Percutaneous gastrostomy in a child

Percutaneous gastrostomy and gastrojejunostomy

Gastrostomy allows enteral nutrition to continue in patients who are unable to meet their caloric requirements orally. Though the indications for gastrostomy placement are varied, dysphagia secondary to a neurological condition is the most common. These catheters were initially placed surgically, but percutaneous endoscopic placement is now the routine in most centers. Interventional radiologists have been performing this procedure under fluoroscopic guidance for several years with encouraging results. Percutaneous radiological gastrostomy is reported to have a success rate comparable to that of the endoscopic method, with lower morbidity and mortality rates. A further benefit is that it may be performed in patients for whom the endoscopic method would be difficult or dangerous, such as those with head and neck malignancies. One of the main factors currently limiting the use of this procedure is the shortage of interventional radiology facilities and specialists.This article describes a technique for routine percutaneous radiological gastrostomy catheter placement and procedural variations for difficult cases. Indications and contraindications will be discussed, as will complication rates and how these compare with the traditional methods of gastrostomy tube placement.

The role of the interventional radiologist in enteral alimentation

The provision of enteral nutrition through the placement of gastrostomy/gastrojejunostomy tubes is a well-established procedure. Traditionally, these catheters have been placed either surgically or endoscopically; however, over the past two decades interventional radiologists have increasingly performed these procedures successfully. The perceived advantages of this route lie in the reported lower morbidity and mortality rates. In addition, percutaneous radiologically guided (PRG) catheters may be placed in certain subgroups of patients in whom it would be technically difficult or impossible by other routes, e.g., patients with head and neck or oesophageal tumours. The aim of this review is to describe the techniques of radiologically placed gastrostomy/gastrojejunostomy, discuss its indications and contraindications, describe any associated potential complications and compare PRG results with the more established techniques of open surgical and endoscopic placement. We also describe some recent procedural and catheter modifications.

Fluoroscopically guided percutaneous radiological gastrostomy: technique, methodology and pitfalls

Fluoroscopically guided percutaneous gastrostomy tube placement is an uncommon but well-established interventional procedure. We present our experience of this procedure in a series of 23 patients, concentrating on the methodology, technique and pitfalls.

Future directions in interventional pediatric radiology

In conclusion, the explosion of interventional radiology and its impact on the pediatric patient have resulted in a completely new approach to the subspecialty of interventional pediatric radiology. The interventional radiologist has become an integral part of the management of patients and has become directly involved in the day-to-day care of patients. The use of interventional MR imaging recently has been described in clinical trial. Open-configuration magnets that allow full access to the patient and are equipped with instrument tracking systems provide an interactive environment in which biopsies, endoscopic procedures, and minimally invasive interventions or surgeries are performed. In addition, thermal ablation and image-based control of energy deposition also can be performed. Among these procedures, noninvasive MR-guided focused ultrasound ablation has the most promising future and may replace some conventional surgery. The merging of new and exciting technologies including MR, ultrasound, CT, and fluoroscopy into an environment in which both surgical and interventional radiologic procedures can be performed with image guidance is the basis of the operating room of the future. The role of the interventional radiologist as both the imager and interventionalist is central to this procedural environment; however, the interventional radiologist must accept all the responsibilities of imaging, therapy, patient care, and associated complications.

Percutaneous feeding tube placement in pediatric patients: immediate and 30-day results

PURPOSE

To evaluate fluoroscopically guided percutaneous feeding tube placement in pediatric patients.

MATERIALS AND METHODS

Sixty-one procedures were performed. Periprocedural care protocol was changed after patient nine. Forty-eight-hour and 30-day outcomes were assessed.

RESULTS

Almost 97% of procedures were successful. The 48-hour major and minor complication rates were 1.9% and 9.6%, respectively, after the initial nine procedures. Risk factors for early complications were the use of the initial care protocol (P < .01) and patient weight below the 50th percentile (P < .05). Major and minor 30-day complication rates were 8.3% and 12.0%, respectively. Risk factors for delayed complications were placement of a gastrojejunostomy tube rather than a gastrostomy tube (P < .05) and immunosuppression (P < .05).

CONCLUSION

Percutaneous feeding tubes can be placed in children with a high rate of technical success. Optimal results require attention to periprocedural care. Morbidity is common during the first month of tube use.

Retrograde percutaneous gastrostomy: a prospective study in 57 children

We prospectively studied Retrograde Percutaneous Gastrostomy (RPG) in 57 children (age 3 weeks-17 years, 1.7-48 kg) as the feasibility and complications of this technique have not been reported in a large series of children. We used IV sedation (42), oral sedation (4 neonates), general anaesthesia or local anaesthesia only. The retrograde approach for gastrostomy or gastrojejunostomy catheter placement is described. Catheter placement was unsuccessful in only one child, due to the presence of marked hepatosplenomegaly. Catheters were successfully placed in all the other 56 children. In one of these, catheter misplacement occurred due to retraction of the stomach from the anterior abdominal wall during its insertion. This was recognized during the procedure. The catheter was removed and reinserted on the same occasion. One catheter was accidentally pulled out after six days and was subsequently replaced. Two children had mild, local abdominal tenderness and fever for up to 48 hours but post procedure septicemia or significant infection were not encountered. All children benefitted from gastrostomy feeding and gained weight.

Fluoroscopically guided percutaneous gastrostomy in children

Percutaneous gastrostomy was performed in 27 patients with ages ranging from 7 months to 18 years (mean, 8 years). Patient weights ranged from 4.7 to 73 kg (mean, 25 kg). Access to the stomach was planned and achieved with only fluoroscopic guidance. The technical success rate was 100%. Major procedure-related complications including death, sepsis, hemorrhage, peritonitis, or early tube removal did not occur. The minor complication of local skin infection occurred in six patients. Twenty-six patients (96%) tolerated tube feedings well. Mean follow-up was 184 days, and median follow-up was 103 days. At 30 days, 26 patients (96%) were alive. Percutaneous gastrostomy under fluoroscopic guidance is a safe and effective method of obtaining long-term nonparenteral nutritional access in pediatric patients.

Percutaneous radiologic gastrostomy

Percutaneous radiologic gastrostomy is comparable to endoscopic gastrotomy in its simplicity, high success rate and lack of complications. Furthermore, it compares favourably with endoscopic gastrostomy in significant aspects such as a lower incidence of wound infection, reduced risk of aspiration and ease of conversion to jejunal placement. There are also fewer contraindications to radiologic placement and the cost is likely to be less than for endoscopic gastrostomy. Since the emergence of percutaneous endoscopic gastrostomy, clinicians have been re-evaluating the role of the gastrostomy in managing patients requiring nutritional support or gastrointestinal decompression. Percutaneous radiologic gastrostomy is an eminently suitable alternative to endoscopic or surgical gastrostomy.

Gastrostomy: operative or nonoperative?

Percutaneous endoscopic gastrostomy (PEG) is clearly better than operative gastrostomy performed under general anesthesia. Whether or not PEG offers any significant advantage over operative gastrostomy performed using local anesthesia remains to be proved. Operative gastrotomy performed with local anesthesia seems comparable to nonoperative techniques.