Radiologically inserted gastrostomy (RIG) is a minimally invasive procedure generally performed for patients who cannot safely or sufficiently receive oral nutrition due to conditions including oropharyngeal cancers and dysphagia following a cerebrovascular accident. Postoperative complications are observed in 5.1% to 6.8% of patients, with 1.4% to 3.0% of patients experiencing a major complication (peritonitis, migration, infection, malposition, and bleeding).^1,2 The most frequently occurring acute complications are superficial wound infection (2%), peritonitis (1.7%) and severe pain (0.9%).³ Late (> 24 hours) complications arise in up to 30% of patients, with ongoing mild pain (30%), tube displacement (2%) and persistent peritonitis (1.2%) being the most frequent of these.³ The 30-day mortality rate has been reported at 1%,³ although mortality as a direct consequence of gastrostomy placement is rare and associated in particular with ascites.⁴ We experienced gastrostomy complications in four patients at our hospital who underwent RIG to overcome feeding difficulties associated with carcinoma of the tongue, larynx, and oesophagus. We report the treatment of these patients’ complications and their clinical courses.

Materials and methods

This study included four patients treated at Canberra Hospital between August 2018 and October 2020. These patients were included in the cases series for the educational value of their complications and management. All patients receiving gastrostomy provided written informed consent for the RIG procedure.

RIG was undertaken for these patients to enable enteral feeding and administration of medication when tumour bulk, pain, or the effects of radiation treatment had led to inadequate or unsafe oral feeding.

RIG was performed under deep conscious sedation administered by the attending anaesthetist. A nasogastric tube was placed under fluoroscopic guidance to enable gastric air insufflation, with 10–20 mg of hyoscine butylbromide (or 1 mg of glucagon if hyoscine was contraindicated) administered immediately prior to induce gastric hypotonia. This was followed by the insertion of three gastropexy anchors (dissolvable Saf-T-Pexy sutures; Avanos, Chatswood, Australia) at the gastric antrum and the insertion of a Halyard gastrostomy tube (MIC G-tube; Avanos), using the Seldinger technique and a 22-Fr telescopic peel-away sheath (except in one case, in which we used an 18-Fr peel-away sheath to insert a 14-Fr tube). An 18-Fr gastrostomy tube was used in consultation with dietitians to prevent sporadic blockage issues seen with the previous standard 14-Fr tubes. The retaining balloon was inflated with water and the appropriate position was confirmed with a contrast injection. The intended retention of gastropexy sutures is 5 to 7 days. Prophylactic antibiotics were not routinely administered following RIG placement, and a nurse trained in gastrostomy management followed patients’ post-procedural courses in the community.

Results

Between August 2018 and October 2020, there were 152 RIG procedures performed at our hospital. The four cases described are the major complications arising from these procedures (a rate of 2.6%).

Table 1 shows the characteristics of each of the four patients included in this study. Two of the patients had bleeding from an injury to the right gastroepiploic artery (RGEA), one patient experienced gastric fluid leakage and wound dehiscence, and one patient experienced a penetration of the transverse colon and required post-procedural surgical repair. Resolution of complications was achieved in three patients; however, one patient required gastrostomy tube removal and surgical gastrostomy closure.

Table 1 . Summary of Cases.

Age (yr)/sex	Reason for RIG	Comorbidities	Complication	Additional complication	Follow-up (mo)	Learning points
78/Male	Base of tongue squamous cell carcinoma	Cerebrovascular accident, cardiac pacemaker	Arterial haemorrhage	Iatrogenic pulmonary oedema	10	Cessation of anticoagulant 48 hr before the procedure
65/Male	Epiglottic squamous cell carcinoma	Chronic obstructive pulmonary disease	Gastric fluid leak, peritonitis, pneumo- peritoneum	Gastric fluid leak, partial-thickness burn, gastrostomy dehiscence, liver laceration	8	Replace any gastropexy sutures removed during the procedure and retain the sutures for 5–7 days
75/Female	Supraglottic squamous cell carcinoma	Osteoporosis	Ileus and peritonitis due to tube penetration of colon	Gastrostomy tube crack and leakage	30	Provide oral barium the night prior to procedure to visualise colon
81/Male	Radiation-induced mucositis, base of tongue squamous cell carcinoma	Gastro-oesophageal reflux disease, atrial fibrillation, cardiovascular disease, hypertension	Arterial haemorrhage, RIG site infection	-	9	Avoid gastrostomy placement near posterior wall of greater curvature

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RIG, radiologically inserted gastrostomy..

