How to secure a Gastrojejunostomy (GJ) tube in the stomach?

Securing a Gastrojejunostomy (GJ) Tube in the Stomach

For GJ tubes, do NOT rotate the tube—only push it inward weekly (at least 2-3 cm, ideally up to 5-10 cm) and then pull it back, maintaining 0.5-1 cm of free space between the external bolster and skin. 1

Critical Distinction: GJ Tubes vs Standard Gastrostomy Tubes

GJ tubes and gastrostomy tubes with jejunal extensions require fundamentally different handling than standard gastrostomy tubes:

• Never rotate a GJ tube because the jejunal component can become twisted or malpositioned 1
• Standard gastrostomy tubes should be rotated daily after tract healing, but this does NOT apply to GJ tubes 1

Initial Placement and Fixation (First Week)

Immediate Post-Placement (Day 0-1)

• Position the external fixation plate with very low traction, without tension 1
• The external bolster must allow at least 5 mm of free movement along the tube shaft 1, 2
• Maintain approximately 0.5-1 cm of free distance between the skin and external bolster 1
• Use a Y-compress or sterile dressing placed under the external disc plate to cushion movements and prevent moisture accumulation 1

Daily Care During First Week

• Change dressings daily with sterile technique during days 1-7 1
• Inspect the wound area for bleeding, erythema, secretion, induration, or allergic reactions 1
• Clean and disinfect the site, then dry completely 1
• Do NOT rotate the tube during this initial healing period 1

Alternative Dressing Option

• Consider using a glycerin hydrogel or glycogel dressing as an alternative to daily dressing changes, which can be applied the day after placement and changed weekly for four weeks (Grade B recommendation) 1

Long-Term Maintenance (After Week 1)

Weekly Mobilization Protocol

Once the gastrostomy tract has healed (approximately one week):

• Push the tube inward at least 2-3 cm (ideally 5-10 cm to ensure you're moving the tube and not just the abdominal wall) 1
• Pull the tube back carefully until you feel resistance from the internal fixation device 1
• Return the tube to its initial position with 0.5-1 cm free distance between skin and external bolster 1
• Perform this weekly mobilization without rotation 1

Routine Stoma Care

• After healing, cleanse the site twice weekly with fresh tap water and soap using a clean cloth 1
• Gently and thoroughly dry the skin after cleaning 1
• Dressings can be reduced to once or twice weekly after stoma healing 1

Critical Complication Prevention: Buried Bumper Syndrome (BBS)

Why This Matters for Morbidity and Mortality

BBS is a severe, preventable complication where the internal fixation device migrates through the gastric wall, potentially ending up anywhere between the stomach mucosa and skin surface 1. This can lead to:

• Tube obstruction and feeding intolerance
• Chronic infections
• Abdominal pain
• Complete tube loss requiring replacement 1

Warning Signs of BBS

Monitor for these alarming signals:

• Difficulty mobilizing the tube during weekly maintenance 1
• Leakage around the insertion site when flushing the tube 1
• Frequent feeding pump alarms suggesting obstruction 1
• Abdominal pain 1
• Chronic site infections 1
• Resistance when administering feeds or fluids 1

Primary Risk Factor

Excessive compression between internal and external bolsters is the most important risk factor for BBS 1. This is why maintaining that 0.5-1 cm free space is non-negotiable.

Additional Securement Considerations

• For patients at high risk of tube dislodgement, consider additional fixation devices to minimize traction on the stoma site 1
• Ensure the incision at the puncture site is sufficiently large (approximately 8 mm) to prevent pressure-related skin lesions 1
• The tube should move freely without causing ischemia to surrounding tissue 1, 2

Special Considerations for GJ Tubes

If Gastropexy Sutures Are Present

• Delay mobilization until sutures are removed (usually after two weeks) if the stomach was fixed to the abdominal wall with sutures during placement 1

Tube Replacement

• GJ tubes commonly require replacement due to mechanical failure (clogging, cracking, deterioration) or dislodgement 3
• Replacement methods include guidewire techniques, endoscopy-guided approaches, or fluoroscopy-guided placement 3, 4

Common Pitfalls and How to Avoid Them

Pitfall #1: Rotating a GJ Tube

Never rotate a GJ tube as this can twist the jejunal extension and cause malposition or obstruction 1. Only push in and pull out.

Pitfall #2: Excessive Tension on External Bolster

Placing the external bolster too tightly causes local ischemia, tissue necrosis, infection, and BBS 1, 2. Always maintain at least 5 mm of free movement 1, 2.

Pitfall #3: Inadequate Weekly Mobilization

Pushing the tube only 2-3 cm may just move the abdominal wall rather than the tube itself 1. Push 5-10 cm when possible to ensure true tube mobilization 1.

Pitfall #4: Using Occlusive Dressings

Occlusive dressings promote moisture and skin maceration 1. Use breathable dressings or Y-compresses that don't shed fibers 1.