Radiologic Placement Through An Established Gastrostomy Tract
1. Select the appropriate size MIC* Gastric-Jejunal feeding tube and prepare according to the Tube Preparation directions
listed above.
2. Under fluoroscopic guidance, insert a floppy-tipped guidewire, up to .038”, through the indwelling gastrostomy tube.
3. Remove the gastrostomy tube over the guidewire.
4. Direct the guidewire through the stoma and coil in the stomach.
5. Advance a .038” guidewire compatible flexible catheter over the guidewire until the catheter tip is at the pylorus.
6. Negotiate the pylorus and advance the guidewire into the duodenum. If the catheter is difficult to advance through the
pylorus, reduce the length of the catheter coiled in the stomach. A rotational motion on the flexible catheter may allow
easier passage over the guidewire.
7. Advance the guidewire and catheter to a point 10–15 cm beyond the Ligament of Treitz.
8. Remove the catheter and leave the guidewire in place.
Tube Placement
1. Advance the distal end of the tube over the guidewire and into the stomach.
2. Rotate the HALYARD* MIC* Gastric-Jejunal tube while advancing to facilitate passage of the tube through the pylorus and
into the jejunum.
3. Advance the tube until the tip of the tube is 10–15 cm beyond the Ligament of Treitz and the balloon is in the stomach.
4. Using a slip tip syringe, inflate the balloon with 7–10 ml of sterile or distilled water.
Caution:
Do not exceed 20 ml total balloon volume. Do not use air. Do not inject contrast into the balloon.
5. Gently pull the tube up and away from the abdomen until slight tension is felt and the balloon contacts the inner stomach
wall.
6. Gently slide the SECUR-LOK* external retention ring down the tube toward the abdomen until it rests 2-3 mm
(approximately 1/8 inch or thickness of a dime) above the skin. Do not suture the ring to the skin.
7. Remove the guidewire.
8. Verify proper tube placement according to Verify Tube Position section above.
Suggested Endoscopic Placement Procedure
1. Select the appropriate MIC* Gastric-Jejunal feeding tube and prepare according to the Tube Preparation directions listed
above.
2. Perform routine Esophagogastroduodenoscopy (EGD). Once the procedure is complete and no abnormalities are identified
that could pose a contraindication to placement of the tube, place the patient in the supine position and insufflate the
stomach with air.
3. Transilluminate through the anterior abdominal wall to select a gastrostomy site that is free of major vessels, viscera and
scar tissue. The site is usually one third the distance from the umbilicus to the left costal margin at the midclavicular line.
4. Depress the intended insertion site with a finger. The endoscopist should clearly see the resulting depression on the anterior
surface of the gastric wall.
5. Prep and drape the skin at the selected insertion site.
Gastropexy Placement
Caution:
It is recommended to perform a three point gastropexy in a triangle configurati on to ensure attac hment of the
gastric wall to the anterior abdominal wall.
1. Place a skin mark at the tube insertion site. Define the gastropexy pattern by placing three skin marks equidistant from the
tube insertion site and in a triangle configuration.
Warning: Allow adequate distance between the insertion site and gastropexy placement to prevent
interference of the T-Fastener and inflated balloon.
2. Localize the puncture sites with 1% lidocaine and administer local anesthesia to the skin and peritoneum.
3. Place the first T-Fastener and confirm Intragastric position. Repeat the procedure until all three T-Fasteners are inserted at
the corners of the triangle.
4. Secure the stomach to the anterior abdominal wall and complete the procedure.
Create the Stoma Tract
1. Create the stoma tract with the stomach still insufflated and in apposition to the abdominal wall. Identify the puncture
site at the center of the gastropexy pattern. With endoscopic guidance confirm that the site overlies the distal body of the
stomach below the costal margin and above the transverse colon.
Caution:
Avoid the epigastric artery that courses at the junction of the medial two-thirds and lateral one-third of the
rectus muscle.
Warning: Take care not to advance the puncture needle too deeply in order to avoid puncturing the
posterior gastric wall, pancreas, left kidney, aorta or spleen.
2. Anesthetize the puncture site with local injection of 1% lidocaine down to the peritoneal surface.
3. Insert a .038” compatible introducer needle at the center of the gastropexy pattern into the gastric lumen directed toward
the pylorus.
Note:
The best angle of insertion is a 45 degree angle to the surface of the skin.
4. Use endoscopic visualization to verify correct needle placement.
5. Advance a guidewire, up to .038”, through the needle into the stomach. Using endoscopic visualization, grasp the guidewire
with atraumatic forceps.
6. Remove the introducer needle, leaving the guidewire in place and dispose of according to facility protocol.
Dilation
1. Use a #11 scalpel blade to create a small skin incision that extends alongside the guidewire, downward through the
subcutaneous tissue and fascia of the abdominal musculature. After the incision is made, dispose of according to facility
protocol.
