Quality Improvement Guidelines for Pediatric Gastrostomy and ...

17 downloads 753862 Views 564KB Size Report
Practice Committee members by telephone conference calling or face- to-face meeting. The finalized draft from the Committee is sent to the. SIR membership for ...
STANDARDS OF PRACTICE

Quality Improvement Guidelines for Pediatric Gastrostomy and Gastrojejunostomy Tube Placement John J. Crowley, MB, Mark J. Hogan, MD, Richard B. Towbin, MD, Wael E. Saad, MD, Kevin M. Baskin, MD, Anne Marie Cahill, MD, Drew M. Caplin, MD, Bairbre L. Connolly, MB, Sanjeeva P. Kalva, MD, Venkataramu Krishnamurthy, MD, Francis E. Marshalleck, MD, Derek J. Roebuck, MD, Nael E. Saad, MD, Gloria M. Salazar, MD, Leann S. Stokes, MD, Michael J. Temple, MD, T. Gregory Walker, MD, and Boris Nikolic, MD, MBA, for the Society of Interventional Radiology Standards of Practice Committee and the Society for Pediatric Radiology Interventional Radiology Committee ABBREVIATIONS GJ tube = gastrojejunostomy tube, G tube = gastrostomy tube

PREAMBLE The membership of the Society of Interventional Radiology (SIR) Standards of Practice Committee represents experts in a broad spectrum of interventional procedures from the private and academic sectors of medicine. Generally, Standards of Practice Committee

From the Department of Radiology (J.J.C.), Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania; Department of Vascular and Interventional Radiology (M.J.H.), Nationwide Children’s Hospital and The Ohio State University, Columbus, Ohio; Department of Radiology (R.B.T.), Phoenix Children’s Hospital, Phoenix, Arizona; Department of Radiology (W.E.S., V.K.), Division of Vascular and Interventional Radiology, University of Michigan Medical Center, 1500 E. Medical Drive, SPC 5868, Cardiovascular Center, #5588, Ann Arbor, MI 48109-5868; Advanced Interventional Institute (K.M.B.), Pittsburgh, Pennsylvania; Department of Interventional Radiology (A.M.C.), Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Radiology (D.M.C.), Division of Interventional Radiology, Northshore University Hospital, Manhasset, New York; Centre for Image Guided Therapy (B.L.C., M.J.T.), Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; University of Texas Southwestern Medical Center (S.P.K.), Dallas, Texas; Riley Hospital for Children (F.E.M.), Indiana University School of Medicine, Indianapolis, Indiana; Department of Radiology (D.J.R.), Great Ormond Street Hospital, London, United Kingdom; Department of Radiology (N.E.S.), Division of Vascular and Interventional Radiology, and Department of Surgery (N.E.S.), Mallinckrodt Institute of Radiology, Washington University in St. Louis School of Medicine, St. Louis, Missouri; Department of Radiology (G.M.S., T.G.W.), Division of Vascular Imaging and Intervention, Massachusetts General Hospital, Boston, Massachusetts; Vanderbilt University Medical Center (L.S.S.), Nashville, Tennessee; and Stratton Medical Center (B.N.), Albany, New York. Received June 5, 2014; accepted August 1, 2014. Address correspondence to W.E.S.; E-mail: [email protected] R.T. has a royalty agreement with Siemens, Germany, Merit Medical, and Boston Scientific. K.C. and W.E.S. are paid consultants for Siemens, Germany, Merit Medical, and Boston Scientific. S.P.K. is a paid consultant for Celenova Biosciences, has a royalty agreement with Amirsys and Elsevier, and is an owner of Althea Healthcare. None of the other authors have identified a conflict of interest. & SIR, 2014 J Vasc Interv Radiol 2014; 25:1983–1991 http://dx.doi.org/10.1016/j.jvir.2014.08.002

members dedicate the vast majority of their professional time to performing interventional procedures; as such, they represent a valid, broad expert constituency of the subject matter under consideration for standards production. Technical documents specifying the exact consensus and literature review methodologies as well as institutional affiliations and professional credentials of the authors of this document are available on request from SIR, 3975 Fair Ridge Drive, Suite 400 North, Fairfax, VA 22033.

METHODOLOGY SIR produces its Standards of Practice documents by using the following process. Standards documents of relevance and timeliness are conceptualized by the Standards of Practice Committee members. A recognized expert is identified to serve as the principal author for the standard. Additional authors may be assigned depending on the magnitude of the project. An in-depth literature search is performed with use of electronic medical literature databases. Then, a critical review of peer-reviewed articles is performed with regard to the study methodology, results, and conclusions. The qualitative weight of these articles is assembled into an evidence table, which is used to write the document such that it contains evidence-based data with respect to content, rates, and thresholds. When the evidence of literature is weak, conflicting, or contradictory, consensus for the parameter is reached by a minimum of 12 Standards of Practice Committee members by using a modified Delphi consensus method (Appendix A). For the purposes of these documents, consensus is defined as 80% Delphi participant agreement on a value or parameter. The draft document is critically reviewed by the Standards of Practice Committee members by telephone conference calling or faceto-face meeting. The finalized draft from the Committee is sent to the SIR membership for further input/criticism during a 30-day comment period. These comments are discussed by the Standards of Practice Committee, and appropriate revisions are made to create the finished standards document. Prior to its publication, the document is endorsed by the SIR Executive Council.

INTRODUCTION Percutaneous gastrostomy tube (G tube) and gastrojejunostomy tube (GJ tube) placements are widely accepted techniques with low

1984



Guidelines for Pediatric G Tube and GJ Tube Placement

morbidity and high success rates that can be carried out with the use of local anesthesia and sedation (1,2). These procedures have become an important component of pediatric interventional practices; both antegrade and retrograde approaches to G tube and GJ tube placement in children have been reported; and G tube placement in infants weighing o 1.5 kg is well described (1–6). Although techniques are similar to techniques in adults, radiation protection is a particular concern, and small body size and different sedation requirements call for particular skill sets compared with adult practice; in addition, G tubes and GJ tubes need to be placed in children with conditions that are rarely, if ever, encountered in adult practice, such as esophageal atresia and microgastria (1). In addition to required informed consent of the parent or guardian to G tube or GJ tube placement, which covers the nature of the procedure, indications, contraindications, risks and benefits, surgical and medical alternatives, and expected outcomes, assent refers to an informed agreement by minors to a planned procedure. The knowledgeable and willing participation of the patient increases comfort and cooperation (7). The present guidelines are written to be used in quality improvement programs to assess percutaneous G tube and GJ tube placement in pediatric practice. The most important processes of care are (a) patient selection, (b) technique of tube placement, and (c) monitoring of the patient. The indicators or outcome measures for these processes are indications, success rates, and complication rates. Outcome measures are assigned threshold levels.

