Published online before print May 5, 2008, 10.1148/radiol.2481061193
(Radiology 2008;248:247-253.)
© RSNA, 2008
Gastrostomy and Gastrojejunostomy Tube Placements: Outcomes in Children with Gastroschisis, Omphalocele, and Congenital Diaphragmatic Hernia1
Jodine Rosenberg, BSc,
Joao G. Amaral, MD,
Cindy M. Sklar, BSc,
Bairbre L. Connolly, MD,
Michael J. Temple, MD,
Philip John, MD, and
Peter G. Chait, MD
1 From the Department of Diagnostic Imaging, Division of Image Guided Therapy, the Hospital for Sick Children, 555 University Ave, Toronto, ON, Canada M5G 1X8. Received July 11, 2006; revision requested September 13; revision received October 16, 2007; accepted January 8, 2008; final version accepted January 31.
Address correspondence to J.G.A. (e-mail: joao.amaral{at}sickkids.ca).
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ABSTRACT
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Purpose: To retrospectively evaluate the technical success, safety, and outcomes of radiologically guided retrograde percutaneous gastrostomy and gastrojejunostomy tube placements in terms of weight gain and growth in children with gastroschisis, omphalocele, and/or congenital diaphragmatic hernia (CDH).
Materials and Methods: Research ethics board approval, with waived informed patient consent, was obtained for review of the data of 37 children (17 male, 20 female; age range, 1–20 months; mean age, 4.3 months) in whom gastrostomy or gastrojejunostomy tubes were inserted between 1995 and 2004. Twenty-two patients had CDH, eight had gastroschisis, five had omphalocele, and two had both CDH and omphalocele. The technical success and complications of the procedures were recorded. Tube maintenance problems were analyzed separately from postprocedural complications. Initial and final patient growth percentiles were compared by using a one-sided paired Student t test.
Results: Thirty-six of the 38 procedures performed in the 37 patients were successful. There were three intraprocedural complications (two cases of access difficulty, one case of bleeding) and three major complications (one skin and prosthetic material infection, one track loss during tube replacement, one delayed gastrostomy track closure necessitating surgery). Sixteen patients had at least one minor complication (cellulitis, feeding intolerance, skin-site bleeding, intussusception). Twenty-two patients had at least one tube maintenance problem. All patients gained weight (mean weight gain, 4.7 kg) after the procedure, with a significant increase in growth percentile (average increase, 6.5%; P = .029).
Conclusion: Radiologically guided percutaneous gastrostomy and gastrojejunostomy tube placements in children with gastroschisis, omphalocele, and/or CDH are associated with high success rates and low major complication rates. Although tube maintenance problems and minor complications are common, use of gastrostomy and gastrojejunostomy tubes effectively improves nutritional support.
© RSNA, 2008
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INTRODUCTION
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Omphalocele and gastroschisis are congenital abdominal wall defects that result in herniation of the peritoneal contents through the abdominal wall with (omphalocele) or without (gastroschisis) a membranous cover (1). Congenital diaphragmatic hernia (CDH) refers to a defect in the diaphragmatic muscle, with passage of abdominal contents into the chest cavity. The majority of children with these disorders have high rates of successful surgical repair and survival and go on to live normal lives (2–4). However, nutritional problems can be a source of morbidity for survivors because some of them have feeding aversion, prolonged bowel dysmotility, and/or gastroesophageal reflux; these conditions typically require the placement of a gastrostomy or gastrojejunostomy tube.
Gastrostomy and gastrojejunostomy tubes effectively enable long-term nutrition in children who are unable to consume food by mouth. Radiologically guided percutaneous gastrostomy has become a widely accepted procedure since it was introduced in 1981 (5). With ultrasonography (US) and fluoroscopy as guiding tools, interventional radiologists can ensure the correct placement of gastrostomy or gastrojejunostomy tubes with lower morbidity and fewer major complications compared with the morbidity and major complications associated with using percutaneous endoscopic or surgical techniques, as reported in previous studies in the English-language literature (6–10).
