Gastrostomy Tube Replacement 

Gastrostomy tube (G-tube) placement (placing a tube into the stomach)^{[1, 2]} to provide nutrition and medication for patients unable to feed themselves was first described in the mid 19th century. Initially, this procedure was often complicated by the development of peritonitis and a high mortality rate. Currently, however, G-tube placement now routinely occurs with few complications when placed percutaneously and guided by endoscopy or interventional radiology techniques.^[3] Neurologic disease is the most common indication for G-tube placement.^[4]

Patients with dislodged G-tubes often present to the emergency department (ED) or other acute care setting to have their tube replaced. This article focuses on G-tube replacement, but the technique can be extended to duodenostomy and jejunostomy tubes, as well.^[5]

• A G-tube should be replaced as quickly as possible in the ED, unless the tube was recently placed.
• A feeding tube tract can narrow or close within hours of tube removal.
• A simple gastrostomy requires approximately 1-2 weeks to form a tract.^[6] More complicated procedures, such as the Witzel tunnel, may take 3 weeks to create a mature tract.
• If the tract appears fresh, immediately contact the provider who placed the tube prior to ED replacement, as operative or fluoroscopic replacement may be required.

• Replacing a G-tube that has not formed a tract can lead to misplacement in the peritoneal cavity. As mentioned above, simple G-tubes generally take 1-2 weeks to form a mature tract. Information on when the G-tube was initially placed should be obtained to assess if nonoperative ED tube replacement can proceed safely.
• Replacement should not be performed if any evidence of infection (see the image below), such as extensive erythema, exudate, or warmth, is appreciated around the G-tube site. Regarding tube-site infections, most catheter-related infections involve local cellulitis, as shown here, with erythema and tenderness. These infections frequently respond to local wound care and oral antibiotics.

• G-tube replacement generally requires no anesthesia.
• If the skin site is sore, local administration of lidocaine or bupivacaine can decrease discomfort associated with tube replacement. For more information, see Local Anesthetic Agents, Infiltrative Administration.

Ideally, the patient arrives in the ED with the dislodged G-tube. The same tube or same type of tube can be placed. The fact that the G-tube was dislodged often indicates a malfunction with that particular tube (such as balloon rupture); thus, a new tube should be used. When information on the tube type is not available or known to the patient, a dedicated feeding tube suffices. If no feeding tube is accessible, a Foley catheter (at least 16F) can be used temporarily until a dedicated feeding tube can be placed.

Prior to G-tube replacement, gather the following items:

• Gloves
• Stethoscope
• G-tube or Foley catheter
• External bolster
• Lubricant
• Syringe that fits tube for air insufflation
• Syringe that fits tube for saline inflation (if balloon is involved)
• Saline
• Suture material
• Needle driver
• Scissors

Certain tubes require specialized plugs, connectors, and clamps, which should be specified on the packaging insert. In addition, some tubes necessitate the use of a hemostat, endotracheal tube stylet, guidewire, or other support to assist tube passage.

Two types of catheters are depicted in the images below.

• G-tube replacement most easily occurs with the patient in a comfortable recumbent position.

G-tube removal

• Often, the gastrostomy tube (G-tube) is only partially dislodged when the patient arrives in the emergency department (ED). In such cases, the tube must be removed prior to replacement.
• Not all G-tubes can be removed safely in the ED. Standard de Pezzer and mushroom catheters modified with rings or bolsters upon insertion may require endoscopy for removal. However, most G-tubes can be taken out with simple traction. When in doubt, contact the provider who inserted the tube to determine if removal can be completed safely in the ED. Of note, the visible portion of the G-tube outside the skin may or may not indicate what type of internal stabilization exists.
• G-tube removal begins with deflating the balloon, if one exists. Then, while providing traction on the tube, press a flat, gloved hand against the abdominal wall for countertraction.
• The tube should slide out with minimal resistance. If significant resistant is felt, the procedure should be aborted, as an internal ring or bolster that requires endoscopic removal may exist.

