Gastrointestinal Interventions

Fluoroscopically Guided Percutaneous Gastrostomy Eric 5. Malden, M D Marshall E. Hicks, M D Daniel Picus, M D Michael D. Darcy, M D Thomas M . Vesely, M D Michael A. Kleinhoffer, RT

Index terms: Feeding tube, 72.1299 Gastrostomy, 72.1299 Interventional procedures, in infants and children

JVIR 1992; 3573-677 Abbreviations: GE = gastroesophageal reflux, LESP = lower esophageal sphincter pressure, PEG = percutaneous endoscopic gastrostomy

From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110. Received February 24, 1992; revision requested May 24; revision received June 26; accepted July 8. Address reprint requests to M.E.H.

' SCVIR, 1992

Percutaneous gastrostomywas 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-sixpatients (96%)tolerated tube feedings well. Mean follow-upwas 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-termnonparenteral nutritional access in pediatric patients.

OVER

the past decade, percutaneous nonendoscopic gastrostomy has been developed and refined as an alternative to percutaneous endoscopic gastrostomy (PEG) and surgical gastrostomy. With technical success rates close to loo%, major morbidity of only 1%-6%, and excellent long-term results, percutaneous nonendoscopic gastrostomy has ushered in a new standard of care for adult gastrostomy tube placement (1,2).However, experience with this technique is less extensive in the pediatric population. Previously reported results have been encouraging but limited (3-6). The most appropriate technique and the need for supplemental imaging (ie, ultrasonographic [US] or barium studies in adhtion to fluoroscopy)have not been well defined. Therefore, we report our experience with percutaneous nonendoscopic gastrostomy in 27 consecutive pediatric patients with use of only fluoroscopic guidance.

PATIENTS AND METHODS Study Population Between March 1989 and October 1991,27 percutaneous gastrostomies

were ~erformedbv interventional radioiogists on infants or children. All gastrostomy tubes were placed under fluoroscopic guidance only. We retrospectively examined each patient's medical records from the periods before, during, and after the procedure. Follow-up-through contact with the child's parents, pediatrician, and/or extended care facility employees-was obtained a t 30 days in all cases (excluding one patient who died 10 days after the procedure) and averaged 185 days (range, 30 days to 2.4 years). Patients included 15 boys and 12 girls, whose ages were 0-1 year (n = 2),1-2 years (n = 3),2-6 years (n = 5), 6-12 years (n = 7), and 12-18 years (n = 10). The mean age was 8 years. Patient weights ranged from 4.7 to 73 kg (mean, 25 kg). All tubes were placed for nutritional support. The most common indication for placement was a disorder of the central nervous system (n = 21 [78%]). This included head trauma (n = 71, encephalopathies of various origins (n = 51, neoplasms (n = 21, and cases of Alexander disease, cerebral palsy, submersion injury, sagittal sinus thrombosis, and

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spinal muscular dystrophy. Six patients (22%)had miscellaneous indications including intrauterine benzodiazepine exposure causing failure to thrive, rejection following kidney or liver transplantation with failure to meet caloric needs, tetralogy of Fallot, and methylmalonic aciduria. At the time of the procedure, through the wishes of the families, five patients (19%)had orders written instructing care givers not to resuscitate the child in the event of a cardiopulmonary arrest. Preprocedural examinations for gastroesophageal (GE) reflux were not routinely performed. Incidentally, five patients had undergone prior studies, with reflux characterized as absent in two patients, mild in two, and severe in one. The patient with severe GE reflux underwent the study prior to gastrostomy; however, the results were not discovered until after the procedure. In the remaining 22 patients, the presence or absence of GE reflux was unknown.

