.

INTRODUCTION

Gastrostomy tubes may be placed endoscopically, surgically, or radiologically.

Many of the complications seen with the various placement techniques are similar
with similar approaches to management.

This topic will review the management of complications related to gastrostomy

tube placement, with a focus on percutaneous endoscopic gastrostomy tubes. The
indications for gastrostomy tubes, the placement of gastrostomy tubes, the
routine care of gastrostomy tubes, and the management of dysfunctioning
gastrostomy tubes are discussed separately. (See "Gastrostomy tubes: Uses,
patient selection, and efficacy in adults" and "Gastrostomy tubes: Placement and
routine care".)

INCIDENCE OF COMPLICATIONS

Complications of gastrostomy tube placement may be minor (wound infection,

minor bleeding) or major (necrotizing fasciitis, colocutaneous fistula). Most
complications are minor. The reported rates of complications following
percutaneous endoscopic gastrostomy (PEG) tube placement vary from 16 to 70
percent [1-5]. The variable frequency of complications observed in reports in part
reflects differences in the definitions used and the populations under study. Most
studies have suggested that complications are more likely to occur in older adults
with comorbid illnesses, particularly those with an infectious process or who have
a history of aspiration [4].

Some of the studies looking at complications found the following:

●In one series, complications were described in 70 percent of 97 patients, of

which 88 percent were considered to be minor, including tube dislodgement,
peristomal wound leakage, and PEG wound infection [1].
●A much lower rate of complications was observed in another report of 314
patients, of whom 13 percent had minor and 3 percent had major
 complications, including gastric perforation, gastric bleeding, and hematoma
development [2].
●In a prospective study with 484 patients, 85 patients (18 percent) died within
two months of PEG tube placement [3]. Excluding those who died,
complications including abdominal pain, peristomal infection, diarrhea, and
leakage were seen in 39 percent of patients at two weeks and in 27 percent of
patients at two months.
●In a study including 119 patients who underwent PEG tube placement,
complications occurred during hospitalization in 27 percent of patients and
the 30-day mortality rate was 10 percent [6]. The most common complication
was tube dislodgement (14 percent of patients). Twelve of the complications
(10 percent of patients) were classified as serious. None of the deaths was
directly related to PEG tube placement. Indications for PEG tube placement
included tumors (55 percent), neurologic disease (29 percent), and dementia
(3 percent).
●In a study including 452 patients who underwent placement of either a PEG
or a percutaneous radiologic gastrostomy with at least 30 days of follow-up,
the overall complication rates were not significantly different between the
two groups (27 versus 30 percent) [7].
●In a database study including over 33,000 gastrostomy tube placements,
percutaneous radiology-guided gastrostomy placement was associated with
higher rates of 30-day mortality, colon perforation, bleeding, and peritonitis
compared with percutaneous endoscopic gastrostomy tube placement [8].

COMPLICATIONS THAT MAY OCCUR AT ANY TIME

Many of the complications associated with gastrostomy tube placement may be

seen at any time following gastrostomy tube placement. These include infection,
bleeding, peristomal leakage, and inadvertent tube removal.