Despite the successes in using the radiologically guided technique, inserting gastrostomy or gastrojejunostomy tubes in patients with omphalocele, gastroschisis, and/or CDH can be challenging to interventional radiologists. After undergoing surgical repair, these patients often have a distorted abdominal anatomy or adhesions. The stomach, liver, spleen, and bowel may be located in an unusual position, and the associated adhesions may prevent the approximation of the stomach to the abdominal wall. These anatomic changes may turn a simple gastrostomy or gastrojejunostomy tube placement into an extremely difficult procedure for the interventional radiologist. The purpose of this study was to retrospectively evaluate the technical success, safety, and outcomes of retrograde percutaneous gastrostomy and gastrojejunostomy tube placements in terms of weight gain and growth in children with gastroschisis, omphalocele, and/or CDH.
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MATERIALS AND METHODS
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Patients
The study was conducted with approval from The Hospital for Sick Children Institutional Research Ethics Board; the requirement for informed patient consent was waived. Of 356 patients treated in the tertiary pediatric center between May 1995 and March 2004, 119 received a diagnosis of gastroschisis or omphalocele and 237 received a diagnosis of CDH. In 37 (10.4%) of these 356 patients, a gastrostomy or gastrojejunostomy tube was inserted by an interventional radiologist (P.G.C., B.L.C., M.J.T.) (Table 1).
There were 17 male patients and 20 female patients (age range, 1–20 months; mean age, 4.3 months). The weights of these patients at the time of tube insertion ranged from 2.3 to 6.8 kg (mean weight, 4.3 kg). All patients were below the 10th percentile for growth at presentation. The specific indication for percutaneous placement of a gastrostomy or gastrojejunostomy tube was nutritional support for 29 patients, gastroesophageal reflux for seven patients, and recurrent aspiration for one patient.
Tube Insertion
Radiologically guided retrograde percutaneous gastrostomy or gastrojejunostomy was performed as previously described (6,11). A pediatric interventional radiologist performed all procedures: A radiologist (P.G.C.) with an average of 8.6 years experience (range, 4–13 years experience at the time of the procedure) performed 16 procedures. A radiologist (B.L.C.) with an average of 4.1 years experience (range, 2–7 years experience at the time of the procedure) performed 13 procedures. A radiologist (M.J.T.) with an average of 2.0 years experience (range, 1–4 years experience at the time of the procedure) performed nine procedures.
Procedures were performed with sedation, general anesthesia, and/or local anesthesia induced in the patients. The hemoglobin levels and platelet counts were routinely measured before the procedure in the children younger than 1 year. Antibiotics (30–40 mg of cefazolin [Novopharm, Toronto, Ontario, Canada] per kilogram of body weight) were administered intravenously at the beginning of the procedure. The positions of the lower edges of the liver and the spleen were marked on the skin by using US. The colon was then identified by using diluted barium, which was injected rectally with fluoroscopic guidance. Glucagon (0.1–0.3 mg) (Eli Lilly Canada, Toronto, Ontario, Canada) was administered to induce gastroparesis and pyloric constriction. To choose a site for placement of a gastrostomy tube, we inflated the stomach with air delivered through a nasogastric tube. The chosen puncture site was infiltrated with lidocaine (Xylocaine 1%; Astra-Zeneca Canada, Mississauga, Ontario, Canada) by using a 27-gauge needle, and the stomach was punctured with an 18-gauge needle (BSDN; Cook, Bloomington, Ind) that contained a pediatric retention suture (Cook). Nonionic iodine contrast material (iohexol, Omnipaque 300; GE Healthcare Canada, Mississauga, Ontario, Canada) was injected to confirm the intragastric position of the needle, and one retention suture was deployed into the stomach with a 0.035-inch straight guidewire. A Coons dilator (Cook) was then used to dilate the track to the same size as the gastrostomy tube. The dilator was removed, and the gastrostomy tube (Dawson-Mueller Mac-loc Tube; Cook) of a chosen size (8.5–10.2 F) was introduced over the guidewire. To confirm the correct tube placement or identify any leaks, we checked the tube position by using contrast material. The retention suture was cut 14 days after the procedure.
If the insertion of a gastrojejunostomy tube was required for the primary procedure, access was gained by using the same approach used to gain access for gastrostomy and a 0.035-inch Benston wire (Cook) was advanced through the needle deploying the retention suture. A 5-F directional catheter (JB1 Catheter; Cook) was introduced over the guidewire. Both the catheter and the guidewire were maneuvered out of the pylorus and into the duodenum and proximal jejunum. The catheter was removed once the guidewire was in position, and after the track was dilated to the required size, a gastrojejunostomy catheter (8.5–10.0-F/5-F Ultrathane Carey Alzate Coons pediatric catheter, or 8-F Ultrathane pediatric gastrojejunostomy catheter; Cook) was introduced over the guidewire. The position of the gastrojejunostomy tube was then confirmed with contrast material.
