Keywords dysphagia - nutrition - gastrostomy - gastrojejunostomy - enteric access - esophageal
atresia - tracheoesophageal fistula
Introduction
Gastrostomy tubes allow for safe, long-term delivery of enteral nutrition in those
unable to maintain adequate nutrition orally. In infants, pathologies that may necessitate
gastrostomy tube placement include congenital anomalies, malnutrition secondary to
neuromuscular disorders, intractable food aversions, and alimentary dysfunctions.
Although temporary enteral access may be obtained via a nasogastric or nasojejunal
feeding tube, these tubes are prone to occlusion, malposition, and dislodgement. Therefore,
a more durable option should be considered if required for > 8 to 12 weeks.
In the pediatric population, indications for placement of a gastrostomy include enteral
feeding, decompression of the gastrointestinal tract, and diversion of intestinal
contents to promote healing of intestinal fistulas.[1 ] Fluoroscopic-guided placement of gastrostomy tubes provides an effective and safe
alternative to endoscopic and surgical techniques. A meta-analysis by Wollman et al
comparing fluoroscopic-guided, endoscopic, and surgical-placed gastrostomy demonstrated
fewer major complications using fluoroscopy (5.9%) compared with endoscopy (9.4%).[2 ] Although surgical placement was 100% technically successful, complication rates
were higher than fluoroscopic- or endoscopic-placed tubes (19.9%; p < 0.001).[2 ]
[3 ] Fluoroscopic-guided access techniques include antegrade, retrograde, and combination
(“push-pull”) methods.
Antegrade techniques entail passing the gastrostomy through the mouth, esophagus,
and into the stomach. When performed by interventional radiology, this requires percutaneous
access to the gastric lumen subsequently brought through the mouth by either orogastric
snare capture and withdrawal or retrograde catheter and wire cannulation of the esophagus.[4 ] Following oropharyngeal wire capture, the wire is exchanged for a snare. A ring-bolster
retained gastrostomy is secured and withdrawn into final position from the percutaneous
access. Coaxial placement of a 6- or 8-French feeding tube into the proximal small
bowel completes a modular gastrojejunostomy.
Retrograde techniques require gastric insufflation, percutaneous suture anchor gastropexy,
percutaneous needle and wire access to the stomach followed by tract dilation, and
placement of a balloon- or pigtail-retained gastrostomy.[3 ] Combination techniques utilize antegrade access to create an opening and retrograde
techniques for gastrostomy placement.
Congenital gastrointestinal anomalies in pediatric patients pose unique challenges
in establishing long-term nutritional access. Conditions such as tracheoesophageal
fistula and esophageal atresia are associated with microgastria. Severe underdevelopment
of the stomach has been shown to cause gastrostomy failure due to insufficient capacity
resulting in gastric outlet obstruction.[5 ] These patients also have significant reflux that often necessitates postpyloric
feeding to minimize symptoms from reflux and improve weight gain. This can be a complex
task in patients with recent esophageal anastomosis after repair of esophageal atresia.
Gastrostomy failure in these patients necessitates revision to gastrojejunostomy with
intermittent or continuous gastric venting. Techniques for revision in this population
are not well-established and are further complicated by difficulties obtaining the
proper angle for gastrojejunostomy placement via the traditional entry points of preexisting
gastrostomy. In patients with microgastria, the lower profile of ring-bolster retained
gastrostomy tubes may be a preferred option. If related to esophageal pathology, however,
traditional antegrade placement techniques are contraindicated due to the presence
of a surgical anastomosis.
The objective of this article is to report a technique for gastrostomy to gastrojejunostomy
revision with retrograde placement of a ring-bolster retained gastrostomy component
in patients with microgastria and esophageal pathology precluding standard techniques.
Materials and Methods
Patient Selection
This study complied with the Health Insurance Portability and Accountability Act.
Institutional review board approval was not required for this type of study. Pediatric
patients undergoing gastrostomy to gastrojejunostomy revision using the technique
described were included in the study. Between January 2016 and January 2018, three
patients underwent enteric access revision as described. Technical success, complications,
clinical success, and follow-up were recorded.