Tube dysfunction — The approach to patients with a dysfunctional gastrostomy

tube is discussed separately. (See "Gastrostomy tubes: Placement and routine
care", section on 'Managing dysfunctioning gastrostomy tubes'.)
Infection — Most infections are minor, though severe infections such as
peritonitis and necrotizing fasciitis can occur. Wound infection is more likely to
occur when a gastrostomy has been placed through a contaminated procedure
field or with poor technique, in debilitated patients, and those who did not receive
antibiotic prophylaxis [9-11].
Wound infection — Signs of a wound infection include increased erythema,
tenderness, and a purulent exudate. Most infections will respond to a first-
generation cephalosporin or a quinolone. Methicillin-resistant Staphylococcus
aureus (MRSA) has emerged as an important cause of gastrostomy-site infections
in some centers and may require different antibiotic treatment [12]. Fungal-related
gastrostomy infectious complications occur, although much less commonly than
bacterial infections. These include fungal peristomal cellulitis, candidal peritonitis,
and intra-abdominal abscesses [13-16]. (See "Antibiotic prophylaxis for
gastrointestinal endoscopic procedures" and "Antimicrobial prophylaxis for
prevention of surgical site infection in adults".)
In patients with wound infections, culturing the site is generally not helpful. If the
infection responds to antibiotics, the tube generally does not need to be removed.
However, if signs of peritonitis (rebound tenderness) or necrotizing fasciitis
(worsening edema and erythema, development of bullae) develop, the tube should
be removed and additional therapy instituted. (See 'Necrotizing fasciitis' below.)
Attempts have been made to decrease the risk of wound infection. Antibiotic
prophylaxis (typically with a third-generation cephalosporin) at the time of the
procedure has been shown to reduce wound infections. At least two studies found
that nasopharyngeal decontamination of patients with MRSA, along with standard
prophylactic antibiotics, significantly reduced the incidence of wound infections
[17,18]. Another study found that administration of a third-generation
cephalosporin intravenously and a povidone-iodine spray to the abdominal wall
before percutaneous endoscopic gastrostomy (PEG) tube placement reduced
wound infections compared with intravenous cephalosporin or povidone-iodine
spray alone [19].
One study looked at prophylaxis with sulfamethoxazole and trimethoprim to
prevent cellulitis [20]. A total of 234 patients were assigned to either a 20 mL
solution of sulfamethoxazole 800 mg plus trimethoprim 160 mg given through the
PEG tube immediately after placement or to cefuroxime 1.5 gm intravenously one
hour before PEG tube placement. After 7 to 14 days of follow-up, there was no
significant difference in the rate of wound infections between the patients in the
sulfamethoxazole-trimethoprim group compared with the patients who received
cefuroxime (9 versus 12 percent).
Necrotizing fasciitis — Necrotizing fasciitis (necrosis of the fascia layers) is a rare
complication of gastrostomy tube placement [21,22]. Patients with diabetes
mellitus, wound infections, malnutrition, and a compromised immune system are
at increased risk [23]. Signs of necrotizing fasciitis include edema, erythema, and
development of bullae. If necrotizing fasciitis develops, immediate treatment with
antibiotics and surgical debridement is required. (See "Necrotizing soft tissue
infections".)
Traction and pressure on the gastrostomy wound can predispose to the
development of necrotizing fasciitis. One study demonstrated that patients who
had their gastrostomy tube external bolster set directly against the abdominal wall
were more likely to develop wound infection, peristomal drainage, and fasciitis
compared with patients whose external gastrostomy tube bolster was left 3 cm
from the abdominal wall [24]. It was hypothesized that the distant placement of
the external bumper prevented compression of the tissue in the gastrostomy tract,
which in turn prevented wound breakdown [25].
Prevention of necrotizing fasciitis is imperative since treatment requires large
surgical debridement, antibiotics, and extensive hospital support. It is important to
allow the external bolster of the gastrostomy tube to "free-float" 1 to 2 cm from
the abdominal wall after gastrostomy tube placement to prevent this complication.
(See "Gastrostomy tubes: Placement and routine care", section on 'Proper
placement of the external bolster'.)
Bleeding — Hemorrhage following gastrostomy tube placement is rare. Most
bleeding can be controlled by simple pressure over the abdominal wound.
Endoscopy should be performed if the bleeding persists or if there is evidence of
significant bleeding, such as a drop in hemoglobin, aspiration of frank blood from
the stomach, melena, hematochezia, or hemodynamic instability.
Bleeding may originate from the gastrostomy tract, the gastric vasculature, or
from gastric ulceration (often seen if the tube is apposed too tightly to the
abdominal wall). Less common causes of bleeding include gastric artery
perforation, superior mesenteric artery perforation, retroperitoneal hemorrhage,
aortic perforation, esophageal ulceration, abdominal wall pseudoaneurysm, and
gastric wall and rectus sheath hematomas [26-33].
To decrease the risk of bleeding, it is recommended that patients have normal
coagulation parameters at the time of gastrostomy tube placement. We hold
antiplatelet agents (eg, clopidogrel) for five days prior to gastrostomy tube
placement. We also instruct patients to hold aspirin-containing products for 24
hours prior to gastrostomy placement. Selective serotonin reuptake inhibitors
(SSRIs) may also increase the risk of bleeding [34], though there are no guidelines
regarding whether to stop SSRIs prior to gastrostomy tube placement. Our
practice is to hold SSRIs for three days prior to gastrostomy tube placement in
patients with other risk factors for bleeding. (See "Management of anticoagulants
in patients undergoing endoscopic procedures", section on 'Elective
procedures' and "Management of antiplatelet agents in patients undergoing
endoscopic procedures", section on 'P2Y12 receptor blockers'.)
While most bleeding can be controlled by simple pressure over the abdominal
wound, if the bleeding appears to be coming from the gastrostomy tract and
pressure does not work, the external bumper can be tightened against the
abdominal wall to compress the gastrostomy tract. Compression should be
released within 48 hours to avoid gastrostomy tract wound breakdown. Only rarely
will surgical intervention be necessary for gastrostomy-associated bleeding
complications.

