Introduction

• The inadvertent removal of a gastrostomy tube/device demands prompt attention. A replacement tube of some sort should be reinserted within 4 hours.  If nothing is placed back in the tract, it will close over and the patient will require an operation to replace the gastrostomy.
• If the initial gastrostomy has been in place for less than 2 months, the tract may not be fully established.  In these cases, the Unit responsible for the initial insertion of the gastrostomy tube (usually either Gastroenterology or General Surgery) should be contacted for advice.
• If the gastrostomy has been in place for more than 2 months, replacement can be safely attempted.
• If there have previously been problems replacing a tube, advice should be sought from either Gastroenterology or General Surgery before attempting reinsertion.

Balloon tubes (long and short) can usually be replaced by trained staff or parents with experience in this area.  In the Emergency department, this should only be attempted by senior medical staff (Fellow or Consultant).

Non-balloon, low profile tubes are normally replaced under anaesthetic using endoscopy to confirm position. This type of device should NOT be replaced acutely.  However, as with the removal of any gastrostomy device, some form of replacement tube needs to be reinserted within 4 hours.

Non Balloon	Balloon
Initial G Tube	G Tube	Long tube
Bard Button Duration up to 5 years (avg 2 yrs)	MIC-key   Duration 3-6 months	Short tube (button)    Low profile
Malecot	Corpak

Suitable tubes for replacement

1. The device that has fallen out (if it is a balloon type tube).
2. A replacement gastrostomy tube.
3. A Foley catheter. The catheter needs to be the largest that fits - it should be a snug fit. An adult size Foley catheter may be required. If it is a loose fit, remove it and place a larger one. The largest size tube possible may avoid a surgical procedure (dilation of the tract).

In general, the original tube should be replaced.  If there is damage to the tract or if the tract is now too tight, a different tube or Foley catheter should be used.
Care must be taken with the length of the tube reinserted.  The skin flange should be tightened to keep the tube snug, but not so tight as to cause pressure necrosis.

Obtaining gastrostomy tubes

During Hours: Contact the Gastrostomy Service Nurse Coordinator.

After hours: The Nursing Supervisor can access the stores cupboard in the Gastroenterology Department on the 9th floor. If a gastrostomy tube is obtained after hours, the Gastrostomy Service Nurse Coordinator must be informed the following day so stocks may be replenished.

Checking the balloon

All balloon gastrostomy devices have two lumens on the skin side of the tube. One is for gastric access for feeds and the other is for inflation of the balloon. Check that the balloon inflates easily and does not leak before inserting the new tube.

Analgesia

Reinsertion of a gastrostomy tube can be painful.  Analgesia should be considered prior to commencing any procedure. Appropriate analgesics include parenteral opioid and rectal paracetamol. Topical application of viscous lignocaine to the gastrostomy site is another option. Consider also sedation eg with nitrous oxide, which can assist with the process of reinsertion.

Cleaning the insertion site

The device and skin around the gastrostomy tract need to be clean but not sterile.

Inserting the tube

With the balloon deflated, apply a little water-based lubricant to the balloon part of the tube. Insert the lubricated tube into the tract smoothly. It should be a snug fit and a little twist sometimes helps.  Excessive resistance should not be encountered. If it is, then insertion may be at the wrong angle. It is possible to make a false passage or insert into the peritoneal cavity.

Inflate the balloon with water:

• If the balloon takes 5 mls, inflate with approx 4.5mls
• If the balloon takes 10 mls, inflate with approx 7mls

If using a Foley catheter, insert approximately 5 cm (can vary according to size of patient), inflate the balloon, then pull back until there is resistance.

Checking tube placement

Tube position should always be checked by attempting to aspirate gastric fluid and testing with litmus paper.
If firm resistance is encountered or several attempts are required to insert the tube, position should be checked with a dye study.

Restarting fluids and feeds

If tube placement is confirmed, feeding can restart immediately. However, if there is doubt about position and there is a delay in obtaining confirmatory imaging, patients may require intravenous fluids. The fluid status of patients MUST be assessed, and appropriate fluids given.

Complications of feeding after gastrostomy tube replacement

If the patient becomes unsettled whilst recommencing feeds, consider the following complications:

1. Ileus (this can be identified by the presence of pain associated with reduced bowel sounds and bloating).
2. Leakage of feed into the peritoneum (this may be difficult to identify but is typically associated with pain and distress with abdominal distension).

If either of these is suspected, cease feeds and contact the on-call Gastroenterologist.

Who to call for help

For practical issues during working hours, the Gastrostomy Service Nurse Coordinator or the dedicated Stomal Therapist can be contacted via switchboard.  At other times, contact the on-call Gastroenterology Consultant or general Surgery Registrar.