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CIRSE STANDARDS OF PRACTICE GUIDELINES
CIRSE Standards of Practice Guidelines on Gastrostomy
James Sutcliffe1 • Andrew Wigham1• Niall Mceniff2 • Petr Dvorak3 •
Laura Crocetti4 • Raman Uberoi1
Received: 2 June 2015 / Accepted: 6 April 2016 / Published online: 16 May 2016
� Springer Science+Business Media New York and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2016
Abstract
Purpose Surgical Gastrostomy has been around since the
19th century but in 1980 the first successful percutaneous
endoscopic gastrostomy was reported. A year later the first
successful percutaneous gastrostomy was performed using
fluoroscopic guidance. The technique for percutaneous
insertion and the equipment used has been refined since
then and it is now considered the gold standard for gas-
trostomy insertion. Here we present guidelines for image-
guided enteral feeding tubes in adults.
Material and Method We performed a review and analysis
of the scientific literature, other national and international
guidelines and expert opinion.
Results Studies have shown fluoroscopic techniques have
consistently higher success rates with lower rates of major
complications than endoscopic techniques. However, the
Achilles’ heel of many fluoroscopic techniques is the
requirement for smaller gastrostomy tube sizes resulting in
them being more prone to blockages and thus requiring
further intervention.
Conclusion Radiological feeding tube insertion is a safe
and effective procedure. Success rates are higher, and
complication rates lower than PEG or surgical gastrostomy
tube placement and innovative techniques for gastric and
jejunal access mean that there are very few cases in which
RIG is not possible. The principal weakness of radiologi-
cally inserted gastrostomies is the limitiation on tube size
which leads to a higher rate of tube blockage. Per-oral
image-guided gastrostomies have to an extent addressed
this but have not been popularised. Currently many centres
still consider endoscopic gastrostomies as the first line
unless patients are too unwell to undergo this procedure or
previous attempts have failed, in which case radioloically
inserted gastrostomies are the technique of choice.
Keywords Gastrojejunostomy/percutaneous
endoscopic gastrostomy (PEG) � Radiologicallyinserted gastrostomy (RIG) � Per-oral image-guided
gastrostomy (PIG) � Subspecialty/technique � Enteralfeeding � Sub-specialty/technique � Non-vascularinterventions � Specialty � Gastrointestinal � Organ �Stroke � Disease
Introduction
Malnutrition is prevalent in hospital inpatients with studies
showing that 29–33 % of hospital inpatients are malnour-
ished [1, 2], while almost 43 % of patients were at risk of
& Raman Uberoi
James Sutcliffe
Andrew Wigham
Niall Mceniff
Petr Dvorak
Laura Crocetti
1 Radiology Department, Oxford University Hospitals NHS
Trust, Oxford, UK
2 Radiology (DiagIm), St. James’s Hospital, Dublin, Ireland
3 Radiology Department, Faculty Hospital Charles University,
Prague, Czech Republic
4 Diagnostic Imaging and Intervention, Department of
Hepatology and Liver Transplants, University of Pisa, Pisa,
Italy
123
Cardiovasc Intervent Radiol (2016) 39:973–987
DOI 10.1007/s00270-016-1344-z
malnutrition [2]. Access for enteral nutrition may be con-
sidered for any patient with a functional gastrointestinal
tract but who is unable to swallow safely [3]. Beyond basic
hydration and nutrition, the aim of enteral feeding is to
attenuate the metabolic response to stress, prevent oxida-
tive cell injury and to favourably modulate the immune
response [3]. Gastrostomy feeding is a well-established
technique to enable long-term enteral feeding for those
patients in whom oral intake is either not possible or
unsafe, and early gastrostomy feeding has been shown to
improve recovery from ischaemic stroke and reduce overall
complications from gastrostomy insertion [4, 5].
Surgical gastrostomy has been performed since the
nineteenth century, but requires a general anaesthetic,
which is associated with high morbidity, and mortality, and
consequently, it has been replaced by percutaneous meth-
ods. In 1980, Gauderer and Ponsky [6] described the first
successful percutaneous technique with the aid of endo-
scopy. A year later, Preshaw described the first successful
percutaneous technique using fluoroscopic guidance [7].
His technique, commonly referred to as radiologically
inserted gastrostomy (RIG), has now been established as a
safe and effective technique for enteral nutrition or gastric
decompression.
Percutaneous endoscopic gastrostomy (PEG) has tradi-
tionally been the gold standard for gastrostomy insertion. It
is readily available and allows primary insertion of large
bore gastrostomy tubes. One of the perceived advantages of
endoscopic gastrostomy insertion is the ‘free’ endoscopic
examination and potential for therapeutic intervention [8].
However, more recent studies dispute this, Laasch et al. [9]
demonstrated peptic disease in 21 % of patients undergo-
ing gastrostomy (not unexpected in starved patients) an
8.5 % incidence of other benign gastric pathology, which
did not alter patient management and no undiagnosed
malignancies. Other disadvantages of PEG tube insertion
include the increased risk of wound infection due to con-
tamination with oral flora and the potential for tumour
seeding in head and neck cancer cases. The image-guided
techniques, per-oral image-guided gastrostomy (PIG) [10]
and RIG [11] are usually successful where PEG has failed,
or in clinical scenarios where PEG cannot be performed
including a tight stenosis of the upper GI tract, a large
hiatus hernia or significant obesity where trans illumination
is difficult [10–12]. In addition, endoscopic gastrostomy
insertion almost always requires conscious sedation, which
may be contraindicated in patients with neuromuscular
weakness.
In contrast, consistently high success rates for placement
of RIG tubes are reported (95–100 %) [13, 14]. In their
meta-analysis, Wollman et al. [15] found rates of suc-
cessful RIG placement to be 99.2 versus 95.7 % for PEG.
They also found the prevalence of major complications
rates were lower in the RIG group—5.9 versus 9.4 % for
PEG [15]. However, more recent studies have demon-
strated similar complications rates [10].
The principal disadvantage of a pure percutaneous
method is the smaller sizes of tubes usually used in this
technique, which are more prone to blockage and may
require fluoroscopic guidance when exchanged [9, 12].
Modifications of the percutaneous technique allow per-oral
placement of the gastrostomy tube enabling larger bore
tubes to be inserted [9, 11, 12, 16]. Primary placement of
button type catheters that are less prone to occlusion has
also been described [12, 17].
This document contains guidelines including the indi-
cations, personnel specification, procedural steps, post-
procedure care and outcomes of image-guided enteral
feeding tubes in adult patients. It is based on review and
analysis of the available literature, other national and
international guidelines and expert opinion. It is not
intended as a set of unconditional instructions and the
judgement of the responsible healthcare professional, based
on the complexities of each case, must take precedence
over the recommendations offered here. Nevertheless, it is
anticipated that the following will provide direction in
many of the situations encountered when inserting and
maintaining gastrostomy tubes.
