Gastrostomy Tube Replacement Technique

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; it can lead to the creation of a false tract.

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]

Inadvertent removal or dislodgment is one of the more common complications encountered in patients with a gastrostomy tube. Philipose et al reported the case of a 52-year-old woman with inadvertent removal of a percutaneous endoscopic gastrostomy (PEG) tube, which was replaced successfully via endoscopy at the same site 24 hours after removal. ^[14] This is in contrast to the standard recommendation that the tube be replaced within 24 hours of removal (on the grounds that the tract usually closes after this time).

Endoscopic rescue after early inadvertent PEG tube dislodgment is a feasible noninvasive option for PEG tube replacement, as reported in a retrospective analysis of 11 patients. ^[15] The mean operating time in this study was 68 minutes, and there were no complications related to endoscopic rescue. With this approach, morbid procedures such as laparoscopic or open surgical intervention can be avoided.

Confirmation of tube placement

Before the G-tube is used for feedings, placement must be confirmed. ^[16] 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. ^[17] 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 ^[18] ; however, further studies are needed to confirm the efficacy of this technique.

In a study that included 50 pediatric patients, Frank et al confirmed gastrostomy tube placement by means of US performed prior to contrast injection following replacement. ^[19] They reported this approach to have a sensitivity of 96% and a specificity of 100% and found it to be a safe and a reliable technique, especially in patients at high risk for complications from incorrect placement.

Like US, portable radiography system is safe and reliable in facilitating tube replacement, especially in patients receiving home medical care. Eguchi et al reported the use of a portable x-ray system in an 81-year-old woman to assist with PEG tube replacement after accidental removal. ^[20]

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 ^[21] :

• Follow ASPEN guidelines for G-tube care ^[22]
• 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

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). ^[23] 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. ^[24]  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. ^[25]  If patient has granulation tissue around the previously placed G-tube, the infection may be exacerbated. ^[26]

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. ^[27]

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. ^[28]  However, cases in which the buried bumper was removed by external traction alone through two radial millimeter skin incisions have been reported. ^[29]

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, ^[30] 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.

In a retrospective single-center study (N = 303) aimed at assessing the occurrence of tube complications in patients with PEG tubes retained for more than 6 months as compared with those with tubes retained for less than 6 months, Sbeit et al showed that PEG tube replacement was needed in 16.2% of patients and that the most common complication was a peristomal PEG tube leak. ^[31] The two groups were comparable in terms of PEG insertion, obstruction, and dislodgment.