Fig. 45.1
Typical initial PEG/PRG tube with internal “bumper” and external “crossbar”
When a G-tube is placed surgically, the type of initial tube can vary from a standard mushroom-type tube such as the Malecot or Pezzer, a standard balloon tube such as Kimberly Clark, or a low-profile balloon tube such as AMT or MIC-KEY. The choice is often based on surgeon’s preference while accounting for any clinical benefits of one type of tube or another for a particular patient. An initial surgically placed G-tube could be changed within 4–6 weeks. Regardless of the method of G-tube placement, the timing, method, and personnel involved in initial tube change vary from institution to institution. Commonly, an initial PEG- or PRG-placed tube remains in place for 12 weeks; then, it is replaced with a low-profile device or standard replacement tube under fluoroscopic guidance. Thereafter, the tube can be changed by nursing staff or parents who have been thoroughly educated on the G-tube change procedure.
It is essential that families are well educated regarding the care and maintenance of enteral feeding devices and, as mentioned, it is preferable that the success of enteral nutrition via nasogastric tube has been previously documented. Once the decision has been made to pursue gastrostomy tube placement, it is important that the family be familiar with the type of gastrostomy tube being placed, that is, standard PEG versus low-profile gastrostomy tube, the length of time that the family can expect the initial tube to be in place, and who will perform the first change. All of these vary with institutions and specialties. An example of this is a surgically placed gastrostomy tube that could be a balloon low-profile device, a balloon replacement tube, or a mushroom-type Malecot® tube. Table 45.1 depicts the various types of gastrostomy and gastrojejunal (GJ) tubes. The personnel involved in the tube replacement procedure also varies based on who placed the original tube and the direct visualization is now recommended either through radiology or a repeat endoscopic procedure.
Table 45.1
Examples of types of enteral feeding devices and securement devices
Gastrostomy tubes | GJ tubes | ||
|---|---|---|---|
Initial nonsurgical G-tube  | Initial PEG/PRG tube with internal bumper and external crossbar (Corpak)  |  | Initial GJ tube with J limb threaded through G-tube |
Low profile  | Low-profile balloon tube  |  | Standard replacement GJ tube |
Mushroom tube secured  | Standard mushroom tube (Malecot® or Pezzer®)  |  | Low-profile balloon GJ tube |
 | Standard balloon tube––can be initial surgical tube (eg Kimberly Clark®)  |  | Low-profile balloon transgastric jejunal tube |
 | Low-profile mushroom-type tube (eg Bard®)  |  | “G-JET” low-profile balloon GJ tube |
Securement devices  | Hollister Drain/Tube Attachment Device®––can be used to secure and stabilize both G-tubes and GJ tubes |  | Benik® enteral tube securement belt used to prevent accidental dislodgment of tube |
The initial care of the gastrostomy site may vary from institution to institution. There is also some variation in the initial care depending on the type of tubes. For all tubes, the initial gauze dressing is kept in place for 48 hours. The patient may sponge bathe during this time; after 48 hours they can shower, but emersion of the site in a tub bath is avoided for the first 2 weeks. After the initial dressing is removed, care of the site consists of simply cleaning daily with mild soap and water and avoiding any aggressive scrubbing. A small amount of serous or mucoid drainage is normal. Use of hydrogen peroxide should be avoided as it causes unnecessary drying and irritation of the skin. For initial surgically placed low profile tubes, securement of the device with tape for the first 1-2 weeks helps minimize movement in the track. For initially placed PEG/PRG tubes with a cross bar, the crossbarnot the tube—is rotated 3 times a day for the first week to avoid pressure. It is important for the tube to have a good fit and to be well stabilized. Excessive movement in the tract can cause leakage, erosion of the stoma, and hypergranulation tissue formation. Similarly, excess traction on the tube can cause mucosal prolapse and erosion of the tract. Dressings should be minimized and only added as needed. A small amount of serous or mucoid drainage is normal after initial placement and should resolve over time if the tube has a good fit and is well stabilized. If the patient has a low-profile tube in place, it is important to remove the feeding extension when not in use. Keeping the feeding extension in place at all times defeats the purpose of a low-profile tube and can cause undue lateral traction on the stoma, thereby causing erosion of the tract, “buried bumper syndrome,” leakage, and/or mucosal prolapse.
Complications of Gastrostomy/Gastrojejenunostomy Tubes
Commonly encountered complications of enteral devices include infection, leakage, hypergranulation tissue, peristomal skin breakdown, stomal prolapse or erosion, tube migration, tube obstruction, and persistent fistula after removal [3–6]. Table 45.2 outlines common complications and treatment strategies.