Definitions
Enteral Feeding
The delivery of nutrients directly into the stomach, duo-
denum or jejunum.
Gastrostomy
A stoma from the skin to the stomach through which a tube
is placed to allow additional nutritional support or some-
times for gastric decompression.
Transabdominal Access
The gastrostomy tube is inserted through the abdominal
wall into the stomach.
Transoral Access
The gastrostomy is inserted into the mouth and pulled or
pushed into the stomach.
Neurogenic Dysphagia
Neurogenic dysphagia is a disorder characterised by diffi-
culty in swallowing. It occurs as a result of nervous system
974 J. Sutcliffe et al.: Gastrostomy…
123
disorders such as stroke, motor neuron disorders, traumatic
brain injury, cerebral palsy, Parkinson’s disease and mul-
tiple sclerosis.
Radiologically Inserted Gastrostomy (RIG)
Radiologically inserted gastrostomy was first described in
1981 by Preshaw [7]. It is a Seldinger technique in which
the stomach is insufflated with air following the passage of
a nasogastric tube or peroral catheter. A needle is then
passed percutaneously into the stomach under fluoroscopic
guidance and a wire passed through the needle. A gas-
trostomy tube is then passed over the wire.
Percutaneous Endoscopic Gastrostomy (PEG)
Percutaneous endoscopic gastrostomy was first described
in 1980 by Gauderer and Ponsky [6]. It is an endoscopic
technique in which a gastroscope is passed orally into the
stomach, which is then insufflated with air. A trocar is then
passed percutaneously into the stomach and a gastrostomy
tube passed, using either a ‘‘push’’ or ‘‘pull’’ technique.
Per-Oral Image-Guided Gastrostomy (PIG)
In 1988, a hybrid technique was developed known as per-
oral image-guided gastrostomy (PIG) that allowed the
passage of larger gastrostomy tubes [18]. Like RIG, PIG is
a Seldinger technique in which the stomach is punctured
first, and the oesophagus catheterised in a retrograde
fashion. A guidewire is passed out of the patient’s mouth
and the gastrostomy advanced over the wire through the
oropharynx, through the oesophagus and stomach and out
of the gastrostomy site.
Gastropexy
Gastropexy is the method of apposing the anterior wall of
the stomach to the anterior abdominal wall. Percutaneous
gastropexy was first described in 1986 by Brown et al. [19]
and is performed in order to prevent the stomach being
pushed away during catheterisation and to reduce the risk
of peritoneal leakage. It is usually performed with metal
T-fasteners introduced percutaneously with special needles
or surgical sutures.
Pre-treatment Imaging
Adequate gastric distension by insufflation of air is
essential for gastrostomy placement. For radiological
placement, this can be done through a pre-existing naso-
gastric tube. Alternatively a standard angiography catheter
can be passed from the mouth at the beginning of the
procedure.
Before performing RIG, it is essential to identify a ‘safe
window’ for gastric puncture avoiding the left lobe of the
liver and in particular the transverse colon. This is usually
straight forward on fluoroscopy, but CT may be required in
patients with complex surgical history or large hiatus her-
nia to establish whether there is a safe percutaneous win-
dow for insertion. If difficulties are anticipated with
fluoroscopic guidance, such as difficult access to the
stomach or interposed colon, CT guidance is recommended
[11, 12].
Some operators advocate oral/nasogastric contrast
media, e.g. 100 ml barium sulphate, 50–100 % W/V,
administered 24 h before gastrostomy to opacify the large
bowel. In a recent UK multicentre survey, only 17 % of
cases were performed following the administration of oral
contrast media. Although this is a cheap and reliable
method to visualise the colon, there is no evidence avail-
able to establish whether this decreases the incidence of
colonic injury [20].
Ultrasound can be used to delineate the liver and bowel
prior to the procedure. The study by Lowe et al. [20]
showed that 30 % of cases were performed with ultrasound
to identify these structures.
Indications
Patients to be considered for gastrostomy should be at
high-risk of malnutrition and be unlikely to recover their
ability to feed orally in the short term [21], or those who
require long-term gastric decompression [12, 22–24].
These include patients with disorders such as
• Neurogenic dysphagia with high risk of aspiration
• Cerebrovascular event [9, 21, 25, 26]
• Traumatic brain injury where there is cognitive
impairment and depressed consciousness [9, 21, 27,
28]
• Cerebral palsy [9, 21]
• Neurodegenerative syndromes [9, 21]
• Head and neck malignancy—where there is local
neurological involvement, physical tumour obstruction
[29] or where side-effects of the treatment such as
radiotherapy and chemotherapy prevent adequate oral
nutrition [9, 21, 30]
• Oral/throat surgery [21, 30]
• Endoscopy contraindicated or PEG failed [9, 21]
• Gastric decompression/diversion—bowel rest in GI
fistulae [12]
• Patients with impaired absorption due to systemic
illnesses such as
J. Sutcliffe et al.: Gastrostomy… 975
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• Crohn’s disease [21, 29, 31–33]
• Systemic sclerosis [29, 34]
• Radiation enteritis [21, 29]
• Patients requiring additional nutritional supplementation
• Severe burns [35, 36]
• Hydrocephalus [29]
• Severe congenital heart disease [29]
• Anorexia [21]
• Profound depression [1].
The role of gastrostomy in decompressing small-bowel
obstruction from end-stage malignancy, the so-called
venting gastrostomy, remains to be defined.
Contraindications
Absolute
There are few absolute contraindications to enteral access.
These include
• Uncorrected coagulopathy
• Active peritonitis
• Bowel ischaemia
• GI tract obstruction (unless the indication is
decompression)
• Patients with portal hypertension and gastric varices,
which can bleed profusely.
Relative
There are a number of conditions that represent relative
contraindications to enteral access. These include:
• Ascites
• Billroth partial gastrectomy
• Large hiatus hernia and gastric volvulus
• Oesophagectomy with gastric pull through
• Colonic interposition
• Diaphragmatic denervation with superiorly displaced
stomach
• Ventriculoperitoneal shunt
• Patients on long-term steroids or immunosuppression
• Open wounds, previous incisional hernia mesh repairs
and adjacent stoma sites.
The presence of ascites has previously been regarded as an
absolute contraindication, due to the risk of bacterial
peritonitis, impaired track maturation and risk of tube
migration if the ascites re-accumulates. Gastrostomy may
be performed following paracentesis and gastropexy is
mandatory to prevent peri-tubal leakage and tube [37].
Ultrasound follow-up and repeat paracentesis is
recommended to ensure against the recurrence of large
volume ascites which can cause dislodgement even with
gastropexy placement [38].
