Gastrostomy Tube Placement Techniques

Gastrostomy Tube Placement

• Rates of gastrostomy tube (GT) placement are rising in the US due to increased appreciation for nutrition support and refined placement techniques.
• Initial placement techniques for balloon gastrostomy tubes (BGT) include percutaneous endoscopic, radiologic, laparoscopic, and open surgical methods.
• Pediatric GTs are mostly placed by surgeons and interventional radiologists, with many surgeons performing primary placement of low-profile balloon gastrostomy (LPBG) tubes.

Advantages and Challenges of LPBG Tubes

• LPBG tubes are appreciated by patients and caregivers for their aesthetic appeal and ease of use.
• They sit at skin level, can be concealed, and provide limited interference with clothing.
• LPBGs are thought to have fewer adverse events, such as accidental dislodgement and leakage, compared to percutaneous tubes.

Replacement and Verification of BGT Placement

• BGTs require replacement due to wear and tear and unexpected dislodgement.
• Management for routine and non-routine tube replacement lacks standardization and varies widely among institutions and settings.
• No overall standard of care exists for placement verification following BGT replacement.
• Replacement can occur in various settings, including pediatric inpatient units, emergency departments, outpatient clinics, and residential pediatric care facilities.

Consequences of Misplaced GTs

• Gastrostomy tube displacement in children leads to ED visits in up to 61% of patients within 30 days of initial placement.
• Timely replacement of a displaced GT is required to prevent stoma stenosis.
• Misplaced tubes can lead to serious consequences, including ED visits, hospital readmissions, additional surgical interventions, etc.

Importance of Verification of Appropriate Placement

• Verification of proper placement is essential to detect potential misplacement or adverse events.
• Tract disruption is a common adverse consequence of GT replacement, which may lead to dislodgment, leakage of gastric contents, infection, development or worsening of granulation tissue, or peritonitis.

ASPEN Guidelines for BGT Replacement Verification

• In 2012, ASPEN convened the NOVEL workgroup to address nasogastric tube misplacement issues.
• A multi-organizational workgroup was later convened to develop evidence-based or expert opinion clinical guidelines for BGT replacement verification in pediatric patients.

Nutrition Guidelines for Adult Perioperative Cardiac Patients

• Patients undergoing cardiac surgery are at increased risk of iatrogenic underfeeding during the pre- and postoperative course.
• Delays in initiating medical nutrition therapy (MNT) and lower overall total nutritional adequacy are common in this population.
• Acute nutritional deficiencies may exacerbate pre-existing malnutrition, leading to complicated and prolonged critical illness courses.

Nutrition Guidelines for Adult Head and Neck Cancer

• Head and neck cancer patients present special nutrition challenges and are at higher risk for malnutrition due to difficulties with chewing and swallowing.
• Treatment toxicities and tumor-related symptoms can further compromise nutritional status in this population.

ASPEN/SCCM Pediatric Critical Care Nutrition Guideline

• Nutritional status on admission, nutrient delivery, and nutritional deterioration are important factors that impact outcomes from pediatric critical illness.
• Preexisting malnutrition is common in children admitted to the pediatric intensive care unit (PICU).
• Imbalance between nutrient requirement and delivery, excessive nutrient losses, and altered nutrient absorption or utilization during critical illness may result in nutritional deterioration.