Technique
All procedures were performed by an attending pediatric interventional radiologist
under general anesthesia. Existing gastrostomy tubes were removed over a 0.035-inch
Amplatz wire which was then negotiated into the small bowel or looped within the gastric
fundus using a 4-French angled catheter. The gastrostomy tracts were dilated over
the wire with 20-French peel-away introducer sheath (Cook Medical, Bloomington, Indiana,
United States). A 16-French ring-bolster retained gastrostomy tubes (CorFlo, Halyard,
Alpharetta, Georgia, United States) was cut to approximately 20 cm length and loaded
onto the percutaneous enteral access wire. Note that 19-gauge (3.2-French) angiocatheters
were placed into the sidewall port for aspiration decompression of the gastrostomy
ring bolsters. Peel-away sheaths were placed over the wires and over the gastrostomy
tubes. Note that 6-French vascular sheaths or JAKO fine suction tubes were placed
over the wire and through the gastrostomy tubes for pushability. The decompressed
ring bolsters were lubricated and withdrawn into the peel-away sheaths, followed by
manual tapering of the distal sheaths. The constructs were advanced over the wire
and through the gastrostomy tracts. The suction tube or vascular sheath and gastrostomy
tubes were advanced as units beyond the peel-away sheaths and the peel-away sheaths
were removed. The ring bolsters were reinflated using the angiocatheters and brought
into apposition with the anterior gastric wall. Following contrast injection to confirm
position and absence of extravasation, dual port feeding adaptors were placed (C.R.
Bard, Tempe, Arizona, United States) followed by standard coaxial 8-French jejunal
feeding tube placement. A benchtop demonstration of construct assembly is depicted
in [Fig. 1 ] and a sample case is depicted in [Fig. 2 ]. A completed assembly hub is depicted in [Fig. 3 ]. Standard stoma peristomal skin care including daily site wash with soap and soft
cloth was initiated on postprocedure day 1.
Fig. 1 Benchtop construct assembly. A 16-French ring-bolster retained gastrostomy as packaged
(CorFlo, Halyard, Alpharetta, GA) (A ). Transected gastrostomy tube with placement of an 18-gauge angiocatheter into the
sidewall port for aspiration decompression of the gastrostomy ring bolster (B ). Over-the-wire placement of the gastrostomy, 20-French peel-away introducer sheath
(Cook Medical, Bloomington, IN) and inner 6-French vascular sheath prior to constraining
the gastrostomy ring bolster within the peel-away (C ).
Fig. 2 Three-month-old male with CHARGE syndrome status postrepair of esophageal atresia,
tracheoesophageal fistula ligation, and surgical gastrostomy tube placement, now requiring
postpyloric feeds. Anteroposterior fluoroscopic image following removal of the surgical
gastrostomy tube, jejunal catheterization, and 0.035-inch Amplatz wire placement (A ). The tract is dilated with a 20-French dilator and peel-away sheath (B ). A construct of 16-French CorFlo gastrostomy (open arrow), 6-French vascular sheath
(open arrowhead), and constraining 20-French peel-away sheath (black arrow) are placed
through the stoma and the CorFlo gastrostomy is subsequently advanced into the gastric
lumen (C ). The CorFlo gastrostomy ring bolster is reinflated (open arrows) and the peel-away
sheath is removed (D ). The gastrostomy disc is withdrawn into apposition with the anterior gastric wall
and contrast injection confirms position (E ). An 8-French feeding tube is placed coaxially into the jejunum, completing the gastrojejunostomy
(F ).
Fig. 3 Completed gastrojejunostomy assembly. Following placement of the CorFlo gastrostomy,
a dual port feeding adaptor (C.R. Bard, Tempe, AZ) is placed at the cut end of the
tube. Jejunal access is then achieved via coaxial 4-French catheter and 0.035-inch
wire, followed by coaxial, over-the-wire placement of an 8-French jejunal feeding
cut to length. Zip tie placement (not depicted) may be applied to both the adaptor
entry point (black asterisk) and around the combination of the adaptor and feeding
tube hub (white asterisk).
Variables and Outcomes
Technical success was defined as successful revision of gastrostomy to a ring-bolster
retained gastrostomy tube and coaxial jejunal feeding tube. Clinical success was defined
as successful initiation of postpyloric feeds.
Results
Patient characteristics and results are summarized in [Table 1 ]. Mean patient age and weight at time of revision were 5.7 months (range: 3–7 months)
and 5.7 kg (range: 3.7–6.8 kg), respectively. All patients had prior esophageal atresia
repair. Initial gastrostomy placement was created with a 10-French silicone Malecot
catheters (Cook Medical LLC, Bloomington, United States). Two patients underwent surgical
gastropexy at the time of gastrostomy.
