Gastrostomy Tube Replacement 

Updated: May 26, 2020
Author: Erik D Schraga, MD; Chief Editor: Vikram Kate, MBBS, MS, PhD, FRCS, FACS, FACG, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS, FFST(Ed) 

Overview

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 now 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-rela 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.
 

Periprocedural Care

Equipment

Ideally, the patient arrives in the emergency department (ED) with the dislodged gastrostomy tube (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 (eg, 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 (≥16 French) can be used temporarily until a dedicated feeding tube can be placed.

Before 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 a 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, guide wire, or other support to assist tube passage.

Two types of catheters are depicted in the images below.

Commonly used by radiologists, Cope loop catheters 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.
Commonly used for surgical, endoscopic, and radiol Commonly used for surgical, endoscopic, and radiologic gastrostomy access, balloon catheters provide secure intraluminal retention and are simple to place and replace.

Bentley et al reported the outcomes of balloon vs nonballoon G-tubes in 145 patients, of whom 37.2% had a balloon-type G-tube and 62.8% had a non-balloon-type tube.[7]  Patients in the nonballoon group had 1.14 emergency department (ED) visits related to the G-tube (range, 0-15), whereas those in the balloon group had 0.48 (range, 0-6). The nonballoon tubes had both radiologic and surgical tube replacement, whereas the balloon types were managed radiologically. These findings underscore the importance of  selection of the appropriate type of G-tube.

Patient Preparation

Anesthesia

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.

Positioning

G-tube replacement is most easily performed with the patient in a comfortable recumbent position.

 

Technique

Replacement of Gastrostomy Tube

Removal of tube

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 before 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. Keep in mind that 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.

Replacement of tube

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.

Before 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 tr 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; doing so can lead to a false tract or separation of the stomach from the external stoma.

Aspiration of gastric contents or ultrasound examination can be carried out to confirm the placement of the tube in the stomach. 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.[8] A large study described the placement of Foley catheters in children and found this procedure to be safe, with no severe complications.[9] However, complications have been reported, such as catheter traction into the duodenum leading to gastric outlet obstruction.[10]

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 two holes. Insert a hemostat through the two holes, grab the catheter, and pull the catheter through.

Before inserting the Foley catheter, check the balloon to ensure its integrity. Lubricate the distal catheter and tract opening, then slide the Foley catheter down the tract. Confirm the placement, as mentioned above. If the 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 bolsters can result in a short stoma and abscess formation.

In rare cases, Foley catheter migration leading to compression necrosis of mucosa by the balloon leading to perforation can occur.[11] External tube fixation should be carried out firmly to prevent this complication.

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 Percutaneous Gastrostomy and Jejunostomy. A procedure whereby jejunal extension tubes are placed through previously placed gastrostomy tubes under fluoroscopic control has also been described.[12]

In pediatric patients who present with dislodged G-tubes, serial dilatation of the tube stoma site has been found to allow successful replacement with minimal complications.[13]

Confirmation of tube placement

Before the G-tube is used for feedings, placement must be confirmed.[14] Classically, confirmation is achieved by injecting 20-30 mL of water-soluble contrast solution (diatrizoate meglumine diatrizoate sodium) into the tube and taking a supine abdominal radiograph within 1-2 minutes. This is best done in the radiography suite. Barium should never be used, because its injection into the peritoneal cavity can be devastating.

If the tube is placed properly, contrast outlines the stomach on the radiograph. A study comparing verification of G-tube replacement with air insufflation versus contrast radiography determined the two methods to be equal in efficacy.[15] However, obtaining a contrast radiograph is generally considered the current standard of care.

In pediatric patients, point-of-care ultrasonography (POCUS) is an attractive option for confirmation of G-tube reinsertion in the ED[16] ; however, further studies are needed to confirm the efficacy of this technique.

Pearls

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 16-French Foley catheter to keep the tract open temporarily until a G-tube can be obtained.

Risk reduction strategies for minimizing tube dislodgment

The most frequent cause of G-tube dislodgment is pulling exerted on the tube by the patient. A dislodged tube is an adverse event that can result in serious harm to the patient. To prevent, recognize, and manage dislodged tubes, the following best practices and risk reduction strategies are suggested[17] :

  • Follow ASPEN guidelines for G-tube care [18]
  • Document the tube type, location, and external markings (cm) in the medical record at the time of insertion and follow-up assessment
  • Institute daily self-assessment of the G-tube, confirm the position of the tube and external bumper, and ensure daily skin care
  • Apply an external securing device to G-tubes without external bumpers
  • In patients with cognitive impairment, restrain the hands
  • Consider T-fasteners in children and patients at high risk for dislodgment
  • Perform a radiologic contrast study to confirm tube placement
  • Avoid using tubes such as urinary or gastrointestinal drainage tubes as replacements for G-tubes
  • Educate nurses and other clinicians about the design, care, and maintenance of commonly used tubes
  • Educate family members about tube care
  • In tubes with retention balloons, check the volume of water weekly

Complications

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 days).[19] Starting tube feeds into the peritoneum often leads to serious morbidity and mortality. This complication can be avoided by obtaining a verification study before using the tube.

Malpositioning of a replaced G-tube causing gastric outlet obstruction has been reported after an accidental removal of a G-tube.[20]  The patient presented with epigastric pain and refractory vomiting, and computed tomography showed that the tip of the G-tube was extending into the proximal duodenum, leading to gastric outlet obstruction. After the tube was retracted several centimeters proximally, the symptoms resolved.

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 consultation with a specialist.

Wound infection with manipulation at the site of insertion is possible.[21]  If patient has granulation tissue around the previously placed G-tube, the infection may be exacerbated.[22]

External bolsters that are 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.[23]

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.

Buried bumper syndrome is a potentially life-threatening condition that may follow percutaneous endoscopic gastrostomy (PEG) and often warrants removal and reinsertion of the G-tube by endoscopic or laparoscopic means.[24]  However, cases in which the buried bumper was removed by external traction alone through two radial millimeter skin incisions have been reported.[25]

In rare instances, PEG tube rupture can occur with sudden-onset abdominal pain following long-standing use of PEG. In a case report by al Halabi et al,[26] separation of the PEG tube into two fragments was found; this was managed conservatively with removal of the fragments, advancement of a guide wire through the distal fragment, and placement of a new PEG.

 

Questions & Answers