DEFINITIONS Gastroenteric access is the establishment of an artificial access into the gastrointestinal tract to provide feeding or decompression or both (8). This communication to the gastrointestinal tract can be percutaneous or through natural orifices (8). This quality improvement guideline is confined to percutaneous access in a pediatric population. Percutaneous gastrostomy is an artificial access into the stomach that is created through a small incision in the abdominal wall (8). Percutaneous gastrojejunostomy is the creation of access to the jejunum via the stomach through a small incision in the abdominal wall (8). Image guidance is the use of imaging methods, such as fluoroscopy, ultrasound, or computed tomography, to visualize the intestinal tract and adjacent organs to assist in creation of the enteric access (8). Gastropexy is the tacking or securing of the anterior gastric wall to the anterior abdominal wall (8), which is achieved by the use of a gastropexy device, such as a T fastener or suture. Although practicing physicians should strive to achieve perfect outcomes (eg, 100% success, 0% complications), all physicians in practice will fall short of this ideal to a variable extent. Indicator thresholds may be used to assess the efficacy of ongoing quality improvement programs. For the purposes of these guidelines, a threshold is a specific level of an indicator that should prompt a review. “Procedure thresholds” or “overall thresholds” refer to a group of indicators for a procedure (eg, major complications). Individual complications may also be associated with complication-specific thresholds. When measures such as indications or success rates fall below a (minimum) threshold or when complication rates exceed a (maximum) threshold, a review should be performed to determine causes and to implement changes, if necessary. For example, if the incidence of peritonitis is one measure of the quality of G tube placement, values in excess of the defined threshold, in this case 5%, should trigger a review of policies and procedures within the department to determine the causes and to implement changes to lower the incidence of the complication. Complications can be stratified on the basis of outcome. Major complications result in admission to a hospital for therapy (for outpatient procedures), an unplanned increase in the level of care, prolonged hospitalization, permanent adverse sequelae, or death. Minor complications result in no sequelae; they may require nominal therapy or a short hospital stay for observation (generally overnight)

Crowley et al



JVIR

(Appendix B). The complication rates and thresholds in this document refer to major complications.

INDICATIONS There are four main indications for placement of a G tube or GJ tube in a child: gastric feeding, small bowel feeding, decompression of the gastrointestinal tract, and diversion of intestinal contents to aid healing of intestinal fistulas. Some children, such as children with cystic fibrosis, may feed by mouth but are unable to maintain an adequate caloric intake, whereas others, such as children with cerebral palsy, are entirely unable to feed by mouth. Some children require gastrostomy or gastrojejunostomy access for management of fluid and electrolyte abnormalities (eg, children with diabetes insipidus). The threshold for these indications is 95%. When o 90% of procedures are for these indications, the department will review the process of patient selection.

Gastric Feeding Many studies have shown that children with chronic diseases have decreased caloric intake or increased nutritional requirements (9,10). Although temporary access to the gastrointestinal tract can be obtained via a natural orifice such as with a nasogastric or nasojejunal feeding tube, such tubes are notoriously prone to occlusion and dislodgment (8,11). These tubes, which are usually inserted for o 6 weeks, keep the gastroesophageal junction open, increasing the risk of gastroesophageal reflux and aspiration (9); cause impairment of oral feeding; cause irritation of the nasal mucosa; and are a considerable cosmetic and social handicap (9). In addition, a study of adult patients in an intensive care unit who were fed through a nasoenteric tube demonstrated an increased incidence of nosocomial sinusitis (odds ratio, 14.1) (12). Percutaneous enteral access plays an important role in children who are unable to feed by mouth, most commonly secondary to neurologic disorders, or unable to maintain an adequate caloric intake, such as patients with cystic fibrosis. Intravenous total parenteral nutrition, although useful in many children, bypasses the gastrointestinal tract and may cause changes in the barrier function of the intestinal mucosa, predisposing patients to bacteremia and sepsis (9,13). In addition, long-term use of total parenteral nutrition in children can lead to cholestatic liver disease and liver failure requiring liver transplantation (9,14,15). For all these reasons, placement of a percutaneous G tube has become a commonly performed procedure. In adults, the most commonly used artificial feeding route is via a gastrostomy with feeds delivered directly into the stomach (8). To receive a G tube, a child must have normal or near-normal gastric and small bowel motility, and gastric anatomy must be adequate (8). At least in the newborn, transpyloric feedings do not appear to offer any advantage over gastric feedings and should be reserved for infants at risk of aspiration, such as infants with gastroesophageal reflux or delayed gastric emptying (16).

Small Bowel Feeding Patients who are unable to tolerate gastric feedings, cannot receive a gastric feeding tube as a result of altered anatomy, have gastric outlet or duodenal obstruction, have a gastric or duodenal fistula, or have severe gastroesophageal reflux disease should receive a jejunal feeding tube (8). There is evidence from the adult literature that in critically ill patients, feeding into the small bowel, rather than stomach, significantly reduces vomiting, reduces microaspiration, and achieves nutritional goals earlier (17,18). There is anecdotal evidence that the same holds true in children; however, it would be valuable to confirm this by an appropriately designed study.

Gastrointestinal Decompression Gastric decompression is another possible indication for placement of a G tube, although this is probably a less common indication in children than in adults (19). Some GJ tube systems have two ports and can be used for concurrent jejunal feeding and gastric decompression (8).

Volume 25



Number 12



December



2014

Gastrointestinal tubes may be placed proximal to a known intestinal fistula to divert contents and food material or distal to a fistula for tube feeding in an attempt to bypass the fistula site. Participation by the radiologist in patient follow-up is a vital part of G tube or GJ tube placement. The interventionalist performing the procedure or a colleague should be intimately involved in monitoring the patient and managing the feeding tube after placement and until the feeds have reached the desired rate, which is usually within 3 days.

EVALUATION BEFORE PROCEDURE In general, given the procedural, sedation, and radiation risks to children, more time is spent in communication with referring teams, consulting services, and the family before procedures than for comparable adult procedures (20,21). The initial issue to address is the length of time for which the tube will be required. In general, if a tube is likely to be needed for o 6 weeks, placement of a nasogastric or nasojejunal feeding tube should be considered (8). The procedure should be performed only when the family have had an adequate opportunity to consider the effects on the child’s life; these are rarely emergent procedures, and families should never feel under pressure to give consent. Depending on the technique employed, it may be dangerous to remove a G tube, without a surgical intervention, for a matter of months. The coagulation status of each patient must be considered. These procedures are designated as category 2 according to SIR guidelines, implying a moderate risk of bleeding (22). The following procedures should be followed:

1985

enteric procedures in children are low (1–10 per 10,000) (26). It has been estimated that 60 minutes of fluoroscopy is required to increase the associated risk for fatal malignancy to 1–2 per 1,000, a risk comparable to pediatric abdominal computed tomography (26,29). When using fluoroscopy, it is the responsibility of the physician performing the procedure to see that parameters such as kilovolt peak (kVp) and milliamperes per second (mAs) are appropriate to the patient being imaged and that the pulse frequency is the lowest that can reasonably be used; a pulse frequency of 3/s is usually adequate. Even new G tube placement rarely requires high spatial resolution of the kind that is required for cerebral angiography. The use of fluoroscopy only and the avoidance of spot exposures further reduce dose (26). Enteral tube placement should not involve radiation exposure to highly radiosensitive organs such as the eye and breast. In girls, it is particularly important to use appropriate collimation to ensure that the ovaries are not included in the irradiated area. Replacing GJ tubes is a common procedure in pediatric interventional practices and one that can be technically challenging and potentially require significant fluoroscopic time (26). In addition, in small children, it may be particularly difficult for the operators’ hands to remain out of the primary beam; in these cases, both the patient and the operator may receive a significant radiation dose. In these cases, it is particularly important to pay attention to good technique with regard to exposure parameters—kVp, mAs, pulse repetition rate, and, perhaps most importantly, tight collimation to the area of interest and minimizing magnification. The main source of radiation exposure to the operator is scatter radiation from the patient, so in small children, this source of exposure is significantly reduced.