Table 1
Patient and procedural characteristics
Patient
Age
Weight
Diagnosis and indication for revision
Original gastrostomy
Surgical gastropexy
Gastrostomy maturation
Technical success
Complications
Fluoroscopy time
AK
1
7mo
6.8 kg
Long gap esophageal atresia repair
10-Fr Malecot
Yes
8 mo
Yes
None
18.7 min
26.0 mGy
2
7mo
6.7 kg
VACTREL association, tracheoesophageal fistula ligation, esophageal atresia repair
10-Fr Malecot
No
7 mo
Yes
None
13.9 min
12.0 mGy
3
3mo
3.7 kg
CHARGE syndrome posttracheoesophageal fistula ligation and esophageal atresia repair
10-Fr Malecot
Yes
3 mo
Yes
None
8.8 min
27.4 mGy
Abbreviation: AK, air kerma.
All revisions were technically successful. Mean fluoroscopy time and air kerma were
13.8 minutes (range: 8.8–18.7 minutes) and 21.8 mGy (range: 12–27.4 mGy). There were
no complications.
Discussion
Gastrostomy tubes are a common method of establishing long-term nutritional access
in patients who are unable to feed orally. In the pediatric population, up to 6% require
gastrostomy revision, most commonly due to prolapse of the stomach through the gastrostomy
tract, migration of the gastrostomy site, excessive leakage, and chronic pain at the
gastrostomy site.[6 ] Establishing safer, minimally invasive methods of enteral access revision are necessary
to optimize feeding and to troubleshoot dysfunction. Fluoroscopic gastrojejunostomy
revision after surgical or endoscopic gastrostomy can be performed within weeks, provided
gastropexy is used or in a delayed fashion (> 8 weeks) to allow tract maturation.
The three cases described here demonstrate successful gastrojejunal (GJ) revision
following failed initial gastric feeds due to reflux associated with esophageal pathology
and gastric underdevelopment.
While no complications were encountered in these cases, risks associated with fluoroscopic
GJ revision include possible disruption of surgical gastropexy or other iatrogenic
gastric injury. Complications due to primary GJ placement include colocutaneous fistula,
gastric outlet obstruction due to tube prolapse, and bezoar formation.[7 ] Additionally, the time from gastrostomy placement to revision ranged from 3 to 8
months; however, earlier revision could result in higher complication rates due to
less tract maturation and/or interval gastric growth. The described technique was
prompted by a need for revision and concern that a balloon-retained GJ would lead
to intolerance. In a series by Gill et al describing 34 patients undergoing de novo
balloon-retained gastrojejunostomy, no instances of gastric outlet obstruction were
observed despite generally small patient size (median weight 7.5 kg, range: 2.9–31.6 kg).[8 ] Although clinical indications varied, no patients in the Gill et al series had structural
esophageal pathology with microgastria.
Primary limitations with regard to this case series include a small sample size; however,
technical success in larger series is difficult to establish due to the infrequent
presentation of patients with obstructive congenital pathologies. The methods described
in this case series present a possible avenue for reestablishing safe, effective,
and minimally invasive nutritional access in patients who have failed gastric feeds
due to reflux or microgastria, or a combination of factors. While generalizability
to different patient populations, and causes of failure, have not been established,
the high rate of technical success and low rate of complications within this narrow
subset of patients is promising.
Conclusion
Gastrostomy to gastrojejunostomy revision via retrograde placement of a ring-bolster
retained gastrostomy component is a safe and feasible option for patients with intolerance
of gastric feeds and esophageal pathology precluding standard techniques.
A ring-bolster retained gastrostomy tubes offer high retention forces with a low intraluminal
gastric profile and allow coaxial placement of a 6- or 8-French feeding tube into
the proximal small bowel to make a modular gastrojejunostomy.
Antegrade techniques entail passing the gastrostomy through the mouth, esophagus,
and into the stomach after percutaneous access to the gastric lumen and retrograde
cannulation of the esophagus.
Children with esophageal pathology may not be able to tolerate transesophageal placement
of a ring-bolster retained gastrostomy tube, and associated microgastria introduces
risk of gastric obstruction by comparatively larger profile and caliber of balloon-retained
gastrojejunostomy tubes.
The technique described in this note may be considered when clinical conditions necessitate
retrograde placement of a ring-bolster retained gastrostomy tube.