Previous surgery such as Billroth partial gastrectomy,
and oesophagectomy with gastric pull through increase the
complexity of the procedure but careful planning and
technique modifications, such as utilisation of CT guidance
for gastric puncture and balloon dilatation of the stomach,
may render the procedure possible [29].
Colonic interposition is a relative contraindication, but
the utilisation of infracolic methods have been shown to be
successful [39]. In this situation, additional punctures from
gastropexy increase the risk of vascular injury in the
transverse mesocolon.
Neurological disorders may result in diaphragmatic
denervation and a superiorly displaced stomach. The same
applies to large hiatus herniae or gastric volvuli. To over-
come such difficulties, an angled sub-costal or intercostal
approach has been successfully utilised with no additional
morbidity [40].
The placement of a gastrostomy in patients with a
ventriculoperitoneal shunt may increase the risk of
ascending meningitis [41].
Patients on long-term steroids or immunosuppression
are predisposed to infective complications leading to stoma
retraction and have been found to be at higher risk of peri-
tubal leakage [42].
Open wounds, previous incisional hernia mesh repairs or
adjacent stoma sites are not absolute contraindications, and
if a suitable window away from the area can be identified,
then gastrostomy can be performed.
Patient Selection and Preparation
Patient selection for gastrostomy is critical and the decision
whether it is appropriate should be based on the principles
of beneficence and non-maleficence. In certain patient
groups, this is relatively straightforward. For example, in
patients with dysphagia following stroke, it has been shown
that over half will recover their neurologic function, and
gastrostomy feeding can provide valuable enteral nutrition
in the interim [43]. However, there is controversy sur-
rounding the insertion of gastrostomy tubes in patients with
advanced dementia and terminal malignancy. No consistent
benefit has been shown from gastrostomy insertion in these
patients [12, 44]. If symptoms of thirst, hunger or dry
mouth are expressed these are usually transient and can
usually be alleviated with small amounts of food, fluids
and/or by the application of ice chips and lubrication to the
lips [44]. The mortality rate in patients with advanced
dementia is not altered by gastrostomy tube placement as
the death rate is more related to the underlying condition
and co-morbidities [45]. In fact, gastrostomy tube
976 J. Sutcliffe et al.: Gastrostomy…
123
placement may actually have a negative effect on patients
quality of life due to the loss of hand feeding and the
associated touch, taste and social interaction [25] and due
to the occasional need to chemically or physically restrain
patients to prevent them from dislodging the tube [12, 43,
46]. The current literature supports an individual but crit-
ical and restrictive approach to gastrostomy feeding in
dementia patients [33].
To ensure correct patient selection for gastrostomy, all
cases must be discussed in a multidisciplinary meeting,
including the supervising clinician, the interventional
radiologist, the speech therapist and the dietician. Once the
decision has been made that gastrostomy placement is
appropriate, then the patient should be assessed on the ward
by the interventional radiologist and if possible informed
consent should be obtained. A significant number of
patients undergoing RIG are unable to give informed
consent and institutional protocols for patients lacking
capacity should be followed. The patient, their family and
caregivers should be fully included in discussions at all
stages, but the ultimate decision lies with the patient and in
cases of reduced capacity the medical team.
In some patients, such as those with neuromuscular dis-
orders or tracheostomies, anaesthetic support may be
required to ensure safe administration of sedation. If so,
anaesthetic review should be arranged prior to the procedure.
Haematological and coagulation screens should be
reviewed and acted upon accordingly. Gastrostomy place-
ment is classified as a category 2 procedure with a mod-
erate risk of bleeding in the recently published consensus
guidelines for peri-procedural management of coagulation
status [47]. These guidelines make a number of recom-
mendations (1) target haematological parameters are an
INR\ 1.5 and platelets[ 50 9 109/L, (2) If the patient is
on low molecular weight heparin then the dose before the
procedure should be stopped, (3) clopidogrel should be
stopped 5 days before the procedure and (4) aspirin can be
continued. However, given the often diverse array of
patient variables, comorbidities and concomitant haemo-
static defects management should always be tailored to the
individual patient.
The patient should have an empty stomach and any
enteral feeding should be stopped 12 h pre-procedure. A
final safety checklist should be completed in the periop-
erative setting prior to any anaesthetic. Two common
examples are the WHO surgical safety checklist for radi-
ological interventions [48] and the CIRSE interventional
radiology checklist [49]. Non-invasive monitoring equip-
ment should be applied and BP, pulse and oxygen satura-
tions should be monitored throughout the procedure. The
skin should be prepared using standard aseptic technique
and sterile drapes applied.
Personnel Specification
Ideally, the interventional team should consist of an
interventional radiologist, an operating assistant, a nurse
for supervision of the patient and observation monitoring, a
radiographer and an anaesthetist and anaesthetic assistant if
required. However, though desirable this is not always
possible. Nonetheless, the team should consist of at least
one radiologist experienced in the procedure, a nurse who
is trained to administer analgesia and sedation and who can
monitor the patient and a trained radiographer.
The operator should have appropriate image interpreta-
tion skills appropriate to gastrostomy insertion [50] and
sufficient training in radiation protection to allow optimi-
sation of medical exposures [51, 52]. The European
Commission’s Council Directive 97/43/EURATOM
establishes in Article 7 that member states shall ensure that
practitioners should have adequate and theoretical practical
training for the purposes of radiological practices, as well
as relevant competence in radiation protection [53]. Com-
petency to perform the procedure should be evaluated
locally, based upon national/international training guide-
lines. Structured assessment tools for assessing compe-
tency are being increasingly utilised in interventional
radiology training [54]. Currently, there is no requirement
for trainees to complete an examination at the end of their
training which identifies their skills as an interventional
radiologist. However, the Cardiovascular and Interven-
tional Radiology Society of Europe, the European Society
of Radiology and the European Union of Medical Spe-
cialists Interventional Radiology Division now organise
and endorse the European Board of Interventional Radi-
ology examination which aims to standardise training
across Europe and give patients and colleagues confidence
in interventional radiology [55]. No specific number of
procedures has been shown to equate to individual com-
petency. Nevertheless following formal training, it would
be prudent to have performed at least five supervised
procedures under indirect supervision by an experienced
operator prior to gaining independent practitioner status.
Two experienced practitioners should perform complex
cases. The operator should keep a log of cases and com-
plications, and local arrangements should be in place to
allow regular audit of outcomes and complications.
Equipment Specifications
The procedure should be performed with fluoroscopic
image intensification and should provide diagnostic image
quality and recording. The equipment should be capable of
an accelerating voltage [100 kVp. Digital subtraction
angiography is not necessary.
J. Sutcliffe et al.: Gastrostomy… 977
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The facility should have equipment for non-invasive
monitoring of vital signs, supplemental oxygen, suction for
the oral cavity and upper respiratory tract and be able to
respond to life-threatening emergencies.
An ultrasound machine should be available with a low
frequency curvilinear probe in cases where hepatomegaly
is suspected.