Data Collection
A chart review was conducted (by J.R. or J.G.A.) from the time of tube insertion until either the time of tube removal or the date of the last recorded tube checks. Additional patient- and procedure-related information (eg, type of anesthesia) was also obtained from the computer database of the Image Guided Therapy Center or from the radiology information system.
The procedure success rate was calculated. Gastrostomy or gastrojejunostomy tube placement was considered to be successful if the tube was correctly placed during the first attempt. If a gastrostomy tube could not be inserted, the procedure was deemed unsuccessful. If a gastrojejunostomy tube insertion was attempted but no tube or only a gastrostomy tube could be inserted, this procedure was also deemed unsuccessful. The numbers and types of procedures performed in each patient and the total number of tubes inserted were documented.
All procedural fluoroscopic images were reviewed, and the tube insertion position (right or left upper quadrant, right or left flank, right or left lower quadrant, epigastrium, umbilical region, or hypogastrium) was determined by two authors (J.R., J.G.A.) in consensus in an attempt to assess the technical challenges related to the distorted abdominal anatomy faced by interventional radiologists.
Complications were classified as intraprocedural or postprocedural problems. Intraprocedural complications occurred only during tube placement and included access difficulty (liver or bowel interposition) and bleeding. Postprocedural complications were further categorized into early (<30 days after procedure) or late (
30 days after procedure) complications and into minor or major complications according to standards of practice of the Society of Interventional Radiology (12): Minor complications either required no therapy or required nominal therapy and an overnight hospital stay for observation only. We considered local skin infection, site bleeding, feeding intolerance, and tube-related intussusception to be minor complications, and major complications were those that required therapy with a short hospital stay (<48 hours); required major therapy, an unplanned increase in level of care, and prolonged hospitalization (>48 hours); had permanent adverse sequelae; and/or resulted in death.
Tube maintenance problems were recorded separately from postprocedural complications as minimal or not requiring intervention. Tube maintenance problems included leaks, blockages, kinks, tube cracks and breaks, accidental removals, and position changes. Tube maintenance problems were also categorized as early (<30 days after procedure) or late (30 days after procedure) problems, and each tube maintenance problem was counted independently. This distinction was made because gastrostomy and gastrojejunostomy tube tracks mature in approximately 30 days and tube manipulations during the earlier period are associated with higher risks of track disruption.
Follow-up information regarding the average length of time the tube was in place, the presence of gastroesophageal reflux (progression and management), tube changes (from gastrostomy to gastrojejunostomy tube or vice versa), and tube removals was also collected by two authors (J.R., J.G.A.). Finally, the patient weights at the time of tube insertion and at the time of last tube check or removal were recorded. These weights were plotted according to patient age on growth charts. Initial and final growth percentiles were compared.
Statistical Analyses
Statistical analyses were conducted by using SPSS 2004, version 13.0, software (SPSS, Chicago, Ill). To assess any increases in growth percentile, we used a one-sided paired Student t test to compare the initial and final growth percentiles for each patient. P < .05 was considered to indicate statistical significance. Descriptive statistical analysis, including the calculation of means and percentiles, was also performed.
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RESULTS
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Procedures and Success Rates
Thirty-eight procedures were performed in the 37 patients (Fig 1). The tubes were placed with general anesthesia administered with the assistance of an anesthetist in 35 procedures (92%), with sedation and local anesthesia in two procedures (5%), and with only local anesthesia in one procedure (3%).
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Figure 1: Flowchart shows numbers of procedures performed and numbers of gastrostomy (G) and gastrojejunostomy (GJ) tubes inserted. One patient had a gastrostomy tube and a gastrojejunostomy tube inserted during separate procedures (*). One patient had a gastrostomy tube and a gastrojejunostomy tube inserted during the same procedure (#).
