible PEG flange usually requires GA in children. Logistics and waiting times for GA can be impractical and GA is not without risk [4]. Additional complications related to endoscopic removal of PEG tubes have been reported, not least airway compromise and oesophageal trauma [6]. Given the complete avoidance of these complications and avoidance of waiting for GA, C\u0026amp;P - a minimally invasive alternative to endoscopic retrieval, appears a favourable alternative. This alternative is only acceptable however if it is not associated with patient harm. We have not identified any evidence of harm in our series but acknowledge that it is a relatively small cohort. It will be important to further actively monitor for any evidence of harm and report larger patient numbers in due course. This is of particular importance since on discussion with colleagues at other centres, we are aware of a small number of cases involving impaction of the retained flange in the oesophagus in children following C\u0026amp;P, presumably following reflux / regurgitation from the stomach. Full details of these are not available but we are aware that they have been the cause of significant patient morbidity. Such a complication has been reported in the literature by Haanstra and colleagues but details are limited since the article is in Dutch [7]. Given the rare risk of significant complications we recommend that cases are actively reviewed following C\u0026amp;P to identify any evidence of harms and that these be reported for the benefit of all clinicians.\u003c/p\u003e \u003cp\u003eA greater literature is available regarding safety and effectiveness of C\u0026amp;P in adults. This suggests complications following C\u0026amp;P are uncommon. In a systematic review including 5 cohort studies and 22 case studies with a total of 373 cases of C\u0026amp;P, a complication rate of less than 1% was identified [1]. The most frequent complication was gastrointestinal obstruction. While often resolving spontaneously, these complications sometimes require intervention such as laparotomy or endoscopy [1]. A small number of case studies report significant complications following C\u0026amp;P in adults including peritonitis, bleeding and even mortality [8\u0026ndash;11]. Extrapolating the incidence of these complications is not possible however due to lack of reported denominators. When gastrointestinal obstruction does occur, it has been reported in various sites, from the oesophagus and stomach through the intestine and at ileostomy sites. Time until obstruction ranged up to almost 2 years following C\u0026amp;P in adults, most frequently occurring at around 9 weeks post procedure [1]. Overall, in the adult literature, the majority of complications are seen in patients who have either undergone previous abdominal surgery or who have comorbidities increasing risk of decreased intestinal motility or intestinal stricture [1].\u003c/p\u003e \u003cp\u003eLiterature that is specific to paediatric populations is limited. In an update to the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition position paper from 2015, Homan et al recommends that C\u0026amp;P should be avoided in paediatric populations [12]. Homan et al draw this conclusion from Thomas et al 2018, who compared C\u0026amp;P to the \u0026lsquo;traction\u0026rsquo; technique in a paediatric cohort, where 94 cases underwent C\u0026amp;P and 33 cases underwent \u0026lsquo;Traction\u0026rsquo; technique [13]. The traction technique refers to pulling collapsible type PEG flanges through the abdominal wall with an outward pulling force [13]. Their findings suggest the C\u0026amp;P technique significantly reduces the need for procedural sedation compared to the traction technique but they did identify a higher rate of complications with C\u0026amp;P. Most notably, given the anecdotal experience reported above, flange impaction in the oesophagus requiring endoscopic retrieval occurred in 3.2%. They also report more minor complications associated with C\u0026amp;P occurring in 6.4% of their cohort; these included vomiting PEG remnants and aspiration pneumonia. Complications following C\u0026amp;P correlated strongly with lower patient body weight (mean weight in those with a complication was 9kg and all complications occurred in children under 12kg), and patient age (mean age in those with a complication was 26 months and all complications occurred in children under 5 years). Thomas et al specifically comment that younger children appear to be more likely to vomit the residual bumper [13]. A small number of paediatric case reports highlight complications, some significant, following C\u0026amp;P although most again, do not allow an understanding of the incidence of this problem. Kliener and colleagues report a case of asymptomatic flange remaining in the oesophagus of a two year old [14]. Mollitt and colleagues report an incidence of retained internal crossbar (SILASTIC\u0026rdquo; (Dow Coming, Midland, MI) bolster) in 2.1% (5 of 234 cases) following C\u0026amp;P. This consisted of oesophageal impaction in 3 cases, and failure of passage beyond the stomach in 2 cases (including 1 which was asymptomatic). Of note one case was as young as 6 months. Their report from 1998, reporting C\u0026amp;P in the context of the \u0026lsquo;crossbar\u0026rsquo; predecessor to the current flange in modern PEG devices [15]. Pitersen-Oberndorff [16] report 3 complications following C\u0026amp;P including one fatal case of oesophageal impaction, one case of asymptomatic gastric retention and one case of distal ileal obstruction amongst small bowel adhesions in a child who had a ventriculo-peritoneal shunt. To our knowledge this is the only case of obstruction distal to the pylorus reported in the paediatric literature, a fact which supports the use of some inclusion criteria based on age or weight. We theorise that weight should correlate with the size of pyloric outlet; a larger pyloric outlet should reduce risk of pre-pyloric complications.\u003c/p\u003e \u003cp\u003eParallels can be drawn between a PEG flange pushed into the stomach and ingested gastric foreign bodies. Data regarding ingested foreign bodies is more available in the paediatric literature, with up to 90% of cases presenting to hospital passing spontaneously [17\u0026ndash;19]. We would therefore anticipate that a PEG flange should pass spontaneously. We took these factors into account when introducing our service and took measures to minimise incidence of harms. These include a minimum weight limit and absence of previous gastrointestinal surgery. We reasoned that with the majority of complications in children occurring proximal to the gastric outlet, a small pyloric lumen in small patients would likely be the key mechanism underlying increased risk of complications in children [13]. Whether there are additional co-morbidities such as known gastro-oesophageal reflux, hiatus hernia, neurological disability, and kypho-scoliosis that further increase the risk of complications is not clear. Haanstra and colleague\u0026rsquo;s report opens the possibility of specific co-morbidities increasing the risk of pre-pyloric complications of C\u0026amp;P in older children [7].\u003c/p\u003e \u003cp\u003eOver the 18 months for which our service has been running, we have encountered a few patients who did not fulfil our original inclusion criteria yet who have been included in this report (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Most of these (3 of 4) have been unplanned cases due to accidental severing of the PEG tube. This was replaced with a button gastrostomy device and the flange allowed to pass as has been previously reported. Similarly, some of these cases have been managed remotely under the guidance of our specialist nursing team, thereby avoiding transfer or admission to our regional specialist centre. These are additional indications for which C\u0026amp;P may carry advantages. During this time period, patient feedback has been positive. Although we have not formally measured patient satisfaction, particular benefits reported by parents are reducing time to PEG removal and avoiding a GA.\u003c/p\u003e \u003cp\u003e The principal limitation to our report is the relatively limited sample size, yet it is one of the largest reported series in the paediatric literature. A strength is that we have included ALL children who had a C\u0026amp;P procedure, with no exceptions, even some cases which did not meet our ongoing criteria. A further strength is that we have contacted the patients\u0026rsquo; parents following C\u0026amp;P to determine any evidence of adverse events related to C\u0026amp;P procedure. The duration following C\u0026amp;P is limited and it will be important to monitor this cohort for a longer period of time to ensure any later complications are captured. We acknowledge we have not formally assessed patient/parent satisfaction, nor the impact of introducing this technique on resource utilisation and costs. These are important considerations and worthy of further investigation.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion these data suggest C\u0026amp;P is an effective means to facilitate minimally invasive and prompt PEG removal / change in children. Whilst the absence of any adverse events in our series is reassuring it is important to continue to monitor for these in a larger population and for a longer period of time to confirm the safety of this approach. The literature suggests that the flange not passing through the pyloric sphincter is the primary mechanism leading to complications in children. We therefore recommend minimum age and weight criteria for C\u0026amp;P and routine follow-up following C\u0026amp;P. Further investigation should include measures of patient / parent satisfaction and impact of resource utilisation and cost savings. Refinement of inclusion/exclusion criteria may be warranted as we gather greater experience.