In all patients, the 8- to 30-month follow-up courses did not involve any further gastrostomy-related complications.

Individual cases

Case 1

The patient was a 78-year-old male who presented for elective RIG insertion. He had been receiving definitive radiotherapy since he was diagnosed with a T4aN2M0 base of tongue squamous cell carcinoma (SCC). He had a background of cerebrovascular accident 2 months prior and had a single-lead permanent pacemaker inserted for treatment of atrial flutter and fibrillation 7 years prior. Of note, the patient was on apixaban for atrial fibrillation, which was stopped only 24 hours prior to the scheduled time for RIG.

Gastrostomy: RIG was performed as described in the Methods section, using a mixture of adrenaline and Marcaine as local infiltration. A high entry point close to the left subcostal margin was chosen given an elevated left hemidiaphragm and rostral position of the stomach. Two gastropexy anchors were used, with an 18-Fr gastrostomy tube. Cone-beam computed tomography (CT) also confirmed appropriate positioning, and further that the transverse colon had not been transgressed.

Post-procedure: The gastrostomy procedure was performed seemingly without incident. However, post-procedure monitoring detected a fall in systolic blood pressure (SBP) to 54 mmHg, which was investigated by contrast-enhanced abdominal CT (ceCT), which revealed a large hemoperitoneum, with active extravasation detected in close proximity to both the distal RGEA and left margin of the gastrostomy tube, anterior to the ventral gastric wall, suggestive of RGEA injury. The patient urgently underwent angiography via the right common femoral artery using a 5-Fr sheath with a contrast injection at the coeliac artery and super-selective injection of the RGEA confirming active bleeding between the left gastric anchor and left lateral margin of the gastrostomy tubing. A microcatheter was advanced beyond the injury and distal/proximal coil embolization was performed. Final super-selective RGEA and coeliac injections demonstrated no further extravasation (Fig. 1).

Figure 1. (A) Computed tomography with arterial-phase contrast for case 1, taken 30 minutes post-gastrostomy, showing active extravasation (arrow) near the gastrostomy tube, which was in close proximity to the right gastroepiploic artery (arrowhead). (B) Digital subtraction angiography (DSA) demonstrating active extravasation from the right gastroepiploic artery (arrow). (C) DSA demonstrating successful coil embolization of the bleeding vessel.

Postoperative course: The patient was admitted to the intensive care unit for monitoring and recovery after the arterial haemorrhage and noted to be vasoplegic. Noradrenaline was required for vasopressor support. He received 3 units of packed red blood cells (PRBCs) and was additionally fluid-resuscitated with crystalloid, which was complicated by acute pulmonary oedema that required high-flow oxygen via nasal cannula (35 L/35% O2) to maintain saturations above 92%. Despite the fluid overload, diuresis was delayed due to the risk of hypotension given the vasoplegia in the intensive care unit, ongoing low SBP, and inability to mount tachycardia to increase cardiac output. Upon stabilisation of SBP above 120 mmHg on day 4, intravenous (IV) furosemide was given, leading to 3 L of urine output over 12 hours, during which time the patient was able to be weaned off supplemental oxygen. Due to the requirement for supplemental oxygen, a number of radiotherapy sessions were missed, with resumption of treatment on day 6. No further complication of the gastrostomy or recurrence of the arterial haemorrhage has been observed in the 10-month period following admission.

