This post was authored by Ashley Endres, a senior pediatric resident at Cincinnati Children’s. It details how to replace a dislodged or malfunctioning G-tube.
Replace a G-tube
Gastrostomy tube dislodgment and malfunction are top causes for G-tube related ED visits in pediatric patients so it is important to understand how to replace a G-tube.
Gastrostomy tubes can be placed surgically or endoscopically. It is important to determine how the G-tube was placed and how long ago. It typically takes ~3 months for the tract between the skin and the stomach to mature. If the G-tube has been in for less than 3 months, it’s a good idea to talk with the department who placed it (i.e surgery or GI) before you mess with it.
First you need to determine some key facts about the G-tube
- How was it placed (surgical vs endoscopic)
- When was it placed – generally if it was placed within the last 30-60 days the tract is not mature and surgery should be contacted if the tube becomes dislodged
- How long has it been dislodged
- Did the family place a foley catheter in the stoma to keep it patent. It is important that families replace the G-tube or use a foley within 4 hours to help maintain patency of the stoma as the stoma can close quickly.
- What is the size in diameter (French) and length of the G-tube.
Now, let’s walk through the steps of replacing a Mic-key or Mini ONE button G-tube and how to dilate the stoma using a foley catheter if the stoma has begun to close.
Supplies
- Sterile water (~5mL)
- Catheter tipped syringe
- Water soluble gel
- New G-tube with same French diameter and length (usually comes in a kit)
- Gauze
Step 1: Test the new G-tube
- Ensure the new g-tube is the correct diameter and length
- Check how much water is needed to fill the balloon. This is in the instruction manual that comes with the tube
- Fill the balloon with the correct volume (typically 2.5- 5mL) by attaching the catheter tipped syringe to the BAL port on the button
- Inspect the balloon for leakage
- Remove entire volume of water from the balloon
- Place small amount of lubricant on the tip of the tube
Courtesy of Nationwide Childrens – nationwidechildrens.org/feeding-tube-changing
Step 2: Removing current G- tube
- Remove water from the balloon using a catheter tipped syringe. Again typically 2.5-5mL
- Gently pull G-tube out from stoma and use gauze to clean any drainage
Courtesy of Nationwide Childrens – nationwidechildrens.org/feeding-tube-changing
Step 3: Placing new G-tube
- Gently insert new G-tube with lubricated tip into the stoma
- Fill the balloon with appropriate volume of water
- Gently pull up on the G-tube until you feel resistance to ensure G-tube is secure
- Attach extension piece to aspirate gastric contents to ensure correct positioning. If you are unable to aspirate gastric contents then you may need a fluoroscopic study to determine correct positioning. DO NOT give feeds through the G-tube until positioning is verified. If you aspirate gastric contents – either stomach juices or instilled water – then placement is confirmed. Showalter et a;. performed a retrospective review of g-tube replacements and noted that imaging was usually not warranted and only resulted in a considerably longer length of stay in the ED.
How to dilate the stoma if the G-tube has been dislodged for a prolonged period of time
Pro-Tip: You want to start small and work up to the patient’s typical size
Supplies
- Foley catheters in a variety of sizes ( example 8, 10, 12, 14 french)
- New G-tube with same french and length as patient’s original
- Sterile water
- Water soluble lubricant gel
Step 1
- Apply water soluble gel to smallest foley. Typically start 2-3 sizes below the patient’s G- tube size.
- Remember that French sizes are for internal diameter. A foley catheter is narrower than a g-tube. So, a 12-Fr holy has a smaller external diameter than a 12-French G-tube.
- Gently insert foley catheter
- Fill balloon with correct volume of water
- Allow the foley to stay in place for 5-10 minutes
- Depending on the maturity of the tract, and patient comfort you can decrease this time interval and insert the dilating Foley sequentially. Guage this based on ease of insertion and patient comfort.
Step 2
- Remove water from foley balloon
- Remove foley catheter and repeat step 1 with a foley that is the next size up. Ex 8 —>10
- Continue to repeat these steps until you have reached the foley size that matches the patient’s G-tube. At that point you can follow the step of inserting new G-tube
Bonus Videos
These are 2 good videos on how to replace G-tubes. The first video is by NEJM. The second video is by Nemours Children’s Hospital. The steps on how to insert a new G-tube occurs at minute 11.
References
Juern, Jeremy, and Amy Verhaalen. “Gastrostomy-Tube Exchange.” New England Journal of Medicine, vol. 370, no. 18, 2014, doi:10.1056/nejmvcm1207131.
http://www.nationwidechildrens.org/feeding-tube-changing
Saavedra, Heather, et al. “Gastrostomy Tube-Related Complaints in the Pediatric Emergency Department.” Pediatric Emergency Care, vol. 25, no. 11, 2009, pp. 728–732., doi:10.1097/pec. 0b013e3181bec847.
Showalter, Cory D., et al. “Gastrostomy Tube Replacement in a Pediatric ED: Frequency of Complications and Impact of Confirmatory Imaging.” The American Journal of Emergency Medicine, vol. 30, no. 8, 2012, pp. 1501–1506., doi:10.1016/j.ajem.2011.12.014.
Goldin, Adam B., et al. “Emergency Department Visits and Readmissions among Children after Gastrostomy Tube Placement.” The Journal of Pediatrics, vol. 174, 2016, doi:10.1016/ j.jpeds.2016.03.032.
Bhambani, Shiloni, et al. “Replacement of Dislodged Gastrostomy Tubes After Stoma Dilation in the Pediatric Emergency Department.” Western Journal of Emergency Medicine, vol. 18, no. 4, Jan. 2017, pp. 770–774., doi:10.5811/westjem.2017.3.31796.