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003ePEG =\u003c/strong\u003e Percutaneous Endoscopically placed Gastrostomy\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eC\u0026amp;P =\u003c/strong\u003e Cut and Push\u0026rsquo; method\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGA =\u0026nbsp;\u003c/strong\u003eGeneral anaesthesia\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003e\u003cstrong\u003eAuthorship Contribution and Conflict of interest statement\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eEach author has participated sufficiently in the project and takes public responsibility for appropriate portions of the manuscript contents. No individual other than the authors listed have contributed substantially to the preparation and revision of the manuscript.\u003c/p\u003e\n\u003cp\u003eAll authors declare that they do not have any conflicts of interest.\u003c/p\u003e\n\u003cp\u003eAll authors declare that they do not have any financial and/or personal relationships with other people or organizations that could inappropriately influence (bias) their work to disclose.\u003c/p\u003e\n\u003cp\u003eNo financial support has been given/sort for the completion of this study.\u003c/p\u003e\n\u003ch3\u003eAuthorship Contribution Form and Statement\u003c/h3\u003e\n\u003cp\u003eEach author has participated sufficiently in the project and takes public responsibility for appropriate portions of the manuscript contents. No individual other than the authors listed have contributed substantially to the preparation and revision of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy conception and design:\u003c/strong\u003e H Claxton, N Hall.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData acquisition:\u003c/strong\u003e H Claxton, K Dick, R Taylor, M Allam, F Stedman, C Keys, N Hall.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis and data interpretation:\u003c/strong\u003e H Claxton, N Hall.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDrafting of the manuscript:\u003c/strong\u003e H Claxton, K Dick, R Taylor, M Allam, F Stedman, C Keys, N Hall.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCritical revision:\u003c/strong\u003e H Claxton, F Stedman, C Keys, N Hall.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePratt J, Green S (2017) Removal of percutaneous endoscopic gastrostomy tubes in adults using the \u0026ldquo;cut and push\u0026rdquo; method: A systematic review. Clin Nutr ESPEN 21:59\u0026ndash;65. https://doi.org/10.1016/j.clnesp.2017.05.004\u003c/li\u003e\n\u003cli\u003eLohsiriwat V (2013) Percutaneous endoscopic gastrostomy tube replacement: A simple procedure? World J Gastrointest Endosc 5:14\u0026ndash;18. https://doi.org/10.4253/wjge.v5.i1.14\u003c/li\u003e\n\u003cli\u003eIsoldi S, Cucchiara S, Repici A, et al (2021) Gastrointestinal endoscopy in children and adults: How do they differ? Dig Liver Dis 53:697\u0026ndash;705. https://doi.org/10.1016/j.dld.2021.02.016\u003c/li\u003e\n\u003cli\u003eHansen TG, Engelhardt T, Weiss M (2019) Outcomes after paediatric anaesthesia: which ones should have the priority? Curr Opin Anaesthesiol 32:392\u0026ndash;397. https://doi.org/10.1097/ACO.0000000000000720\u003c/li\u003e\n\u003cli\u003ePearce CB, Goggin PM, Collett J, et al (2000) The \u0026ldquo;cut and push\u0026rdquo; method of percutaneous endoscopic gastrostomy tube removal. Clin Nutr Edinb Scotl 19:133\u0026ndash;135. https://doi.org/10.1054/clnu.2000.0100\u003c/li\u003e\n\u003cli\u003ePalmer GM, Frawley GP, Heine RG, Oliver MR (2006) Complications Associated with Endoscopic Removal of Percutaneous Endoscopic Gastrostomy (PEG) Tubes in Children. J Pediatr Gastroenterol Nutr 42:443\u0026ndash;445. https://doi.org/10.1097/01.mpg.0000189361.61298.9f\u003c/li\u003e\n\u003cli\u003eHaanstra H B, Vastert Sj, Vos Gd, Pelleboer Ra (2007) [Two children with severe complications following incomplete removal of a percutaneous endoscopic gastrostomy (PEG) catheter]. Ned Tijdschr Geneeskd 151:\u003c/li\u003e\n\u003cli\u003eBurdick JS, Venu R,, Hogan W (1993) Replacement of the percutaneous gastrostomy tube is the indrect non-endoscopic visualization technique safe. Gastrointest Endosc Vol. 39:249\u0026ndash;249\u003c/li\u003e\n\u003cli\u003ePeacock O, Singh R, Cole A, Speake W (2012) The \u0026ldquo;cut and push\u0026rdquo; technique: is it really safe? BMJ Case Rep 2012:bcr2012006607. https://doi.org/10.1136/bcr-2012-006607\u003c/li\u003e\n\u003cli\u003eWeston AP, Campbell DR (1995) Distal small bowel obstruction by a severed PEG tube: Successful endoscopic management by ileoscopic retrieval. Gastrointest Endosc 42:269\u0026ndash;271. https://doi.org/10.1016/S0016-5107(95)70106-0\u003c/li\u003e\n\u003cli\u003eHarrison E, Dillon J, Leslie FC (2011) Complications of the cut-and-push technique for percutaneous endoscopic gastrostomy tube removal. Nutr Clin Pract Off Publ Am Soc Parenter Enter Nutr 26:230\u0026ndash;231. https://doi.org/10.1177/0884533611405533\u003c/li\u003e\n\u003cli\u003eHoman M, Hauser B, Romano C, et al (2021) Percutaneous Endoscopic Gastrostomy in Children: An Update to the ESPGHAN Position Paper. J Pediatr Gastroenterol Nutr 73:415\u0026ndash;426. https://doi.org/10.1097/MPG.0000000000003207\u003c/li\u003e\n\u003cli\u003eThomas H, Yole J, Livingston MH, et al (2018) Replacing gastrostomy tubes with collapsible bumpers in pediatric patients: Is it safe to \u0026ldquo;cut\u0026rdquo; the tube and allow the bumper to pass enterally? J Pediatr Surg 