A feeding tube may have to be removed because it is irreversibly clogged, leaking, or broken; persistently developing kinks; too large or too small; causing a hypersensitivity reaction; associated with an abscess; or not the appropriate length for feeding into the desired viscus. Before a new transabdominal feeding tube is inserted, the old tube must be removed. Most, but not all, tubes can be removed without endoscopy. It is imperative to know whether the tube in place is safe to remove before attempting to remove it. Standard de Pezzer or mushroom catheter that have been modified with bolsters or rings at the time of endoscopic or surgical insertion may no longer be safe to remove with sutures or rigid internal bumpers or stays. It is rare, however, to encounter a tube that cannot be removed with traction. Recently placed feeding tubes may need to be left in until a tract has formed (1 to 2 weeks dependingon the procedure) even if the tube is nonfunctional. The externally visible tube does not always reveal the internal stabilization (see Fig. 41-18).
A simple Foley catheter gastrostomy is easiest to remove. Once the Foley balloon is deflated, the tube should slide right out. If the Foley balloon cannot be deflated, cutting the tube may allow the balloon to deflate. The catheter must not be cut so close to the abdomen that it will be impossible to maintain a grip on it for a traction removal if the balloon still does not deflate. The balloon also may be punctured to cause it to deflate. To puncture a Foley balloon, traction is applied to the catheter to draw the balloon up against the ostomy. Using the taut feeding tube as a guide, a 20- or 21- ga needle is passed along the tube tu puncture the balloon. It may be necessary to try again on the other side of the catheter, because the balloon may be asymmetrically anflated, and contact with the needle may be established on one side and not the other. The clinician should be careful not to tract away from the ostomy into the patient’s abdominal wall or to cause separate punctures of the stomach. The balloon is allowed a minute to deflate before another attempt is made at traction removal. Large nondeflating balloons should probably be punctured, whereas small balloons may be removed with traction.
Traction is an acceptable removal technique for feeding tubes that are secured by a small mushroom. A towel is placed over the orifice, and the clinician applies counterpressure with the flat part of the hand against the abdominal wall as the tube is placed under tension (Fig. 41-21). This causes the tube and end mushroom to narrow, and the tube should come out easily. The inner crossbar, if present, may remain in the stomach when the rest of the feeding tube complex is removed by traction. Obstruction from the crossbar, which will pass in the stool, has yet to be reported for adults. In small children, obstruction is a possibility, and the crossbar should be removed by endoscopy.
A local anesthetic may be useful in selected cases of feeding tube removal, especially when the tube is in some way secured subcutaneously-for example, by a Dacron cuff. It may be difficult to remove a catheter accidentally caught by fascial suture during operative closure.
Removal of gastrostomy tubes with moderate to large mushrooms may be easier if the mushroom is distended with a sound or stylet. The length of the gastrostomy tube should be known so that the sound be known so that the sound may be inserted to the correct depth. Firm resistance should be noted at deeper depths represent pressure on the viscus wall and can result in viscus puncture. The premeasured stylets that come with feeding devices are useful instruments for assisting in removal. This is particularly true of gastrostomy “button”, whose ands resemble de Pezzer catheter. Because button come in a variety of lengths, it is important to have the prorer stylet. Following elective permanent removal of a gastrostomy tube, a pressure dressing should aid in closure of the fistula.
Some clinician and surgeon may strongly condemn cutting off the tube at the skin, even when the risks posed by the procedure are very low. It is always advisable to cantact the patient’s private clinician before cutting the tube. In some cases endoscopic retrieval of the tube remmant will be preferred to allowing rectal passage, and the tube should not be cut until just before or during endoscopy to ensure that migration does not occur before endoscopy.
