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The safety and efficacy of percutaneous endoscopic gastrostomy (PEG) have been well documented [1,2]. With regard to the removal of PEG tubes, the standard method used recently has been nonendo− scopic removal: the percutaneous remov− al method should cost less and be less time−consuming because it obviates the need for an endoscopy. However, compli− cations arising from such PEG tube ex− change procedures have been reported [3, 4]. We encountered a patient who de− veloped problems as a result of a PEG tube exchange, in whom it was discovered that the the PEG tube had gone through the posterior wall of the stomach, reach− ing as far as the anterior aspect of the pan− creas.

A Percutaneous Endoscopic Gastrostomy Tube Pushed Through the Posterior Wall of the Stomach as far as the Pancreas During Nonendoscopic Tube Exchange