1. Correct international normalized ratio to r 1.5. 2. Ensure platelet count is 4 50,000.

SEDATION AND ANESTHESIA

3. Withhold clopidogrel for 5 days before the procedure. 4. Do not withhold aspirin.

Ensuring patient comfort and immobility is a challenge in this population with a high proportion of swallowing and gastrointestinal motility disorders, gastroesophageal reflux, and poor gastric emptying. These are features that may place the unprotected airway at risk. Even intubation does not exclude the possibility of aspiration (30). Pharmacologic interventions targeted to decrease the patient’s level of consciousness will likely increase these risks. The selection of an appropriate level of sedation and immobility must account for not only patient comfort but also patient safety and airway integrity. Both historically and currently, the volume of cases requiring sedation exceeds the resources of most departments of anesthesia. Nonanesthesiologist providers, including pediatric interventional radiologists, have performed sedation competently and safely for many procedures, including gastrostomy, for many years (1,5). It is nevertheless concerning that a large minority of sedations performed by nonanesthesiologists from multiple specialties do not follow published guidelines (31). “Sedation providers must demonstrate sufficient knowledge regarding the preprocedural evaluation, the necessary monitors and equipment availability, the commonly administered medications and their reversal agents, and when a patient has recovered from sedation and can appropriately be discharged. Each institution offering sedation services must follow the federal and state regulations on moderate and deep sedation, and sedation providers must have the appropriate qualifications. The specific education and training required of sedation providers differs among institutions. Although most institutions adopt the guidelines and standards of the American Society of Anesthesiologists, each professional society also has its own set of guidelines. In the end, whether sedation is administered by anesthesia or nonanesthesia providers, patient safety is of utmost concern” (32). Light sedation, analgesia, and anxiolysis in general refer to a condition in which the patient is relaxed (eg, using oral benzodiazepines or o 50% nitrous oxide inhalation) and protected by local anesthetics from local painful stimuli, but whose consciousness and existing mechanisms of airway protection are unimpaired. For example, in patients thought to be at risk from deep sedation or general anesthesia, primary G tube placement has safely been carried out using local

5. Withhold one dose of low-molecular-weight heparin before the procedure. 6. Partial thromboplastin time is recommended only for patients receiving unfractionated heparin. In some institutions, it is not routine to check the coagulation status of children in whom there is no reason to suspect a coagulopathy before G tube or GJ tube placement. In the rare case where the patient is coagulopathic, oral vitamin K, fresh frozen plasma, cryoprecipitate, or platelet transfusion may be indicated. In the case of transfusions, as in other invasive procedures, it is important that they be provided immediately before or during the case to optimize protective effects of the transfusion (21). The patient’s medical record should be examined for conditions known to make G tube or GJ tube placement difficult, such as hepatosplenomegaly or microgastria (1). A history of esophageal stricture or conditions such as dystrophic epidermolysis bullosa or active oral candidiasis may preclude an antegrade approach.

RADIATION PROTECTION There has been a dramatic increase in recent years in awareness of the hazards of iatrogenic radiation exposure and determined efforts to reduce the effective radiation dose to children from common interventional radiologic procedures such as enteral tube placement (23–27). Children are more radiosensitive than adults, and it is incumbent on all practitioners performing these procedures on children to do all that is reasonably possible to reduce radiation exposure (28). Placement of G tubes and their exchange or conversion to GJ tubes, almost always requires exposure to ionizing radiation because using alternative modalities such as ultrasound and magnetic resonance imaging is not usually feasible. Primary placement or exchange of G tubes or GJ tubes rarely exceeds the 2-Gy threshold for deterministic skin effects (26). The stochastic radiation risks of fatal malignancy associated with

1986



Guidelines for Pediatric G Tube and GJ Tube Placement

anesthesia alone; Chait et al (1) used only local anesthesia for gastrostomy in 56 of 505 children (11.1%). In the same series, general anesthesia was used only in 11.5%, with most (77.5%) being carried out under local anesthesia and intravenous sedation (1). The same institution reported that in 1989, 60 G tubes were inserted surgically before interventional radiology began offering this service; in 1999, 230 tubes were inserted by the image-guided technique, a remarkable growth, which has been suggested may be due to the ability of interventional radiology to provide primary gastrostomy without general anesthesia “in even the most medically fragile patients who were not believed to be candidates for anesthesia or surgery in the past” (33). Beyond light sedation, the spectrum from moderate and deep sedation to general anesthesia is semantically and clinically uncertain (34). Changes in reimbursement policy from the Centers for Medicare and Medicaid in 2008 regarding provision of deep sedation have led the American Society of Anesthesiologists to argue for exclusive use of some agents commonly used for deep sedation by nonanesthesiologists for procedures such as gastrostomy (35). The American Society of Anesthesiologists has pointed to these definitions to control credentialing, privileging, and reimbursement for the spectrum from moderate sedation to general anesthesia (34), despite recognition that properly trained nonanesthesiologists, including radiologists and interventional radiologists, can and do safely and effectively employ strategies for deep sedation in children (36,37). Various agents suitable for moderate to deep sedation are available. Intravenous dexmedetomidine and etomidate and inhaled nitrous oxide have each been incorporated in successful sedation strategies for pediatric procedures expected to be of short duration and minimally to moderately painful (38). Most strategies include a sedative such as intravenous midazolam or propofol in combination with an analgesic such as fentanyl or ketamine. In children and adolescents, this combination of analgesia and sedation “can prevent the emotional trauma that would result from a painful procedure, while often enhancing the quality of the procedure itself” (39). Deep sedation for procedures such as gastrostomy can be safely performed outside the operating room by nonanesthesiologists even in moderately high-risk pediatric patients (40). At this time, there are no specific published guidelines for deep sedation per se. Nevertheless, existing guidelines for sedation by nonanesthesiologists (41,42) mandate for such procedures:  That they be performed by personnel trained and experienced in

sedation practice  That at least one provider be qualified to manage airway and

resuscitation issues that may arise should sedation deepen to an unintended level  That appropriate resuscitation medications, supplies, and equipment be immediately available  That one qualified provider be exclusively tasked with medication delivery and patient monitoring  That monitoring include at minimum continuous pulse oximetry (with acoustic signal), continuous electrocardiography, and noninvasive blood pressure measurement (before the start of sedation, then at 5-min intervals) Monitoring of ventilation (by precordial stethoscope and sidestream capnography) is also recommended for moderate or deep sedation for early detection of microalveolar hypoventilation and prevention of hypoxemia (43,44). It is also essential that sedation providers properly recognize patients at high risk for sedation complications (39), including newborns and infants, and patients with:  Respiratory impairment  Cardiovascular disease  Symptomatic gastroesophageal reflux or poor gastric emptying  Restricted hepatic and renal clearance  Neuromuscular and metabolic diseases