Technique A variety of tubes were used for gastrostomy including 8-F nephrostomy (n = 21, 10-F nephrostomy (n = 7), 12-F Cope gastrostomy (n = 61, and 14-F Cope gastrostomy (n = 12) tubes. Procedures were performed with the Mallinckrodt Institute of Radiology percutaneous gastrostomy set (Cook, Bloomington, Ind) for 14-F tube placement and with the Wills/Oglesby percutaneous gastrostomy set (Cook) for tubes that were 12 F or smaller. Procedures were performed with administration of local anesthesia alone (n = 15) or with a combination of local anesthesia and intravenous anesthesia consisting of midazolam and morphine sulfate (n = 11). One patient received an orally administered sedative. All procedures were performed with only fluoroscopic guidance and without sonographic or barium imaging. Antibiotics were not routinely used except in one child in whom a ventriculoperitoneal shunt was placed prior to gastrostomy. The abdominal portion of the shunt was

not near the gastrostomy tract, and no com~licationsoccurred. All t;bes were placed by using the method described by Wills and Oglesby (7).Children were given nothing by mouth for a t least 6 hours prior to the procedure. Intravenous glucagon (0.25-1.0 mg) (Lilly, Indianapolis) was used to inhibit gastric motility. The stomach was insufflated via a nasogastric tube to (a)provide counterforce for insertion of the needle, dilators, and catheter; (b)separate the anterior and posterior gastric walls; ( c )displace the overlying and surrounding bowel; ( d )oppose the anterior gastric wall to the anterior abdominal wall; and (el provide adequate visualization of the stomach. For these reasons, adequate insufflation facilitated the procedure and eliminated the routine need and added risk of T bars or Cope fasteners. Fluoroscopy was usedto localize the stomach, small bowel, and colon. With the same technique described for use in adult patients, an 8-cm 18gauge Teflon-sheathed needle (Cook) was used to ~ u n c t u r ethe anterior body of the itomach midway between the lesser and greater curvatures (2). On the basis of the scarcity of liverrelated complications in adult percutaneous gastrostomy (hemorrhage, peritonitis, death, and difficult placement), deliberate attempts a t localizing and avoiding the left lobe of the liver were not made (1,2). After contrast material was injected to confirm intragastric placement, a 0.038-inch extra-stiff guide wire (Cook) was threaded through the needle and coiled in the stomach. The tract was serially dilated, and the appropriate self-retaining tube was placed. The feeding catheter was then secured to the skin with 0-prolene (Ethicon, Somerville, NJ). Catheters were sutured in place to prevent distal tube migration and to provide additional security from removal during the immediate postprocedural period. In only two cases, a T-fastener fixation device (Cook) was used to secure the stomach in a position adjacent to the abdominal wall. In these cases, procedure reports did not indicate any

placement difficulties and indications for T-fastener placement are unknown. Twenty-four hours after the procedure, feeding was usually begun and the nasogastric tube was removed. Local wound care at the tube site was given daily.

RESULTS Technical success of placement was achieved in all 27 cases (100%). No procedural modifications were required. Minor difficulties in placement occurred in three cases (11%). One patient experienced bradycardia to 88 bpm for 3 minutes immediately following gastric distention. Atropine was administered, and the child's heart rate quickly returned to normal. In two cases (10- and 12-F tubes), extragastric tube placement occurred. The incorrect position was immediately recognized, and a second puncture was performed with successful placement. Antibiotics were not administered, and no complications ensued. After the procedure, feeding began within 24 hours (n = 23 [85%]),48 hours (n = 2), or 72 hours (n = 1). In one child with severe GE reflux (discovered after gastrostomy), feeding was not initiated for 72 hours, while conversion to a gastrojejunostomy was considered. A decision was made to try gastric feeding with antireflux precautions, and this was well tolerated. Intravenous fluid support was given in small infants prior to gastrostomy feedings. One child, who experienced hepatic valproate toxicity, renal failure, and rejection of his second liver transplant, continued to receive intravenous nutrition due to his critical condition. On postprocedural day 7, the child received his first and only feeding, 5% dextrose in water, with a high residual amount. His clinical status continued to deteriorate, and on postprocedural day 10 the child died of multiple organ failure. The other 26 children (96%)tolerated feedings without difficulty. One child (4%)tolerated feedings but required metoclopramide to decrease

