PEG Push versus Pull Technique: Patient Safety at Stake

Abstract

There are 2 commonly used techniques for Peroral Endoscopic Gastrostomy (PEG) placement, the push technique and the pull technique. We report a case of equipment malfunction using the push method (Sachs-Vine). A 50 year old female with a history of metastatic endocervical adenocarcinoma was admitted for small bowel obstruction. She was also found to have new abdominal wall and omental lesions on CT. PEG tube placement was scheduled for decompression. After the endoscopic evaluation, the location of the incision was identified by transillumination as well as finger indentation and ballottement. Through sterile methods, a scout needle was used to define the tract. A trocar was introduced through the gastric wall. A guide string was then introduced and snared. The endoscope was removed with the wire in place. Gastrostomy tube was fed over the wire until the tip reached the abdominal wall. As the tubing was being pulled through and the dilator reached the level of the abdominal wall, it broke causing the bumper end to become lodged in the back of the oropharynx. This caused airway compromise and transient desaturation down to 60%. The broken tubing was located and removed with rat tooth forceps and a new PEG placed successfully using the Pull method (Ponsky). There are multiple percutaneous techniques used for PEG tube placement including the Pull method, Push method, introducer (Russell) method, and the Versa which uses T-fasteners. With the pull method, the tube is tapered at the end with a loop that is connected and it is pulled down and out through the abdominal wall with the wire. With the Push method, the tube is fed over the wire, this requires the tube to be much longer and is made of two pieces connected together with a small dilator. Both the Push and Pull method are used regularly with no significant difference in complications reported. Although this may be a rare complication, considering the already deteriorated state of many patients getting PEG tube placement and the possible deadly consequences of this complication, choosing the Pull method over the Push method is something to be considered especially in patients with abdominal wall abnormalities.