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Gastrostomy or gastrojejunostomy tube placement was initially successful in 36 (95%) of the 38 procedures (Fig 1). Two procedures were unsuccessful owing to liver and bowel interposition that caused access difficulties: In the first patient, the second attempt at placing a gastrostomy tube 4 days after failed gastrostomy was successful. This procedure was difficult because the liver blocked access to the stomach and no direct route could be found. With US guidance, a 22-gauge Chiba needle was advanced between the liver edge and the colon, and access to the stomach was gained. A 0.018-inch guidewire (Terumo Medical, Somerset, NJ) was advanced through the needle into the stomach and was snared out through the mouth. With secured access to the stomach, the abdominal wall was dilated and the gastrostomy tube finally could be inserted. In the second patient, access could not be gained because the liver and the small-bowel loops were anterior to the stomach. A repeat attempt at tube insertion was not performed in this patient, who was subsequently treated with surgical jejunostomy.
A total of 38 tubes (24 for gastrostomy, 14 for gastrojejunostomy) were inserted in 36 of the 37 patients. In two patients each, both a gastrostomy tube and a gastrojejunostomy tube were inserted: one patient with both tubes inserted during the same procedure and one patient with the tubes inserted during different procedures (Fig 1). The positions of the tubes were as follows: 19 tubes (50%) were placed in the left upper quadrant; nine (24%), in the umbilical region; six (16%), in the epigastrium; and four (11%), in the left flank (Fig 2). Five gastrostomy tubes were later converted to gastrojejunostomy tubes owing to severe gastroesophageal reflux. Five gastrojejunostomy tubes were later converted to gastrostomy tubes: in four patients after fundoplication and in one patient owing to gastrojejunostomy tube feeding intolerance.
Complications
A total of three patients (8%) had intraprocedural complications: two cases of access difficulty due to bowel interposition (major) and one case of bleeding (minor).
No postprocedural complications occurred in 12 (33%) of the 36 patients with successfully inserted tubes. Sixteen (44%) patients had at least one minor postprocedural complication (Table 2), and 22 (61%) had at least one tube maintenance problem (Table 3). After any complication, the patient's tube was checked by a gastrostomy tube clinic nurse or by a pediatric interventional radiologist (J.G.A., B.L.C., M.J.T., P.J., P.G.C.). Most skin infections were successfully treated by using topical (Polysporin Ointment; Pfizer, Arnprior, Ontario, Canada) or oral antibiotics, with good results. Intussusception was lessened by removing the tube over the guidewire, cutting the distal pigtail catheter, if present, and changing the tube position. (Cutting the distal pigtail catheter increases the risk of bowel perforation from the raw surface of the tube.)
There were only three (8%) major postprocedural complications (Table 2); the first was a late (68 days after tube insertion) abdominal wall infection that occurred after gastrostomy and gastrojejunostomy tube insertions. The patient had CDH and required a polytetrafluoroethylene patch (Gore-tex Patch; W. L. Gore and Associates, Flagstaff, Ariz) to close the abdominal wall when his hernia was repaired. Owing to extension of the abdominal wall infection and involvement of the polytetrafluoroethylene patch, the patch was surgically removed. The second major complication occurred 4 months after the insertion of a gastrojejunostomy tube in a patient with CDH. In an attempt to replace the patient's dislodged gastrojejunostomy tube, the track was lost. The patient was treated with systemic antibiotics, and a new gastrojejunostomy tube was placed at a different site 3 days later. The third major complication occurred in a 4-year-old patient with gastroschisis after the removal of a gastrostomy tube that had been in place for 3 years. The tube site in this patient did not heal spontaneously, and the patient required surgical closure of the gastrostomy track.
Patient Follow-up and Outcomes
The gastrostomy or gastrojejunostomy tubes were in the patients for an average of 18.1 months (minimal duration, 52 days; maximal duration, 56 months). In 11 patients, the tubes were removed during the study period. At the time of tube placement, 27 patients were below the third growth percentile and seven were below the 10th percentile according to age-based data plotted on growth charts. All patients in whom the tubes were used for nutritional purposes gained weight, with an average overall weight gain of 4.7 kg. When we compared the growth percentiles for each patient, there was an average percentile increase of 6.5%, which was significant (P = .029). Three patients were excluded from this analysis. In two of these patients, the tubes had never been used for feeding despite successful primary placement: One tube was inserted for gastric decompression only, and one was not used because the patient was able to eat and achieve nutrition by mouth. The other patient (described earlier) underwent unsuccessful gastrojejunostomy tube insertion and was treated with surgical jejunostomy.
