With excessive tightening of the external bolster, what complication may occur and what is the incidence?

• A. Perforation of stomach
• B. Tracheal injury
• C. Tube dislodgement
• D. Ischemic necrosis of the gastric wall and migration of the internal bolster

Answer: (D)

Excessive tightening of the external bolster creates too much pressure on the gastrostomy tract, compressing the gastric wall where the internal bolster sits. This pressure cuts off blood flow to the gastric wall, leading to ischemia and eventual necrosis. As the tissue becomes necrotic, the internal bumper can lose its secure fixation and migrate, potentially moving into the stomach or along the tract. This combination of ischemic necrosis and internal-bumper migration is a direct consequence of over-tightening and distinguishes it from other issues like simple tube dislodgement or unrelated injuries. The exact incidence is not consistently defined in guidelines and is considered uncommon but serious, underscoring the importance of avoiding overly tight securement.