Abnormal coagulation parameters should also be corrected prior to traction

removal of gastrostomy tubes to prevent gastrostomy tract hemorrhage.
However, gastrostomy tube replacement devices with a balloon tip can be placed
and removed safely in patients with abnormal blood coagulation parameters,
unless it is anticipated that the gastrostomy tract will require dilation prior to
insertion of the replacement tube.

Peristomal leakage — Peristomal leakage usually occurs within the first few days
after gastrostomy tube placement, though it may also be seen in patients with a
mature gastrostomy tract. Treatment includes management of comorbidities, such
as malnutrition and hyperglycemia, loosening of the external bolster, and local
measures to address skin breakdown (such as powdered absorbing agents or a
skin protectant such as a paste of zinc oxide).

Peristomal leakage is more likely to occur in malnourished patients and those with
diabetes mellitus who may have poor tissue healing and are prone to wound
breakdown. In addition, placement of the external bolster of the gastrostomy tube
too tightly against the external abdominal wall may lead to poor tissue blood flow,
wound breakdown, and peristomal leakage.

Placement of a larger size gastrostomy tube through the same gastrostomy tube
tract will not solve the problem. Once the gastrostomy tube tract has started to
leak, placing larger gastrostomy tubes through the same tract will serve only to
further distend and distort the tract and will not promote tissue growth or healing.
If the gastrostomy tract has had time to mature (ie, up to four weeks after
placement), the gastrostomy tube can be removed for 24 to 48 hours, permitting
the tract to close slightly; a replacement gastrostomy tube can then be placed
through the same, partially closed tract [35]. However, as a note of caution,
different tracts will close at different rates, and there is a chance that in some
patients the tract may close in as few as 24 hours. Leaving a guidewire in place
may help maintain tract patency until a replacement gastrostomy tube is inserted.
This technique works well for patients with a gastrostomy tract that started to leak
a month or more after initial insertion. It does not work as well for patients with
early tract leakage since these patients are usually experiencing poor wound
healing from comorbid disease processes.

In some patients with a mature gastrostomy tract and peristomal leakage, the
gastrostomy tube will need to be fully removed, allowing the tract to close
completely. Another gastrostomy tube can then be placed at a different location
on the abdominal wall. In our experience, the new gastrostomy tube can be placed
when there is at least 50 percent closure of the old gastrostomy tube tract, at
which point the initiation of feedings will not have a significant impact on leakage
or inhibition of tissue healing of the old gastrostomy tract.

