CIRSE Standards of Practice Guidelines on Gastrostomy€¦ · CIRSE STANDARDS OF PRACTICE...

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

[email protected]

James Sutcliffe

[email protected]

Andrew Wigham

[email protected]

Niall Mceniff

[email protected]

Petr Dvorak

[email protected]

Laura Crocetti

[email protected]

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

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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

123

• 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


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.


123

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.


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.


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


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


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


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,


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].


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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