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gastric residuals. At 30 days, 26 children (96%) were alive and no major tube morbidity had occurred. The average hospital stay was 50 days with an average postgastrostomy stay of 22 days. Long hospital stays were a reflection of the serious underlying illnesses in these children. However, 12 patients left the hospital within 5 days of gastrostomy tube placement. Disposition included home (n = 12 [44%]),a n extended care facility (n = 12 [44%]),or continued hospitalization (n = 2 [a%]).Clinical follow-up ranged from 30 to 861 days and averaged 184 days. Major complications of peritonitis, hemorrhage, sepsis, death, early tube extrusion, leakage around the tube, or gastrocolic fistulas did not occur. Wound infection, classified as local erythema, local tenderness, and any discharge, occurred in six cases (22%).All infections were treated with standard wound care and topical antibiotics and were self-limiting. Antibiotics were given via the gastrostomy tube in three cases. Isolated transient fever or leukocytosis, which occurred in six patients, was not treated with antibiotics; these resolved spontaneously without sequelae. Minor skin bleeding, skin excoriation, or small bowel obstruction did not occur. Tube malfunctions included migration, plugging, and GE reflux. Migrations of the tube tip into the small intestine occurred nine times in three patients (at 7 days to 15 months after placement), involving nephrostomy tubes (n = 6) and gastrostomy tubes (n = 3). In these cases, the tube was repositioned (n = 31, exchanged for a new tube over a guide wire ( n = 51, or converted to a button (n = 1). Clogged tubes (10 F) occurred twice (4 weeks and 3 months after placement) and were opened with injection of normal saline through a 3-mL syringe. Documented GE reflux occurred in two patients while supine but ceased when the head of the bed was raised to 30" (both had prior studies documenting no GE reflux). During follow-up visits, tubes were intentionally removed in five patients

and converted to a gastric button (Bard, Billerica, Mass) in six patients. Tubes were inadvertently pulled out seven times (14 davs to 7 months after placement; mean, 3 months) in six patients. The tract was easily recannulated, and a new tube was inserted in all six cases. Six children were eating well, and the tubes were discontinued: of these. one tube had been inadvertently re6oved. Gastric button revision occurred a t a median interval of 16 weeks (range, 8-132 weeks). Three patients stayed a t extended care facilities where the Cope tubes were exchanged for Foley catheters. Finally, one tube hub cracked, requiring tube exchange over a wire. In one case 3 months after gastrostomy, a 6-year-old child who pulled out her Cope feeding tube underwent placement of a Foley catheter by a local emergency room physician through the well-formed tract. One month later, this child was admitted with a 4-day history of low-grade fevers, watery diarrhea, and emesis of fresh, nondigested tube feedings. An abdominal radiograph demonstrated the Foley catheter tip to be in the region of the xiphoid and possibly causing gastric outlet obstruction; however. a tube iniection was not performed. Respiratory distress syndrome and a clinical picture of septic shock developed. After an unremitting deteriorating course and at the wishes of the family, mechanical ventilation was discontinued and the patient died.

DISCUSSION Access for long-term nutrition in children has been achieved through " surgical gastrostomy, PEG, and percutaneous radiologically guided gastrostomy (3-6,8,9). PEG was originally developed as an alternative to surgery in high-risk patients. The attractive characteristics of this procedure are ( a )performance a t the bedside, (b)need for intravenous and local sedation only, (c)decreased cost, ( d ) direct visualization of any gastric pathology, and