Ulceration — Patients may develop ulcers related to the gastrostomy tube, either
underneath the internal bolster or on the gastric wall. While this typically is seen in
patients with longstanding gastrostomy tubes, it can be seen in patients with
recently placed gastrostomy tubes, particularly if the external bolster is set such
that the internal bolster is pulled tightly against the gastric wall. The ulcer often
responds to loosening of the external bolster, which allows the internal
gastrostomy tube bolster to be released from the gastric mucosa. In patients who
have a rigid internal bolster, the gastrostomy should be exchanged for one with a
flexible internal bolster to reduce the potential for future gastric ulceration. Of
note, rigid bolsters cannot be pulled through the gastrostomy tract for removal
and are typically removed endoscopically after cutting the gastrostomy tubing at
the skin.
Ulceration of the contralateral gastric wall from the site of the gastrostomy tube
can occur with balloon gastrostomy replacement tubes. In some of these tubes,
the tip of the gastrostomy tube may extend out from the inflated balloon and act
as a mechanical irritant. The balloon gastrostomy tube should be removed and
replaced with a non-balloon replacement gastrostomy tube or a replacement
gastrostomy tube in which the gastrostomy tube tip is contained within the
inflated balloon [36]. (See "Gastrostomy tubes: Placement and routine care",
section on 'Replacement tubes'.)
Gastric outlet obstruction — Gastrostomy tubes can migrate forward into the
duodenum and cause gastric outlet obstruction [37]. This occurs if the external
bolster on the gastrostomy tube is allowed to migrate away from the abdominal
wall, allowing the gastrostomy tube to slide forward through the gastrostomy tract
and into the duodenum. A similar problem has been reported with balloon
gastrostomy tubes, where the inflated balloon is allowed to migrate through the
pylorus, resulting in an obstruction [38]. This complication can be avoided by
making sure the external bolster is appropriately positioned. (See "Gastric outlet
obstruction in adults" and "Gastrostomy tubes: Placement and routine care",
section on 'Proper placement of the external bolster'.)
Small bowel obstruction caused by gastrostomy tube placement has also been
reported [39].
Inadvertent gastrostomy tube removal — Gastrostomy tubes may be
inadvertently removed if traction is placed on the tube. Inadvertent gastrostomy
tube removal is a common complication, usually occurring in combative or
confused patients who pull on the tube. Many gastrostomy tubes are designed to
be externally removed with 10 to 14 pounds of external pull pressure. If the
gastrostomy tract has had time to mature (eg, is at least four weeks old), a
replacement tube or a Foley catheter may be placed through the gastrostomy
tract. The tract will begin closing within 24 hours (in some cases within four to
eight hours), so placement of a replacement tube should not be delayed.
(See "Gastrostomy tubes: Placement and routine care", section on 'Replacement
tubes'.)
Gastrostomy tubes that are inadvertently removed within the first four weeks of
gastrostomy tube placement should not be replaced blindly at the bedside.
Because the gastrostomy tract may not have matured adequately, the gastric wall
and the abdominal wall may have separated. Thus, blind replacement of the
gastrostomy tube at the bedside may result in its placement in the peritoneal
cavity instead of the stomach.
If the gastrostomy tube is removed early (prior to four weeks after initial
placement), the gastrostomy tract should be allowed a few days to heal, and then a
new gastrostomy can be placed at a different site. Alternatively, there are reports
of successful endoscopic gastrostomy tube replacement through the original
gastrostomy site [40]. (See "Gastrostomy tubes: Placement and routine care",
section on 'Replacement tubes'.)

Regardless of the approach to gastrostomy tube replacement, patients who have

early inadvertent removal should be treated with intravenous antibiotics and
monitored for signs of peritonitis, which would require surgical intervention. The
antibiotics used are the same as are used in patients with upper gastrointestinal
tract perforations due to other causes. If signs of peritonitis do not develop, the
antibiotics can be discontinued after seven days.

If there is ever a concern about the possibility of a replacement gastrostomy tube

being positioned within the peritoneal cavity, a water-soluble contrast study
through the gastrostomy tube should be obtained to confirm proper position prior
to the initiation of feedings.
Leakage of gastric contents or tube feeds into the peritoneal
cavity — Peritonitis has been reported from leakage of gastric contents from the
gastrostomy site into the peritoneal cavity with the gastrostomy tube in situ [41]. If
the contents include tube feeding formula, a combination of a chemical and
bacterial peritonitis may develop [2]. It is hypothesized that peritonitis develops
when the introducer needle enters the stomach tangentially rather than directly
through the abdominal wall, leading to a long laceration along the greater
curvature, which allows for escape of gastric contents. If peritonitis develops, tube
feeds should be stopped and antibiotics should be started. Abdominal imaging
should be performed to look for evidence of a perforation, and surgical
consultation should be obtained. In addition, the patient should be evaluated for a
wound infection, as this is a more common cause of peritonitis. (See 'Wound
infection' above.)
Introduction of tube feeds into the peritoneal cavity has also been described
following routine removal of "traction removable" PEG tubes [42]. If the balloon
replacement tube is inadvertently placed within the peritoneal cavity, peritonitis
can develop when tube feeds are resumed. If there is any concern about the tube
tip position following balloon replacement tube positioning, a contrast radiograph
study through the PEG tube should be obtained.

