Complications Associated With Image-Guided Gastrostomy and Gastrojejunostomy Tubes in Children
* Division of Pediatric Medicine and Pediatric Outcomes Research Team, University of Toronto, Toronto, Ontario, Canada
Department of Family Medicine, McGill University, Montreal, Quebec, Canada
Department of Diagnostic Imaging, Hospital for Sick Children, and Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Objective. To evaluate the complications associated with the image-guided insertion of gastrostomy (G) and gastrojejunostomy (GJ) tubes in children, performed by the retrograde percutaneous route.
Methods. A convenience sample of 208 charts of 840 patients recorded as having G and/or GJ tubes placed by the interventional radiology service in a 4-year period (1995–1999) at the Hospital for Sick Children in Toronto, Canada, were selected for review. Complications were categorized as major (including subcutaneous abscess, peritonitis, septicemia, gastrointestinal bleeding, and death) or minor.
Results. In total, 253 tubes (208 G tubes, 41 GJ tubes, 4 G and GJ tubes) were placed in the 208 patients reviewed. The median age at the time of insertion was 15 months (range: 7 days–18 years). The most common diagnostic category was neurologic disease (47%). The main indications for tube insertion were recorded as failure to thrive (57%) and risk of aspiration (47%). Major complications were seen in 5% of patients. Peritonitis was noted in 3%, and there was 1 death related to tube insertion (0.4%). Minor complications were found in 73% of patients, including tube dislodgement (37%), tube leakage (25%), and G-tube site skin infection (25%). GJ tubes had a higher rate than G tubes of obstruction, migration, dislodgement, leakage, and intussusception. Site infection, gastroesophageal reflux, and bleeding from the site were seen less frequently in patients with GJ tubes compared with G tubes.
Conclusion. G and GJ tubes placed by the image-guided retrograde percutaneous method are associated with a wide range of complications. The majority of these are minor and are predominantly related to tube maintenance, but major complications, including death, do occur.
Key Words: gastrostomy tube • gastrojejunostomy tube • image-guided • complications
Abbreviations: G tube, gastrostomy tube • GJ tube, gastrojejunostomy tube • PEG, percutaneous endoscopic gastrostomy • GER, gastroesophageal reflux
The placement of gastrostomy tubes (G tubes) and gastrojejunostomy tubes (GJ tubes) has become a widely accepted method of providing enteral nutrition.1 Previous studies have reported the low morbidity and high success rates of the percutaneous nonendoscopic or radiologic gastrostomy technique.1–9 However, few studies evaluated the complications associated with radiologic G and GJ tube insertion in a large pediatric population.2–4
There has been a marked increase in the number of patients in our hospital who receive G and GJ tubes since the introduction of the image-guided, retrograde percutaneous technique. In the year before the introduction of this technique (1989), 60 G tubes were inserted surgically. One decade later in 1999, 230 tubes were inserted by the image-guided technique, in addition to the G tubes placed surgically in patients who required other surgical interventions, eg, fundoplication. This 4-fold increase in the number of tubes being placed may relate to the ability of the interventional radiologists with their minimally invasive technique to place tubes without general anesthesia2–4 in even the most medically fragile patients who were not believed to be candidates for anesthesia or surgery in the past. In a previous review from our hospital, the failure rate with this technique was quoted as 1.2%.2 All patients undergo a standardized screening process by the enterostomy nurse practitioner together with a general pediatrician to review the indications and investigations done before scheduling of the tube insertion.
We have noticed a number of unusual complications after enterostomy tube insertion (eg, peritonitis, intussusception), in addition to the rare tube-related death, which were not mentioned in our previous review published in 1996.2 The purpose of our study was to describe the complications related to the insertion of G and GJ tubes performed by the image-guided retrograde percutaneous route. As this procedure becomes more common, it is important that the physicians and the rest of the multidisciplinary team who look after these patients be aware of the potential complications.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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The study was conducted at the Hospital for Sick Children, a tertiary care pediatric hospital with 320 inpatient beds, affiliated with the University of Toronto in Ontario, Canada. A list of all 840 patients who had a G or GJ tube placed by the interventional radiologists between 1995 and 1999 was obtained. A convenience sample of 208 of these patients, representative of all 5 years of the review, were included in this retrospective audit. After the charts were obtained, all inpatient and outpatient visits (including those to any of the hospital clinicians) and documentation of telephone calls were reviewed in full detail by the first 2 authors (J.N.F., S.A.) from the time of tube insertion until the time of the review. Demographic data including age, weight at time of tube insertion, underlying diagnosis, and indication for tube insertion were recorded. The research was approved by the Hospital for Sick Children Research Ethics Board.
