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Original Research |
1 Department of Diagnostic Imaging, The Hospital for Sick Children, 555
University Ave., Toronto, ON, Canada M5G 1X8.
2 Department of Cardiology, The Hospital for Sick Children, Toronto, ON,
Canada.
3 Department of Statistics–Child Health Evaluative Sciences, The Hospital
for Sick Children, Toronto, ON, Canada.
4 Ellesmere X-ray Associates, Scarborough, ON, Canada.
Received January 9, 2008;
accepted after revision April 13, 2008.
Address correspondence to J. G. Amaral
(joao.amaral{at}sickkids.ca).
Abstract
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MATERIALS AND METHODS. Retrospective chart review of 58 children with cardiac disease who underwent radiologic percutaneous gastrostomy from November 2001 to June 2005 was conducted. Patient data were collected until January 2007. The patients' weights were collected at the time of insertion and 6, 12, 18, and 24 months after insertion, and weight-for-age z-scores were calculated.
RESULTS. The mean weight-for-age z-score increased from –2.79 at the time of radiologic percutaneous gastrostomy insertion to –2.33 (p = 0.05) at 6 months after insertion, –1.89 (p = 0.001) at 12 months, –1.65 (p = 0.0002) at 18 months, and –1.40 (p = 0.0004) at 24 months. Repeated measures regression analysis showed a significant increase in weight-for-age z-score over time (p < 0.0001), with an estimated mean increase in weight-for-age z-score of 0.055 per month. No mortality was associated with the insertion or usage of radiologic percutaneous gastrostomy. Major complications included intestinal perforation (3.4%) and aspiration pneumonia (12.1%).
CONCLUSION. Radiologic percutaneous gastrostomy is a safe method for providing long-term nutritional support in children with cardiac disease and is effective for improving growth and nutrition in this group of patients.
Keywords: cardiac disease • congenital heart disease • gastrojejunostomy • gastrostomy • interventional radiology • nutrition
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Gastrostomy tubes and gastrojejunostomy tubes have been established as appropriate methods for providing long-term (> 30 days) enteral nutrition for pediatric patients [8, 9] including those with diseases such as cancer and cystic fibrosis [10–12]. Several methods of gastrostomy placement have been described, including retrograde radiologic percutaneous gastrostomy. In adults, radiologic percutaneous gastrostomy insertions are considered less invasive than surgical gastrostomy or percutaneous endoscopic gastrostomy because of the lower incidence of major complications [13].
However, there have been very few studies focused on the use of retrograde radiologic percutaneous gastrostomy and gastrojejunostomy for nutritional support in children with CHD or cardiac disease. The main purpose of this study was to assess the effectiveness of radiologic percutaneous gastrostomy for providing nutritional support in children with heart problems. A secondary objective was to determine the safety of radiologic percutaneous gastrostomy in these children as measured by its technical success, related complications, and mortality.
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Patient weights were obtained from medical records at the time of inpatient admissions or clinic visits. Patients were followed up until January 2007 or until the gastrostomy tube was removed or the patient died. Patient weights were recorded at the time of insertion and 6, 12, 18, and 24 months after tube placement. If there was no specific weight available at these time points, the available patient weights were plotted in individual graphs and the weight was estimated using a cubic linear regression model using functions included within the Microsoft Excel program. Weight percentiles and weight-for-age z-scores were calculated using a reference population from the National Center for Health Statistics/Centers for Disease Control and Prevention (CDC) data [14]. The z-score is a measure of distance in SD of a sample from the mean of this population. It allows the conversion of a raw score (in this case the weight-for-age) to a standardized score, considering a normal distribution of the population. The growth percentiles of preterm infants were calculated according to reference values for that specific population [15].
Complications related to radiologic percutaneous gastrostomy were also reviewed from the patients' charts. Major complications included peritonitis, aspiration pneumonia, sepsis, and death. Minor complications included granulation tissue formation, site infection requiring topical or systemic antibiotics, and intussusception (for gastrojejunostomy tubes only). These complications were then divided into early (< 30 days) and late (> 30 days). Tube maintenance issues, such as tube leakage, tube dislocation, tube blockage, tube kink, and tube migration, were classified separately and calculated as a rate per 1,000 tube days.
The two-tailed paired Student's t test was used to compare the difference in weight-for-age standardized scores (z-scores) from tube insertion to weights at 6, 12, 18, and 24 months after tube insertion. Repeated measures regression analysis was also used in this study to evaluate the data longitudinally. Subgroup analysis of z-scores between preterm and term patients was performed using an independent Student's t test assuming unequal variance. A p value of < 0.05 was considered significant. For most analyses, SAS, version 9.1 (SAS Institute) was used.