(el only a short-duration postprocedural ileus. Disadvantages of this technique include the need to perform endoscopy on all patients, the inability to introduce the endoscope in cases of esophageal obstruction, and wound infections due to contamination of the tube as it Dasses the normal flora of the oropharynx. In adults, PEG had good results, which were equal or better than those of surgery; however, radiologically guided gastrostomy was introduced as another and possibly better access option (8-10). In adults, fluoroscopically guided percutaneous gastrostomy has the same advantages over surgery as PEG, excluding the ability to be performed a t the bedside. Additional advantages over the endoscopic alternative include the need for only local sedation, a higher technical success rate, usability in cases of esophageal obstruction, and a smaller risk for aspiration (10). In several large reviews, results of radiologic gastrostomies, including 30-day mortality, procedure-related mortality, major complications, and minor complications, were equivalent or superior to those from PEG or surgery (1,2,8, 9,11,12). These results from over 500 reported placements support percutaneous radiologic gastrostomy as a preferred method of placement in the adult population in many situations (1,2,12). Although experience is extensive in adults, reported pediatric gastrostomy series are limited. A technique involving both an antegrade and percutaneous approach has been reported by Keller et al in a 2-year-old child with cyanotic congenital heart disease and in 25 pediatric cases reported by Towbin et al (3,5). In the series of Towbin et al, US was performed to identify the left hepatic lobe, and a limited contrast material enema was used to identify the transverse colon. The authors used a 14-F gastrostomy tube with a flexible crossbar to maintain intragastric fixation. No major complications occurred. Minor complications included only local wound infection (n = 3).

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Over the 20-month follow-up, no tube dislodgments had occurred. Tubes were removed by cutting the tube flush with the skin and allowing the tube and crossbar to pass rectally (5). Using a technique that eliminated the need for antegrade manipulations, vansonnenberg e t a1 performed percutaneous gastrostomies in two children without complication (4). Cory et al expanded the experience with this technique through 16 percutaneous gastrostomies in 14 infants and children (6). In two cases, postprocedural septicemia developed and required antibiotics. Also, two catheters became dislodged and necessitated a second complete procedure for placement. No major complications or infections a t the gastrostomy site occurred. Our series provides more experience with pediatric percutaneous gastrostomy using the procedure as it is commonly employed in adults. As in many other fluoroscopic and endoscopic gastrostomy series, neurologic disorders were the most common indication for placement (1,2,5,8).Our technique differs from previously described pediatric methods in several ways. First, identification of the interposing bowel between the stomach and the anterior abdominal wall is made only with fluoroscopy. Identification of the left lobe of the liver with sonography was not done. Second, preprocedural evaluation of GE reflux was not done. Third, coiling the guide wire within the gastric body and distending the stomach with air provided sufficient stabilization for tract dilation and tube insertion: thus, an antegrade approach was not needed. Fourth, T fasteners or crossbars were not routinely used. Our infection prevalence in six of 27 patients is higher than that seen in large adult series (1,2). This may be due in part to our low threshold of classification. Local infections were not culture proved, and diagnosis was only based on local erythema, local tenderness, and any discharge. We believe that the 0-prolene skin suture is unrelated to infection since it

is used in our adult patients with only a 4.4% local infection rate (1). Although the preprocedural presence of reflux was unknown. antireflux precautions were implemented and there was no clinical or radiographic evidence of aspiration in any patient with a Cope gastrostomy tube. Interestingly, in animal experiments, Papaila et a1 reported no statistical difference in lower esophageal sphincter pressure (LESP) following percutaneous gastrostomy without anterior fixation of the stomach. However, with anterior fixation, LESP significantly decreased following percutaneous gastrostomy (13). In the single patient who died, a new Foley feeding catheter had been inserted in the emergency room 3 months after radiologic gastrostomy. Although it is not definitively known, the emesis of fresh tube feedings and the radiographic location of the Foley tip suggest that the Foley balloon may have obstructed the pylorus, causing reflux of feedings. Foley catheter gastrostomy tube complications include esophageal rupture, mediastinitis, pneumothorax, gastric or bowel erosions, necrosis, perforation, pneumatosis, enteroenteric fistula, gastrocolic fistula, and small bowel obstruction (14). In our experience, the potential for these complications has precluded Foley catheter use. We leave the Cope tube in place during tract maturation with subsequent conversion to a gastric button if desired. Early in our experience, conversion to a button was not offered. More recently, the decision was based on parental preference and the child's activity level after discussion with the radiologist. All seven tubes that were unintentionally removed were easily replaced through recannulation. Since the tracts were well formed, T fasteners (which were not used in any of these cases) would not have provided any additional long-term benefits. The 0-prolene suture does provide tube security in the short-term but often erodes out of the skin over time. In three cases, both the braided Cope suture and the 0-prolene suture