EARLY COMPLICATIONS OF ENDOSCOPIC GASTROSTOMY

TUBE PLACEMENT

Some complications are seen immediately following percutaneous endoscopic

gastrostomy (PEG) tube placement. These include pneumoperitoneum, ileus,
perforation of the esophagus or stomach (at a site other than the gastrostomy), or
damage to other intra-abdominal organs, such as the liver or colon.

Pneumoperitoneum — Pneumoperitoneum is common following PEG tube

placement [43]. Its etiology is thought to be secondary to the insufflation of air
associated with the endoscopic procedure and needle puncture of the gastric wall.
In the absence of peritonitis, it has no consequence, does not require treatment,
and should not preclude feedings. However, pneumoperitoneum may be the
result of damage to structures such as the colon, and may cause confusion for
clinicians in those patients where clinical features raise concern about a ruptured
viscus. In these settings, a radiologic study using water-soluble contrast should be
obtained to confirm the position of the PEG tube within the stomach and to
exclude a leak. A contrast computed tomography (CT) scan of the abdomen is also
beneficial in deciding if a pneumoperitoneum is associated with damage to any
contiguous abdominal structure [44].
Subcutaneous air has also been described after PEG tube placement. It occurs
from air being introduced between the cutaneous and subcutaneous tissues [45].
In the absence of other findings, it is inconsequential and should not preclude
feeding [45]. Pneumomediastinum without perforation of a viscus structure has
been described following PEG placement [46]. The etiology remains unknown.
Ileus — Some patients develop nausea and vomiting after PEG tube placement,
which may be due to transient gastroparesis. In rare patients, an ileus develops,
which is a complication that may be more likely in patients with significant
pneumoperitoneum [47]. These patients can be identified by the presence of post-
procedure abdominal distention, vomiting, and absence of bowel sounds. After a
gastric or duodenal perforation has been excluded, patients who develop an ileus
should be treated with bowel rest and, if necessary, gastric decompression.
Feedings should not be resumed until the ileus has resolved.
Esophageal and gastric perforation — Gastric and esophageal perforations are
known complications of upper endoscopy, but they are rare. (See "Overview of
upper gastrointestinal endoscopy (esophagogastroduodenoscopy)", section on
'Adverse events'.)
Other early complications — Other early complications include:
●Small bowel obstruction from a small bowel wall hematoma following
gastrostomy tube placement. In a case report, a hematoma developed on a
jejunal loop of bowel near the stomach following PEG tube placement. An
operative procedure allowed evacuation of the hematoma and resolution of
the small bowel obstruction [48].
●Transhepatic placement of a gastrostomy tube. In one report, a PEG tube
malfunctioned and was replaced with a balloon gastrostomy tube 2.5 years
after initial placement [49]. The replacement tube was difficult to push back
through the gastrostomy site. A contrast study showed that the balloon
gastrostomy tube was inflated within the liver. Contrast from the tube
entered the portal venous system. A fistula tract had developed between the
liver and the stomach. Subsequent surgical exploration allowed the tube to
be removed safely with resection of the gastrohepatic fistula tract, argon
plasma coagulation (APC) of the liver bed to prevent bleeding, and
replacement of the gastrostomy with a Stamm gastrostomy. Two additional
reports of transhepatic PEG tube placement resulted in very different
outcomes. One case required emergency surgery and repair of the liver
 laceration [50]. The second case resulted in the PEG tube being left in place
for three months, at which time the tube was removed endoscopically [51].
●Damage to other intra-abdominal organs, such as the colon [52].
●Sigmoid volvulus from a PEG tube that had been placed through the colonic
mesentery with subsequent rotation of the mesentery around the tube [53].
●Pancreatitis from a PEG tube that migrated distally and resulted in occlusion
of the ampulla by the internal bolster (a balloon) [54].