Table 45.2
Management of common complications of percutaneous enteral tubes
Problem | Likely etiology | Prevention | Treatment |
|---|---|---|---|
Dislodgment | Improper or inadequate securement | Adequate securement; use of products such as Griplock® or Hollister Drain Tube Attachment Device® to secure to abdominal wall; use of protective belts such as Benik Belt®; disconnect extension tubing when not in use to avoid lateral traction on tube | Replacement and securement |
Leaking, peristomal irritant dermatitis | Inadequate stabilization, poorly fitting tube, inadequate balloon volume; stomal enlargement/erosion | Adequate fit of tube; securing properly; adequate balloon volume | Consider alternative types of tubes; secure well; increase balloon volume to maximum recommended; consider removing tube to allow site to contract; peristomal skin protection with silicone sealant, cyanoacrylate, or moisture barriers |
Hypergranulation | Inadequate stabilization, moisture, friction | Adequate stabilization, decrease moisture, avoid moist dressings | Silver-impregnated hydrofiber or alginate; topical steroid ointment; chemical or surgical cauterization |
Infection | Preoperative/preprocedure antibiotics; treatment of oral, gut, or vaginal fungal colonization; immunosuppression | Treatment of oral, gut, or vaginal fungal infection; avoid pressure injury from too tight a tube fit which can lead to cellulitis | Topical antifungal powder, sealed in with silicone liquid sealant; topical antifungal ointment or cream; topical antifungal spray; oral or systemic antibiotics |
Obstruction | Inadequate flushing, buildup of residue within tube | Consistent flushing schedule before and after all feeds and medications; dilute medications; use liquid solutions whenever possible | Flushing, declogging agents (Clog-zapper®) |
Infection
Gastrostomy tube infections are more common in the first several weeks following percutaneous placement. It has been estimated that 25–33% of patients develop a peristomal infection [4]. Few studies have addressed the issue of peristomal infections in children. The underlying medical condition of the child may influence their risk for infection and hinder wound healing. Antibiotic prophylaxis with placement of percutaneous endoscopic gastrostomies is recommended [7].
Infection of the peristomal area can present with a variety of symptoms. Fever, spreading erythema, tenderness, pain, induration, and purulent discharge are typical. However, the yellow-brown crusty discharge that is commonly seen around the gastrostomy site is not a sign of infection, a finding that is confusing to families and caregivers. There can be mild erythema from friction at the site, which is also not indicative of infection. In case of infection, treatment with a topical antibiotic may be all that is needed, or in some cases, oral antibiotics may be necessary. Most infections respond to a first generation cephalosporin. Abscess formation adjacent to the stoma is another potential complication. These lesions have a rapid onset of a pustule or a red-purple fluid-filled lesion that is tender to the touch. When it ruptures, a punctuate opening is apparent and may drain for several days. Treatment with warm compresses and antibiotic therapy is recommended. Although there is little prospective comparison data available, a large retrospective review of surgical versus PEG/PRG G-tube placement technique revealed surgically placed G-tubes had a lower infection rate than PEG/PRG tubes, but PEG/PRG-placed tubes had lower costs and length of stay [8].
Feeding tubes may become colonized with microbial organisms, including fungus. There have been more than 100 different microorganisms isolated from gastrostomy tubes, with the most common being Candida (Fig. 45.2), Pseudomonas, Escherichia coli, Enterobacter cloacae, Streptococci, Lactobacillus, Staphylococcus aureus, and Bacteroides. The significance of gastrostomy tube colonization is unclear; however, in the face of recurrent infections, culture of the site and treatment with the appropriately sensitive antibiotic are recommended.
Fig. 45.2
Peristomal Candida infection
Tube Migration and Dislodgment
Migration of the gastrostomy tube with aberrant tract formation has been reported. The buried bumper syndrome (retrograde migration of the gastrostomy tube’s internal bumper into the abdominal wall or into the stoma tract) is well described [9]. This occurs when there is traction placed on the external portion of the gastrostomy tube that results in excessive tension on the internal bumper at the time of placement. A false tract may develop as a late complication when the shaft length of the low-profile gastrostomy tube is not resized in a growing child. Failure to remeasure the shaft length may result in a too short tube causing the balloon or internal bumper to move up into the tract. Leakage and focal abdominal discomfort may result. Long-term migration of the balloon into the tract may result in the development of a false tract or dilatation of the gastric opening. This allows for drainage of gastric contents onto the skin resulting in peristomal skin excoriation and breakdown.
It is important to remeasure the stomal tract correctly and accurately. It is best to measure with the patient in both a supine and sitting position. If the measurements significantly differ in either position, the tract length should be the average between the two measurements. It is recommended that tracts be remeasured at least annually. Patients who are gaining weight, however, will need to have the fit remeasured more frequently. Figure 45.3 depicts a teenager with Crohn’s disease who initially at the time of tube placement was thin and undernourished, then gained weight while undergoing treatment, causing tightly fitting tube.