53:942\u0026ndash;945. https://doi.org/10.1016/j.jpedsurg.2018.02.020\u003c/li\u003e\n\u003cli\u003eKleiner GI, Vergara TM (1998) Esophageal obstruction after incomplete removal of a percutaneous endoscopic gastrostomy tube. Pediatr Emerg Care 14:133\u0026ndash;135. https://doi.org/10.1097/00006565-199804000-00011\u003c/li\u003e\n\u003cli\u003eMollitt DL, Dokler ML, Evans JS, et al (1998) Complications of retained internal bolster after pediatric percutaneous endoscopic gastrostomy. J Pediatr Surg 33:271\u0026ndash;273. https://doi.org/10.1016/s0022-3468(98)90445-6\u003c/li\u003e\n\u003cli\u003ePietersen-Oberndorff KM, Vos GD, Baeten CG (1999) Serious complications after incomplete removal of percutaneous endoscopic gastrostomy catheter. J Pediatr Gastroenterol Nutr 28:230\u0026ndash;232. https://doi.org/10.1097/00005176-199902000-00030\u003c/li\u003e\n\u003cli\u003eWright CC, Closson FT (2013) Updates in pediatric gastrointestinal foreign bodies. Pediatr Clin North Am 60:1221\u0026ndash;1239. https://doi.org/10.1016/j.pcl.2013.06.007\u003c/li\u003e\n\u003cli\u003eLee JH, Lee JS, Kim MJ, Choe YH (2011) Initial location determines spontaneous passage of foreign bodies from the gastrointestinal tract in children. Pediatr Emerg Care 27:284\u0026ndash;289. https://doi.org/10.1097/PEC.0b013e318213131a\u003c/li\u003e\n\u003cli\u003eASGE Standards of Practice Committee, Ikenberry SO, Jue TL, et al (2011) Management of ingested foreign bodies and food impactions. Gastrointest Endosc 73:1085\u0026ndash;1091. https://doi.org/10.1016/j.gie.2010.11.010\u003c/li\u003e\n\u003cli\u003eCuschieri S (2019) The STROBE guidelines. Saudi J Anaesth 13:S31\u0026ndash;S34. https://doi.org/10.4103/sja.SJA_543_18\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1 -\u003c/strong\u003e Demographics of the cases included in this report. Cases outside the inclusion criteria are justified in table 2.\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"625\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"50%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDemographic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"50%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCases (Total 27)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"50%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"50%\"\u003e\n \u003cp\u003e19 male, 8 female\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"50%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"50%\"\u003e\n \u003cp\u003eMedian: 6 Years 138 Days\u003c/p\u003e\n \u003cp\u003e(range 1y86d \u0026nbsp;- 18y82d)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"50%\"\u003e\n \u003cp\u003e\u003cstrong\u003eWeight\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"50%\"\u003e\n \u003cp\u003eMedian: 17kg (range 9-48kg)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2 -\u003c/strong\u003e Description of four cases outside of the original inclusion criteria for the C\u0026amp;P service. The weight or age outside the intended range is marked with a ‘*’.\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"600\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"12.333333333333334%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCase number\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.166666666666666%\"\u003e\n \u003cp\u003e\u003cstrong\u003eWeight and Age\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"75.5%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDetails\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"12.333333333333334%\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.166666666666666%\"\u003e\n \u003cp\u003e4 years 156 days\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e13kg*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"75.5%\"\u003e\n \u003cp\u003eUnplanned case, PEG tube snapped in the community and was replaced by a ‘button gastrostomy’ out of hours in the emergency department.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"12.333333333333334%\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.166666666666666%\"\u003e\n \u003cp\u003e3 years 281 days\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e9kg*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"75.5%\"\u003e\n \u003cp\u003eUnplanned case, PEG tube snapped in the community and was replaced by a ‘button gastrostomy’ out of hours in the emergency department.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"12.333333333333334%\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.166666666666666%\"\u003e\n \u003cp\u003e4 years 192 days\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e13kg*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"75.5%\"\u003e\n \u003cp\u003eElective removal of PEG tube as child no longer needed a feeding gastrostomy. Anxiety from parents at unused PEG appearing damaged resulted in pressure for urgent removal, this was at the time of the most significant delays due to the COVID pandemic. Consultant consented to the carers to the theoretical increased risk of obstruction increased by low weight of child, they chose to proceed.