How to replace a gastrostomy tube

The original post was authored by Ashley Endres in 2018. this is an updated version for July 2023

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 al. 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

This 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.