2. Advance a dilator over the guidewire and dilate the stoma tract to the desired size.
3. Remove the dilator over the guidewire, leaving the guidewire in place.
Tube Placement
1. Advance the distal end of the tube over the guidewire, through the stoma tract and into the stomach.
2. Using endoscopic guidance, grasp the suture loop or the tip of the tube with atraumatic forceps.
3. Advance the HALYARD* MIC* Gastric-Jejunal feeding tube through the pylorus and upper duodenum. Continue to advance
the tube using the forceps until the tip is positioned 10–15 cm beyond the Ligament of Treitz and the balloon is in the
stomach.
4. Release the tube and withdraw the endoscope and forceps in tandem, leaving the tube in place.
5. Using a Luer slip syringe, inflate the balloon with 7–10 ml of sterile or distilled water.
Caution:
Do not exceed 20 ml total balloon volume. Do not use air. Do not inject contrast into the balloon.
6. Remove the guidewire.
7. Gently pull the tube up and away from the abdomen until the balloon contacts the inner stomach wall and a slight tension
is felt. The balloon should now abut the stomach wall.
8. Gently slide the SECUR-LOK* external retention ring down the tube toward the abdomen until it rests 2–3 mm above the
skin. Do not suture the ring to the skin.
Verify Tube Position
1. Verify proper tube placement radiographically to avoid potential complication (e.g. bowel irritation or perforation) and
ensure that the tube is not looped within the stomach or small bowel.
Note:
The jejunal portion of the tube contains tungsten which is radiopaque and can be used to radiographically confirm
position. Do not inject contrast into the balloon.
2. Flush the gastric and jejunal lumens to verify patency.
3. Check for moisture around the stoma. If there are signs of gastric leakage, check the tube position and the external bolster
placement. Add fluid as needed in 1–2 ml increments.
Caution:
Do not exceed 20 ml total balloon volume.
4. Check to make sure that the external bolster is not placed too tightly against the skin and rest 2–3mm above the abdomen.
5. Document the date, the type, the size, and lot number of the tube, the fill volume of the balloon, skin condition and patient
tolerance to the procedure. Start feeding and medication administration per physician orders and after confirmation of
proper tube placement and patency.
Endoscopic Placement Through An Existing Gastrostomy Tract
1. Select the appropriate MIC* Gastric-Jejunal feeding tube and prepare according to the directions in the Tube Preparation
section listed above.
2. Following established protocol, perform routine Esophagogastroduodenoscopy (EGD). Once the procedure is complete and
no abnormalities are identified that could pose a contraindication to placement of the tube, place the patient in the supine
position and insufflate the stomach with air.
3. Manipulate the endoscope until the indwelling gastrostomy tube is in the visual field.
4. Insert a floppy-tip guidewire into the indwelling gastrostomy tube and remove the tube.
Tube Placement
1. Advance the HALYARD* MIC* Gastric-Jejunal feeding tube over the guidewire and into the stomach.
2. Refer to step 2 in the Tube Placement section above and complete the procedure according to the steps listed.
3. Verify proper placement according to the directions in the Verify Tube Position section listed above.
Jejunal Feeding
1. Open the feeding port cover
(Fig 1-B)
located at the top of the Transgastric- Jejunal Feeding Tube.
2. Using a catheter tip syringe flush the Jejunal port with 30 ml of sterile or distilled water.
3. Remove the syringe and insert the feed set into the Jejunal port. Use a firm 1/4 twist to secure the connection.
4. Open the feed clamp if present.
5. Flush the Jejunal and Gastric ports every 4-6 hours with at least 30 ml of water. Do not use force.
6. If formula is present in the gastric drainage, stop feeding and notify the physician or health care provider.
Caution:
Never connect the Jejunal port to suction. Do not measure residuals from the Jejunal port.
Gastric Decompression
1. Open the gastric port and connect it to gravity drainage or low, intermittent suction to allow stomach contents or gas to
escape.
2. Flush the gastric port every 4–6 hours with at least 30 ml of water.
Caution:
Do not use continuous or high intermittent suction. High pressure could collapse the tube or injure the
stomach tissue and cause bleeding.
Medication Administration
Use liquid medication when possible and consult the pharmacist to determine if it is safe to crush solid medication and mix with
water. If safe, pulverize the solid medication into a fine powder form and dissolve the powder in water before administering
through the feeding tube. Never crush enteric coated medication or mix medication with formula.
Using a catheter tip syringe flush the tube with the prescribed amount of water.
Tube Patency Guidelines
Proper tube flushing is the best way to avoid clogging and maintain tube patency. The following are guidelines to avoid
clogging and maintain tube patency.
• Flush the feeding tube with water every 4–6 hours during continuous feeding, anytime the feeding is interrupted, before
and after every intermittent feeding, or at least every 8 hours if the tube is not being used.
• Flush the feeding tube before and after medication administration and between medications. This will prevent the
medication from interacting with formula and potentially causing the tube to clog.
• Use liquid medication when possible and consult the pharmacist to determine if it is safe to crush solid medication and
to mix with water. If safe, pulverize the solid medication into a fine powder form and dissolve the powder in warm water
before administering through the feeding tube. Never crush entericcoated medication or mix medication with formula.
• Avoid using acidic irrigants such as cranberry juice and cola beverages to flush feeding tubes as the acidic quality when
combined with formula proteins may actually contribute to tube clogging.
