Gastrostomy tube displacement following spinal surgery

Abstract

Abstract We present the case of a 12 year-old female with spastic quadriplegia whose gastrostomy tube button was inadvertently displaced resulting in the intraperitoneal administration of formula with subsequent severe peritonitis, septic shock and death within 48 h. The operating room findings included 700 cc of formula in the peritoneal cavity and the partial separation of the gastric wall at the gastrostomy site from the abdominal wall. The patient had undergone spinal corrective surgery 5 months prior and her gastrostomy tube has been replaced per routine by the caregiver the day prior to the onset of symptoms. We hypothesize that the postsurgical positional changes resulting from her spinal corrective surgery changed her stomach relationship to the abdominal wall placing the gastrostomy button on tension and resulting in the erosion of the balloon through the stomach wall with disruption of the gastrostomy tract. We recommend that meticulous monitoring, changing button to a regular gastrostomy tube and potential repositioning of the gastrostomy tube site be considered after spinal corrective surgery in such patients.