Ward placement of nasogastric tubes can save time but
if this is not possible a selective 5–6Fr per-oral catheter, for
example a cobra or vertebral configuration, with a hydro-
philic guidewire can be quick and easily performed in the
department. A 50-ml syringe will also be required for
gastric insufflation. Gastric distension is improved by
intravenous administration of a smooth muscle relaxant
such as hyoscine butylbromide or glucagon.
Standard materials include the following: gastropexy
sutures; 18G needle for gastric puncture; hydrophilic and
stiff 0.035 guidewires; serial dilators; peel-away sheath of
appropriate size (for balloon-retained device); and gas-
trostomy tube. Most gastrostomy sets include the requisite
equipment. Contrast is required for confirmation of intra-
gastric placement. The modified PIG technique requires a
haemostatic vascular sheath and may require snares.
Angioplasty balloons may be required for track dilation
and length measurement if button type devices are being
inserted.
A number of gastropexy devices are available. They
consist of a metal T-bar fastener attached to a suture and a
mechanism to enable suture fixation outside the skin. A
needle, pre-loaded with the T-fastener, is passed into the
stomach and following aspiration of air its intragastric
positioned is confirmed by the injection of contrast. The
T-fastener is then pushed through the needle into the
stomach and the needle removed. Traction can then be
applied to the T-fastener allowing gastric wall apposition
and the suture is fixed. Care should be taken to avoid
excessive traction on the sutures as gastric deflation at the
end of the procedure increases tension on the sutures.
Traditional gastropexy sutures were made of non-ab-
sorbable nylon; absorbable gastropexy sutures are now
available which obviate the need for suture removal.
There are numerous commercially available gastros-
tomy tubes. The type of tube should be selected based on
the patient requirements:
Loop Retained Tubes
These are 10–14F polyurethane tubes held in place by a
loop in the catheter, which is formed by traction on a
retaining string once intragastric position is confirmed.
They can be placed rapidly and safely often with only local
anaesthetic, which may be advantageous in patients with
neuromuscular weakness. The relatively narrow calibre and
long length leads to high occlusion rates [11] and tube
rotation or degradation of the locking thread by gastric acid
can lead to tube displacement [22].
Balloon Retained Tubes
These tubes are retained by a balloon filled with water and
are available in sizes from 10 to 22Fr. Though larger in
calibre than loop retained tubes the size of the lumen is
reduced due to relatively thick silicone walls and the
presence of the inflation channel for the balloon. The
deflated balloon adds approximately 4Fr to the nominal
tube size. Tube retention by an intact balloon is excellent
but problems with displacement still exist due inadvertent
balloon deflation or balloon rupture [56].
Low Profile ‘‘Button’’ Gastrostomy Tubes
These are very short catheters with an external hub that
just protrudes above skin level. It can be disconnected
between meals, and due to its low profile the device is
more aesthetically pleasing and harder for confused
patients to remove. It does however require a higher level
of dexterity to connect and disconnect the extension tubes.
Button gastrostomies are available with a balloon or a
mechanical retainer. The latter need less maintenance, but
require significant oversizing of the track, making these
difficult to insert and replace. Button gastrostomies were
originally designed for placement in mature tracks, how-
ever de novo placement of balloon-retained button-type
gastrostomies has been performed with a 98 % success
rate [57].
Bumper-Retained Push- and Pull-Type PEG-Tubes
Utilising the hybrid (PIG) technique allows placement of
large calibre endoscopic type gastrostomy tubes made
either of silicone or polyurethane. The push type catheters
have a long tapered dilator, which is pushed through the
mouth over the wire and through the gastrostomy track.
Pull type catheters are pulled from the mouth into the
gastrostomy track using a traction string that is passed from
below. The traction string is designed to be retrieved
endoscopically from the stomach after percutaneous
insertion. Pull-PEGs are more difficult to place radiologi-
cally and wire-guided push-PEGs are preferable. Both
push- and pull-PEGs are retained by mechanical bumpers.
Semi-solid bumpers allow removal by forced traction
under local anaesthesia. Tubes with rigid bumpers however
require removal from the mouth, either endoscopically or
after capture with a snare.
978 J. Sutcliffe et al.: Gastrostomy…
123
Procedure
Puncture sites are selected for the gastrostomy and gas-
tropexies by placing radiopaque markers, such as artery
forceps, along the costal margin to delineate them on flu-
oroscopy. Ideally the puncture sites should be to the left of
the midline, from the mid-body to the antrum and
equidistant from the lesser and greater curvatures to avoid
the gastric and gastro-epiploic vessels. They should also be
lateral to the rectus abdominis muscle in order to avoid the
inferior epigastric vessels. A curved artery forceps at the
planned puncture site easily confirms the ideal position on
fluoroscopy.
The puncture site and any planned gastropexy puncture
sites are liberally infiltrated with lidocaine, taking care to
anaesthetise the underlying peritoneum.
Radiologically Inserted Gastrostomy
To fix the stomach for a RIG procedure, metal T-fasteners
are then inserted into the distended stomach under fluoro-
scopic guidance using a needle attached to a syringe con-
taining contrast media. The position is confirmed by
aspirating air into the syringe and then injecting contrast
under fluoroscopy and looking for the typical rugae of
gastric mucosa. Once the T-fastener is deployed, the
stomach is then apposed to the anterior abdominal wall and
secured in position. Applying traction should be avoided,
as tension subsequently increases with gastric deflation at
the end of the procedure. A tight gastropexy is one of the
commonest causes of post-procedure pain.
Once gastropexy has been completed, a small skin
incision is made between the sutures with a scalpel. An
18-gauge introducer needle attached to a syringe contain-
ing contrast media is then inserted through the incision and
into the stomach and position again confirmed in the same
manner as for gastropexy. The puncture should be in the
anteroposterior plane, taking the shortest route across the
peritoneum. If primary gastrojejunostomy is performed or
future conversion anticipated, then directing the needle
towards the pylorus is helpful. After the position is con-
firmed a stiff guidewire is inserted through the needle and
coiled within the stomach. The puncture needle is then
removed, and the track is dilated to a size 4Fr larger than
the selected gastrostomy catheter. Dilation of the track can
be performed using serial dilators or an angioplasty bal-
loon. For balloon-retained devices, a peel-away sheath of
4Fr larger than the nominal tube size is used to support the
introduction of the gastrostomy catheter into the stomach.
Once inserted, the gastrostomy is secured by instilling the
recommended volume of sterile water into the retention
balloon. Finally, the position is confirmed with contrast
media injection under fluoroscopy.