broke, allowing the self-retaining intragastric loop to uncoil and the tube to extrude. Presumably, broken sutures were the likely cause in the four other instances of accidental tube removal. Close attention by family members to the skin suture and intermittent follow-up examinations may detect suture breakage before accidental tube removal. However, management within 48 hours of accidental removal through tube replacement via recannulation alleviates the need for a second percutaneous gastrostomy. Tube migrations occurred nine times but in only three patients (11%).Active peristalsis in combination with a low antral gastric puncture may direct the catheter into the small bowel. Retraction and fixation of the Cope loop to the anterior gastric and abdominal wall minimize the intragastric catheter length. This maneuver along with a more cephalad access route should decrease the prevalence of tube tip migration. Since tube tip migration can be frequent in a small number of children, and the average inadvertent tube removal occurred 3 months after placement, conversion to a gastric button may be very beneficial 12 weeks following the procedure.

CONCLUSIONS Interval or permanent nutritional support via gastrostomy catheters will continue to be of benefit in sick infants and children. Percutaneous gastrostomy performed under fluoroscopic guidance is a safe and effective method of access for long-term enteral nutrition in the pediatric population. References 1. Hicks ME, Surratt RS, Picus D, Marx MV, Lang EV. Fluoroscopically guided percutaneous gastrostomy and gastroenterostomy: analysis of 158 consecutive cases. AJR 1990; 154:725-728. 2. Halkier BK, Ho CS, Yee ACN. Percutaneous feeding gastrostomy with the Seldinger technique: review of

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252 patients. Radiology 1989; 171: 359-362. Keller MS, Lai S, Wagner DK. Percutaneous gastrostomy in a child. Radiology 1986; 160:261-262. vansonnenberg E, Wittich GR, Edwards DK, et al. Percutaneous diagnosis and therapeutic interventional radiologic procedures in children: experience in 100 patients. Radiology 1987; 162:601-605. Towbin RB, Ball WS, Bissett GX. Percutaneous gastrostomy and percutaneous gastrojejunostomy in children: antegrade approach. Radiology 1988; 168:473-476. Cory DA, Fitzgerald JF, Cohen MD. Percutaneous nonendoscopic gas-

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trostomy in children. AJR 1988; 151:995-997. Wills JS, Oglesby JT. Percutaneous gastrostomy. Radiology 1988; 167:41-43. Gauderer MWL. Percutaneous endoscopic gastrostomy: a 10-year experience with 220 children. J Pediatr Surg 1991; 26:288-294. Shellito PC, Malt RA. Tube gastrostomy. Ann Surg 1985; 201:180185. Yeung EY, Ho CS. Percutaneous radiologically guided gastrostomy: an under-utilised technique. J Intervent Radio1 1991; 6:43-49. Larson DE, Burton DD, Schroeder KW, DiMagno EP. Percutaneous

endoscopic gastrostomy. Gastroenterology 1987; 93:48-52. 12. Saini S, Mueller PR, Gaa J , et al. Percutaneous gastrostomy with gastropexy: experience in 125 patients. AJR 1990; 154:1003-1006. 13. Papaila JG, Vane DW, Colville C, et al. The effect of various types of gastrostomy on the lower esophageal sphincter. J Pediatr Surg 1987; 22: 1198-1202. 14. O'Keefe KP, Dula DJ, Varano V. Duodenal obstruction by a nondeflating Foley catheter gastrostomy tube. Ann Emerg Med 1990; 19:1454-1457.

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 ...
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