Technique
A full description of the percutaneous retrograde G tube insertion technique is beyond the scope of this article.2 Briefly, the colon is outlined by dilute barium, and the liver and spleen are marked by ultrasound. The stomach is inflated with air injected through a nasogastric tube after intravenous glucagon has been given. Local anesthetic is injected around the site chosen for puncture. The distended stomach is punctured under fluoroscopic control, and a retention suture is deployed with a wire. The tract is dilated over the wire before advancing the pigtail catheter over the wire. The wire is removed, and the pigtail is formed in the stomach. The stomach is held in apposition to the anterior abdominal wall by the retention suture.
Definition of Complications
A list of possible complications of enterostomy tube insertion were collected a priori from the relevant medical literature.1–8,10–14 Both early (within 30 days) and late (after 30 days) complications were assessed. Consensus was reached on classification of these complications as major (requiring significant medical intervention) or minor (requiring minimal or no intervention). For example, tube dislodgement would be considered a major complication if it occurred in the first week after insertion before the tract had matured, necessitating replacement in a new site; after a week, however, it was classified as a minor complication if it could be replaced over a wire through the same site. It was decided that ongoing tube maintenance problems (eg, occlusion, breakage of the catheter), resulting in a nonelective tube change or requiring intervention by hospital personnel, would be classified as minor complications. Multiple occurrences of the same complication involving the same tube were counted once only.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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A total of 253 tubes were placed in the 208 patients reviewed. Of the 253 tubes placed, 208 (82%) were G tubes, 41 (16%) were GJ tubes and 2 (2%) were both G and GJ tubes. There were no unsuccessful placements. The follow-up period ranged from 5 months to 5 years. The median age of the patients at the time of insertion was 15 months (range: 7 days–18 years). Patient weights at the time of tube insertion ranged from 1.7 to 93 kg.
Underlying disease processes included neurologic disease in 47%, 17% with "'syndromes," 14% with cardiac disease, 8% with cancer, and the remaining 14% with a combination of respiratory or gastrointestinal problems in addition to failure to thrive and human immunodeficiency virus. Specific indications for tube placement are listed in Table 1. Most of the children had >1 indication for tube insertion recorded. The incidence of major (5%) and minor (73%) complications is presented in Tables 2 and 3, respectively.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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We found a major complication rate of 5% and a minor complication rate of 73% after the insertion of G and GJ tubes by the image-guided retrograde percutaneous route. Although the 5% rate of major complications that we found in this review is comparable to numbers (5.9%) quoted in the meta-analysis of Wollman et al,1 the incidence of minor complications (affecting 73% of tubes) is extremely high and compares unfavorably with other figures quoted in the literature.1–6,8 This is because many would consider that the majority of our "minor" complications, including dislodgement after the first week (37%), leakage (26%), obstruction (12%), and migration (12%), are more appropriately classified as tube maintenance problems and are not really complications at all. We chose to include these as they resulted in some intervention involving either an unscheduled tube change or a visit to the nurse practitioner, which we wanted to record because of the inconvenience to the patient and the family as well as a measure of resource utilization.
This study has some strengths and limitations. Our institution is recognized as an international leader in the radiologic placement of enterostomy tubes by the retrograde percutaneous technique.2 This was a large sample with a meticulous review of both inpatient and outpatient follow-up, which was not possible in our previous review2 as a result of a less formalized system of recordkeeping at the time. Unfortunately, because of the large group of patients, we were able to review only a convenience sample from the total number, and as this was a retrospective review, it is possible that we could have missed some complications. We do not think that sampling error or bias was a major issue, as all of the requested charts were available and our incidence of complications was similar (in the case of major)1 and higher (in the case of minor)1–6,8 when compared with those reported previously.
The safety of the newer radiologic technique for enterostomy tube insertion is supported by good evidence.1,2, 5 Wollman et al1 conducted a meta-analysis of all patients who underwent enterostomy published in the literature from 1980 to 1995, to evaluate the effectiveness and safety of radiologic, percutaneous endoscopic (PEG), and surgical gastrostomy. The population was largely an adult one; however, no study has compared the 3 methods of G tube insertion in a similar manner in a pediatric population. Rates of successful tube placement were significantly higher for radiologic gastrostomy than for PEG (99.2% vs 95.7%; P < .001). Major complications occurred less frequently after radiologic gastrostomy (5.9%) compared with PEG (9.4%), and surgical gastrostomy had a significantly higher complication rate than both (19.9%; P < .001). Minor complications were not significantly different for radiologic versus PEG (7.8% vs 5.9%) but were significantly higher for surgical gastrostomy (9.0%; P = .02). Some patients may be more suitable for PEG or surgical tube placements.9 These include patients in whom the stomach may not be accessible percutaneously because of interposition of bowel or other organs (eg, massive hepatosplenomegaly) as well as those with portal hypertension and gastric varices, for which endoscopy is helpful to avoid bleeding.9 Patients who require another surgical procedure (eg, fundoplication) will often have their tube placed surgically at the same time.