Ten (71%) of the 14 patients with ongoing severe gastroesophageal reflux responded to conservative treatment measures and gastrojejunostomy tube feedings. The remaining four patients required a fundoplication after trial gastrostomy and gastrojejunostomy tube feedings. In the first three patients, gastrojejunostomy tubes had been inserted initially, and at the time of subsequent fundoplication, these tubes were converted to gastrostomy tubes. In the fourth patient, the initially inserted gastrostomy tube was converted to a gastrojejunostomy tube and fundoplication was performed 2 years later when the gastrojejunostomy tube was converted back to a gastrostomy tube. During the study period, two of the 37 children died of causes unrelated to the feeding tubes.
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DISCUSSION
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The indication for and placement of gastrostomy or gastrojejunostomy tubes in patients with gastroschisis, omphalocele, and/or CDH represent a controversial issue that has been previously discussed in the literature (3,4,13). Our study results suggest that gastrostomy or gastrojejunostomy tubes can be beneficial in selected patients with gastroschisis, omphalocele, and/or CDH: All patients gained weight after the procedure, and most of them had a maintained or increase in growth percentile. Muratore et al (4) conducted a study on nutritional morbidity with 121 survivors of CDH and concluded that nutritional problems were a source of morbidity in that patient group and that one-third of the study population (33%) required gastrostomy tube placement to increase their caloric intake. Hrabovsky et al (13) reported that despite the risk of wound infection, the use of gastrostomy tubes, as compared with the use of nasogastric tubes, in patients with abdominal wall defects had several long-term advantages, including safer and easier enteral feeding and better gastric decompression.
Grosfeld and Weber (3), however, were against the placement of gastrostomy or gastrojejunostomy tubes in close proximity to prosthetic material in infants with gastroschisis because of the risk of wound infection, sepsis, and abdominal wall separation around the tube. In their series, a gastrostomy tube was used only if there was associated bowel atresia. These authors also reported that the use of total parenteral nutrition (TPN) was sometimes required in such patients. Although TPN provides nutritional support in these infants, there are recognized risks associated with long-term TPN, including bacteremia, sepsis, central venous access difficulty, and cholestatic liver disease that sometimes leads to liver failure (2,14–16).
Tube access was initially successful in 36 (95%) of 38 procedures. Numerous studies have been conducted to compare the effectiveness of surgical gastrostomy, percutaneous endoscopic gastrostomy (PEG), and radiologically guided percutaneous gastrostomy in adults. However, to our knowledge, no study had been conducted to compare gastrostomy techniques in a pediatric population. Wollman et al (7) conducted an institutional evaluation and meta-analysis of the literature on radiologically guided, endoscopic, and surgical gastrostomy in adults without abdominal wall defects. Major complications occurred less frequently (5.9% of cases) after radiologically guided gastrostomy than after PEG (9.4% of cases). Surgical gastrostomy was associated with a significantly higher complication rate (19.9%) compared with both radiologically guided gastrostomy and PEG (P < .001). There were also substantially fewer tube-related complications with radiologically guided gastrostomy (12.1%) than with PEG (16.0%). These authors concluded that radiologically guided gastrostomy was associated with a higher success rate compared with that of PEG and with less morbidity compared with that associated with PEG and surgery.
Although we achieved a high technical success rate, inserting a gastrostomy or gastrojejunostomy tube in patients with an abdominal wall defect or CDH can be difficult. A safe and adequate window for tube access and insertion sometimes is absent. Both initially unsuccessful tube placements in our series were due to bowel interposition and access difficulty. Surgery can be performed in an attempt to correct the distorted abdominal anatomy; however, an abnormal liver, stomach, and/or bowel position, as well as small-bowel distention, sometimes remains. In addition, postsurgical peritoneal adhesions prevent bowel displacement for appropriate stomach positioning close to the anterior abdominal wall. Review of the locations of tube insertion in our patient population revealed that half (19 of 38) the tubes were placed in the umbilical region, left flank, or epigastrium. (Gastrostomy or gastrojejunostomy tubes typically are placed in the left upper quadrant in our practice.)