Crowley et al



JVIR

 Neurodegenerative diseases  Craniofacial malformations  A history of sedation failure or extreme anxiety

When the patient’s history and comorbidities, current condition, and expected goals and objectives of sedation, either before or during a case, exceed the experience or resources of nonanesthesiology sedation personnel, there should be a low threshold for consultation with an experienced anesthesiologist (45).

PATIENT CARE ISSUES Especially in young children, maintaining the appropriate environment, particularly with regard to ambient temperature, is of paramount importance (21). Interventionalists not used to dealing with children may be unaware of how quickly young children and infants become hypothermic. Hypothermia is particularly a concern in G tube placement where much of the torso will be exposed to room air and the abdomen is often cleansed with alcohol-based disinfectants. It is good practice to have temperature monitoring on any child o 2 years old. As in all interventional procedures, patient size–specific leads and probes for routine electrocardiography, blood pressure, and respiratory monitoring are required, with proper padding of pressure points to minimize nerve palsies (21,45). During antegrade gastrostomy tube placement, care must be taken not to dislodge teeth; also, cuts to the tongue and gums from the wire over which the tube is advanced are a potential concern for the inexperienced operator.

CONTRAINDICATIONS Absolute contraindications to tube placement include mechanical obstruction of the gastrointestinal tract (unless the procedure is indicated for decompression), active peritonitis, uncorrectable coagulopathy, and bowel ischemia (8). Microgastria is an example of a condition that is rarely be seen outside the pediatric population and has been described as a cause of technical failure (1). Large gastric varices make the procedure hazardous, although simultaneous endoscopic control has been described (7). Relative contraindications include ascites, which increases the risk of bacterial peritonitis and may impair maturation of the stoma tract. G tubes may still be placed if paracentesis can prevent reaccumulation for a period of 7–10 days to allow the tract to mature (8). A study of 23 children with ventriculoperitoneal shunt tubes who underwent percutaneous G tube placement showed 2 (9%) developed evidence of peritonitis and subsequently were confirmed to have shunt infections. The authors recommend prophylactic antibiotic therapy for these patients to cover skin and oral flora (46). Massive hepatosplenomegaly has been described as a cause of failure in 2 of 511 patients in whom G tube placement was attempted in the series of Chait et al (1). Morbid obesity is a relative contraindication because shifting of the panniculus in the postoperative period may dislodge the G tube from the stomach (8). As previously mentioned, conditions such as esophageal stricture, dystrophic epidermolysis bullosa, or active oral candidiasis may preclude an antegrade approach, although a retrograde approach is still possible.

ANTIBIOTIC PROPHYLAXIS Patients undergoing G tube placement are often at increased risk for infection because of poor nutritional or immunocompromised status or as a result of significant comorbidities (8). Antegrade techniques have a reported incidence of 5.4%–30% of peristomal infections (47). In the adult literature, these infections are presumably related to dragging a bumper through the mouth and contaminating the tract with oral bacterial flora. It is now generally agreed that prophylactic antibiotics should be given in antegrade G tube placement (48). In contrast, one of the advantages of the transabdominal, or retrograde, route is that it does not expose the

Volume 25



Number 12



December



2014

gastrostomy tract to oral flora, and at least one randomized controlled trial could demonstrate no advantage to the prophylactic administration of antibiotics using the retrograde technique (49).

PROCEDURE There are two techniques for placing percutaneous G tubes in children —the transoral, or antegrade, and the transabdominal, or retrograde, technique (1,5,9,33,46,50). In both techniques, ultrasound is used to ensure that the liver and spleen will not be traversed. The usual site is just lateral to the left rectus abdominis muscle because puncture of the muscle can be uncomfortable and to avoid branches of the superior epigastric artery. Puncture in the midline is not ideal because it can make accessing the duodenum for jejunal tube placement difficult and may cause obstruction if the balloon abuts the pylorus, but it may be the only viable access site, and it is usually satisfactory. It is usual in children to opacify the colon with dilute barium, given either by mouth some hours in advance or by enema just before puncture (1,5,46), although not all operators find contrast opacification of the colon necessary. In the event that a loop of distended air-filled colon is interposed between the abdominal wall and stomach, decompression by a 27-gauge needle introduced percutaneously under fluoroscopic guidance has been described (7), although this is rarely performed. In the antegrade technique, two tubes are advanced into the stomach. An orogastric tube is placed through which a snare is advanced. A nasogastric tube is also placed, which is used to inflate the stomach with air, although it is possible to use only one oropharyngeal catheter, which is used to inflate the stomach and then used to introduce the snare. The stomach is punctured percutaneously with a needle under fluoroscopic guidance, and a wire is introduced. To avoid decompression of the stomach during inflation, most operators give 0.1–1 mg of glucagon intravenously, although not all operators think this is necessary (51). The orogastric snare is then used to grasp the wire and pull it out of the mouth giving wire access from the mouth, down the esophagus, and out of the gastric puncture (5,46). Over this wire, the G tube, with the internal bumper trailing, is introduced. The tube is pulled out of the anterior abdominal wall, and the internal bumper catches on the gastric mucosa (52). The advantage of this technique is the creation of a very stable G tube that is difficult to dislodge accidentally; the disadvantages are some degree of skill and experience required to snare a wire within the gastric lumen and, as previously mentioned, pulling the tube through the mouth may increase the risk of gastrostomy site infections and require periprocedural antibiotics (5,48). Also, removing or replacing an antegrade tube may require a second sedation. Once the G tube is placed, if jejunal feeding is required, a guiding catheter and wire are introduced through the new G tube; the duodenum or jejunum is accessed; the catheter is removed; and, over the wire, the jejunal feeding tube is advanced. The result is a coaxial system with the jejunal tube passing through G tube —the jejunal tube may subsequently be exchanged through the indwelling G tube (5,52). The transabdominal or retrograde technique involves inflating the stomach with air via a nasogastric tube; puncturing the stomach; and, in contrast to the antegrade technique, deploying up to four gastropexy devices (8,53). Use of this technique in infants weighing 800 g has been described (7). In small children, there may be room for only one or two gastropexy devices. The stomach is then punctured, usually with an 18-gauge needle directed toward the pylorus to facilitate future conversion of the G tube to a GJ tube (1,8). A wire is advanced, the tract is dilated, and an appropriate-sized G tube is placed. Some authors suggest the following sizes based on the child’s weight: o 10 kg, 8.5-F; 10–25 kg, 10-F; 4 25 kg, 12-F (1). If a GJ tube is desired, a 5-F catheter is introduced, and the duodenum or jejunum is accessed under fluoroscopic guidance. The gastrostomy site is dilated, and the desired GJ tube is advanced over the wire, with or without the use of a peel-away sheath. GJ tubes designed for children are available with a distal pigtail with side holes and a proximal locking loop that sits in the stomach (Chait tube; Cook, Inc, Bloomington, Indiana) (1). The

