I’ve Got 99 Problems, and a G Tube is One

In this episode of Behind the Knife, Dr. Patrick Georgoff sits down with Dr. Keri Seymour and Dr. Joey Lew to tackle the complex world of gastrostomy tubes. What may seem like a routine and straightforward procedure is anything but—full of nuanced patient considerations, timing dilemmas, technical challenges, and potential complications that can turn a “simple” consult into a 2 a.m. call you won’t forget. From who truly needs a G tube and when to managing difficult post-op issues like dislodgement and buried bumper syndrome, this episode breaks down the practical, evidence-based approach every surgeon should know. Whether you’re managing stroke patients, trauma cases, or navigating the tricky administrative obstacles around enteral access, this episode will equip you with the insights and strategies to confidently dominate your G tube consults.

Hosts:

· Dr. Patrick Georgoff (Acute Care Surgeon, Duke University)
· Dr. Keri Seymour (Minimally Invasive & Acute Care Surgeon, Duke Regional)
· Dr. Joey Lew (Surgical Resident, BTK MIS Team)

Learning Goals:

By the end of this episode, listeners will be able to:
· Understand the nuanced indications for gastrostomy tube (G tube) placement.
· Learn which patients truly benefit from G tubes, and when enteral access is not appropriate or indicated.
· Appreciate the importance of goals of care discussions, assessment of comorbidities, and decision-makers—especially in neurocritical and elderly populations.
· Know evidence-based timing for gastrostomy tube placement in stroke, TBI, and other complex scenarios.
· Understand guideline recommendations and the clinical reasoning behind trial periods of nasogastric feeding versus early G tube placement.
· Describe technical approaches to G tube placement and how to tailor the method to patient anatomy and clinical context.
· Solidify knowledge of when to choose endoscopic, laparoscopic, open, or interventional radiology-guided placement.
· Recognize, manage, and strive to prevent common and serious complications of G tubes, including early and late dislodgement, buried bumper syndrome, infection, bleeding, and gastrocutaneous fistula.
· Discuss perioperative considerations, including anticoagulation, patient stability, and post-procedural care.
· Understand why routine suturing of the G tube or bumper is not recommended, and how administrative and facility factors can drive clinical decisions.
· Gain practical pearls and quick decision trees to dominate G tube consults and troubleshooting, day or night.