LATE COMPLICATIONS OF GASTROSTOMY TUBE PLACEMENT

Late complications occur after the gastrostomy tract has matured. They include
deterioration of the gastrostomy site, buried bumper syndrome, and
colocutaneous fistula formation.

Deterioration of the gastrostomy site — Deterioration of the mature

gastrostomy site is a common problem. It may result in skin maceration, leakage,
enlarging tract diameter, or complete breakdown of the tissue at the gastrostomy
site. Normally, the site should be dry with minimal exudate. Since the tendency is
for the gastrostomy tract to close down around the tube, an enlarging opening
around the tube suggests tissue breakdown. Breakdown can then lead to other
complications such as infection, leakage, buried bumper syndrome, and bleeding.
(See 'Infection' above and 'Bleeding' above and 'Peristomal leakage' above
and 'Buried bumper syndrome' below.)
Prevention and treatment include ensuring the external bolster is appropriately
positioned and maintaining a clean and dry gastrostomy site. Any complications
that develop will also require specific treatment (eg, antibiotics for a wound
infection). (See "Gastrostomy tubes: Placement and routine care", section on
'Proper placement of the external bolster' and "Gastrostomy tubes: Placement and
routine care", section on 'Routine care'.)
Buried bumper syndrome — Buried bumper syndrome is a long-term
consequence of tight apposition of the external bolster of the gastrostomy tube
against the abdominal wall [55]. The internal bolster of the gastrostomy tube
slowly erodes into the gastric wall as tension is created on the gastrostomy tube
tract, which ultimately causes pain and the inability to infuse feedings. The
diagnosis can be confirmed on endoscopy, which will demonstrate the internal
bumper buried within the gastric mucosa.
The treatment of buried bumper syndrome depends upon the type of gastrostomy
tube [56]. If the internal bolster is collapsible, as it is on externally removable
gastrostomy tubes, the gastrostomy tube can be removed by simple external
traction. In a modification of this technique, the gastrostomy tube can be cut short
and a guidewire passed through the stump into the gastric cavity [56]. The
guidewire is snared endoscopically and pulled out of the oral cavity and attached
to a new gastrostomy tube. The guidewire at the abdominal surface is pulled,
pulling the new gastrostomy tube into the gastric cavity. The dilating portion of the
new gastrostomy engages the buried bumper on the old gastrostomy. As the new
gastrostomy tube is pulled through the abdominal wall, the old gastrostomy tube
is pushed out of the abdominal wall and removed.
However, if the internal bumper on the gastrostomy tube is rigid, the gastrostomy
tube may have to be removed by gastrostomy wound tract cut-down or the push-
pull T-technique [57]. The push-pull T-technique requires the gastrostomy tube to
be cut 3 cm from the abdominal wall. An endoscope is introduced into the
stomach, and a snare is passed through the scope and through the gastrostomy
tube opening in the gastric wall. Once the snare is protruding externally through
the gastrostomy tube, an additional short piece of gastrostomy tube is cut from
the excess gastrostomy tubing. The snare is opened, and this short piece of tubing
is grasped and pulled back against the gastrostomy tube, creating a T-shape. A
Kelly clamp is placed across the T-shape. The endoscopist slowly removes the
endoscope, snare, and gastrostomy tube orally as a second operator pushes the
Kelly clamp and gastrostomy tube into the gastric lumen. This combined
procedure frees the internal bumper from the gastric wall. Once the gastrostomy
tube is removed, a new gastrostomy tube can be placed through the existing
gastrostomy tract using direct endoscopic visualization. A standard gastrostomy
tube placement technique should be used to permit the gastrostomy tube dilator
to re-expand the partially closed gastrostomy tube tract. (See "Gastrostomy tubes:
Placement and routine care", section on 'Endoscopic placement'.)
Other reported techniques for managing buried bumper syndrome include use of
a needle-knife or papillotome to incise the gastric mucosa to reach the internal
bolster [41]. For some patients, surgical removal of the gastrostomy tube is
required.
Prevention of the buried bumper syndrome requires good care and patient
instruction. As mentioned above, the external bolster of the gastrostomy tube
should be left 1 to 2 cm from the abdominal wall. Gauze pads should be placed
over the external bolster, not underneath, which would create pressure on the
gastrostomy tube tract wound. In addition, the gastrostomy tube itself should be
pushed forward into the wound slightly and rotated during daily care. This will
ensure that the internal bumper does not become buried into the gastric mucosa.
After rotation, the gastrostomy should be placed back into its original position.
Colocutaneous fistula — A colocutaneous fistula is a rare complication associated
with percutaneous gastrostomy tube placement [58]. It occurs as a result of
interposition of bowel, usually the splenic flexure, between the anterior abdominal
wall and the gastric wall. The gastrostomy tube is placed directly through the
bowel into the stomach. Patients in whom this complication has occurred are often
asymptomatic, except for transient fever or ileus. This complication can often be
treated by removing the gastrostomy tube and allowing the fistula to close [59].
However, surgery is sometimes necessary to correct the internal gastric-bowel
fistula.