1987

gastropexy sutures are cut 1–3 weeks after G tube placement, although a study in adults showed no complications in 109 patients when the sutures were cut 2 days after the procedure (54). The retrograde technique may be employed in patients with conditions such as esophageal stricture, esophageal atresia, or oropharyngeal abnormalities and in very small patients in whom the antegrade technique would not be possible. In children with esophageal atresia, retrograde G tube placement has been described after gastric distention has been achieved with a 22-gauge needle puncture of the stomach under ultrasound guidance (1). The same authors report that children with esophageal atresia with a tracheoesophageal fistula had adequate distention of their stomachs through the fistula and did not require ultrasound-guided needle puncture or nasogastric tube placement (1). A combination of antegrade and retrograde techniques has also been successfully used in children (Hogan M, Towbin R, personal communication, August 1, 2013). An orogastric snare and nasogastric inflation tube are introduced, the stomach is punctured, and T-fasteners may be deployed. The wire is snared and drawn out of the mouth. The tract is dilated with either fascial dilators or an angioplasty balloon, and the G tube is advanced into the distal esophagus. A little dilute contrast material is introduced into the balloon (or the pigtail is formed) in the distal esophagus to confirm intraluminal positioning, and the catheter is pulled back into the stomach. The wire is removed through the mouth to avoid pulling oral flora back through the tract, and if a jejunal tube is desired, it is then placed coaxially. This technique has been successfully used in infants weighing 2 kg (Hogan M, personal communication, August 1, 2013).

SUCCESS RATES AND THRESHOLDS Technical success of G tube or GJ tube placement is easy to measure, and successful placement has been reported in a high percentage of children (1,2,4,5,9,46,50,55,56). Rosenberg et al (50), in a study using a retrograde technique and confined to patients with gastroschisis, omphalocele, and congenital diaphragmatic hernia, reported a success rate of 94.7%. Technical success for image-guided percutaneous gastrostomy ranged from 94.7%–100% (Table 1). In view of the previously reported data, we believe a reasonable threshold for technical success in children should be 95% (Table 2).

COMPLICATIONS Published rates for individual types of complications in G and GJ placement in children are limited and are based on small sample sizes in retrospective studies (Table 3). In addition, the incidence of complications is highly dependent on patient selection, with the highest incidence of complications occurring in a study confined to patients with ventriculoperitoneal shunts (46). It is also recognized that Table 1 . Success Rates and Thresholds for G Tube or GJ Tube Placement in Children Year

No. Cases

Success Rate (%)

Towbin et al (5)

Author

1988

24

100

Malden et al (2)

1992

27

100

King et al (4) Albanese et al (56)

1993 1993

57 44

98.3 98

Chait et al (1)

1996

511

98.8

Sane et al (46) Lewis et al (9)

1998 2008

205 120

100 100

Rosenberg et al (50)

2008

37

94.7

Nah et al (55)

2010

193

99

GJ tube ¼ gastrojejunostomy tube; G tube ¼ gastrostomy tube.

1988



Guidelines for Pediatric G Tube and GJ Tube Placement

Table 2 . Success Rate and Threshold

Crowley et al



JVIR

Table 4 . Published Complication Rates and Suggested Thresholds Suggested

Outcome Successful placement of

95%

percutaneous G tube G tube ¼ gastrostomy tube. Table 3 . Major Complication Rate after G Tube or GJ Tube Placement in Children

Author Towbin et al (5) Malden et al (2)

Suggested

Threshold Value (%) Specific Major Complication

Rate (%)

Threshold (%)

Death (9)

0.05–0.9

1

Blood loss requiring

0.5–1.7

3

transfusion (9,51) Extraluminal G tube

0.2

0.5

0.2 1.8–3

0.5 5

placement (1) Bowel transgression (1) Peritonitis (9,33)

Major Complication Year No. Cases Rate within 30 Days (%)

Subcutaneous abscess (33)

1988 1992

Septicemia (9,33) VP shunt infection (46)

24 27

0 0

King et al (4)

1993

57

0

Marx et al (51) Chait et al (1)

1996 1996

61 511

3.3 0.39

Sane et al (46)

1998

205

9

Friedman et al (33) Lewis et al (9)

2004 2008

208 120

5 4.2

Rosenberg et al (50) 2008

37

5

Nah et al (55)

193

3

2010

GJ tube ¼ gastrojejunostomy tube; G tube ¼ gastrostomy tube.

a single complication can cause a rate to cross above a complication specific threshold when the complication occurs within a small patient volume, as may be the case in pediatric practice. In this situation, the overall procedure threshold is more appropriate for use in a quality improvement program. Complications may be defined as major or minor depending on management, hospital stay, and outcome in accordance with the SIR Clinical Practice Guidelines (9,57). Complications occur in approximately 5% of patients (1,2,4,5,9,33,46,50,55). Published complication rates and suggested thresholds include the following (Table 4). Marx et al (51) reported 2 major and 11 minor complications in 61 G tube placement attempts, giving a total complication rate of 21% using the retrograde technique. However, after initiation of gastropexy placement, the major and minor complication rates decreased to 1.9% (1 of 52) and 9.6% (5 of 52), respectively. The two major complications were hemorrhage that required endoscopy and transfusion where access to the stomach was lost during the procedure and respiratory decompensation following anesthesia that required reintubation. Minor complications were fever without localizing signs (n ¼ 5), mild peritonitis treated with 48 hours of intravenous antibiotics (n ¼ 3), pain that required increased ventilatory support in a patient with myopathy (n ¼ 1), collapse of right upper lobe that required vigorous pulmonary toilet (n ¼ 1), and seizure treated with intravenous medication for control (n ¼ 1). Malden et al (2) reported no major complications in 27 G tube placements in children with minor complications occurring in 6 cases. The retrograde technique, without the use of gastropexy devices, was used in every patient. All six minor complications were wound infections consisting of local erythema, tenderness, and discharge. The wound infections were successfully treated with “standard wound care” and topical antibiotics and resolved. In an early series, Towbin et al (5) reported no major complications in 34 primary G tube and GJ tube placements using the antegrade technique. During 2–20 months of follow-up, only three minor skin infections were noted, which resolved with oral and topical antibiotics. King et al (4) placed G tubes in 57 children using the retrograde technique. They reported no major and only two minor complications