Case 2

The patient was a 65-year-old male who had been diagnosed with metastatic epiglottic SCC and was awaiting chemotherapeutic treatment with neoadjuvant external beam radiotherapy. He had a background of chronic obstructive pulmonary disease that was treated with inhaled fluticasone furoate to prevent and inhaled salbutamol to relieve exacerbations. He presented for elective RIG insertion prior to initiation of chemotherapy.

Gastrostomy: Gastrostomy was performed as described in the Methods section, using three gastropexy anchors. Only 1 gastropexy anchor was left in place at the end of the procedure after 2 were cut during peel-away sheath insertion, with an 18-Fr gastrostomy tube used. The patient was discharged following the procedure for initiation of chemotherapy.

Post-procedure: The patient presented again on day 2 following gastrostomy with epigastric tenderness and leakage of gastric fluid from the RIG site. He had tenderness to abdominal percussion but was afebrile. All other observations were within the normal limits. Investigations showed a white cell count of 15 × 10⁹/L and a C-reactive protein level of 77 mg/L, indicative of potential infectious peritonitis. This was investigated by ceCT, which revealed the gastrostomy tube with a retaining balloon appropriately positioned in the gastric antrum, with multiple gas locules demonstrated between the stomach wall and the posterior aspect of the abdominal wall, as well as tracking along the anterior aspect of the liver and lateral abdominal wall. These were all expected findings post-gastrostomy. However, a subtle increase in attenuation suggestive of inflammatory changes was noted for the omentum, with a thickened adjacent peritoneum in the upper abdomen.

The patient was admitted to the acute surgical unit and placed on intravenous fluid maintenance while oral intake was ceased. Intravenous antibiotics (metronidazole, gentamicin, and ampicillin) were initiated and leakage from the gastrostomy tube was carefully monitored. With continuing leakage, a fluoroscopy-guided tube check was performed on day 4 using Omnipaque^TM (iohexol 300 mg iodine/mL; GE Healthcare, Chicago, IL, USA). The retaining balloon was located appropriately in the gastric antrum, but there was evidence of leakage around the tube within the gastrostomy tract. This was thought to be due to a larger-diameter tract relative to the gastrostomy tube, and tube replacement was performed, upgrading the 18-Fr gastrostomy tube to a 20-Fr tube over a guidewire under fluoroscopic guidance. The patient’s pain improved, and no ongoing leak was detected. The patient was discharged on day 5 and follow-up with community nursing was arranged.

The patient presented again on day 11 after experiencing 4 days of worsening leakage complicated by a partial-thickness burn to surrounding skin. The ceCT of the abdomen and pelvis revealed that while the balloon of the gastrostomy tube remained appropriately in place within the gastric antrum, dehiscence of the subcutaneous soft tissues underlying the external fixation plate had occurred. Subcutaneous emphysema and fluid were also noted dependently within the subcutaneous tissues adjacent to the gastrostomy tube, with loss of the normal fat plane between the anterior abdominal wall and the anterior wall of the stomach adjacent to the gastrotomy tube. The patient was prepared for exploratory laparotomy to debride the chemical burn, close the gastrostomy, and assess the extent of tissue damage, which was performed on day 16. A paramedian laparotomy was performed, finding an additional gastrostomy tube injury to the inferior part of hepatic segment 3. The tube was removed and the gastrostomy was closed by multiple interrupted absorbable sutures and patching with the falciform ligament. The abdominal wall was debrided with gauze and the skin was debrided with a sharp technique. Closure of the posterior rectus sheath and peritoneum was performed using absorbable sutures, while non-absorbable sutures were used for anterior rectus sheath closure and staples were used for skin closure. A 15-Fr Blake silicone drain was placed prior to closure (Fig. 2).

Figure 2. Computed tomography for case 2, taken 11 days post-gastrostomy, showing dehiscence of the subcutaneous soft tissues underlying the external fixation plate (arrow).

