Gastroenterologist's Guide to Gastrostomies.

Gastroenterologists are frequently consulted for evaluation feeding tube placement, or for management of complications in an existing feeding tube. Though a frequent topic of consultation for GI Fellows, there are few comprehensive resources for feeding tube placement and troubleshooting available. In this review, we discuss different types of feeding tubes, when each should be considered, and various methods and techniques for placement. Considerations for when one type, method, technique, or specialty may be preferred over the other will be discussed. Additionally, we discuss management of the many complications of indwelling feeding tubes. Our goal is to create a comprehensive review for gastroenterologists to cover clinically relevant questions related to feeding tube placement and management.

Race and prevalence of percutaneous endoscopic gastrostomy tubes in patients with advanced dementia.

OBJECTIVE: Millions of Americans may face hard decisions when it comes to providing nutrition for their loved ones with advanced dementia. This study aimed to ascertain whether there is a difference in feeding tube placement between White and Black patients with advanced dementia and whether this potential difference varied by patient's other demographic and clinical characteristics. METHOD: This is a retrospective, observational study conducted at Novant Health, a 15-hospital system in the southeastern United States. Data were obtained from Epic systems and included all hospital admissions with a diagnosis of advanced dementia, a total of 21,939, between July 1, 2015, and December 31, 2018. Descriptive statistics and logistics analyses were conducted to assess the relationship between receiving percutaneous endoscopic gastrostomy (PEG) and race, controlling for demographic and clinical characteristics. RESULTS: Among patients admitted with advanced dementia, the multivariable logistic regression, controlled for age, gender, LOS, palliative care, and vascular etiology showed that Blacks had higher odds of having PEG tubes inserted than White patients (OR 1.97; CI 1.51-2.55; P < 0.001). Patients with longer stays had higher odds of PEG tube insertion. Females had lower odds of PEG tube insertion than males. There was no statistical significance in PEG insertion based on age, etiology, and palliative care consult. SIGNIFICANCE OF RESULTS: The reasons for the observed higher odds of receiving PEG tubes among Black patients than White patients are likely multifactorial and embedded in a different approach to end-of-life care conversations by providers and caregivers of Black and White patients. Providers may need to be more aware of potential unconscious biases when talking to caregivers, especially in race-discordant relationships, have courageous conversations with caregivers, and be more aware of the importance of keeping in mind families' and caregivers' culture, including spirituality, when making end-of-life decisions.

Impact of Design Changes in Gastrostomy Tube (G-tube) Devices for Patients Who Rely on Home-Based Blenderized Diets for Enteral Nutrition.

OBJECTIVE: Blenderized diets are gaining increasing popularity among enteral tube users. Connectors in gastrostomy tubes (G-tubes) are undergoing standardization to reduce misconnections. These standardized G-tubes are referred to as ENFit G-tubes. This study was performed to quantify the in vitro performance of existing (legacy) G-tubes and compare them with ENFit G-tubes for blenderized diets. METHOD: Patient blenderized diet recipes and practices were obtained through patient advocacy groups. Different blenders and blending times were studied. Five legacy G-tube brands and three corresponding ENFit brands, sized between 14 Fr and 24 Fr, were studied under gravity and push modes of feeding. RESULTS: Considering both thin and thick blenderized gravity mode diets, an average increase in feeding time from 20 minutes to 32 ± 18 minutes in transitioning from legacy to ENFit was observed with standard G-tubes, compared to 22 ± 3.5 minutes for low profiles. For push-mode diets, a 60-second push with standard ENFit G-tubes was easier compared to standard legacy G-tubes (61% ± 21% as much force), but faster 5-second pushes required considerably more effort for ENFit standard G-tubes (167% ± 96%). Low-profile ENFit G-tubes required slightly less effort compared to low-profile legacies for both 60-second and 5-second pushes (72% ± 22% and 90% ± 19%, respectively). Clogging was common in both legacy and ENFit devices, particularly under gravity mode. CONCLUSIONS: For a push mode of feeding, patients will largely be unimpacted after the transition to ENFit. For a gravity mode of feeding, some ENFit users may need higher-powered blenders and should expect increased feeding times.

A grounded theory study of the perceptions and meanings associated with gastrostomies among parents of children with palliative needs.

BACKGROUND: There is few literature on the difficulties and different meanings of gastrostomy tubes (GST) for parents of children with palliative needs, and what specific palliative care teams contribute to this process. AIM: To explore the process of information in the decision of performing a gastrostomy and the meanings that parents of children with palliative needs build around them. DESIGN: Semi-structured interviews which were transcribed and analysed using Grounded Theory. SETTING/PARTICIPANTS: Parents and caretakers of children admitted in Paediatric Palliative Care Unit of Madrid Autonomous Community (Spain) whose children bore a gastrostomy device. RESULTS: Two core categories arise ('Fight' and 'The child as a life-meaning generator'). In all the cases, the child supplied the meaning to go on, and the Palliative Care Unit (CPU) helped in the daily care of the child and solving problems derived from the handling of the GT. CONCLUSIONS: It is necessary to improve the process of giving bad news and to introduce models of health care that focus on parents and child as the center of palliative care. It is also necessary to develop educational programs that enable continuity of care at home for children with palliative needs.