2

5

0.9–1 9

2 10

G tube ¼ gastrostomy tube; VP ¼ ventriculoperitoneal.

consisting of abdominal tenderness and low-grade fever lasting o48 hours. In a large series of 511 patients, Chait et al (1) did not classify the complications as major or minor, but they reported one tube placed outside the stomach necessitating laparotomy, one tube that transgressed small bowel, and an appendix epiploica necessitating surgery, resulting in a serious complication rate of 0.39%. In the first 30 days, 20 patients (5.1%) had irritation at the stoma, 11 patients (2.8%) had skin infections, and 6 patients (1.5%) had early tube dislodgment; all six tubes were easily replaced. However, a later series from the same institution, also using the retrograde technique, reported a major complication rate of 5% and a minor complication rate of 73% after insertion of 208 G tubes and 41 GJ tubes using the retrograde technique in children (33). In this series, only a “convenience sample” of 208 charts of 840 patients who had a G tube or GJ tube placed were sampled. Seven patients (3%) developed peritonitis, four patients (2%) developed subcutaneous abscess, and three patients (1%) developed septicemia; there was also one gastrointestinal bleed about which no further information was provided. One child developed peritoneal signs, which progressed to sepsis, and the child subsequently died. Although the minor complication rate is very high in this series (73%), many of the reported complications are probably more accurately reported as tube maintenance problems, including dislodgment after the first week (37%), leakage (26%), obstruction of the feeding tube (12%), and migration (12%) (33). A further series from the same institution was published in 2008 and described a random selection of 120 patients in whom G tube or GJ tube placement was attempted between January 2002 and December 2003 (9). During that time, 358 tubes were inserted. Complications were divided into early (o 30 d after tube insertion) and late (Z 30 d after tube insertion) and were determined to be major or minor according to SIR Clinical Practice Guidelines (57). There were five early major complications after the procedure (two cases of peritonitis, one case of sepsis, one bleed requiring transfusion, and one death). The death occurred in a child with epidermolysis bullosa who developed a site infection, sepsis, and cardiovascular collapse 16 days after G tube placement (9). The same study reported six late major complications after the procedure consisting of three site infections, one tract loss, one tract dissection, and one gastrocutaneous fistula after elective G tube removal that required surgical closure, but, again, many of the late complications could more accurately be described as tube maintenance problems. The early major complication rate was 4.2% As previously mentioned, Sane et al (46) evaluated the experience in G tube placement in children with ventriculoperitoneal shunts in 23 children using the antegrade technique. They found 2 children (9%) developed shunt infections and recommended antibiotic cover for skin and oral flora. No other complications were noted in this series.

Volume 25



Number 12



December



2014

Pneumoperitoneum is frequently seen postoperatively and is of little clinical significance. However, a case of tension pneumoperitoneum after G tube placement in a child with tracheoesophageal fistula undergoing positive pressure ventilation has been described; this was successfully treated with percutaneous aspiration (7). A unique complication of GJ tubes, which is almost totally confined to feeding tubes with a distal pigtail loop, is intussusception (33,58–60). This complication is rarely seen with straight jejunal feeding tubes of the sort usually placed through gastrostomy tubes. Patients who are predisposed to develop intussusception include male patients, young infants, and patients with a distal pigtail loop (33,60). Intussusception can easily be diagnosed with ultrasound and can usually be successfully managed by replacing the GJ tubes with shortened GJ tubes with no distal pigtail (59,60). Thresholds for major and minor complications are more difficult, considering the conflicting evidence already cited; however, major complications should not occur in 4 5% of patients within 30 days of G tube or GJ tube placement, and minor complications should not occur in 4 25% within 30 days of placement. It is difficult to offer guidelines on complication rates beyond 30 days because many of the problems described, such as skin infection and irritation and leakage, reflect different tube and site management regimens.

ETHICAL CONSIDERATIONS The decision to place a feeding tube may raise difficult ethical issues, particularly in a child with perceived poor quality of life (61). Medical ethics, as applied to G tube and GJ tube placement, follows five basic principles: autonomy, beneficence, nonmaleficence, justice, and futility. Autonomy is self-determination or the ability to govern oneself. Beneficence is the concept that the intervention should provide net good. Nonmaleficence, the reverse of maleficence (which is the act by a person in a position of trust that is unwarranted and harmful), includes the concept described by the Latin phrase Primum non nocere, or “First, do no harm.” Justice refers to the quality of being fair and involves the just allocation of medical resources. Lastly, futility involves the concept that a medical intervention would have either no effect or none that would benefit the patient (8,61). The decision to proceed should be based on the presumption that it would provide net benefit to the patient and not harm, that the benefits would outweigh the risks of the procedure, and that the procedure would be offered to the patient regardless of his or her socioeconomic status (61). G tubes or GJ tubes should not be placed where they will merely prolong patient suffering; in adult practice, it is discouraged to place G tubes or GJ tubes in patients with end-stage, incurable cancer (8).

CONCLUSIONS Percutaneous placement of G tubes or GJ tubes using image guidance can be safely achieved in even tiny infants with impressive success rates. They are a safe and effective alternative to surgical and endoscopic placement.

APPENDIX A. SOCIETY OF INTERVENTIONAL RADIOLOGY STANDARDS OF PRACTICE COMMITTEE CLASSIFICATION OF COMPLICATIONS BY OUTCOME Minor Complications A. No therapy, no consequence B. Nominal therapy, no consequence; includes overnight admission (r 23 h) for observation only

Major Complications C. Require major therapy, minor hospitalization (Z 24 h but o 48 h) D. Require major therapy, unplanned increase in level of care, prolonged hospitalization (4 48 h)

1989

E. Permanent adverse sequelae F. Result in death

APPENDIX B. CONSENSUS METHODOLOGY Reported complication-specific rates in some cases reflect the major complication rate. Minor complication rates are difficult to evaluate because there are conflicting standards for what constitutes a minor complication, and some studies include problems, such as jejunal tube occlusion, that are more properly regarded as tube management problems. Thresholds are derived from critical evaluation of the literature, evaluation of empirical data from Standards of Practice Committee members’ practices, and, when available, the SIR HI-IQ System national database. Consensus on statements in this document was obtained utilizing a modified Delphi technique (62,63).

ACKNOWLEDGMENT Dr John J. Crowley authored the first draft of this document and served as topic leader during the subsequent revisions of the draft. Dr Wael E. Saad is chair of the SIR Standards of Practice Committee. Drs Mark Hogan and Richard Towbin are co-chairs of the Pediatric Interventional Radiology Subcommittee. Dr Boris Nikolic is Councilor of the SIR Standards Division. All other authors are listed alphabetically. Other members of the Standards of Practice Committee and SIR who participated in the development of this clinical practice guideline are (listed alphabetically) James A. Charles, MD, G. Peter Feola, MD, Manraj K.S. Heran, MD, and Carrie M. Schaefer, MD.

