Gastrostomy Tube Replacement Technique

Updated: May 26, 2017
  • Author: Erik D Schraga, MD; Chief Editor: Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS  more...
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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.

To check placement initially, 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]  A large study described the placement of Foley catheters in children and found this procedure to be safe, with no severe complications. [8] However, complications have been reported, such as catheter traction into the duodenum leading to gastric outlet obstruction. [9]

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. 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 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 Percutaneous Gastrostomy and Jejunostomy. A procedure whereby jejunal extension tubes are placed through previously placed gastrostomy tubes under fluoroscopic control has also been described. [10]

Confirmation of tube placement

Before the G-tube is used for feedings, placement must be confirmed. [11] Classically, confirmation is made 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 performed 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. [12] However, obtaining a contrast radiograph is generally considered the current standard of care.

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.

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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). [13] 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.

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. [14]  If patient has granulation tissue around the previously placed G-tube, the infection may be exacerbated. [15]

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. [16]

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. However, cases in which the buried bumper was removed by external traction alone through two radial millimeter skin incisions have been reported. [17]

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