Paediatric gastrostomy stoma complications and treatments: A rapid scoping review.

AIMS AND OBJECTIVES: To provide a scoping review of the types of treatments used to address paediatric skin-related stoma complications specific to infection, hypergranulation and gastric leakage, and explore their effectiveness and indications for use. BACKGROUND: Stoma-related complications can be a common occurrence for children with gastrostomy (G) and gastrojejunostomy (GJ) tubes. Nurses require guidance to inform decision-making of the broad spectrum of treatments used in clinical practice. DESIGN: A scoping review using a rapid review approach. METHODS: Working with a multidisciplinary health professional team, search terms were generated. A systematic search of CINAHL, MEDLINE and EMBASE databases was completed, coupled with an Internet search to identify relevant clinical practice guidelines and hand searching of citation lists. Eligible articles were peer-reviewed English publications, focused on paediatric populations aged 18 years and under, dating from 2002-2016 and described complications and treatment approaches related to G- and GJ-tube stomas. Pertinent information was extracted using a standardised template, and a narrative synthesis approach was used to analyse the data. RESULTS: Twenty-five articles were included in this review. Study designs varied, and complication management was often a secondary focus. A broad spectrum of treatments was used to manage each complication type. There was a lack of consensus on lines of therapy; however, a stepwise approach was often used for complication management, particularly for infections. CONCLUSIONS: The evidence on the comparative effectiveness of different treatment strategies of skin-related gastrostomy stoma complications in paediatric practice is sparse. Current evidence is generally limited to expert opinions. Future studies examining efficacy of treatments and their indications for use with children are warranted. RELEVANCE TO CLINICAL PRACTICE: Effective management of skin-related stoma complications is important to maintain health and wellness among children who rely on G- and GJ-tubes for nutrition support.

Design and Evaluation of a Spoke-Based Double-Lumen Pediatric Gastrostomy Tube.

Gastrostomy tubes (G-tubes) are the gold standard for feeding assistance for children with feeding dysfunction. Current G-tubes pose complications that interrupt the delivery of feed, including tube displacement and difficulty of at-home use. This study details an alternative, spoke-based, double-lumen G-tube design and preliminary validation of its function and usability. Pull force testing was performed on spoke G-tube models across three sizes and two classifications (hard/soft). Preliminary models were evaluated against market standards. Though the pull force of the spoke model was found to be lower than that of both market standards, hard modifications to the spoke model improved retentive force. Ease of use was tested amongst users unfamiliar with G-tube placement. The spoke design required 12.3 ± 4.7 s to deploy, less than half the time required for market standards. However, balloon G-tubes were still perceived to be easiest to use by 70% of participants, with indications that a spoke design may be easier to use if sized similarly to current G-tubes, with auxiliary improvements to factors such as grip. While there is a need for improvements in the material properties and manufacturing of the proposed design, this study provides early validation of the potential to address complications of existing G-tubes.

An assessment of the relationship between body mass index and minor complications in percutaneous gastrostomy tubes.

Objectives: The aim of our study was to determine if patients with obesity have different postoperative outcomes than their peers. Material and Methods: A single-center retrospective review of all fluoroscopically-guided percutaneous gastrostomy tube, with 183 patients and 90 patients in the BAG and dilator groups, respectively. Patients were stratified, based on body mass index (BMI) percentile and for age. Demographic information and data on medical comorbidities and post-operative complications were collected. All analyses were conducted using Chi-square or Kruskal-Wallis testing. Results: The median BMI was 26.6 kg/m2 with a standard deviation of 7.7. 106 (38.8%) patients were classified in the normal BMI category, 57 (20.9%) were overweight, and 50 (28.3%) were classified as obese. No major complications were reported in either group. 106 patients (38.8%) reported minor complications. The most common complication observed across both groups was procedural pain, with a higher incidence in the balloon group compared to the dilator group (17.5% vs. 12.2%). Dislodgement emerged as the second most common complication, occurring more frequently in the balloon group (12%) compared to the dilator group (6.7%). When considering weight categories, the overall rate of minor complications was highest among underweight patients (57.6%, P = 0.124). Both underweight and normal BMI patients showed a significantly higher incidence of tube dislodgement compared to other BMI categories (27.2% and 9.4%, respectively, P = 0.015). In a multivariable logistic regression, age was associated with an increased risk of minor complications (odds ratio [OR] 1.03, F [1.01, 1.05], P = 0.002). BAG had a greater OR for minor complication rate compared to dilator-assisted gastrostomy, although the difference was not statistically significant (OR 1.19, 95% confidence interval [0.69, 2.06]). Conclusion: Few studies have identified the relationship between BMI and complications related to gastrostomy tube placement. Our study highlights the importance of individualized care for patients across different BMI classes to minimize complications and improve patient outcomes.