Per-Oral Image-Guided Gastrostomy
In cases where a more robust PEG tube is preferable, these
can be placed non-endoscopically. For the hybrid (PIG)
procedure, the stomach is insufflated with air and local
anaesthesia applied as for RIG. Gastropexy is not required
in this case. The puncture should be directed towards the
fundus to facilitate oesophageal cannulation. Following
insertion of a guidewire, a haemostatic vascular sheath is
inserted into the stomach. A catheter and a hydrophilic
guidewire are then used to cannulate the oesophagus ret-
rogradely and the catheter advanced out through the mouth.
In the case of a push-PEG, the hydrophilic wire is replaced
with the 0.03500 exchange wire from the gastrostomy kit.
The gastrostomy can then be inserted per-orally and
advanced into place.
At least one randomized trial supports the use of gas-
tropexy for RIG, which has a number of proposed advan-
tages. It fixes the anterior gastric wall during dilation of the
track, it prevents intraperitoneal leakage of stomach con-
tents prior to track maturation, and it can be helpful in re-
siting tubes should they become dislodged prior to track
maturation [58].
Controversy exists about the number of gastropexy
sutures required with considerable variation between
groups. In their study, Shin et al. [59] reported a single
anchor technique considered to be safe and effective, but
others have demonstrated an increase in major complica-
tion rates, with a high rate of anchor dislodgement using
this technique [60]. In their multicentre survey, Lowe et al.
[20] showed that the majority of operators used two or
three gastropexy sutures.
If oesophageal access to the stomach is not possible,
then gastric distension can be achieved by directly punc-
turing the stomach with a 21G needle under ultrasound or
CT guidance, then directly insufflating through this [13].
Primary gastrojejunostomy is controversial. It is postu-
lated that placement of the tip of the catheter in the jejunum
reduces incidence of aspiration, and some advocate their
placement in patients with a history of aspiration or reflux.
Some groups have suggested the absence of clinically sig-
nificant aspiration in their group is due to primary gastroje-
junostomy placement [61], whilst others have demonstrated
persistence of reflux despite gastrojejunal placement [62]. It
is reasonable to consider conversion to gastrojejunostomy
when there are large gastric residual volumes or recurrent
aspiration. Conversion to gastrojejunostomy can also be
performed to bypass a duodenal obstruction.
J. Sutcliffe et al.: Gastrostomy… 979
123
The technique for primary radiological gastrojejunostomy
is similar to primary gastrostomy, except that the gastric
puncture is angled towards the pylorus. The pylorus is can-
nulated with a catheter and hydrophilic guidewire, the
catheter is then advanced to the proximal jejunumand thewire
exchanged for a stiff 0.03500 wire. The track is then dilated,
and a gastrojejunal catheter placed. Conversion gastroje-
junostomy may be performed at any time after gastrostomy
placement if gastropexy is employed. If not, then the track
should be allowed tomature (usually 4–6 weeks). Conversion
to gastrojejunostomy utilises the existing gastrostomy track,
and cannulation of the pylorus may be hampered by the
angulation of the initial gastrostomy towards the fundus.
Facial dilators and rigid or angled sheaths can be used to
facilitate cannulation of the pylorus and track redirection [34].
Direct percutaneous jejunostomy was first described by
Gray et al. [63] in 1987. The procedure may be required for
patients whose stomachs are inaccessible or who have
undergone gastrectomy. The procedure is complicated by the
mobility of the small intestine, the small intestine’s compli-
ance, the difficulty of maintaining it in a distended state and
the proximity of vital non-targeted structures [64]. For these
reasons, surgical jejunostomy using a Witzel tunnel is
preferable to attempts at radiologic jejunostomy. Various
techniques are described for identification and puncture of the
target bowel. An angiographic catheter can be passed into the
jejunum, which is then distended by instilling warm saline
[37], and the distended jejunum is then punctured under US
guidance, followed by placement of anchoring sutures [65,
66]. While little evidence exists to recommend the ideal
number of anchoring sutures, care should be taken when
anchoring the jejunum as it is more delicate than the stomach.
CT can also be helpful to guide the puncture of the jejunum.
Once cannulated, a small amount of contrast or air can be
injected before rescanning to ensure intraluminal needle
position [67]. Other techniques that include the placement of
an angioplasty balloon or loop snare have been described
[68]. After T-fastener placement a 0.03500 guidewire is passedand looped in the jejunum, followed by track dilatation and
tube placement [11, 37]. Most groups describe the use of
loop-retained catheters for percutaneous jejunostomy place-
ment. Secondary jejunostomy is performed to re-establish a
previously created surgical jejunostomy. The technique is
similar to primary insertion, but T-fasteners may not be
required due to surgical adhesions securing the loop to the
abdominal wall.
Medication and Periprocedural Care
Intravenous sedation and analgesia are commonly required
for the procedure and a nurse trained in administering
intravenous drugs and monitoring patients is necessary.
Midazolam and fentanyl citrate are usually sufficient. Non-
invasive monitoring equipment is essential and the
patient’s heart rate, blood pressure and oxygen saturation
must be monitored and recorded regularly during the
procedure.
Intraluminal distension is vital for the success of the
procedure and antispasmodics such as hyoscine butylbro-
mide or glucagon hydrochloride are useful, particularly in
cases where it proves difficult to maintain gastric distension.
One of the advantages of RIG is that it does not traverse the
oropharynx and therefore does not expose the gastrostomy
tube or track to the oral flora. Thus infective complications of
RIG are rare, with a reported incidence of 2 % [69]. In a
recent review of antibiotic prophylaxis in interventional
radiology, Sutcliffe et al. [70] concluded that the routine use
of antibiotic prophylaxis in percutaneous gastrostomy inser-
tion does not reduce infection rates, and there is currently no
evidence to support their use. Similarly, the use of methi-
cillin-resistant staphylococcus aureus prophylaxis does not
affect the rate of wound infection [20]. However, there is
some evidence that prophylactic antibiotics may be useful in
patients with head and neck cancer where infection rates can
reach 15 % [71]. Cantwell et al. [71] suggested two regimens,
which reduced infections rates among head and neck cancer
patients to zero (p = 0.039): 1 g cephazolin IV at the time of
the procedure followed by twice-daily cephalexin 500 mg for
5 days orally or via gastrostomy; or 600 mg clindamycin IV
at the time of the procedure followed by twice-daily clin-
damycin 600 mg for 5 days orally or via gastrostomy. The
use of prophylactic antibiotics has been shown to reduce
infection rates in transorally placed hybrid gastrostomy
insertion to levels comparable with pure percutaneous RIG
insertion [9]. In patients undergoing PEG, the Endoscopy
Committee of the British Society of Gastroenterology rec-
ommends a single dose of intravenous co-amoxiclav during
the hour before the procedure except in patients already
receiving broad-spectrum antibiotics who need no additional
prophylaxis. In patients with penicillin allergy, they endorse
teicoplanin [72].