The major complication rate in our study was 8% (three of 36 patients). One major complication was a severe abdominal wall infection that occurred in a patient with CDH who had a gastrojejunostomy tube inserted in close proximity to a polytetrafluoroethylene patch. Wound infection is common in patients with a gastrostomy or gastrojejunostomy tube (3,13); however, such infection in the presence of a patch can be catastrophic. Therefore, the interventional radiologist and the surgeon should discuss both the extent of the need for gastrostomy or gastrojejunostomy and the exact location of the patch. The second major complication involved loss of the track during gastrojejunostomy tube replacement, which can happen with any type of gastrostomy technique. The third major complication involved a gastrostomy track that did not heal spontaneously after tube removal; this complication necessitated surgery. Although this case represented a major complication according to standards of practice of the Society of Interventional Radiology because the patient needed a surgical procedure, some authors may consider this a common finding after a track has been in place in the abdominal wall for a long time. The minor complications encountered in our study, including skin infections, bleeding, and intussusception, are common problems that often occur after tube placement for gastrostomy or gastrojejunostomy. The skin infections at the gastrostomy or gastrojejunostomy tube site usually were resolved with saline soaks and antibiotic ointment (17).
Tube maintenance problems inevitably occur in patients with long-term gastrostomy or gastrojejunostomy tubes. In our study, most maintenance problems occurred more than 30 days after the tube insertion. Some may consider tube leaks, blockages, cracks, accidental removals, position changes, and kinks as complications that necessitate an examination by the gastrostomy tube clinic nurse or an unscheduled tube check or change by a pediatric interventional radiologist. However, these protocols can be inconvenient to the patient and family, and they expend hospital resources. After an active child has had a tube in place for several months, mechanical issues frequently occur; these are not necessarily complications related to the tube placement; rather, they may be maintenance problems that can occur with the prolonged use of any tube. We do not routinely change gastrostomy or gastrojejunostomy tubes at our institution, although some physicians at other institutions do.
There were limitations in our study. This was a retrospective review of data from a small patient sample. A larger sample would have yielded more statistical power. Also, only the initial and final patient growth percentiles were compared. If the patient weights throughout the study period had been available, a more thorough analysis of each patient's growth and weight gain could have been performed. Furthermore, the population whose data were used in this study was a subset of patients with congenital abnormalities from a single institution; thus, they may not have been representative of all patients with abdominal wall defects. No comparisons with other insertion techniques could be performed. Surgical gastrostomy was reserved for those patients in whom radiologically guided gastrostomy was unsuccessful.
Despite anatomic difficulties, radiologically guided retrograde percutaneous gastrostomy and gastrojejunostomy tube placements in children with gastroschisis, omphalocele, and/or CDH are associated with high technical success rates and low major complication rates, and they lessen the majority of the nutritional problems experienced by patients who undergo them. Tube maintenance problems and other minor complications are common.
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ADVANCES IN KNOWLEDGE
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- Radiologically guided percutaneous gastrostomy and gastrojejunostomy tube placements in children with gastroschisis, omphalocele, and/or congenital diaphragmatic hernia (CDH) had a high success rate (95%) and a low major complication rate (8%).
- Although tube maintenance problems and other minor complications were common, gastrostomy and gastrojejunostomy tube placements effectively improved nutritional support in the pediatric patient sample.
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IMPLICATIONS FOR PATIENT CARE
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- Despite anatomic difficulties, radiologically guided retrograde percutaneous gastrostomy and gastrojejunostomy tube placements can be successfully performed in children with gastroschisis, omphalocele, and/or CDH to improve nutritional support.
- Gastrostomy and gastrojejunostomy tube maintenance problems and other minor complications are common.
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FOOTNOTES
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Abbreviations: CDH = congenital diaphragmatic hernia
Author contributions: Guarantors of integrity of entire study, J.R., J.G.A.; study concepts/study design or data acquisition or data analysis/interpretation, all authors; manuscript drafting or manuscript revision for important intellectual content, all authors; manuscript final version approval, all authors; literature research, J.R., J.G.A., C.M.S., B.L.C., P.J., P.G.C.; clinical studies, J.R., J.G.A., C.M.S., B.L.C., P.J., P.G.C.; statistical analysis, J.R., J.G.A.; and manuscript editing, all authors
Authors stated no financial relationship to disclose.
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References
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ABSTRACT
INTRODUCTION