A comparison of balloon-assisted versus dilator in percutaneous gastrostomy tube placement.

Objectives: This study assesses the safety and efficacy of balloon-assisted gastrostomy (BAG) compared to conventional techniques using dilators. Material and Methods: A single-center retrospective review of all fluoroscopically-guided percutaneous gastrostomy tube insertions from July 2017 to September 2020 was performed. Two hundred and seventy-three patients were included in this study, with 183 patients and 90 patients in the BAG and dilator groups, respectively. Fluoroscopy time, peak radiation dose, pain management, days to interventional radiology (IR) reconsultation, and post-operative complications (major and minor) for each procedure were reviewed to evaluate for statistical differences. Results: There were shorter fluoroscopy times (5.13 min vs. 7.05 min, P = 0.059) and a significantly lower radiation use (Avg = 102.13 mGy vs. 146.98 mGy, P < 0.05) in the BAG group. The BAG group required significantly lower operating time (41 min vs. 48 min, P < 0.01) and received lower pain management (fentanyl 75 mcg and midazolam 1.5 mg, P < 0.001). The mean days to IR reconsultation for the BAG group was greater (29 days vs. 26 days, P = 0.38). The overall rate of minor complications (grades 1 and 2, according to the CIRSE classification system) was higher in the dilator group (39% vs. 35% in BAG group, P = 0.53). No major complications were reported in either group. Conclusion: BAG is a safe and efficient technique for percutaneous gastrostomy tube placement. BAG patients required significantly lesser radiation, OR time, post-operative pain management, and recorded lower postoperative complications compared to their counterparts in gastrostomies utilizing dilators.

School Nurses on the Front Lines of Healthcare: Children With Medical Devices-A "BOLUS" of Information About Gastrostomy Tube Malfunctions and Infections.

An important subgroup of children with special healthcare needs are children with medical complexities that require long-term, intensive healthcare interventions and treatments. As medical technology continues to advance and children with complex medical needs survive the neonatal period and progress into school-age, it is essential for school nurses to be able to recognize and acutely manage complications and malfunctions of devices in children requiring assistance from medical devices. An example of a common medical device includes gastrostomy tubes (aka G-tubes or GJ-tubes), ensuring nutrition in children with failure to thrive, significant developmental delay, swallowing dysfunction, or severe gastroesophageal reflux. These devices put children at serious medical or surgical risk when they malfunction, so it is important for healthcare providers, especially school nurses who are the first responders in schools, to recognize malfunctions and initiate appropriate care management.

A retrospective review of the use of oxymorphone immediate release for long term pain control in cancer patients with gastrostomy tubes.

BACKGROUND: Cancer patients often require feeding or venting gastrostomy-tubes (G-tubes) for enteral nutrition or symptom palliation. The administration of most extended-release (ER) opioids via the G-tube or orally followed by clamping of the venting G-tube is contraindicated. Oxymorphone immediate release (IR) may be useful because of its longer half-life compared to other IR opioids. We examined the use of oxymorphone IR administered every 8 hours in patients with G-tubes. METHODS: This was a retrospective chart review of 40 consecutive cancer patients with G-tubes who underwent opioid rotation (OR) to oxymorphone. Demographics, symptoms, morphine equivalent daily dose (MEDD), and oxymorphone dose were collected. Successful OR was defined as a 2-point or 30% reduction in pain score and continued use of oxymorphone at follow-up in outpatient setting, or discharge in inpatient setting. Opioid rotation ration (ORR) between MEDD and oxymorphone in patients with successful OR was calculated as MEDD before the OR divided by total oxymorphone dose/day at follow-up or discharge. RESULTS: The median age was 56 years, 57.5% were white, 68% male, 47.5% (n=19) had head and neck cancer, 90% had advanced disease, 67.5% (n=27) were inpatient, and 15% (n=6) had venting G-tubes. 25/40 (62.5%) patients had successful OR to oxymorphone. The median ORR from MEDD to oxymorphone was 3.5 (IQR, 3.1-4). There were no independent predictors for successful OR, and ORR did not significantly differ among various groups. CONCLUSIONS: Oxymorphone IR can be used successfully in cancer patients with G-tubes using an ORR of 3.5 to calculate dose from MEDD.

Reducing the Unintended Dislodgement of Gastrostomy Tubes in a Long-Term Acute Care Hospital: A QA/QI Pilot Study.