Tube Placement Technique
Patients referred by cardiologists were assessed preoperatively by a
multidisciplinary team (pediatrician, dietitian, and gastrostomy tube nurse)
regarding the indication for a gastrostomy. The patient was then assessed for
anesthetic requirements. Informed consent was obtained from the patient or
patient's parent or legal guardian by the interventional radiologist. Risk of
bleeding, infection, peritonitis, abdominal organ damage, tube misplacement,
insertion failure, and death were discussed.
Antibiotic prophylaxis was administered in accordance with published guidelines [16]. The patient was then transferred to the interventional suite and sedated or anesthetized. The lower edges of the liver and spleen were marked on the skin using sonographic guidance and a barium enema was performed to delineate the colon. Glucagon 0.1–0.3 mg (Lilly Glucagon, Eli Lilly Canada) was given IV to produce gastroparesis. The stomach was then inflated through a nasogastric tube. The site for gastrostomy tube placement was chosen, and the skin was infiltrated with local anesthetic. The stomach was then punctured percutaneously with an 18-gauge needle loaded with a pediatric retention suture (Cope Pediatric Gastrointestinal Suture Anchor Set, Cook). Contrast material was injected to confirm the position of the needle, and the retention suture was deployed into the stomach with a 0.035-inch straight guidewire. The guidewire was then coiled in the stomach. The tract between the skin and the stomach was dilated with fascial dilators, and the gastrostomy tube (8.5-, 10.2-, or 12-French Ultrathane MAC-LOC Dawson-Mueller pigtail tube, Cook) was introduced over the wire into the stomach. Fluoroscopic images after contrast injection confirmed the proper intragastric position of the tube, clearance of the colon, evidence or absence of pneumoperitoneum, and absence of leaks or tube damage [8, 17]. The retention suture thread was wrapped in a small roll of gauze close to the skin, applying gentle tension on the anterior stomach wall. Fourteen days after the procedure, the retention suture thread was cut, and the retention suture was passed by the patient.
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The two most prevalent cardiac defects were single ventricles (29.3%) and right heart obstructive lesions (24.1%). Table 1 shows the general categories of cardiac disease for this cohort of patients. Ten (17.2%) patients ultimately underwent heart transplantation. Reflux and aspiration were detected in 23 patients (39.7%) through imaging and feeding studies. Clinical evidence of reflux or aspiration was suggested in 27 patients (46.6%). Forty-eight patients (82.8%) were taking antireflux medication before gastrostomy or gastrojejunostomy tube insertion. Paralysis of the vocal cords was documented in eight patients (13.8%). Eight patients (13.8%) died within the first year after gastrostomy or gastrojejunostomy tube insertion, but, in all patients, death was due to the underlying cardiac disease.
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Radiologic Percutaneous Gastrostomy Insertion
The mean corrected age at the time of radiologic percutaneous gastrostomy
insertion was 6.9 ± 7.1 months (range, 23 days to 47.5 months). The
indications for radiologic percutaneous gastrostomy included a combination of
failure to thrive (FTT), poor weight gain, and difficulties in feeding. At the
time of the procedure, 96.6% of the patients (56/58) met the general
definition of FTT, which is a weight at or below the third percentile
(n = 44) or a drop of at least two growth percentile lines
(n = 12). The mean weight-for-age z-score at the time of
radiologic percutaneous gastrostomy insertions was –2.79 ± 1.21
(range, –5.86 to –0.15), which corresponds to a mean of the third
growth percentile.
Radiologic percutaneous gastrostomy placement was successful in 57 of 58 patients (98.3%). Only one gastrojejunostomy tube insertion was unsuccessful because of a duodenal rupture requiring surgery. Fifty children initially had a gastrostomy tube inserted, six had gastrojejunostomy tubes inserted, and one had both a gastrostomy tube and gastrojejunostomy tube inserted at the same time. The procedures were completed under conscious sedation in 11 patients (19.0%), whereas 47 patients (81.0%) required general anesthesia (18 patients intubated).
Overall, major complications were seen in 15.5% (n = 9) of our
population (Table 2). The total
major short-term (
30 days) complication rate was three of 58 (5.2%). The
most significant complication was a patient who developed a duodenal rupture
during gastrojejunostomy tube placement, as already mentioned. This patient
underwent an emergent laparotomy and required a partial small-bowel resection,
a surgical gastrostomy and jejunostomy insertion, and admission to the
intensive care unit. This patient was subsequently included in all our
analyses because the patient was still fed through an enterostomy tube. The
other two patients developed aspiration pneumonia. Both patients had a
documented risk of aspiration. No further episodes of aspiration pneumonia
occurred in these two patients. The total major long-term (> 30 days)
complication rate was six of 58 (10.3%). One patient (1.7%) had a bowel
perforation after a gastrojejunostomy tube change that resulted in peritonitis
and required operative repair. Five (8.6%) patients had aspiration pneumonia,
three of whom had recurrent episodes. All five had histories or feeding
studies that confirmed the risk of aspiration or reflux before the insertion
of the gastrostomy tube. Of these five patients, two eventually required
fundoplication. There were no cases of sepsis or death related to insertion or
use of radiologic percutaneous gastrostomy.