Post Procedure
Post-procedure imaging is usually not necessary; a cor-
rectly placed tube is easily rotated and advanced into the
stomach. However if there is any doubt about intragastric
placement then a limited unenhanced CT should be per-
formed for clarification. Erect chest x-rays to exclude
perforation are of no value as pneumoperitoneum is a
natural consequence of puncturing a distended stomach and
free subdiaphragmatic air must not be considered a reliable
sign of bowel perforation. No consensus exists as to how
soon feeding can be commenced after tube insertion. Most
980 J. Sutcliffe et al.: Gastrostomy…
123
centres apply a 4–6 h period of fasting before testing the
tube by injection of water. Prior to feeding the patient
should be reviewed by a trained member of the nutritional
support team to make a decision as to whether the tube can
be used, clearly documenting the review and the decision
in the notes. Of note a recent meta-analysis confirmed the
safety of early feeding, even immediately, following PEG
tube insertion [73].
Post procedure analgesia protocols should be in place to
ensure pain is managed appropriately. Studies have
demonstrated that peak pain occurs 6 h post gastrostomy,
and at this time patients may still be drowsy from the
sedation or are unable to communicate due to the under-
lying condition [74].
Patients may experience post-procedural discomfort or
pain at the T-fastener site and may be associated with exco-
riation or ulceration [58]. Resolution usually occurs after
removal of the T-fasteners, which have customarily stayed in
for 7–14 days. Some have advocated removing T-fasteners as
early as 2 days post procedure, demonstrating a reduction in
post-procedural pain and superficial skin infections with no
increase in complication rate [75]. Systems should be in place
to ensure that the gastropexy sutures are released at an
appropriate time. Enthusiasm for early removal of gastropexy
sutures needs to be tempered by the risk of peritoneal dis-
placement of the feeding tube in case of balloon failure.
Gastrostomy tubes should be flushed after each use to
prevent blockage and many manufacturers recommend
warm water. It is important to check and adhere to the
manufacturers instructions for use. Tube blockages are
most commonly a consequence of instilling crushed tablets
through the tube or the combination of chemically
incompatible medications [76]. Flushing with saline or
carbonated fluids may clear the blockage, but small syr-
inges (2 ml or less) carry the risk of bursting the tube due
to the high pressure generated. Failing that a guidewire can
be inserted into the tube to try to relieve the obstruction.
Ultimately it may be necessary to replace the gastrostomy.
When exchanging gastrostomy catheters in an immature
track a stiff wire can be inserted and an exchange made
over the wire. In a situation where the gastrostomy is no
longer in place or has dislodged, the track can be probed
with a soft, hydrophilic wire or dilator to try and re-
establish the existing track and allow gastrostomy
replacement but should only be carried out by experienced
operators, preferably with access to fluoroscopy.
Care of the Gastrostomy Site
After 24 h, the tube should be cleaned daily with soap and
warm water and kept dry. The tube should be rotated and
pushed in and out every day to promote epithelialisation of
the track. Tubes must not be sutured in. A correct, snug fit
of the external fixator is essential to apply the internal
fixator to the gastric side of the stoma and prevent leakage
of gastric content. Dressings around the tube should be
avoided as they retain moisture and gastric acid and lead to
skin excoriation and infection.
Outcomes
Consistently high success rates for placement of RIG tubes
are reported (95–100 %) [11, 13, 14]. In their meta-anal-
ysis, Wollman et al. [15] found rates of successful RIG
placement to be 99.2 versus 95.7 % for PEG. RIG is also
often successful where PEG has failed [11]. Rates of
complication were also shown to be lower in the RIG
group—5.9 versus 9.4 % for PEG; these were statistically
significant for wound-related problems (major infection,
septicaemia, wound dehiscence, etc.), aspiration and peri-
tonitis [15], which has been confirmed in a more recent
analysis [9].
High success rates have also been reported for de novo
insertion of balloon-retained gastrostomy buttons [56] and
radiological gastrostomies using push-PEGs [22, 77].
The success rate for primary gastrojejunostomy place-
ment is also high ranging between 90 and 100 % [78, 79].
High success rates are also reported for conversion to
gastrojejunostomy [61, 80]. Shin et al. [80] reported a
100 % success rate for placement of primary and conver-
sion gastrojejunostomies.
Technical success rates for direct percutaneous
jejunostomy range between 85 and 90 % [66, 81, 82]. The
main reported reasons for failure are difficulty in accessing
the mobile jejunal loop. Endoscopic guided jejunostomy
placement allows larger calibre, more secure mushroom-
type tubes to be inserted, with resultant lower rates of tube
dysfunction [69].
There is significant variation in the reported 30-day
mortality rate, and early mortality is often due to the severe
nature of the patients’ underlying illnesses. In their study,
Bell et al. [61] reported a 30-day mortality rate of 17.1 %,
with 71 deaths out of 416 treated patients, of which only
two were procedure related. Other groups report similarly
high 30-day mortality rates 11–14 %, but with a low
incidence of procedure-related mortality [83, 84]. In a
multicentre study, Laasch et al. [9] demonstrated an overall
mortality rate of 1 % (5/643). Although these studies
demonstrate significantly different overall 30-day mortality
rates, they all demonstrate a low incidence of procedural-
related mortality, and emphasise the importance of careful
patient selection.
In a prospective randomized trial, Thornton et al. [58]
demonstrated that gastropexy placement reduces the risk of
J. Sutcliffe et al.: Gastrostomy… 981
123
intraperitoneal tube placement. Other cited advantages
include rapid maturation of the gastrocutaneous track,
reduced intraperitoneal leakage of gastric contents with
peritonitis, and track access in case of inadvertent early
tube removal.
Catheter occlusion is a relatively common complication.
Narrow calibre tubes have been shown to have a higher
incidence of occlusion. Hoffer et al. [78] reported a 30-day
occlusion rate of 13.6 % in 10F tubes versus 1.6 % in 22Fr
tubes. De Beare’s group report a 30 day occlusion rate of
7.3 % using 16–18Fr catheters [13]. Lower occlusion rates
are reported with the newer button catheters—Funaki’s
group reported only one occlusion in 55 patients with
mushroom retained catheters [22] and Lyons group repor-
ted no occlusion using balloon retained button catheters
[17]. The small diameter and more complex configurations
of gastrojejunostomy tubes, means they often require more
frequent maintenance and replacement.
Complications
Complications of percutaneous gastrostomy are classified
as major and minor as defined by the Society of Inter-
ventional Radiology classification system for complica-
tions by outcome (Table 1) [85].
Table 2 shows the minor and major complications
associated with percutaneous radiologic gastrostomy and
their reported frequency [86]. Death due to procedure is
reported as 0.3 % though this can be significantly higher in
hospitalised patients [87] and patients with diabetes mel-
litus, poor nutritional status, or long-term corticosteroid
administration [88].