REFERENCES 1. Chait PG, Weinberg J, Connolly BL, et al. Retrograde percutaneous gastrostomy and gastrojejunostomy in 505 children: a 4 1/2-year experience. Radiology 1996; 201:691–695. 2. Malden ES, Hicks ME, Picus D, Darcy MD, Vesely TM, Kleinhoffer MA. Fluoroscopically guided percutaneous gastrostomy in children. J Vasc Interv Radiol 1992; 3:673–677. 3. Laffan EE, McNamara PJ, Amaral J, et al. Review of interventional procedures in the very low birth-weight infant (o1.5 kg): complications, lessons learned and current practice. Pediatr Radiol 2009; 39:781–790. 4. King SJ, Chait PG, Daneman A, Pereira J. Retrograde percutaneous gastrostomy: a prospective study in 57 children. Pediatr Radiol 1993; 23: 23–25. 5. Towbin RB, Ball WS Jr, Bissett GS 3rd. Percutaneous gastrostomy and percutaneous gastrojejunostomy in children: antegrade approach. Radiology 1988; 168:473–476. 6. Cory DA, Fitzgerald JF, Cohen MD. Percutaneous nonendoscopic gastrostomy in children. AJR Am J Roentgenol 1988; 151:995–997. 7. Chait P, Baskin KM, Temple M, Connolly B. Pediatric gastrointestinal interventions. In: Stringer DA, Babyn PS, editors. Pediatric Gastrointestinal Imaging and Intervention, 2nd ed. Hamilton, Ontario: BC Decker; 2000:97–160. 8. Itkin M, DeLegge MH, Fang JC, et al. Multidisciplinary practical guidelines for gastrointestinal access for enteral nutrition and decompression from the Society of Interventional Radiology and American Gastroenterological Association (AGA) Institute, with endorsement by Canadian Interventional Radiological Association (CIRA) and Cardiovascular and Interventional Radiological Society of Europe (CIRSE). J Vasc Interv Radiol 2011; 22:1089–1106. 9. Lewis EC, Connolly B, Temple M, et al. Growth outcomes and complications after radiologic gastrostomy in 120 children. Pediatr Radiol 2008; 38:963–970. 10. Norman K, Pichard C, Lochs H, Pirlich M. Prognostic impact of diseaserelated malnutrition. Clin Nutr 2008; 27:5–15. 11. Patrick PG, Marulendra S, Kirby DF, DeLegge MH. Endoscopic nasogastric-jejunal feeding tube placement in critically ill patients. Gastrointest Endosc 1997; 45:72–76. 12. George DL, Falk PS, Umberto Meduri G, et al. Nosocomial sinusitis in patients in the medical intensive care unit: a prospective epidemiological study. Clin Infect Dis 1998; 27:463–470.

1990



Guidelines for Pediatric G Tube and GJ Tube Placement

13. Ching YA, Gura K, Modi B, Jaksic T. Pediatric intestinal failure: nutrition, pharmacologic, and surgical approaches. Nutr Clin Pract 2007; 22:653–663. 14. Zambrano E, El-Hennawy M, Ehrenkranz RA, Zelterman D, Reyes-Mugica M. Total parenteral nutrition induced liver pathology: an autopsy series of 24 newborn cases. Pediatr Dev Pathol 2004; 7:425–432. 15. Quigley EM, Marsh MN, Shaffer JL, Markin RS. Hepatobiliary complications of total parenteral nutrition. Gastroenterology 1993; 104:286–301. 16. Macagno F, Demarini S. Techniques of enteral feeding in the newborn. Acta Paediatr Suppl 1994; 402:11–13. 17. Hsu CW, Sun SF, Lin SL, et al. Duodenal versus gastric feeding in medical intensive care unit patients: a prospective, randomized, clinical study. Crit Care Med 2009; 37:1866–1872. 18. Heyland DK, Drover JW, MacDonald S, Novak F, Lam M. Effect of postpyloric feeding on gastroesophageal regurgitation and pulmonary microaspiration: results of a randomized controlled trial. Crit Care Med 2001; 29:1495–1501. 19. Felsher J, Chand B, Ponsky J. Decompressive percutaneous endoscopic gastrostomy in nonmalignant disease. Am J Surg 2004; 187:254–256. 20. Baskin KM, Hogan MJ, Sidhu MK, et al. Developing a clinical pediatric interventional practice: a joint clinical practice guideline from the Society of Interventional Radiology and the Society for Pediatric Radiology. J Vasc Interv Radiol 2011; 22:1647–1655. 21. Hogan MJ, Marshalleck FE, Sidhu MK, et al. Quality improvement guidelines for pediatric abscess and fluid drainage. J Vasc Interv Radiol 2012; 23:1397–1402. 22. Malloy PC, Grassi CJ, Kundu S, et al. Consensus guidelines for periprocedural management of coagulation status and hemostasis risk in percutaneous image-guided interventions. J Vasc Interv Radiol 2009; 20(7 Suppl):S240–S249. 23. Sidhu M, Strauss KJ, Connolly B, et al. Radiation safety in pediatric interventional radiology. Tech Vasc Interv Radiol 2010; 13:158–166. 24. Hall EJ. Radiation biology for pediatric radiologists. Pediatr Radiol 2009; 39(Suppl 1):S57–S64. 25. Stecker MS, Balter S, Towbin RB, et al. Guidelines for patient radiation dose management. J Vasc Interv Radiol 2009; 20(7 Suppl):S263–S273. 26. Govia K, Connolly BL, Thomas KE, Gordon CL. Estimates of effective dose to pediatric patients undergoing enteric and venous access procedures. J Vasc Interv Radiol 2012; 23:443–450. 27. National Research Council. Health Risks from Exposure to Low Levels of Ionizing Radiation: BEIR VII Phase 2. Washington, DC: The National Academies Press; 2006. 28. Pearce MS, Salotti JA, Little MP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet 2012; 380:499–505. 29. Brenner D, Elliston C, Hall E, Berdon W. Estimated risks of radiationinduced fatal cancer from pediatric CT. AJR Am J Roentgenol 2001; 176: 289–296. 30. Nseir S, Zerimech F, Jaillette E, Artru F, Balduyck M. Microaspiration in intubated critically ill patients: diagnosis and prevention. Infect Disord Drug Targets 2011; 11:413–423. 31. Langhan ML, Mallory M, Hertzog J, Lowrie L, Cravero J. Physiologic monitoring practices during pediatric procedural sedation: a report from the Pediatric Sedation Research Consortium. Arch Pediatr Adolesc Med 2012; 166:990–998. 32. Bui AH, Urman RD. Clinical and safety considerations for moderate and deep sedation. J Med Pract Manage 2013; 29:35–41. 33. Friedman JN, Ahmed S, Connolly B, Chait P, Mahant S. Complications associated with image-guided gastrostomy and gastrojejunostomy tubes in children. Pediatrics 2004; 114:458–461. 34. Green SM, Mason KP. Stratification of sedation risk—a challenge to the sedation continuum. Paediatr Anaesth 2011; 21:924–931. 35. Rex DK. Effect of the Centers for Medicare & Medicaid Services policy about deep sedation on use of propofol. Ann Intern Med 2011; 154:622–626. 36. Moran TC, Kaye AD, Mai AH, Bok LR. Sedation, analgesia, and local anesthesia: a review for general and interventional radiologists. Radiographics 2013; 33:E47–E60. 37. American College of Radiology. ACR-SIR practice guideline for sedation/ analgesia. Revision 2010 (Resolution 45). 2010. Available at: http://www. acr.org/~/media/F194CBB800AB43048B997A75938AB482.pdf. Accessed September 2, 2014. 38. Hertzog JH, Havidich JE. Non-anesthesiologist-provided pediatric procedural sedation: an update. Curr Opin Anaesthesiol 2007; 20:365–372. 39. Neuhauser C, Wagner B, Heckmann M, Weigand MA, Zimmer KP. Analgesia and sedation for painful interventions in children and adolescents. Dtsch Arztebl Int 2010; 107:241–247, I–II, I.