The problem is usually discovered months after initial gastrostomy tube placement
when the original gastrostomy tube is removed for gastrostomy tube replacement.
As the replacement gastrostomy tube is passed blindly at the bedside, it is pushed
through the gastrostomy tract opening in the abdominal wall and into the colon
but cannot find its way back into the stomach. Once the tube feedings are
restarted, the patient develops diarrhea from colonic tube feedings and
dehydration from not receiving fluids or nutrition.

Prevention of this complication is related to the initial gastrostomy tube placement

procedure. For endoscopic placement, relying on the combination of
transillumination and finger palpation of the abdominal wall in choosing an
appropriate gastrostomy tube site, rather than one of these techniques alone, will
increase the safety of gastrostomy tube insertion. (See "Gastrostomy tubes:
Placement and routine care", section on 'Endoscopic placement'.)
Persistent gastric fistula following gastrostomy tube removal — A
gastrostomy tube may be removed permanently in patients who recover from
their original disease process. As a general rule, the gastrostomy tract closes
within 24 to 72 hours of gastrostomy tube removal, but on occasion a fistula
persists.
There is no established method for treating the fistulas. Our center uses the
technique of fistula tract lining disruption with either a brush or electrocautery
with subsequent gastric mucosal endoclipping [60]. Treatments that have been
used in small series often include disrupting the epithelial surface within the tract
to allow for healing and closure. In a series of four patients with peristomal
leakage, circumferential argon plasma coagulation (APC) of the gastric mucosa
surrounding the site (followed by endoscopic clipping the internal orifice in two
patients) was used to encourage fistula tract closure [61].
A persistent gastrocutaneous percutaneous endoscopic gastrostomy (PEG) fistula
(PGPF) has been described in 2 to 44 percent of children who underwent PEG tube
placement [62]. The only factor that demonstrated any correlation with the
development of PGPF in these pediatric populations was that the gastrostomy
tube (the original tube or a replacement tube) was in place for greater than eight
months. PGPF has also been reported in the adult literature, although no incidence
data exist.
There are a number of case reports and small series documenting approaches to
the closure of a PGPF. One series documented closure of a PGPF in 7 of 13 cases by
the use of gastric acid suppression with a histamine antagonist and silver
nitrate ablation of the gastrostomy tract lining to disrupt any epithelialization and
to encourage tract closure. The same premise of gastrostomy tract lining
disruption before using a number of closure techniques has been reported in
other series [60,63,64]. There have also been some reports of PGPF closure using
an endoscopic clip closure technique alone without preprocedure fistula tract
lining disruption [65].
PEG tract tumor seeding — Patients with proximal gastrointestinal (GI) tract
cancers, such as head, neck, and esophageal cancers, are at risk of tumor seeding
from the tumor site to the PEG tract by mechanical transfer [66-69]. During
placement, the PEG tube can transfer tumor cells from the tumor to the gastric
and abdominal walls. The use of an overtube across the proximal GI tract tumor
site in theory should allow the PEG tube to be placed through the overtube without
the risk of PEG tube tract seeding, though whether this approach is successful has
not been studied. Overall, the risk of clinically significant seeding appears to be
low.
The risk of PEG tract seeding with malignant cells was demonstrated in a
prospective series that included 40 patients with oropharyngeal or esophageal
cancer who underwent PEG tube placement using a pull-through technique [70].
Cytology using brushings obtained from the tubing and incision site after PEG tube
placement demonstrated malignant cells in nine patients (23 percent). After three
to six months of follow-up, brushings were again obtained from the tubing and
incision site in 32 patients. Malignant cells were seen in three patients (9 percent of
those with a second brushing), all of whom had esophageal squamous cell
carcinoma, suggesting seeding of the tract during PEG tube placement. However,
it should be kept in mind that the finding of malignant cells on brushings
represents a surrogate endpoint, and whether patients are clinically affected (eg,
develop clinically apparent abdominal wall tumors) is unclear. As a result, our
practice is to inform patients of the risk of PEG tract seeding with malignant cells,
but we do not alter our approach to feeding tube placement.
Other late complications — Other late complications of gastrostomy tube
placement include gastric herniation and persistent abdominal wall pain.
Herniation of the stomach through a PEG tube site has been reported. In one
report, a patient was noted to have a leaking PEG site one year following PEG tube
insertion [71]. A bulge was noted at the PEG tube site on the abdominal wall when
the patient coughed. A computed tomography (CT) scan demonstrated that a
portion of the stomach had herniated through the PEG site. The PEG was removed,
but the PEG tract remained open. Surgical repair of the fistula was suggested.
However, the patient died of aspiration pneumonia prior to definitive surgical
therapy.