Minor Complications
Superficial Peristomal Infection
Incidence of superficial peristomal infections have been
reported as high as 45 % in some series [89] but are rarely
as a result of the procedure, rather as a result of poor
wound hygiene after the procedure [12]. Organisms include
bacteria, fungi and yeasts. Skin swabs should always be
taken for culture but are often negative. A range of topical
creams combining antibiotics, antifungals and steroids are
available, as well as non-specific agents including silver,
hydrogen peroxide, potassium permanganate and wound-
healing alginates. Infections can usually be managed on an
outpatient basis. However, care should be taken that the
infection does not progress to a severe infection with skin
breakdown and sometimes, systemic antibiotics may be
necessary. Management of infective complications can be
very demanding and involvement of stoma specialists and
dermatologists should be considered early.
Overgranulation
Overgranulation indicates an underlying problem, either of
infection or mechanical irritation, and needs to be addressed
prior to treatment with topical steroids and compression.
Leakage
Leakage of enteral feed and gastric fluid at the gastrostomy
site happens in 1.4 % of patients [86]. Risk factors for
leakage include gastrostomy site infection, excessive
cleansing with hydrogen peroxide, increased gastric acid
Table 1 SIR classification
system for complications by
outcome [85].
Minor complications
A. No therapy, no consequence
B. Nominal therapy, no consequence; includes overnight admission for observation only
Major complications
C. Require therapy, minor hospitalisation (\48 h)
D. Require major therapy, unplanned increase in level of care, prolonged hospitalisation ([48 h)
E. Permanent adverse sequelae
F. Death
Table 2 Minor and major complications associated with percuta-
neous radiologic gastrostomy and their reported frequency.
Complications Complications rate (%)
Minor complications
Superficial peristomal infection 25–45
Leakage 11.4
Tube occlusion 4.5
Tube dislodgement 1.3–4.5
Major complications
Haemorrhage 1.4
Peritonitis 1.3
Death due to procedure 0.3
Colonic perforation Minimal
Severe skin infection Minimal
982 J. Sutcliffe et al.: Gastrostomy…
123
secretion, buried bumper syndrome [90], excessive tension
on the gastrostomy tube, and excessive lateral pressure on
the tube usually when dressings are applied. The single
anchor technique can also lead to pericatheter leakage by
inducing considerable tension on the gastric wall adjacent
to the track, causing ischaemic change in the gastric wall,
which can in turn cause necrosis and ultimately enlarge-
ment of the gastrocutaneous track. [60].
If leakage occurs the site should be examined for
infection, ulceration or a buried bumper and if the patient is
not already on proton pump inhibitors these should be
started [12]. If excessive lateral pressure is causing ulcer-
ation and enlargement of the track then securing the tube
with a fixation device can be helpful [12]. Alternatively,
exchanging for a thinner or softer tube can relieve the
problem. Some authors have advocated using a larger-di-
ameter tube but this is usually unsuccessful and can even
exacerbate the problem of excessive lateral tension and
resultant pressure on the stoma [91]. Exchanging for a
gastrojejunostomy may also solve the problem by deliv-
ering the feed past the pylorus while at the same time
decompressing the stomach. Once the cause has been
addressed, attention should be given to wound care. Zinc
oxide or stoma adhesive powder can deter local irritation.
Alginate and foam dressings make a good alternative to
gauze, as these can lift away the leaked fluid from the skin
as opposed to gauze which may trap the fluid against the
skin [12]. Leakage may also be secondary to fungal
infections, and consideration should be given to topical
antifungal agents. In intractable cases, it may be necessary
to remove the tube altogether for a few days, sanitise the
stoma with daily dressings of 1:10 000 potassium per-
manganate and allow the track to reduce in size before
replacing the tube, or it may be necessary to re-site the
gastrostomy. Specialist support from a dermatologist or a
tissue-viability nurse should be sought in cases of pro-
gressive stomal retraction.
Tube Occlusion
Tube blockages are most commonly a consequence of
particle obstruction from inadequately crushed tablets,
precipitate formation following interaction between feed
and drug formulations and precipitate formation following
interactions between drugs [76]. Precipitation of enteral
feed accounts for as much as 80 % of tube occlusions [92].
Administration of syrups, granular suspensions and
enteric-coated medications are highly likely to cause tube
occlusion. Enteric-coated tablets, such as esomeprazole
and erythromycin, once crushed are prone to clumping
within the tube. Crushing also destroys the protective
coating meaning the drug’s bioavailability is unpredictable.
Some capsules contain granules which may be either too
large or the suspension too viscous to pass through the
tube, while some capsules may contain enteric-coated
granules, such as lansoprazole, or granules with a modified
release coating, such as slophylline, which are intended to
be delivered intact, which again may occlude the tube [76].
In order to minimise the risk the tube should be flushed
well with water or normal saline before and after each use
to prevent enteral feed from blocking the lumen. When the
lumen does occlude flushing the tube with normal saline
may free the blockage in a third of patients [93]. Small
syringes (2 ml or less) should be avoided as they carry the
risk of bursting the tube due to the high pressure generated.
If normal saline is ineffective. pancreatic enzymes have
been shown to free blockages in a further 50 % [93]. If this
fails, a guidewire passed through the tube to try to relieve
the obstruction may be successful in which case consid-
eration should be given to exchanging the tube. Sometimes,
it may not be possible to remove the blockage in which
case, the gastrostomy tube will need to be exchanged.
Tube Dislodgement
Dislodgement of the tube occurs in 1.3–4.5 % of gastros-
tomies but is more frequent in patients with altered mental
status [12, 86]. If the tube does dislodge the track can be
preserved by inserting a soft straight tube such as a Foley
catheter into the track allowing time to arrange for formal
replacement by an interventional radiologist, but this must
not be used for feeding [94]. Care should also be taken
when advancing the catheter and should be aborted if
resistance is encountered.
Formal replacement by an interventional radiologist
usually involves an attempt at re-cannulation of the gas-
trostomy track but will depend on the age of the track and
time elapsed since the tube was dislodged. Track matura-
tion usually occurs within 7–10 days but may be delayed
by up to 4 weeks in patients who have ascites, are mal-
nourished or are on corticosteroid treatment [12]. Collares
et al. [95] reviewed the management of 170 dislodged
gastrostomies and gastrojejunostomies and found the
reinsertion rate through the original track was 92 % on the
first day of dislodgement, 91 % on the second day, 90 % on
the third day and 71 % on or after the fourth day of acci-
dental removal. However, mean indwell time for the tubes
was 269.3 days (range 6–1898 days). If recognition of the
dislodgement is delayed, then management involves
nasogastric tube suction, broad-spectrum antibiotics and
repeat gastrostomy in 7–10 days’ time [12].
