290 Section VII ■ Tube Replacement

placement), loss of the tube can be treacherous in that the

stomach can separate from the abdominal wall; therefore, the

surgical team should always be notified. Loss of the tube can

result spontaneous stoma closure if not reintroduced promptly.

1. Steps to reintroduce a gastrostomy tube

a. Replace within 4 to 6 hours to avoid stoma closure.

b. In the initial postoperative period prior to the formation

of a well-epithelialized tract, replace with a balloon-type

catheter (a button or a Foley-type catheter). For wellepithelialized tracts, mushroom catheter tubes or balloon-type gastrostomy tubes may be used for placement

c. Lubricate the catheter generously with water-soluble

lubricant, and insert gently.

If resistance is felt and/or the catheter does not

pass easily, stop and reassess.

(a) Attempt passing a flexible guidewire through

the tract.

(b) A catheter is inserted over the wire or the

stoma may be dilated by sequential dilators.

(c) Fluoroscopy can confirm gastric position.

(1) Inflate the balloon with 2 to 4 mL of water, then

pull firmly against the stomach wall.

(2) Secure with a fixation/external bolster device.

(3) Mark outside length of catheter to help detect

internal or external migration of the balloon.

(4) Prior to feeding, confirm placement of gastrostomy with water-soluble contrast study if replacement is difficult or uncertain or if performed

within 4 to 6 weeks of surgical placement.

2. Confirm intragastric position

a. For recent gastrostomy (initial postoperative period)

Instill 15 to 30 mL of water-soluble contrast

through the gastrostomy under fluoroscopic guidance to confirm accurate positioning.

b. For epithelialized gastrostomy tracts

(1) Aspirate for gastric contents and observe for fluctuation of the gastric fluids in the tube with respiration. Fluids should flow back to stomach

with gravity.

(2) If there is any doubt, obtain contrast study prior

to initiating feeding.

L. Discontinuation of Gastrostomy (16)

1. General principles

a. Remove gastrostomy tube and apply gauze dressing.

(1) Spontaneous closure usually occurs in 4 to 7 days.

(2) May also approximate the skin edges with surgical tape.

2. Persistent gastrocutaneous fistula

a. Granulation and epithelialization of gastrocutaneous tract (well-established tract).

(1) Remove gastrostomy tube.

(2) Cauterize the stoma granulation tissue and/or

epithelium with silver nitrate.

(3) Seal orifice with Stomahesive.

(4) Approximate the edges with surgical tape.

b. Persistent gastrocutaneous fistula (>4 to 6 weeks)

(1) Requires surgical closure

(2) If the skin is becoming macerated, replace the

gastrostomy and use protective skin ointment

prior to surgical closure.

M. Complications (1,15,17–19)

Gastrostomy placement can have serious complications. Early

recognition of such complications allows for prompt intervention and prevention of devastating sequelae. The complications associated with neonatal gastrostomy placement may be

characterized as intraoperative, early, or remote (late).

1. Intraoperative complications

a. Pneumoperitoneum

Some pneumoperitoneum is expected after the

laparoscopic and open placement but is most common with PEG placement.

b. Liver or splenic injury

c. Colonic placement

d. Hollow viscus injury

e. Injury to posterior wall of stomach on initial insertion or upon reinsertion (gastrostomy replacement)

f. Bleeding

2. Early complications (within the first 4 postoperative

weeks)

a. Most early complications are technical or mechanical in nature.