Background
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. Currently, however, G-tube placement routinely occurs with few complications when done 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 another 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]
Indications
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 before initiating ED replacement; operative or fluoroscopic replacement may be required.
Contraindications
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 determine whether 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.
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Commonly used by radiologists, Cope loop catheters (illustrated with a metal introducer stiffener) are easily placed into the stomach. However, their small lumina and small side holes predispose them to catheter occlusion.
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Commonly used for surgical, endoscopic, and radiologic gastrostomy access, balloon catheters provide secure intraluminal retention and are simple to place and replace.
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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.
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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.