Different techniques are used for radiologic gastrostomy tube insertion. Chait et al2 reported the largest collection of data on radiologically placed G tubes using the retrograde technique in children. Early complications occurred in 9.4% and were made up of skin infection, stoma irritation, and tube dislodgement. Late complications occurred in 20% and consisted of stoma irritation, skin infection, tube leakage, and discomfort during feeding. Two (0.5%) patients underwent laparotomy, 1 as a result of extragastric misplacement and 1 as a result of small-bowel transgression. There were no recorded cases of peritonitis, intussusception, or tube-related deaths. Several smaller studies have looked at the safety and utility of image-guided percutaneous gastrostomy in children.6–8 All have reported high success rates, with few if any major complications and low minor complication rates.
Our study found that peritonitis was the most common major complication (3%) but has not been reported in previous reviews. Children who develop peritonitis after radiologic gastrostomy may present with vomiting, fever, irritability, tachycardia, and progressive peritoneal signs. This can progress to sepsis syndrome and death, as in the case of our patient who died. Early recognition can often be difficult, especially in young infants, in whom irritability may be misinterpreted as a sign of hunger, or in the severely neurologically impaired child, in whom vomiting, irritability, and abdominal rigidity/spasticity are often related to their underlying problem. When peritonitis occurs early after radiologic gastrostomy, it may be attributable to leakage of small amounts of gastric contents into the peritoneal cavity around the G tube site.9,10 Intraperitoneal placement of the tube or dislodgment of the tube from the stomach into the peritoneal cavity may uncommonly also result in peritonitis.9,10
Any child with suspected peritonitis after radiologic gastrostomy requires prompt evaluation. Feeds should be held, and an urgent G tube check should be performed to confirm position of the G tube and to rule out leakage of gastric contents into the peritoneum. Pneumoperitoneum is a common normal finding immediately after radiologic gastrostomy; however, late or increasing pneumoperitoneum may represent unrecognized perforation of the gastrointestinal tract or ongoing leak around the G tube site.9 Conservative management, including bowel rest, total parenteral nutrition, empiric antibiotics, and close observation, is usually sufficient, but a surgical consultation may be required. Transgression of the small intestine and colon during insertion, migration of the gastric pigtail into the tract, and significant enlargement of the stoma necessitating tube removal have also been observed by the authors but were not seen in our sample of patients.
Sixteen percent of patients had a GJ tube inserted as their initial procedure. In our institution, this is usually on the basis of severe gastroesophageal reflux (GER) and aspiration pneumonia or failure to tolerate nasogastric feedings.3 The technique of insertion is similar and the GJ tube has a distal pigtail with side holes and a proximal locking loop that sits in the stomach.2, 3 Comparing G and GJ tubes, GJ tubes were at a higher risk for obstruction, migration, dislodgment, leakage, and intussusception. Intussusception was found in 20 of the 41 patients who had a GJ tube inserted and was not found in any of the patients with G tubes. Site infection, GER, and bleeding from the site were seen less frequently in patients with GJ tubes.
Albanese et al11 reported an 11.8% incidence of major complications and a 44.1% incidence of minor complications in 44 neurologically impaired children with GER with radiologically placed GJ tubes via an anterograde approach. Others3,12 have shown a high incidence of persistent vomiting despite GJ feeds and that minor complications such as accidental dislodgement are common. Larger and older children tend to have fewer complications than smaller and younger children.12
Small-bowel intussusception around radiologically placed GJ tubes in children has been described previously.3,13, 14 This occurs when a segment of the intestine (the intussusceptum) with the tube inside is enfolded into the contiguous segment (the intussuscipiens). Connolly et al13 reported on the use of sonography as well as fluoroscopy in diagnosing the intussusception in these cases. Predisposing factors seem to include male gender, young infants, and the presence of a distal pigtail on the tube.14 The usual presentation is with vomiting (often bilious) and intolerance of feeds. Patients rarely present with abdominal pain, and some may be entirely asymptomatic. The intussusception is often transient or intermittent. Most intussusceptions have been managed successfully by replacing the GJ tubes with standard or shortened GJ tubes with no distal pigtail.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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G and GJ tubes placed by the retrograde percutaneous method are associated with many different complications. The majority of these are minor and are predominantly related to tube maintenance, but major complications, including death, do occur.
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FOOTNOTES |
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Received for publication Aug 12, 2003; Accepted Dec 29, 2003.
Reprint requests to (J.N.F.) Division of Pediatric Medicine, Hospital for Sick Children, 555 University Ave, Toronto, Ontario M5G 1X8, Canada. E-mail: jeremy.friedman{at}sickkids.ca
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PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics
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