Introduction
Percutaneous feeding tubes allow enteral nutrition and medication into the stomach or jejunum. Percutaneous placement is particularly indicated in high risk anesthesia patients and children with upper airway abnormalities.

Indications
  • Inability to tolerate oral feeds.
  • Gatroesophageal reflux, aspiration, GI dysmotility (GJ)

Contraindication
  • None absolute.
  • Relative: Gross ascites, uncorrectable coagulopathy, recent VP shunt (within 4 weeks).

Pre-Procedure
  • Consults – all referrals require a GI consult.
  • G/GJ tube teaching for parents to be performed by GI.
  • Clinical evaluation – Interdisciplinary, including general surgery.
  • Stop anticoagulation on the day of the procedure.
  • 50 ml of Optiray 320 administered orally / via NG, the night before the procedure.
  • Protocoling: determine if antegrade or retrograde technique, type of G/GJ tube and level of anesthesia.

Imaging
  • ​Review upper GI studies, cross sectional imaging.​

Labs
(high risk category per SIR standards, INR < 1.5, plt >50k)
  • CBC
  • PT/PTT
  • Type and screen.

Technique
Advantages to Antegrade vs. Retrograde
  • Antegrade: Better gastric fixation, no retention sutures required, decreased risk of dislodgement.
  • Retrograde: Less anesthesia requirement, can be performed if upper airway/esophageal disease, can be performed in neonates/infants, possibly decreased risk of infection. 

Procedure
  • Consent: for bleeding, infection (including peritonitis), damage to surrounding structures and include consent for peritoneal, pleural drain placement.
  • Admit night before procedure, place NG/NJ tube, administer oral contrast.
  • Specific procedure room - Biplane preferable.
  • Anesthesia – general anesthesia in majority, can be performed under local anesthesia in older children.
  • Positioning – Head first supine
  • Antibiotics – Cefazolin (50 mg/kg, max 2g), alternative Clindamycin (10 mg/kg, max 900mg), within one hour of procedure.

Supplies​
  • Gastro Retention Anchoring Suture Set (18g)
  • NG tube
  • Coons dilators
  • Peel-away sheaths

Technique
  • Mark the border of the liver and spleen using ultrasound.
  • Prep entire abdomen
  • Fluoroscopy to confirm contrast in colon. If inadequate opacification, perform contrast enema.
  • Administer glucagon (0.2-0.5 mg).
  • Inflate stomach via nasogastric tube.
  • Determine access point under biplane fluoroscopy, preferably lateral to rectus sheath.
  • Angle AP plane to 15 degrees caudal
  • Administer local anesthesia
  • Puncture with 18G needle, confirm with biplane fluoroscopy.

Retrograde
  • Deploy retention suture/s with 0.035” Bentson guidewire. If placing pigtail catheter, a single retention suture will suffice, if Mic-Key or AMT, then 3 sutures in a triangle.
  • If GJ tube, advance guidewire to beyond DJ flexure with 4F Kumpe catheter.
  • Dilate while maintaining gentle traction on retention suture.
  • Place peel-away sheath, then advance catheter over guidewire.
  • Confirm position with injection of contrast.
  • If pneumoperitoneum identified, aspirate with 21-25 g needle.
  • Secure retention suture, tube.
  • Leave catheter and NG tube on free drainage.

​Antegrade
  • 15-20 mm gooseneck snare advanced through the esophagus and used to capture guidewire.
  • Guidewire pulled through the mouth and secured to loop of feeding tube.
  • Catheter and guidewire pulled into the stomach.
  • The tract is dilated if necessary and catheter the pulled through stoma until retention device ensures secure fixation of stomach to anterior abdominal wall.
  • The tube is cut to an appropriate length and left on free drainage.

Post-Procedure
  • PACU recovery.
  • Admission – to GI or referring service.
  • Antibiotics – Continue for 5 days, can transition to oral/intragastric cephalexin or clindamycin (particularly if antegrade technique).
  • Pain management – IV ketorolac, acetaminophen.

Immediate post-procedure care
  • Leave catheters on free drainage.
  • If antegrade tube, feeds can be started when bowel sounds are present.
  • If retrograde, nil through catheter for 12 hours. If bowel sounds present at 12 hours post-procedure, flush with 5 ml of electrolyte solution. If no signs of peritonitis, commence feeds at 14 hours post-procedure.
  • Replace NG and G tube fluid losses as maintenance fluid with KCL 20mmol/L added.
  • Leave dressings for 24 hours then daily until discharge.
  • Advance feeds to goal feeding volume over 48 hours, as per dietitian orders.
  • Monitor for fever, worsening abdominal pain or other signs suggestive of peritonitis.

Complications
  • Major Peritonitis (stop feeds, check catheter position, ultrasound to look for ascites, start broad spectrum antibiotics).
  • Perforation – surgical consult.
  • Inadvertent organ puncture
  • Bleeding
  • Death
  • Minor leakage
  • Dislodgment (for first 4-6 weeks, no catheter should be inserted blindly, tube should be replaced as soon as possible under image guidance).
  • Site infection
  • Obstruction (management as per dislodgement).
  • Migration
  • Intussusception (exchange GJ for gastrostomy tube).

Follow-up
  • Follow-up after discharge with phone call.
  • Review in the IR department in 2 weeks and cut retention sutures.
  • First exchange at 6-8 weeks. Catheter can be upsized at this time.

References
  1. Gastrointestinal Interventions in Children. Parra DA, Temple M. M. Temple and F.E. Marshalleck (eds.), Pediatric Interventional Radiology: 307
  2. Handbook of Vascular and Non-Vascular Interventions, DOI 10.1007/978-1-4419-5856-3_20.
  3. Chait PG, Weinberg J, Connolly BL, et al. Retrograde percutaneous gastrostomy and gastrojejunostomy in 505 children: a 4 1/2-year experience. Radiology. 1996;201(3):691–695. doi:10.1148/radiology.201.3.8939217
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