G-tube replacement

• Once the tube has been removed, replacement should occur as soon as possible to prevent tract narrowing and closure. If a similar G-tube will not pass through the tract or cannot be found, place a smaller tube or a Foley catheter to keep the tract open. A more permanent tube can be placed at a later time.
• Prior to replacing the G-tube, assess the tract (see the image below). Gently dilating the ostium and probing the tract with a cotton swab or hemostat may increase the ease of tube passage. Aggressive probing should be avoided, as a false tract can be created. When gastrostomy tubes are dislodged, the sinus tract (top right) can be readily identified and recanalized for up to several days. With sinus tracts of this diameter, feeding tubes can often be reinserted directly. When tracts are narrower, angiographic catheters and wires are often used, and tract dilatation may be necessary for tube replacement.
• Once the tract has been assessed, lubricate the tube, and slide it gently into the tract.

  • If a mushroom is present and does not slide through the ostomy easily, elongate the mushroom by placing a stylet or Kelly clamp through a side hole into the mushroom tip.
  • Never force the tube, as a false tract or separation of the stomach from the external stoma can occur.
• To initially check placement, insufflate 20 mL of air and listen for borborygmi over the stomach with a stethoscope. Gastric contents should also be easily aspirated. Secure the tube and obtain a confirmation study (see below).
• If a specialized G-tube is not obtainable, a Foley catheter may be used temporarily to prevent tract closure until a G-tube becomes available.^[7]

  • To prevent ingress of the Foley catheter into the ostomy, use an external bolster that can be tied to the skin. To create the bolster, cut a 3-cm segment of tubing from a catheter. Then, bend the tubing in half and cut on each side of the catheter to create 2 holes. Insert a hemostat through the 2 holes, grab the catheter, and pull the catheter through.
  • Prior to insertion, check the Foley catheter's balloon to ensure its integrity.
  • Lubricate the distal catheter and tract opening, then slide the Foley catheter down the tract.
  • Check for borborygmi over the stomach with air insufflation, and aspirate gastric contents.
  • If placement is deemed correct, inflate the balloon with saline and use gentle traction to draw the balloon to the stomach wall.
  • Push the bolster down to the abdominal wall and suture in place 1 cm from the external abdomen. Overly tight external bolsters can result in a short stoma and abscess formation.
• If G-tube replacement does not occur easily, abort the procedure and contact the provider who placed the tube. An interventional radiologist may also be contacted to advance the tube over a wire under fluoroscopic guidance. For more information, see Medscape Reference article Percutaneous Gastrostomy and Jejunostomy.

Confirmation of G-tube placement

• Prior to using the G-tube for feedings, placement must be confirmed.^[8]
• Classically, confirmation is made by injecting 20-30 mL of water-soluble contrast solution (diatrizoate meglumine diatrizoate sodium [Gastrografin]) into the tube and taking a supine abdominal radiograph within 1-2 minutes. This is best performed in the radiography suite.
• Barium should never be used, as its injection into the peritoneal cavity can be devastating.
• If the tube is placed properly, contrast outlines the stomach on the radiograph.
• A recent study compared verification of G-tube replacement with air insufflation versus contrast radiograph and determined the methods to be equal in efficacy.^[9] However, obtaining a contrast radiograph is generally considered the current standard of care.

• Quickly attempt to obtain details of the G-tube type and placement date prior to replacement.
• If the G-tube site looks fresh and tract maturation is uncertain, call the placement provider for guidance.
• Place the largest catheter that passes easily into the ostomy as soon as possible to prevent tract narrowing and closure.
• If no specialized G-tube is available, use a 16F Foley catheter to temporarily keep the tract open until a G-tube can be obtained.

• The most dreaded complication of G-tube replacement is misplacement of the tube into the peritoneal cavity. This is far more common in recently placed tubes but has been reported in patients with mature tracts (>30 d).^[10] Starting tube feeds into the peritoneum often leads to serious morbidity and mortality. This complication can be avoided by obtaining a verification study prior to using the tube.
• As with most procedures, bleeding is a possible complication. A small amount of bleeding can be expected with G-tube replacement. Large amounts of bleeding should prompt a specialist consult.
• Wound infection with manipulation at the site of insertion is possible.^[11]
• External bolsters sutured to the skin too tightly can lead to a short stoma and abscess formation. However, inappropriately secured tubes may result in internal migration and gastric outlet obstruction.^[12]
• Overly vigorous replacement in a narrowed ostomy can separate the stomach from the external stoma and cause viscous leak and peritonitis. Gentle placement is, thus, paramount.