Postoperative course: The patient developed right upper quadrant tenderness on day 17, and intra-abdominal leakage from the closed gastrostomy site was excluded by ceCT. The patient was investigated for a wound infection, with culture showing Enterococcus faecalis and Staphylococcus epidermidis growth, which was treated with vancomycin, stepping down to oral amoxicillin and trimethoprim sulfamethoxazole. No further complication of the gastrostomy has been observed in the 8-month period following admission.

Case 3

The patient was a 75-year-old female who was diagnosed with T3N1M0 left supraglottic SCC and was awaiting initiation of definitive radiotherapy. She had a background of osteoporosis complicated by a neck of femur fracture, managed with cholecalciferol (25 μg) and calcium (600 mg). She presented as planned for RIG insertion prior to initiation of radiotherapy.

Gastrostomy: Gastrostomy was performed as described in the Methods section, using three gastropexy anchors at the antrum of the stomach, with a 14-Fr gastrostomy tube (the standard size at the time). The patient was discharged for initiation of radiotherapy.

Post-procedure: The patient presented on day 4 following gastrostomy with vomiting, constipation, and epigastric pain that had occurred since the evening of gastrostomy insertion. This was investigated by ceCT of the abdomen and pelvis, which revealed extensive pneumoperitoneum anteriorly in relation to the middle to upper abdomen. The gastrotomy tube was assessed as in close proximity to the transverse colon but was thought to be only skirting the inferior colonic serosal surface rather than crossing its lumen. There were locules of free gas and stranding of omental fat adjacent to this location, commensurate with spillage of gastric contents at insertion. Contrast within the colon related to the RIG procedure was observed; however, no extraluminal contrast was evident. Laparoscopic inspection of the transverse colon and re-positioning of the gastrostomy were recommended, and the patient was admitted under general surgery (Fig. 3).

Figure 3. (A) Laparoscopic view for case 3, showing the gastrostomy tube penetrating the transverse colon. (B) Computed tomography showing unintentional transverse colon colopexy and penetration with the gastrostomy tube (arrow).

The patient underwent diagnostic laparoscopy on day 5, with the transverse colon found to be fixed to the anterior wall, with the gastrostomy tube traversing the colonic lumen. The decision was made to convert to open laparotomy by midline incision. The transverse colonic injuries were closed with interrupted absorbable sutures and a new gastrostomy was secured to the abdominal wall by purse-string gastropexy. Full washout of the abdomen was performed, and a drain was inserted.

Intravenous ceftriaxone and metronidazole were commenced to prevent a perioperative infection and the patient was checked for appropriate positioning of the surgically inserted gastrostomy tube on day 8. The patient was upgraded to a normal diet the following day; however, a crack in the external part of the gastrostomy tube led to a feed leakage. This was resolved by exchange of the existing tube and insertion of a new 14-Fr Halyard tube over a wire using fluoroscopic guidance.

Later course of management: Radiotherapy was initiated on day 12 while the patient remained in the surgical ward. The patient was counselled on gastrostomy care and discharged on day 25. No further complication of the gastrostomy has been observed in the 30-month period following admission.

Case 4

The patient was an 81-year-old male who had been diagnosed with T2N1M0 base of tongue SCC and was undergoing definitive treatment with external beam radiotherapy (30 Gy in 35 fractions). He had a background of gastroesophageal reflux disease, atherosclerotic cardiovascular disease, atrial fibrillation and hypertension, which were managed by apixaban (5 mg twice daily), aspirin (100 mg), esomeprazole (40 mg), and clopidogrel (75 mg). He presented with inability to maintain adequate oral intake and ongoing weight loss as a result of severe odynophagia and dysphagia secondary to radiation-induced mucositis. Enteral feeding by nasogastric tube was commenced and morphine was provided by a syringe driver while a gastrostomy procedure was planned. The clopidogrel was stopped 5 days before the planned RIG date, in keeping with current guidelines.