Crowley et al



JVIR

40. Wengrower D, Gozal D, Gozal Y, et al. Complicated endoscopic pediatric procedures using deep sedation and general anesthesia are safe in the endoscopy suite. Scand J Gastroenterol 2004; 39:283–286. 41. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002; 96: 1004–1017. 42. Cote CJ, Wilson S. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Pediatrics 2006; 118:2587–2602. 43. Lightdale JR, Goldmann DA, Feldman HA, Newburg AR, DiNardo JA, Fox VL. Microstream capnography improves patient monitoring during moderate sedation: a randomized, controlled trial. Pediatrics 2006; 117: e1170–e1178. 44. American Society of Anesthesiologists. Standards for Basic Anesthetic Monitoring, Committee of Origin: Standards and Practice Parameters. Available at: https://www.asahq.org/coveo.aspxq=Standards%20for% 20Basic%20Anesthetic%20Monitoring. Accessed September 2, 2014. 45. Mason KP. Pediatric procedures in interventional radiology. Int Anesthesiol Clin 2009; 47:35–43. 46. Sane SS, Towbin A, Bergey EA, et al. Percutaneous gastrostomy tube placement in patients with ventriculoperitoneal shunts. Pediatr Radiol 1998; 28:521–523. 47. McClave SA, Chang WK. Complications of enteral access. Gastrointest Endosc 2003; 58:739–751. 48. Lipp A, Lusardi G. Systemic antimicrobial prophylaxis for percutaneous endoscopic gastrostomy. Cochrane Database Syst Rev 2006;(4): CD005571. 49. Shastri YM, Hoepffner N, Tessmer A, Ackermann H, Schroeder O, Stein J. New introducer PEG gastropexy does not require prophylactic antibiotics: multicenter prospective randomized double-blind placebo-controlled study. Gastrointest Endosc 2008; 67:620–628. 50. Rosenberg J, Amaral JG, Sklar CM, et al. Gastrostomy and gastrojejunostomy tube placements: outcomes in children with gastroschisis, omphalocele, and congenital diaphragmatic hernia. Radiology 2008; 248: 247–253. 51. Marx MV, Williams DM, Perkins AJ, et al. Percutaneous feeding tube placement in pediatric patients: immediate and 30-day results. J Vasc Interv Radiol 1996; 7:107–115. 52. Laasch HU, Wilbraham L, Bullen K, et al. Gastrostomy insertion: comparing the options—PEG. RIG or PIG? Clin Radiol 2003; 58:398–405. 53. Coleman CC, Coons HG, Cope C, et al. Percutaneous enterostomy with the Cope suture anchor. Radiology 1990; 174(3 Pt 1):889–891. 54. Foster A, Given M, Thornton E, et al. Removal of T-fasteners 2 days after gastrostomy is feasible. Cardiovasc Intervent Radiol 2009; 32: 317–319. 55. Nah SA, Narayanaswamy B, Eaton S, et al. Gastrostomy insertion in children: percutaneous endoscopic or percutaneous image-guided? J Pediatr Surg 2010; 45:1153–1158. 56. Albanese CT, Towbin RB, Ulman I, Lewis J, Smith SD. Percutaneous gastrojejunostomy versus Nissen fundoplication for enteral feeding of the neurologically impaired child with gastroesophageal reflux. J Pediatr 1993; 123:371–375. 57. Sacks D, McClenny TE, Cardella JF, Lewis CA. Society of Interventional Radiology clinical practice guidelines. J Vasc Interv Radiol 2003; 14(9 Pt 2):S199–S202. 58. Wales PW, Diamond IR, Dutta S, et al. Fundoplication and gastrostomy versus image-guided gastrojejunal tube for enteral feeding in neurologically impaired children with gastroesophageal reflux. J Pediatr Surg 2002; 37:407–412. 59. Connolly BL, Chait PG, Siva-Nandan R, Duncan D, Peer M. Recognition of intussusception around gastrojejunostomy tubes in children. AJR Am J Roentgenol 1998; 170:467–470. 60. Hughes UM, Connolly BL, Chait PG, Muraca S. Further report of smallbowel intussusceptions related to gastrojejunostomy tubes. Pediatr Radiol 2000; 30:614–617. 61. DeLegge MH, McClave SA, DiSario JA, et al. Ethical and medicolegal aspects of PEG-tube placement and provision of artificial nutritional therapy. Gastrointest Endosc 2005; 62:952–959. 62. Fink A, Kosecoff J, Chassin M, Brook RH. Consensus methods: characteristics and guidelines for use. Am J Public Health 1984; 74: 979–983. 63. Leape LL, Hilborne LH, Park RE, et al. The appropriateness of use of coronary artery bypass graft surgery in New York State. JAMA 1993; 269: 753–760.

Volume 25



Number 12



December



2014

1991

SIR DISCLAIMER The clinical practice guidelines of SIR attempt to define practice principles that generally should assist in producing high-quality medical care. These guidelines are voluntary and are not rules. A physician may deviate from these guidelines as necessitated by the individual patient and available resources. These practice guidelines should not be deemed inclusive of all proper methods of care or exclusive of other methods of care that are reasonably directed toward the same result. Other sources of information may be used in conjunction with these principles to produce a process leading to high-quality medical care. The ultimate judgment regarding the conduct of any specific procedure or course of management must be made by the physician, who should consider all circumstances relevant to the individual clinical situation. Adherence to the SIR Quality Improvement Program will not assure a successful outcome in every situation. It is prudent to document the rationale for any deviation from the suggested practice guidelines in the department policies and procedure manual or in the patient’s medical record.