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Short-term ( 30 days) minor complications included 12 episodes of site
infections and two patients (3.4%) with granulation tissue. Five patients
(8.6%) had issues related to tube maintenance
(Table 3). Long-term (> 30
days) minor complications included 12 patients (20.7%) with site infections,
12 patients (20.7%) with granulation tissue, four patients (6.9%) with minor
bleeding from the site, and 27 patients (46.6%) with tube maintenance issues.
The most frequent tube maintenance issue was accidental dislodgement of the
feeding tube, which occurred in 17 of 58 (29.3%) patients, with an incidence
of 0.82 episodes per 1,000 tube days (Table
3). Intussusceptions occurred in four of 15 patients with
gastrojejunostomy tubes (26.7%) with three of those four patients requiring
conversion to a gastrostomy tube.
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In total, there were 28 documented cases of superficial site infections in 23 patients during the study period. All episodes were treated with topical or oral antibiotics, with no progression to systemic infection or infective endocarditis. Staphylococcus aureus was the most common organism cultured.
The mean duration of tube usage at the end of the study period was 23.4 ± 15.3 months (range, 1 week to 60 months). Nine patients (18%) who originally had gastrostomy tubes inserted later had to undergo conversion to gastrojejunostomy tubes at a mean of 2.4 months (range, 0.2–5.8 months) because of intolerance to gastrostomy tube feeding, with persistent vomiting, reflux, or aspiration. Two of these nine patients required conversion back to a gastrostomy tube because of intussusception. Three pa tients who initially had gastrojejunostomy tubes required conversion to gastrostomy tubes (n = 2) and gastroduodenal tubes (n = 1) at a mean time of 2.7 months (range, 1.3–4.1 months) because of frequent vomiting (n = 1), intussusception (n = 1), and frequent blockage of the gastrojejunostomy tube (n = 1). Fifteen patients had their gastrostomy tube removed after 19.9 ± 13.7 months (range, 3–54.9 months) of tube usage.
Nutritional Status
On the basis of the last documented date in which the patient was still
using a radiologic percutaneous gastrostomy, we were able to obtain weights
for 49 of 58 (84.5%) patients at 6 months (seven patients died due to their
cardiac condition, one patient had the tube removed, one patient was
transferred to another health care institution), 43 of 58 (74%) patients at 12
months, 37 of 58 (64%) patients at 18 months, and 27 of 58 (46.6%) patients at
24 months.
All patients gained weight after insertion. Mean weight percentiles increased from the third percentile at radiologic percutaneous gastrostomy insertion to the seventh percentile at 6 months, 11th percentile at 12 months, 13th percentile at 18 months, and 18th percentile at 24 months. Fifty-seven percent of patients (28/49) showed an increase in weight-for-age z-scores at 6 months. That increased to 69.8% (30/43) at 12 months, 81.1% (30/37) at 18 months, and 77.8% (21/27) at 24 months (Fig. 1).
The increase in z-score over time is seen in Figure 2. The mean weight-for-age z-score significantly increased from –2.79 ± 1.21 at the time of radiologic percutaneous gastrostomy insertion to –2.33 ± 1.24 at 6 months (p = 0.05), –1.89 ± 1.16 at 12 months (p = 0.001), –1.65 ± 1.09 at 18 months (p = 0.0002), and –1.40 ± 1.16 at 24 months (p = 0.0004). Repeated measures regression analysis showed a significant increase in weight-for-age z-score over time (p < 0.0001), with an estimated mean increase of 0.055 weight-for-age z-score per month.
Subgroup analysis comparing 10 preterm infants versus term infants showed no statistically significant difference in the change in weight-for-age z-score between these two groups at 6 (p = 0.20), 12 (p = 0.14), 18 (p = 0.22), or 24 months (p = 0.23).
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Oral feeding alone is often inadequate, and enteral feeding is a method for improving the nutritional status of cardiac patients. Studies have found that short-term gains in weight can be achieved with enteral feedings using nasogastric tubes [20, 21]. However, long-term nasogastric tube feeding has several disadvantages including nasal mucosal irritation, impairment of oral feeding, risk of tube dislodgement and aspiration, and cosmetic inconvenience. Compared with nasogastric tubes, gastrostomy tubes alleviate those issues and decrease the rate of aspiration pneumonia and mechanical malfunctions [22]. Furthermore, gastrostomy tube feeding has been proven to provide adequate nutrition in several groups of children. Sullivan et al. [23] showed improvement in the z-scores of children with cerebral palsy from –3 to –1.6 after 12 months of gastrostomy tube feeding and Rosenfeld et al. [24] showed an increase in weight percentiles from 2% to 19% in children with cystic fibrosis after a period of 30–48 months of gastrostomy tube feeding.