Abdominal wall pain can occur and persist after gastrostomy tube placement. The
work-up should include a full examination to rule out infection of the abdominal
wall. This may include a CT scan to rule out an abdominal wall abscess. In some
cases, the pain will be consistent with neuropathic pain, in which case the remedy
is often removal of the gastrostomy and insertion at a different site. Abdominal
wall injection with an anesthetic agent may also be helpful.

COMPLICATIONS RELATED TO TUBE FEEDS

Complications related to the administration of tube feeds are discussed elsewhere.

(See "Nutrition support in critically ill adult patients: Enteral nutrition", section on
'Monitoring and management of complications'.)

SUMMARY AND RECOMMENDATIONS

●Background – Complications of gastrostomy tube placement may be minor

(wound infection, minor bleeding) or major (necrotizing fasciitis,
colocutaneous fistula). The reported rates of complications related to
percutaneous endoscopic gastrostomy (PEG) tube placement vary from 16 to
70 percent. The majority of complications are minor. Complications appear to
be more likely in older adults with comorbid illnesses, particularly those with
an infectious process or who have a history of aspiration. (See 'Incidence of
complications' above.)
●Placement of the external gastrostomy tube bolster – One key to
preventing complications is proper placement of the external gastrostomy
tube bolster. The external gastrostomy tube bolster should be positioned
such that 1 to 2 cm of in and out movement can be achieved. Loose
apposition of the bolster to the abdominal wall does not result in peritoneal
leakage since an early gastrostomy tube tract forms as a result of tissue
edema and associated tissue secretions. If the tissue between the internal
and external bolsters is compressed, it may lead to pressure necrosis and
breakdown of the gastrostomy site. (See "Gastrostomy tubes: Placement and
routine care", section on 'Proper placement of the external bolster'.)
●Timing – Many of the complications associated with gastrostomy tube
placement may be seen at any time following gastrostomy tube placement.
These include infection, bleeding, peristomal leakage, and inadvertent tube
removal. (See 'Complications that may occur at any time' above.)
•Early complications – Some complications seen immediately following
PEG tube placement include pneumoperitoneum, ileus, perforation of the
esophagus or stomach (at a site other than the gastrostomy), or damage
to other intra-abdominal organs, such as the liver or colon. (See 'Early
complications of endoscopic gastrostomy tube placement' above.)
•Late complications – Late complications occur after the gastrostomy tract
has matured. They include deterioration of the gastrostomy site, buried
bumper syndrome, and colocutaneous fistula formation. (See 'Late
complications of gastrostomy tube placement' above.)