References:
· Braun R, Han K, Arata J, Gourab K, Hearn J, Gonzalez-Fernandez M. Establishing a clinical care pathway to expedite rehabilitation transitions for stroke patients with dysphagia and enteral feeding needs. Am J Phys Med Rehabil. 2024;103(5):390-394. doi:10.1097/PHM.0000000000002387 https://pubmed.ncbi.nlm.nih.gov/36867953/
· Burgermaster M, Slattery E, Islam N, Ippolito PR, Seres DS. Regional comparison of enteral nutrition-related admission policies in skilled nursing facilities. Nutr Clin Pract. 2016;31(3):342-348. doi:10.1177/0884533616629636 https://pubmed.ncbi.nlm.nih.gov/26993318/
· Chaudhry R, Kukreja N, Tse A, Pednekar G, Mouchli A, Young L, Didyuk O, Wegner RC, Grewal N, Williams GW. Trends and outcomes of early versus late percutaneous endoscopic gastrostomy placement in patients with traumatic brain injury: Nationwide population-based study. J Neurosurg Anesthesiol. 2018;30(3):251-257. doi:10.1097/ANA.0000000000000434 https://pubmed.ncbi.nlm.nih.gov/28459729/
· Cleverdon SA, Costantini TW, McGrew TM, Santorelli JE, Berndtson AE, Haines LN. Dysphagia in patients with traumatic brain injury, how often do they really need feeding access? Presented at: Academic Surgical Congress; February 2025; Washington, DC. Abstract 92.33.
· Cmorej P, Mayuiers M, Sugawa C. Management of early PEG tube dislodgement: simultaneous endoscopic closure of gastric wall defect and PEG replacement. BMJ Case Rep. 2019;12(9):e230728. doi:10.1136/bcr-2019-230728 https://pubmed.ncbi.nlm.nih.gov/31488448/
· Galovic M, Stauber AJ, Leisi N, et al. Development and validation of a prognostic model of swallowing recovery and enteral tube feeding after ischemic stroke. JAMA Neurol. 2019;76(5):561-570. doi:10.1001/jamaneurol.2018.4858 https://pubmed.ncbi.nlm.nih.gov/30742198/
· Gallo RJ, Wang JE, Madill ES. Things we do for no reason™. J Hosp Med. 2024;19(8):728-730. doi:10.1002/jhm.13263 https://pubmed.ncbi.nlm.nih.gov/38180160/
· George BP, Hwang DY, Albert GP, Kelly AG, Holloway RG. Timing of percutaneous endoscopic gastrostomy for acute ischemic stroke. Stroke. 2017;48(2):420-427. doi:10.1161/STROKEAHA.116.015119 https://pubmed.ncbi.nlm.nih.gov/27965430/
· Goldberg LS, Altman KW. The role of gastrostomy tube placement in advanced dementia with dysphagia: a critical review. Clin Interv Aging. 2014;9:1733-1739. doi:10.2147/CIA.S53153 https://pubmed.ncbi.nlm.nih.gov/25342891/
· Hartford A, Li W, Qureshi D, et al. Use of feeding tubes among hospitalized older adults with dementia. JAMA Netw Open. 2025;8(2):e2460780. doi:10.1001/jamanetworkopen.2024.60780 https://pubmed.ncbi.nlm.nih.gov/39976967/
· Hochu G, Soule S, Lenart E, Howley IW, Filiberto D, Byerly S. Synchronous tracheostomy and gastrostomy placement results in shorter length of stay in traumatic brain injury patients. Am J Surg. 2024;227:153-156. doi:10.1016/j.amjsurg.2023.10.012 https://pubmed.ncbi.nlm.nih.gov/37852846/
· Kobzeva-Herzog AJ, Nofal MR, Bodde J, et al. Implementation of a quality improvement initiative reduced adult inpatient gastrostomy tube dislodgements. Am J Surg. 2025;(article 116522). doi:10.1016/j.amjsurg.2025.116522 https://pubmed.ncbi.nlm.nih.gov/40782502/
· Kurt Boeykens, Ivo Duysburgh. Prevention and management of major complications in percutaneous endoscopic gastrostomy. BMJ Open Gastroenterol. 2021;8:e000628. https://pubmed.ncbi.nlm.nih.gov/33947711/
· Murphy LM, Lipman TO. Percutaneous endoscopic gastrostomy does not prolong survival in patients with dementia. Arch Intern Med. 2003;163(11):1351-1353. doi:10.1001/archinte.163.11.1351 https://pubmed.ncbi.nlm.nih.gov/12796072/
· Papavramidis TS, Mantzoukis K, Michalopoulos N. Confronting gastrocutaneous fistulas. Ann Gastroenterol. 2011;24(1):16-19. https://pubmed.ncbi.nlm.nih.gov/24714282/
· Rajan A, Wangrattanapranee P, Kessler J, Kidambi TD, Tabibian JH. Gastrostomy tubes: fundamentals, periprocedural considerations, and best practices. World J Gastrointest Surg. 2022;14(4):286-303. doi:10.4240/wjgs.v14.i4.286 https://pubmed.ncbi.nlm.nih.gov/35664365/
· Reddy KM, Lee P, Gor PJ, Cheesman A, Al-Hammadi N, Westrich DJ, Taylor J. Timing of percutaneous endoscopic gastrostomy tube placement in post-stroke patients does not impact mortality, complications, or outcomes. World J Gastrointest Pharmacol Ther. 2022;13(5):77-87. doi:10.4292/wjgpt.v13.i5.77 https://pubmed.ncbi.nlm.nih.gov/36157266/
· Singh D, Laya AS, Vaidya OU, Ahmed SA, Bonham AJ, Clarkston WK. Risk of bleeding after percutaneous endoscopic gastrostomy (PEG). Dig Dis Sci. 2012;57(4):973-980. doi:10.1007/s10620-011-1965-7 https://pubmed.ncbi.nlm.nih.gov/22138961/
· Thosani N, Rashtak S, Kannadath BS, et al. Bleeding risk and mortality associated with uninterrupted antithrombotic therapy during percutaneous endoscopic gastrostomy tube placement. Am J Gastroenterol. 2021;116(9):1868-1875. doi:10.14309/ajg.0000000000001348 https://pubmed.ncbi.nlm.nih.gov/34158462/
· Ward EC, Green K, Morton AL. Patterns and predictors of swallowing resolution following adult traumatic brain injury. J Head Trauma Rehabil. 2007;22(3):184-191. doi:10.1097/01.HTR.0000271119.96780.f5 https://pubmed.ncbi.nlm.nih.gov/17510594/
· Wick B. Timing of PEG tube placement in stroke patients with dysphagia: a multi-center retrospective cohort analysis using the TriNetX database. Am J Gastroenterol. 2024;119(10 Suppl):S1146-S1147. doi:10.14309/01.ajg.0001035684.98119.d5

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