What is the proper procedure for replacing a feeding tube?

Feeding Tube Replacement Procedure

Timing-Based Approach

For gastrostomy tubes displaced more than 4 weeks after initial placement, direct replacement through the existing tract can be safely performed before the tract closes completely. 1

Early Displacement (< 4 Weeks After Initial Placement)

• Tubes removed within the first 7-10 days require endoscopic or image-guided replacement due to immature tract formation, as the stomach and anterior abdominal wall can separate causing free perforation 1
• Tract maturation may be delayed up to 4 weeks in patients with malnutrition, ascites, or corticosteroid treatment 1
• If recognized immediately, a new gastrostomy tube may be placed through or near the original site to seal the stomach against the abdominal wall 1
• For tubes placed less than 2 weeks prior, replacement should be done endoscopically or radiologically through the same site 2
• If recognition is delayed, management consists of nasogastric suction, broad-spectrum antibiotics, and repeat gastrostomy placement in 7-10 days 1

Late Displacement (> 4 Weeks After Initial Placement)

• Direct replacement can be safely attempted through the established tract before it closes completely 1
• The tract typically remains patent for several hours, allowing bedside replacement 1

Verification After Replacement

Water-soluble contrast study using CT abdomen and pelvis is the most reliable method to confirm proper tube position after blind replacement 2

Mandatory Verification Steps

• Verification is essential after any blind replacement to rule out malposition before using the tube 2
• pH confirmation of gastric content (pH ≤5) can be used as a bedside verification method 2
• Irrigation with 3-50 ml sterile water without resistance or leakage helps assess proper positioning 2
• Failure to verify tube position can lead to peritonitis and other serious complications 2

Replacement Technique Considerations

Tube Selection

• Avoid tubes smaller than 15 Charrière (French), as they increase clogging risk 2
• Polyurethane tubes may be more resistant to fungal infection than silicone ones 1
• Low-profile devices (button gastrostomy) can reduce inadvertent removal risk 1

Proper Positioning

• Ensure adequate incision size (≥8mm at puncture site) to prevent pressure-related lesions 2
• Avoid excessive tension on the external fixation plate, which causes pressure necrosis and tube dislodgement 2
• Verify proper tension between internal and external bolsters while avoiding unnecessary tube movement 1
• For balloon-retention devices, ensure balloon volume corresponds with manufacturer's recommendations 1

Special Circumstances Requiring Tube Replacement

Tube replacement is indicated for breakage, occlusion, dislodgement, or degradation 1

Additional Replacement Indications

• Persistent peristomal infection despite appropriate antimicrobial treatment 1
• Stoma tract disruption 1
• Skin excoriation or fungal infection (particularly with silicone tubes in situ) 1
• Refractory leakage after all conservative measures fail 1

Post-Replacement Management

• Gastrostomy tubes held by balloons typically come out with gentle traction after balloon deflation 1
• Tubes with rigid fixation devices usually require endoscopic removal 1
• Do not remove percutaneous gastrostomies for at least 14 days after insertion to ensure fibrous tract establishment 1
• Loosening and rotating gastrostomy tubes weekly helps prevent blockage from gastric mucosal overgrowth 1

Common Pitfalls to Avoid

• Never assume tract maturity before 4 weeks in high-risk patients (malnourished, ascites, immunosuppressed) 1
• Do not proceed with feeding without proper position verification after blind replacement 2
• Avoid replacing with larger-diameter tubes for leakage, as this can enlarge the stoma tract and worsen leakage 1
• Do not rotate tubes with jejunal extensions; instead push in and out weekly 3