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"12.333333333333334%\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.166666666666666%\"\u003e\n \u003cp\u003e\u003cstrong\u003e1 year 83 days*\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e16kg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"75.5%\"\u003e\n \u003cp\u003eUnplanned case, PEG snapped in the community and was replaced by a ‘button gastrostomy’ out of hours in the emergency department.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"pediatric-surgery-international","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pesi","sideBox":"Learn more about [Pediatric Surgery International](http://link.springer.com/journal/383)","snPcode":"383","submissionUrl":"https://submission.nature.com/new-submission/383/3","title":"Pediatric Surgery International","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Paediatric surgery, Upper gastrointestinal, Cut and Push, Percutaneous Endoscopically placed Gastrostomy, PEG, Button gastrostomy.","lastPublishedDoi":"10.21203/rs.3.rs-2381897/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2381897/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch4\u003ePurpose:\u003c/h4\u003e\n\u003cp\u003ePercutaneous Endoscopically placed Gastrostomy (PEG) tubes are frequently used in children. The traditional endoscopic method to remove/change the PEG device requires general anaesthesia in children. \u0026nbsp;A minimally invasive alternative is the ‘Cut and Push’ method (C\u0026amp;P): avoiding the risks/wait times of general anaesthesia and reducing resource burden. Data regarding safety/effectiveness of C\u0026amp;P in children are lacking with concerns raised about the possibility of gastrointestinal obstruction.\u003c/p\u003e\n\u003ch4\u003eMethods:\u003c/h4\u003e\n\u003cp\u003eWe retrospectively reviewed all cases of PEG removal / change to button in children\u003cstrong\u003e \u003c/strong\u003e(\u0026lt;18yrs) between December 2020 and January 2022. Cases were identified from a prospectively maintained database and all cases of C\u0026amp;P included. Parents/carers were asked if the child had suffered any complications following C\u0026amp;P and if flange was visualised in stools.\u003c/p\u003e\n\u003ch4\u003eResults:\u003c/h4\u003e\n\u003cp\u003eDuring the time period, 27 PEGs were either removed or changed to button via C\u0026amp;P. The average waiting time for C\u0026amp;P was 14.29 days, significantly shorter than the minimum 6 month waiting time for elective endoscopy. Our evaluation revealed no complications of C\u0026amp;P at median 70 days (range 25-301). In three cases the flange was visualised in the stool, at 2 days, 3 days and 5 weeksfollowing C\u0026amp;P respectively.\u003c/p\u003e\n\u003ch4\u003eDiscussion:\u003c/h4\u003e\n\u003cp\u003eThese data support the available literature suggesting C\u0026amp;P is an effective means to facilitate minimally invasive and prompt PEG removal / change to button in children. We recommend minimum weight and age parameters for this procedure and further evaluation of the safety and resource implications of this technique.\u003c/p\u003e","manuscriptTitle":"‘Cut and push’ as an alternative to endoscopic retrieval of PEG type gastrostomy tubes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-12-20 14:50:25","doi":"10.21203/rs.3.rs-2381897/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-01-04T21:19:17+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-01-02T11:17:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"cb8048f9-70e8-4b15-871b-4261e6c81a79","date":"2023-01-01T16:21:58+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-01-01T14:05:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-12-17T09:28:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-12-16T06:12:30+00:00","index":"","fulltext":""},{"type":"submitted","content":"Pediatric Surgery International","date":"2022-12-15T13:26:04+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"pediatric-surgery-international","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pesi","sideBox":"Learn more about [Pediatric Surgery International](http://link.springer.com/journal/383)","snPcode":"383","submissionUrl":"https://submission.nature.com/new-submission/383/3","title":"Pediatric Surgery International","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"0f77d39e-b3f1-4281-806b-6ba08f41c9fe","owner":[],"postedDate":"December 20th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T18:43:33+00:00","versionOfRecord":{"articleIdentity":"rs-2381897","link":"https://doi.org/10.1007/s00383-023-05382-5","journal":{"identity":"pediatric-surgery-international","isVorOnly":false,"title":"Pediatric Surgery International"},"publishedOn":"2023-01-30 18:39:55","publishedOnDateReadable":"January 30th, 2023"},"versionCreatedAt":"2022-12-20 14:50:25","video":"","vorDoi":"10.1007/s00383-023-05382-5","vorDoiUrl":"https://doi.org/10.1007/s00383-023-05382-5","workflowStages":[]},"version":"v1","identity":"rs-2381897","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2381897","identity":"rs-2381897","version":["v1"]},"buildId":"ApUGefWb6u5IBVtyqm6d5","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}