Pain
Complications of gastropexy insertion include pain, wound
infection and balloon rupture. In their multicentre survey,
J. Sutcliffe et al.: Gastrostomy… 983
123
Lowe et al. [20] demonstrated that gastropexy reduced the
incidence of pain, but immediate post-procedure pain when
present was more severe and increased with the number of
gastropexy sutures used. If gastropexy sutures are fastened
too tightly, then pain may be severe, particularly once
gastric smooth muscle relaxants wear off and the stomach
deflates.
Major Complications
Haemorrhage
Haemorrhage during a RIG occurs in 1.4 % of patients [86]
and major haemorrhage requiring transfusion in 1.2 %
[96]. Risk factors for major haemorrhage include patients
with peptic ulcer disease, oesophagitis, anticoagulation and
previous anatomic alteration [86, 97]. Management usually
involves assessment by endoscopy and, if possible,
angiography, or both, with ligation, sclerotherapy or
embolization if necessary.
Peritonitis
Peritonitis following a RIG occurs in 1.3 % of patients
compared with 0.5 % after endoscopic placement [86]. It is
generally caused by removal or dislodgement of the gas-
trostomy tube before the track matures, leakage from the
stomach puncture site into the peritoneal cavity and per-
foration of the colon [86]. Mortality rate is high following
peritonitis and so it is important to recognise and treat
it early. A broad range of signs and symptoms are seen in
peritonitis but common manifestations include abdominal
tenderness or distension, rigors, fever, difficulty passing
gas or having bowel movements and vomiting. Manage-
ment involves broad-spectrum antibiotics and supportive
care. Percutaneous drainage and/or surgical drainage may
be necessary.
Colonic Perforation
The risk of perforating the bowel and, in particular, the
colon is extremely low. Risk factors include inadequate
insufflation of the stomach, thereby not displacing the
colon sufficiently and causing poor visualisation of the
transverse colon. If gastric distension is hard to maintain,
then antispasmodics such as Hyoscine bromide and glu-
cagon hydrochloride may be useful. A gastrostomy passing
through the colon will ultimately lead to fistula formation
and may involve the stomach, transverse colon and skin.
Patients can present with colonic perforation, obstruction
or peritonitis but are more likely to present with stool
bypassing around the gastrostomy tube and diarrhoea
which resembles the formula feed being used [12].
Transcolonic placement may remain asymptomatic and
discovered incidentally during a gastrostomy exchange
when the replacement tube is advanced into the colon
rather than the stomach, or it may be identified radio-
graphically [12]. Management of this complication is
usually conservative, simply allowing the fistula to close
after the tube has been removed. Rarely, surgery may be
required if the fistula fails to heal or peritonitis occurs.
If colonic perforation is recognised at the time of the
procedure, or prior to track maturation, then it should be
understood that there is a risk of intraperitoneal leakage of
gastric and colonic contents and hence peritonitis. One option
is to leave the gastrostomy tube in situ andmonitor the patient
while the track matures and then manage conservatively. If
this is not possible or desirable it nevertheless need not
necessitate surgical management. Colonic perforation may
result in a spectrum of illnesses, some of whichmay not result
in clinically significant peritoneal contamination [98].
Whether patients have a high morbidity or mortality rate
will depend on their existing medical conditions, the nature
of the perforation, the method of management, the expe-
rience of the care team and the hospital setting [99]. In a
review of colonic perforations following endoscopy,
Lohsiriwat [99] states the 30-day morbidity and mortality
rates are 21–53 and 0–26 %, respectively, and offers sev-
eral factors for poor outcomes including a large perforation
site, a delayed diagnosis, extensive peritoneal contamina-
tion, corticosteroid use, anticoagulant or antiplatelet ther-
apy, prior hospitalisation, advanced age of patients and
severe comorbid diseases.
The choice between surgical and conservative manage-
ment then will depend on clinical grounds. Conservative
management should be reserved for those whose general
condition is good and show no indication or peritonitis.
Management involves intravenous fluids, complete bowel
rest and intravenous administration of broad-spectrum
antibiotics with patients expected to improve gradually
within 24–48 h. Conservative management has been shown
to have a success rate of between 33 and 73 % [99].
Operative management is reserved for those with diffuse
peritonitis and patients in which non-operative manage-
ment has led to clinical deterioration. A number of surgical
options have been expounded such, as oversewing the
perforation and bowel resection with or without intestinal
continuity, for which endoscopic approaches are possible.
Which surgical management option to choose would
depend on the patient’s condition, the size of the perfora-
tion, any underlying bowel pathology, the time from injury
to diagnosis and the available surgical expertise [99].
With advances in endoscopic technology, the possibility
of endoscopic closure exists. This option would be
dependent on having the appropriate endoscopic equipment
and the skill of local endoscopists [99].
984 J. Sutcliffe et al.: Gastrostomy…
123
Severe Skin Infection
Though minor skin infections are relatively common it is
rare for them to progress to severe infections when
appropriately managed. They are more likely to occur in
patients who have had their gastrostomy sited via a tran-
soral route, patients receiving immune-suppressant therapy
and patients with diabetes mellitus, chronic renal failure,
alcoholism or pulmonary tuberculosis [12]. If diagnosed
early, broad-spectrum oral antibiotics are usually sufficient.
However, if there are systemic signs of infection broad-
spectrum intravenous antibiotics in combination with spe-
cialist wound care are necessary. Necrotising fasciitis is a
potentially lethal complication but is fortunately rare,
particularly following RIG. Management should be
aggressive and includes broad-spectrum intravenous
antibiotics and early surgical debridement. In all cases,
early involvement of a specialist stoma care team is
essential.
Conclusions
Radiological feeding tube insertion is a safe and effective
procedure. Success rates are higher, and complication rates
lower than PEG or surgical gastrostomy tube placement
and innovative techniques for gastric and jejunal access
mean that there are very few cases in which RIG is not
possible. However, the key weaknesses of RIG are the
relatively high occlusion rates due to the inherently smaller
tubes required and the unreliable internal fixation. PIG
attempts to address this but has not been taken up as a
routine alternative to RIG or PEG and so its use will
depend primarily on the local expertise. In the end, there is
a need for robust randomised controlled trials evaluating
PEG versus RIG placement for the delivery of enteral
nutrition and this will guide any future evidence based
guidelines. Consequently, in most institutions, PEG will
remain the first line procedure when gastrostomy feeding is
required while RIG is reserved for patients in which PEG
has already failed and those who are too unwell or
unsuitable for endoscopy, such as those with head, neck or
oesophageal cancer.
Patients undergoing gastrostomy have severe co-mor-
bidities, reflected in reported post-procedural mortality
rates, and it is vital that all patients are discussed in a
multidisciplinary meeting to ensure appropriate patient
selection. The interventional radiologist must be involved
in pre-procedure patient assessment, ensure systems are in
place for post procedure review by the interventional
radiology team, and be available for management of any
complication.
Compliance with Ethical Standards
Conflict of interest None.
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