G/GJ tubes: Primary tube insertion by image guidance

What are gastrostomy (G) and gastrojejunostomy tubes?

Gastrostomy tubes (G tubes) and gastrojejunostomy tubes (GJ tubes) are feeding devices.

A G tube gives liquid nutrition, medication and other fluids directly into the stomach. A GJ tube gives liquid nutrition, medication and other fluids into the small intestine (the jejunum).

Both G tubes and GJ tubes are placed through a small opening in the stomach. This opening is called a "stoma". The tunnel from the outside of the body to the stomach is called the "tract".

Most primary G or GJ tubes at SickKids are placed by an interventional radiologist using image guidance. The radiologist uses images produced by X-rays and ultrasounds to guide the placement of the tube in your child’s belly (abdomen). In some cases, the G or GJ tube will be inserted in the operating room by a general surgeon.

Please review the information on this page before your child’s admission for the G or GJ tube insertion.

What are the risks of a G or GJ tube insertion?

The G or GJ tube insertion is done under a general anaesthetic and is considered a low-risk procedure. However, it does come with some risks and potential complications. Your child will be very closely monitored for these complications during their hospital stay after the tube is inserted.

Some complications related to the procedure include:

• bleeding
• perforation (puncture of other organs in the abdomen such as the colon or liver)
• peritonitis (inflammation of the peritoneum, the thin tissue that lines the inner wall of the abdomen and covers most of the organs in the abdomen)
• sepsis (infection in the blood)
• allergic reaction to the contrast medium used during the procedure
• abnormal blood sugar levels
• inability to successfully place the G or GJ tube
• anaesthesia related complications

How to get a G or GJ tube insertion booking for your child

Your child’s paediatrician, or nurse practitioner (NP) will need to send a referral for a consultation.

You will meet the G tube team for a G or GJ tube primary insertion consultation.

You will have a consultation with the G Tube Feeding Program NP or paediatrician to help you and your family make the decision to insert a G or GJ tube.

You will provide consent for a G or GJ tube insertion

You will need to give an informed consent in order to proceed with the G or GJ tube insertion. At the time of consultation, you will discuss:

• Tube insertion technique (how they place the tube)
• Risks and benefits of tube insertion
• Alternative treatment and risks/benefits of alternative treatment
• Risks and benefits of non-treatment

If you provide your consent to proceed, the G or GJ tube insertion will be planned.

How to prepare your child for a G or GJ tube insertion

Your child may require an anaesthesia consult. This appointment is with an anesthesiologist (a doctor who manages and gives general anesthesia), to discuss anesthesia benefits, risks and plan. The G Tube NP will organize this appointment at the time of the G Tube Consult. Contact the G Tube Feeding Program, if you are unsure whether your child requires an anesthesia consult.

Your child may need to have tests prior to the G or GJ tube insertion. This will be communicated to you prior to the procedure date.

If your child has a NG tube at the time of the G or GJ tube insertion, you do not need to remove it for the procedure. It will be removed during the G or GJ tube insertion by the interventional radiologist.

It is important to follow strict rules about eating and drinking before the procedure. For your child’s safety, your child must have an empty stomach for the procedure. Your child must follow the fasting guidelines below (called NPO guidelines) before the procedure.

To ensure your child is safe during the tube insertion, these rules must be followed. If they are not, your child’s procedure may be cancelled.

If your child takes prescription medicine, ask their doctor or NP when and how to give the medication. You may need to change your child’s usual medication schedule, or the medication may need to be given by a different method (for example, by IV rather than by mouth). This is especially important for essential medications such as heart or seizure medications.

If your child becomes sick before the G or GJ tube insertion

If your child is sick at the time of the procedure, general anesthesia may be unsafe. Your child’s tube insertion may need to be postponed. Contact the G Tube Nurse Practitioner if your child has:

• cough
• runny nose
• a fever
• wheezing
• is vomiting
• is generally feeling unwell

The day of the tube insertion

• Arrive at the Image Guided Therapy Department (IGT) 2 hours before the scheduled tube insertion time. For example, if your child’s G or GJ tube insertion is scheduled for 9:30 am, arrive to IGT at 7:30 am.
• An interventional radiologist and anesthesiologist will speak to you before the procedure to review your child’s history and ensure your child is safe to proceed with the tube insertion.
• You will wait in a waiting room while your child has the procedure.
• When the procedure is complete, someone will speak to you about how it went. If there were complications that occurred during the procedure, you will be made aware of them.
• You will be able to see your child in the Post Anaesthetic Care Unit (PACU) room after your child has awakened safely from the anaesthetic.
• Your child will be transferred to a unit for further recovery. Your child will need to stay in the hospital for at least 3 days. If there are complications, your child may need to stay longer.

How is a G or GJ tube inserted?

Most children receive a general anaesthetic to keep them asleep during the procedure and make sure they do not feel any pain. The general anaesthesia will be given to your child by an anaesthesiologist.

Under general anaesthesia, your child may have a breathing tube put in the throat to help them breathe while asleep.

The procedure to insert a G or GJ tube is a short one. The interventional radiologist and anaesthesiologist are always with your child during the procedure.

What can I expect after the G or GJ tube insertion?

After the procedure, you can expect to see:

• The new G or GJ tube going inside your child’s body.
• An intravenous (IV) line: This is a small tube that is put into a vein in your child's arm, neck or leg to give medications or fluids. The IV delivers water and essential electrolytes to your child. This ensures your child stays hydrated. The IV will also deliver pain medications.
• Possible oxygen: Oxygen can be delivered to your child either by mask over the mouth or prongs in the nose. The breathing tube will be gone. Your child may need oxygen until they are fully awake.