Gastrostomy: Gastrostomy was performed as described in the Methods section. Three gastropexy anchors were used, with an 18-Fr gastrostomy tube. There was oozing of blood around the gastrostomy tube toward the end of the procedure, which could not be controlled by manual pressure. A CT scan was requested, which demonstrated that the gastrostomy tube had traversed through the RGEA without active extravasation. A decision was made to return the patient to the angiography room for digital subtraction angiography with a view towards embolisation of the artery. Percutaneous access to the right common femoral artery was obtained under ultrasound guidance. Contrast injection at the coeliac artery and super-selective injection at the gastroduodenal artery showed contrast extravasation from the RGEA at the gastrostomy tube site. Selective microcatheter cannulation of the injured vessel was followed by distal/proximal coil embolization. This resulted in complete stasis and cessation of extravasation, as observed with coeliac artery contrast injections.

Post-procedure: The patient’s haemoglobin decreased from 108 g/L prior to the procedure to 82 g/L on day 2 following the procedure and he was hence transfused one unit of PRBCs. Feeding via the gastrostomy tube was commenced on this day without complications. The patient opened his bowels for the first time following the procedure on day 4, as a single episode of melaena that was managed by transfusion of an additional unit of PRBCs. The RIG site was noted to be erythematous and malodorous on day 7 and a 5-day course of oral cephalexin was commenced. The patient was discharged home on day 9, having completed the definitive radiotherapy course and having reduced erythema without discharge at the gastrostomy site. No further complication of the gastrostomy has been observed in the 9-month period following admission (Fig. 4).

Figure 4. (A) Computed tomography with arterial-phase contrast for case 4, taken immediately post-gastrostomy, showing the gastrostomy tube in close proximity to the right gastroepiploic artery (RGEA) (arrow) without active extravasation. (B) Digital subtraction angiography (DSA) demonstrating contrast extravasation from the RGEA (arrow). (C) DSA demonstrating successful coil embolization of the bleeding vessel.

As larger retrospective reviews have shown, gastrostomy complications are not infrequent, and some of the more frequently occurring problems are highlighted in this case series.^1,5 An understanding of the contraindications, technical steps, and complications of gastrostomy is essential to ensure patient safety and prevent morbidity. The outcomes of the patients in our case series emphasise that early recognition of these complications enables a prompt diagnosis and effective therapy.

Other major techniques used for gastrostomy include percutaneous endoscopic gastrostomy (PEG) and surgical techniques such as laparoscopic-assisted percutaneous endoscopic gastrostomy (LAPEG) or percutaneous transesophageal gastrostomy (PTEG).⁶ A comparison of PEG and surgical gastrostomy outcomes by Bravo et al⁷ found no significant differences in mortality, major complications, or minor complications, apart from a subgroup analysis of randomised studies that slightly favoured PEG. Considering the relatively lesser expense of RIG and PEG, LAPEG would be best suited as a second-line approach for patients with unfavourable anatomy and for correction of suboptimal gastrostomy placement, as reported by Lodin et al⁸ PTEG plays an important role when patients have contraindications to more standard methods of enteral access, such as massive ascites, peritoneal carcinomatosis, or difficult anatomy due to a hostile abdomen.⁹ Additional advantages of PTEG are the elimination of the possibility of peritonitis and the emergent operative management required with gastrostomy displacement due to access of the oesophagus at the cervical level. The main disadvantage of PTEG, however, is that it is contraindicated in head and neck cancers, which are the most common indications for gastrostomy, as experienced by our four patients. RIG and PEG have similar rates of complications, apart from the rate of tube dislodgement, peritonitis, and mortality, as determined by retrospective reviews.^10–13 In particular, Cherian et al¹³ found that the method of insertion was a strong predictor of tube dislodgement, with RIG 5.4 times more likely to result in dislodgement than PEG, even when three-suture gastropexy was employed. Balloon failure was found to be a significant cause of RIG-inserted tube dislodgement, with 25.3% of dislodgements occurring prior to tract maturation (< 1 month). Hence, retention of gastropexy sutures for an extended period could be considered to help prevent this complication. PEG and then RIG are, therefore, the main preferred methods for providing long-term enteral nutrition in most patients, such as our head and neck cancer patients.

