Gastrostomy tubes: Fundamentals, periprocedural considerations, and best practices

Table 1 Periprocedural pearls for gastrostomy tube placement

Recognize indications, relative contraindications, and absolute contraindications for gastrostomy tube placement

Ensure appropriate informed consent and discussion of the benefits of gastrostomy tubes

Ensure correct selection of gastrostomy technique:

Transoral techniques should be first line except in select indications where transabdominal techniques maybe more appropriate

Placement by radiology is appropriate when the endoscopist is not trained in the transoral or transabdominal technique necessary or lacks availability of materials

Laparoscopic tube placement should be utilized when endoscopic or radiographic gastrostomy fails or is contraindicated

Perform certain periprocedural interventions to reduce adverse events:

Physical exam for oropharyngeal and abdominal wall abnormalities, ascites, and obesity

Hold anticoagulation and antiplatelet therapy appropriately and correct coagulopathy to avoid bleeding

Administer antibiotic prophylaxis targeting skin flora thirty minutes prior to procedure to prevent infection

Drain ascites beforehand and avoid gastrostomy tube placement if fluid reaccumulation is expected to occur within 7-10 d

Obtain cross-sectional imaging (e.g., computed tomography) if colonic interposition and other suspected anatomical abnormalities are suspected

Use reverse Trendelenburg patient positioning, proper transillumination and palpation of anterior gastric wall, and use of safe track maneuver during initial needle puncture to prevent inadvertent liver or colonic puncture

Minimize external bumper traction and ensure tube is rotatable to prevent buried bumper syndrome and ulceration

Consider abdominal binders to restrict access, gastropexy devices, and low-profile gastrostomy button with detachable tubing to prevent patient tube dislodgement

Table 2 Select Indications for gastrostomy placement

Palliative venting for malignant obstruction and peritoneal carcinomatosis[20,46,120-124]	Can reduce symptoms of nausea and vomiting without a cumbersome NG tube
Head and neck malignancy[20,125-130]	Reactive rather than prophylactic gastrostomy can reduce treatment related critical weight loss
Esophageal malignancy[131-136]	Achieves adequate nutritional status better than self-expandable metal stent insertion
Ventilator-dependent respiratory failure including COVID-19[137-144]	Early enteral nutrition can decrease complication rates and length of stay due to a catabolic state in prolonged ventilation
Stroke with dysphagia[145-147]	Can be placed after 28 d if prolonged enteral nutrition is needed
Non-stroke neurologic disease[148-155]	Supported in amyotrophic lateral sclerosis. No guideline specific recommendations in Parkinson’s disease, multiple sclerosis complicated by dysphagia, cerebral palsy, or trauma patients with severe cerebral injury but has been effective
Pregnancy complicated by severe hyperemesis gravidarum[156-159]	Successfully performed in up to a 29 wk gestation with favorable maternal and fetal outcomes
Gastric bypass	Can be performed in concurrence with surgery to avoid reoperation in patients who are at higher risk for an anastomotic leak or gastro-enteric obstruction[20,160,161]

Table 3 Select relative contraindications to gastrostomy placement

	Comments
Certain alterations in abdominal anatomy and motility[2,5]	Open abdomen, ostomy sites, drain tubes, and surgical scars can alter or preclude location for gastrostomy tube placement
Altered oropharyngeal anatomy[2]	Vocal cord paralysis, active radiation, head/neck tumors, facial and skull fractures, and high cervical fractures can obstruct the gastrostomy tube and create an airway emergency
Massive refractory ascites[2,162,163]	Increased risk for bacterial peritonitis, impairment of stoma tract maturation, and tube dislodgement if ascites rapidly reaccumulates over 7-10 d despite paracentesis or PleurX catheter placement; gastropexy devices can increase success
Upper GI bleeding from ulcer or varices[2]	Bleeding peptic ulcers and esophageal varices can have high rates of recurrent bleeding; bleeding from stress gastropathy, gastritis, or angiodysplasia are less likely to recur, and do not need a delay in enteral access
Obesity[2]	Shifting of panniculus increases the risk of tube dislodgement from the stomach into the peritoneal space
Early feeding in stroke with dysphagia[20,29,164-166]	Enteral tubes prior to 28 d rather than temporary NG tubes had greater development of pressure ulcers, sepsis, pneumonia, and GI bleeding over 2 yr
Nutrition in terminal metastatic malignancy[2,167,168]	Administration of nutrition beyond specific patient request plays a minimal role in comfort and does not improve complication rate, survival, or functionality in terminal malignancy
VP shunts[20,46,169,170]	May increase risk of ascending meningitis
Irreversible dementias[171-179]	Does not improve mortality or rehospitalization rate