BACKGROUND: Since their introduction in 1980, gastrostomy tubes have become effective means of providing both short-term and long-term enteral access and nutritional support. These feeding tubes are ubiquitous in many health care facilities that care for the elderly, but carry high rates of unintended dislodgement - a complication that, if not detected promptly, is associated with substantial morbidity and health care costs. This study determined the dislodgment rate of gastrostomy tubes at 90 days in a cohort of 221 patients and tested the hypothesis that the implementation of a concise protocol to care for patients' gastrostomy tubes would reduce these unintended dislodgements. METHODS: The dislodgment rate of gastrostomy tubes at 90 days in a cohort of 221 patients was determined. In addition, a randomized controlled trial was conducted in a long-term acute care hospital in which patients were alternately allocated to either of two geographically separate units: 1) a selected unit where a concise protocol to care for patients' gastrostomy tubes was implemented, and 2) a separate unit where standard care was provided. Enrollment included patients diagnosed with dysphagia - who were receiving mechanical ventilatory support for chronic respiratory failure - who were being administered feedings, fluids and medications via a balloon gastrostomy tube. The primary endpoint was the number of unintended dislodgements of gastrostomy tubes during a 90-day study period. RESULTS: In a cohort of 221 patients with balloon gastrostomy tubes placed that was observed for a period of 90 days, 64 (29.0%) had unintended gastrostomy tube dislodgement (P < 0.028). A total of 34 patients were enrolled in the randomized controlled trial with 17 in the treatment group and 17 in the control group. All subjects were followed for a maximum of 90 days. During the study period, there was one episode of unintended gastrostomy tube dislodgement (5.9%) in the treatment group, compared with six episodes (35.3%) in the control group (P < 0.047) and the previous cohort of 221 patients (P < 0.028). CONCLUSION: This study showed a significant reduction in dislodgements after implementation of a protocol that is an innovative, straightforward and economical solution to the problem of the unintended dislodgement of gastrostomy tubes.

In Vitro Performance Testing of Legacy and ENFit Gastrostomy Tube Devices Under Gravity Flow Conditions.

BACKGROUND: Changes in connector design for the gastrostomy tube were implemented to reduce the risk of misconnections. This study aimed to determine whether there are differences in gravity flow rates between legacy devices and the ENFit devices intended to replace them. MATERIALS AND METHODS: We compared 5 legacy gastrostomy tube brands with 3 corresponding ENFit brands, sized between 14 French (Fr) and 24 Fr. Seven commercial diets were used. One comparison involved low-profile devices. RESULTS: Whether an ENFit device manifested a lower flow rate than a legacy device was not a strong function of diet. One 14-Fr ENFit device, because of its reduced distal inner tube diameter, produced an average feeding time of 56 (±13) minutes from a 20-minute baseline. For other 14-Fr ENFit devices, the increase was much less pronounced (25 ± 4 minutes). At larger sizes, both decreases and increases in feeding time were observed, depending on device type; on average, the 20-minute feeding time increased to 25 (±7) minutes. For low-profile devices, across all sizes, an increase in 20-minute feeding time occurred, but the difference was small (23 ± 2). CONCLUSION: Statistically lower flow rates were observed for 70% of ENFit devices relative to their legacy counterparts. We estimate that 30% of the differences may be noticeable. In the scenarios studied, lower flow rates (relative to other devices at the same Fr number) arise from energy losses in straight tubing. This difference can be reduced by increasing the tube inner diameters in distal end of ENFit tubes.

Pediatric Enteral Access Device Management.

Enteral nutrition (EN) support has proven to be a nutrition intervention that can provide full or partial calories to promote growth and development in infants and children. To supply these nutrients, an enteral access device is required, and the use of these devices is growing. Placement of the proper device for the patient need, along with appropriate care and monitoring, is required for individualized patient management. When complications arise, early identification and management can prevent more serious morbidity. Complication management requires a tiered approach starting with staff nurses and ending with a physician expert. In addition to this, each institution needs to have an approach that is coordinated among disciplines and departments to promote consistency of practice. The formation of an enteral access team is a conduit for clinical experts to provide education to families, patients, and healthcare professionals while serving as a platform to address product and practice issues.

Surgical approaches to treatment of gastroparesis: gastric electrical stimulation, pyloroplasty, total gastrectomy and enteral feeding tubes.

Gastric electrical stimulation (GES) is neurostimulation; its mechanism of action is affecting central control of nausea and vomiting and enhancing vagal function. GES is a powerful antiemetic available for patients with refractory symptoms of nausea and vomiting from gastroparesis of idiopathic and diabetic causes. GES is not indicated as a way of reducing abdominal pain in gastroparetic patients. The need for introducing a jejunal feeding tube means intensive medical therapies are failing, and is an indication for the implantation of the GES system, which should always be accompanied by a pyloroplasty to guarantee accelerated gastric emptying.