Significant bleeds due to arterial injury during RIG or PEG insertion are rare (0.2%–1.5% of patients);^1,12 however, they can be initially undetected, as occurred in case 1, which emphasises the need for careful monitoring of haemodynamic stability for several hours in post-anaesthesia care units and day-stay units prior to discharge. Suzuki et al¹⁴ found a significant relationship between introducer-type (Russell) method gastrostomy construction at the posterior wall of the greater curvature and the early acute complications of puncture and bleeding compared with PEG at other sites, indicating that the posterior wall of the greater curvature should be avoided to prevent these serious complications when there is rotation of the stomach on the long axis. This rotation, where the greater curvature sits close to the anterior abdominal wall, enables dilator puncture to occur tangentially to the posterior wall when it is vertically inserted through the abdominal wall, which can result in tearing and arterial damage on the greater curvature. An oblique puncture of the abdominal wall may be employed in this case, to enable vertical puncture of the stomach wall to avoid the problem. Sealock and Munot¹⁵ also advise that anticoagulant and antiplatelet medication be withheld, according to the American Society for Gastrointestinal Endoscopy guidelines, to prevent large bleeds in the event of an arterial injury.¹⁶

Patients presenting with an acute abdomen, as in cases 2 and 3 in this series, should always be assessed for evidence of gastrostomy tube displacement, which can precipitate peritonitis or pneumoperitoneum. Sealock and Munot¹⁵ identified excessive cleaning with hydrogen peroxide solution, excessive gastric secretions, lateral tube traction, and factors affecting wound healing as risk factors for peristomal leakage. They suggested proton-pump inhibitor use to reduce gastric secretions as a first-line treatment and application of barrier creams such as zinc oxide. Persistent leakage of a mature tract can potentially be remedied by tube removal for 48–72 hours to allow stoma diameter contraction prior to reinsertion. The problem of peristomal infection was present at some point two of the four cases we presented, and studies have reported variable rates of gastrostomy tube infections, potentially due to differences in prophylactic antibiotic use.^5,17 Patients with diabetes are a specific population with a documented greater risk of peristomal infections, and they should therefore be considered for perioperative antibiotic prophylaxis.¹⁷ The findings of a Cochrane review by Lipp and Lusardi¹⁸ suggest that prophylaxis should be extended to all gastrostomy patients, with a significant reduction in the incidence of peristomal infection when prophylactic antibiotics were used (odds ratio, 0.36; 95% confidence interval, 0.26–0.50).

Our case series indicates that there are areas that remain to be improved in terms of reducing avoidable complications relating to RIG insertion. Individual patients’ comorbidities should be carefully considered prior to obtaining patients’ consent for the procedure, with attention paid to anticoagulant and antiplatelet use, comorbidities such as diabetes mellitus and cirrhosis, and consideration of alternative techniques to account for variation in patient anatomy. Early loss of gastropexy anchors or an inadequate number of anchors, as occurred for our cases 1 and 2, could also contribute to loosening of gastropexy tubes and gastric fluid leak. Correction of the deficiency in gastropexy could potentially have prevented the complication in case 2. Specific changes to clinical practice at our institution as a result of these complications include abdominal CT (or review of recent available cross-sectional imaging) prior to the RIG procedure to define the anatomy. Oral barium contrast is provided the night prior to the procedure if the position of the colon is anatomically problematic. Some interventional radiologists at our institution additionally choose to routinely perform ultrasound prior to RIG placement. We also now routinely withhold clopidogrel 5 days prior to the procedure.

We conclude that RIG is an important procedure for the management of feeding difficulties in individuals such as the head and neck cancer patients in our case series. Major complications such as significant haemorrhage and necrotising infections requiring surgical debridement are rare, but awareness of these potential complications is important to drive improvements in the prevention of complications and to facilitate early detection should complications occur.

None.