There are limited published studies regarding the dietary intake in patients with cardiac disease. Barton et al. [25] found that total daily energy expenditure was significantly increased in eight infants with CHD and that an estimate of 143 kcal/kg/d of energy intake would be required for normal growth in these infants as compared with the 100–120 kcal/kg/d recommended for healthy infants. Unger et al. [26] looked into the effect of high-calorie formula and nutritional counseling in 19 children with CHD who were underweight. After 6 months, there was a significant increase in weight, length, and triceps skinfold measurement in these children. Kelleher et al. [27] looked specifically at infants with hypoplastic left heart syndrome and found that there was a high prevalence of malnutrition including a low weight-for-age z-score in these patients after a stage 1 Norwood procedure. These authors also found that infants who received more parenteral nutrition during initial hospitalization and used high-caloric enteral feeding on discharge were associated with improved nutritional status on readmission for a bidirectional Glenn procedure. Kelleher et al. concluded that the use of parenteral and enteral nutrition could help to improve the growth and nutrition of these children.
Very few studies have specifically addressed the use of radiologic percutaneous gastrostomy in children with cardiac disease, especially in terms of long-term nutritional outcomes. One study using percutaneous endoscopic gastrostomy (PEG) showed an increase in weight in a small group of patients (n = 15) at 4 weeks and at 6 months after intervention. Unfortunately, the results from this study were not significant because the sample size was too small [28]. Our results showed that radiologic percutaneous gastrostomy helped provide nutritional support with significant weight gain in children with cardiac disease. At 6 months after insertion, more than half of our patients increased their weight-for-age z-score, and that proportion continued to increase up to about the 80% mark at 24 months.
We have found that radiologic percutaneous gastrostomy can be safely and successfully performed on children with cardiac disease with a low rate of major complications. Only one procedure was unsuccessful in our series. The most common major complication was aspiration pneumonia that occurred in 12.1% of patients. Although aspiration pneumonia secondary to gastroesophageal reflux is considered a major cause of morbidity in patients with gastrostomies, the reflux may not be related to the use of gastric feeding [29]. Reflux itself is a common problem in this population, and the majority of our patients were on antireflux and motility medications even before radiologic percutaneous gastrostomy and continued on these medications. Furthermore, it is extremely difficult to differentiate whether aspiration is due to the gastric feeding or the patient's own oropharyngeal secretions. Therefore, although considered a major complication to the patient, aspiration pneumonia may not be caused by the gastrostomy feeding.
A gastrojejunostomy tube rather than a gastrostomy tube may be considered at the initial insertion if there is a serious concern about reflux. Although an excellent alternative that avoids a surgical procedure such as fundoplication, gastrojejunostomy tube feeding is more expensive and requires a continuous infusion rather than a bolus feed, which is less convenient. Previous studies have also noted that gastrojejunostomy tubes have a higher risk of obstruction, tube migration, dislodgement, leakage, and intussusception. In our study, the rate of intussusception of 26.7% is within the rates reported, which range from 16% to 48% [30, 31].
The most frequent complication noted in our study was early site infection. This was seen at a higher rate compared with other studies of radiologic percutaneous gastrostomy in the general population [32]. It may reflect several issues in these children, including decreased immunity because of the severity of the patients' underlying condition or malnourishment. It may also reflect the increased frequency and length of hospital stays due to surgery or other complications, given that cultures from several patients' wounds were not typical for skin infections. However, in all cases, patients could be treated with a short course of antibiotics, and there was no progression to more serious consequences such as sepsis or endocarditis. Given the relatively common occurrence of this complication, the patient's family should be properly educated on the signs of a site infection so that the patient can be promptly treated.
There are some limitations to this study. Because it was a retrospective study, the accuracy of the measurements could not be controlled and the amount of measurements and length of follow-up varied among the patients. In this study, we were only able to measure one dimension of growth and nutrition using weight. Other dimensions such as length, head circumference, and skinfold thickness would have given a more complete picture of the patients' nutritional status. Furthermore, we were unable to account for differences in the actual amounts and types of nutritional formulas for each patient. Future studies should try to address these points.
From the results of our study, we have concluded that percutaneous radiologic gastrostomy or gastrojejunostomy is a safe method for providing long-term nutritional support to patients with cardiac disease. Both techniques are effective for improving nutrition and growth in this group of patients when used in a long-term setting.
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