What care will my child get during the hospital stay?

Monitoring:

• Your child will be monitored for complications.
• Children with more complex medical histories may need to spend a night or two in the Paediatric Intensive Care Unit (PICU) for closer monitoring.
• In addition to the doctors and nurses on your child’s team, members of the interventional radiology team will check your child every day after the tube insertion, up until your child is able to tolerate full feeds through the new tube. Your child’s primary health-care team will arrange any further imaging or procedures in interventional radiology if your child needs.
• Your child’s vital signs will be checked frequently after the G or GJ tube insertion, and less frequently as your child recovers. Vital signs include temperature, heart rate, breathing rate, blood pressure and oxygen saturation levels.
• Your child’s pain will be monitored as often as their vital signs are monitored.
• Your child’s blood sugar levels will be checked frequently after the G or GJ tube insertion.
• Your child’s team will listen to your child’s bowel sounds with a stethoscope. After a general anaesthetic for a G tube or GJ tube insertion, the bowel sounds are absent or quiet. Once bowel sounds are heard, your child’s gut is ready for fluid and nutrition and the new G or GJ tube can be used.

Fluids/Nutrition:

• Your child will have an intravenous (IV) line through which your child will get fluids. The IV fluid contains sugar and essential electrolytes. If your child’s blood sugar level is too low, your child will receive IV fluid to normalize the blood sugar.
• Your child’s new G or GJ tube will not be used for the first 4- 8 hours after its insertion , except for essential medication that cannot be given by IV.
• After at least 4 hours of the G or GJ tube insertion, and only if bowel sounds are heard, an oral electrolyte solution (OES) can be administered through your child’s new G or GJ tube. The volumes will be small at first but will gradually increase if your child tolerates the increases. Signs of feeding ‘intolerance’ include vomiting, retching, gagging, pain or breathing issues that are out of your child’s baseline (norm) and more than what is expected after this procedure.
• If your child tolerates the OES through their new tube, formula will then be administered through the new tube.
• A dietitian will guide the administration of fluids and nutrition through the new G or GJ tube.
• Your child cannot have anything to eat or drink by mouth until they are able to tolerate full feeds through the new tube. This usually takes about 1-2 days.
• Your child may be permitted ice chips, sponges or sips of water after 8 hours of the G or GJ tube insertion. Speak to your child’s team about this.

Tube and stoma care:

• G tubes remain open to straight drainage for minimum of 4 hours.
• The G port of a GJ or combination tube will remain open to straight drainage for minimum of 4 hours.
• It is important to prevent the tube from pulling or tugging at the stoma. The tube can be taped to the abdomen for further securement.
• The stoma may be washed with soap and water 24 hours after the tube insertion.
• Your child may bathe 48 hours after the tube insertion.

Managing pain:

• Your child may have acetaminophen or morphine for pain. The pain is at the stoma (the hole created through the abdomen to the stomach) and should improve as each day passes. Please tell your child’s health-care team if your child’s pain worsens as days pass.
• Using distraction or comfort items is an effective way to help children cope with pain. For example, babies and toddlers may be comforted by music, books or cuddling toys. Children and teenagers may benefit from video games, reading or music.

Education and learning how to use the new G or GJ tube:

• You will receive education on how to care for your child’s tube and stoma. This one-to-one education session is with a nurse who will help you better understand how to care for your child’s G or GJ tube. They will also teach you how to manage tube issues (i.e. dislodgement, migration, blockage, breakage) and stoma issues (i.e. infection, granulation tissue, leakage). This education session happens before your child goes home.
• You will have opportunities to practice what you have learned at the bedside during your child’s hospital stay. Your child’s nursing and medical teams will be a source of information and support.
• You will receive a phone call or email from the G Tube Resource Nurse two to four weeks after your child’s G or GJ tube insertion. This is another opportunity to ask questions or express any concerns you might have.

Supplies/Equipment:

• You will need to purchase the supplies and equipment needed for G or GJ tube feeds care. Your team will guide you through this.
• Your child’s team will help you complete forms for any financial support for which your family may be eligible.

When can my child go home?

Your child will be discharged when:

• Your child’s vital signs are stable
• Your child tolerates feeds through their new G or GJ tube
• There are no signs of complications
• Your child is not receiving other treatments that require a longer hospital stay
• You have learned how to care for your child’s tube and stoma. You will need to be able to:
• Give feeds and medications through the tube, either by pump or gravity
• Use and care for the equipment
• Identify, monitor and manage complications and challenges that may arise at home
• Protect the tube and care for the stoma

How long will my child's tube last?

G and GJ tubes need to be exchanged eventually. The time of your child’s tube change will depend upon the type of tube they had placed. Your child’s G Tube team will review and help decide when to exchange the tube and what type to exchange your child’s tube to.

At SickKids

Interventional Radiology at SickKids is called Image Guided Therapy (IGT).

Education and learning about how to use the tube and troubleshooting is done through Connected Care.

For SickKids patients and families:

• If you are preparing for your child's G or GJ tube insertion and you have questions or concerns, contact the G Tube Feeding Program nurse practitioners at g.tubenp@sickkids.ca.
• If your child already has a G or GJ tube and you have questions or concerns about the tube or stoma, contact the G Tube Resource Nurse at g.tubenurse@sickkids.ca.