Percutaneous radiologic gastrostomy is a classic interventional radiology procedure. As patient populations and preferences change, and as newer devices and approaches are established, it is essential for interventional radiologists to evolve individual and institutional conventions and adopt data-driven practices that minimise risks on a patient-tailored basis, writes Rahul Sheth.
Percutaneous radiologic gastrostomy placement is a well-established method for enteral access in patients who are often not suited for surgical or endoscopic approaches. Since its introduction in the 1980s, it has demonstrated a high technical success rate in patients who would conventionally be considered “high risk” due to underlying medical conditions such as head and neck malignancy or neuromuscular disorders including amyotrophic lateral sclerosis.
There is, generally speaking, consensus in the existing literature regarding the major complication rate for percutaneous radiologic gastrostomy, with multiple reports of hundreds of patients indicating that the occurrence of post-procedural major haemorrhage, peritonitis, or abscess formation is in the 2–6% range.
On the other hand, there is little agreement regarding the rate of minor complications, particularly the rate of tube malfunction requiring catheter exchange: while some studies have suggested that this occurs as infrequently as in 3% of patients, others have indicated that up to 36% of patients undergo “unplanned” catheter exchanges following percutaneous radiologic gastrostomy placement. Though such exchanges are technically “minor” in severity, the burden to patients and providers can be anything but.
The apparent wide variation in catheter-related complications is at least in part due to the wide variations in institutional patient populations as well as procedural approaches to the procedure. Moreover, anecdotally there seems to be an uptrend in complication rates since the introduction of percutaneous radiologic gastrostomy due to the evolving, increasingly complex patient population referred for this procedure. It is therefore imperative that interventional radiologists familiarise themselves with potential risk factors for complications that can occur due to the procedure. Not only does such knowledge facilitate the implementation of proactive measures to reduce preventable complications, it also substantiates data-driven discussions with referring physicians and patients regarding risks and benefits of the procedure.
Risk factors for complications can be divided into two categories: patient-specific and procedural. Regarding the former, it is not surprising that demographic characteristics that indicate poorer overall health are associated with higher catheter malfunction rates. For example, patients with neurologic disorders and those who require anaesthesia support for procedural sedation have a higher rate of post-procedure catheter malfunction. However, as most “unplanned” catheter exchanges occur within the two months following percutaneous radiologic gastrostomy placement, patients with very short life expectancies, such as those in the intensive care unit, have relatively fewer catheter exchanges.
Procedural approaches to percutaneous radiologic gastrostomy placement can vary greatly, particularly with regards to certain techniques: transabdominal vs. transoral approach, creation of a gastropexy, and the type of gastrostomy tube used. Transoral, or “pull”-type percutaneous radiologic gastrostomy catheters, exhibit very low rates of catheter malfunction (~2%) for patients eligible for this approach, i.e. those with patency of the oropharynx and oesophagus. Moreover, while initial reports for transoral percutaneous radiologic gastrostomies suggested a higher rate of infection and “buried bumper” syndrome, subsequent studies have not borne this out. Gastropexy is another technique with entrenched opinions. Though there are limited comparison studies assessing the risks and benefits for this approach, the purported increased occurrence of post-procedure bleeding with gastropexy has not been shown in large trials, while low rates of peritonitis, abscess formation, and bowel perforation as well as a high rates of successful gastrostomy tract “rescue” following complete catheter dislodgement have been shown with gastropexy. Lastly, gastrostomy catheters come in all shapes (including pigtail and balloon-retention) and sizes. Early use of balloon-retained catheters suggested a higher rate of tube malfunction and dislodgement, but more recent studies have not shown any difference with pigtail catheters. Given their low external profile, balloon-retained catheters are often the device of choice for patients with neurologic disorders.
Percutaneous radiologic gastrostomy is a classic interventional radiology procedure. As patient populations and preferences change, and as newer devices and approaches are established, it is essential for interventional radiologists to evolve individual and institutional conventions and adopt data-driven practices that minimise risks on a patient-tailored basis.
Rahul Sheth is assistant professor, Department of Interventional Radiology, Division of Diagnostic Imaging, MD Anderson Cancer Center, Houston, USA. He has reported no disclosures pertaining to this article.