Mistakes in gastrostomy insertion and how to avoid them

Medical treatment and technological advancements have led to cohorts of patients surviving to an advanced age with significant comorbidities.⁵ In practice, this accentuates what can be a delicate balance of risk for patients who are frail with clinically significant weight loss, malnutrition and little physical reserve as a consequence.

Outcomes following gastrostomy may have improved since the publication of the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Report in 2004⁶, which reported that approximately 3% of the cohort died within 7 days. However, the material risk remains, with ≤10% 30-day mortality^7,8 and ≤3% procedure-related deaths.^9,10

Underlying disease, comorbidities and frailty affect the outcomes of these cohorts, not just the technical suitability to undergo a procedure. Therefore, the most potent modifier of outcomes may be the experience and clinical understanding of the multidisciplinary ‘nutrition’ team, who assess and consider the risks, benefits and alternatives in collaboration with the referring specialities. Effective patient selection cannot be protocol driven and relies on the availability of experienced teams. Where suitable, gastrostomy is a very effective method of providing long-term (four weeks or more) enteral tube feeding.² Key considerations regarding whether to perform gastrostomy are summarised in Figure 1.

Figure 1: Key considerations to keep in mind when selecting patients for gastrostomy. GI, gastrointestinal; IV, intravenous.

Gastrostomy insertion is not an emergency procedure. When presented with such a request, the mortality and morbidity risk for this self-selecting cohort will already be significant due to the acute presentation, underlying disease, comorbidities, deconditioning and malnutrition that usually precede such a presentation.

A period of admission, monitoring and optimisation may avoid any intervention that might be considered futile in retrospect. It is the responsibility of the local experts to offer treatment where appropriate and, conversely, when not to do so. There may be a delicate balance of risk and benefit, and the views of the clinician with overall responsibility for the patient must be considered and addressed delicately. Nasoenteric and parenteral artificial nutrition and hydration methods may be fundamental in this scenario. Nasoenteric tube feeding is most commonly used for short-term feeding, up to four weeks. However, device dwell times vary due to tube function and manufacturer licence.

Clinical nutrition is a broad and complex area of clinical practice, essential for all specialities but often led by those most involved with oral, enteral and parenteral nutrition. Advancements in modern medicine have led to more paediatric cohorts surviving to adulthood¹¹ and increasing recognition of functional disorders.¹² A multidisciplinary approach is fundamental to managing these cohorts comprehensively.^2,13 Inclusion of community and acute teams helps to ensure holistic and realistic expectations regarding the stark reality of life-long enterally fed patients. Improved mortality rates and patient selection are both expected and reported with multidisciplinary team input.¹⁴

Following the de-novo insertion of a bumper-retained gastrostomy, due consideration should be made regarding the final positioning of the internal and external fixators. Correct positioning is required for adhesion between the stomach and anterior abdominal wall. The internal fixator should be pulled with gentle traction until resistance is felt. Then the external fixator should be adjusted to maintain this position, ensuring that the tube’s centimetre (cm) marking is in proportion to the body habitus, e.g. a 10 cm bumper-to-skin distance would suggest that the internal fixator is not appropriately positioned against the anterior gastric wall (Figure 2).

If the bumper-to-skin distance is too short, it increases the risk of pressure sores, poor healing and bumper migration. Too long, and the stomach wall cannot adhere to the anterior abdominal wall, increasing the risk of poor healing, leakage and peritonitis. A distance of 0.5 cm between the skin and the external fixator may be considered optimal. As a rule of thumb, no dressings are required. Many organisations recommend that only an appropriately trained specialist reposition the device for two to three weeks after insertion.

Figure 2: The correct positioning of the internal and external fixators for bumper-retained gastrostomy tubes.

The Seldinger technique is used to insert a gastrostomy tube percutaneously using a needle, trocar and wire under endoscopic or fluoroscopic guidance. Poor technique can result in major and minor complications from an iatrogenic injury to a poorly tolerated site due to its location. Important considerations when performing this technique are summarised in Figure 3.

Figure 3: Considerations when using the Seldinger technique for gastrostomy. CT, computed tomography.

Whether required for decompression or long-term enteral nutrition, there are three primary modalities of de-novo gastrostomy insertion: endoscopic (pull and push), radiological (pull and push) and multiple surgical techniques. Each has unique limitations and benefits (Figure 4 - click on image to enlarge).

Figure 4: Tube insertion methods. CT, computed tomography; Fr, French gauge.
a: Endoscopic (pull). Percutaneous endoscopic gastrostomy (PEG) insertion involves the perforation of the stomach under endoscopic guidance and the pull-through of a bumper-retained gastrostomy tube.¹⁸
b: Endoscopic (push) percutaneous endoscopic gastrostomy (PEG) insertion requires the use of gastropexies, facilitating balloon-retained gastrostomy insertion but avoids the pull-through technique.¹⁹
c: Radiological. Per-oral image-guided gastrostomy (PIG) involves the perforation of the stomach under fluoroscopic and CT or ultrasonic guidance, facilitating a bumper-retained gastrostomy tube.⁹
d: Radiologically inserted gastrostomy (RIG) requires gastropexies, facilitating balloon-retained gastrostomy insertion but avoids the pull-through technique.⁹
e: Surgical (Stamm). It is more invasive than percutaneous methods and additionally requires general anaesthesia. Required where percutaneous access fails and/or is contraindicated, e.g. by an interposed colon or high stomach.²⁰

Patients present in various settings for elective and urgent assessment and treatment across primary and secondary care. Having an electronic resource that captures summaries of decision-making, patients’ wishes, procedures, and device sizing and measurements, minimises the likelihood of missed opportunities, unnecessary procedures and complications. In its most simple form, an integrated patient record and/or email communication with the relevant team facilitates best practice.

Upon displacement of a gastrostomy tube, urgent replacement or cannulation with a feeding tube, Foley catheter or stoma-saving device will preserve stoma patency. Introducing a device the same size or smaller increases the likelihood of cannulating the tract.

Replacement feeding tubes of 12–16 Fr (French gauge; diameter of the tube) may be too large for the partially closed stoma, resulting in a referral to a modality where dilatation can be performed. Paediatric catheters (6–10 Fr) can facilitate successful cannulation and/or serial dilatation of the stoma at the bedside. This may avoid prolonged loss of access to nutrition, medication and hydration, as well as any requirement for prolonged hospitalisation or speciality input such as interventional radiology.²¹

Nutrition and hydration are fundamental to survival and subject to ethical and legal principles of common law and statute.² Clinicians, patients and carers may assume that artificial nutrition and hydration will improve the length and quality of life; however, there is little evidence to support these assumptions in various scenarios. Beneficence and non-maleficence are key considerations for any clinical decision-making.²²
The literature regarding patients with advanced dementia is an example where, albeit in largely non-randomised retrospective studies, no improvement in survival, quality of life and nutritional status have been identified.^23,24 Articulating the evidence base as well as the views and experience of relevant multidisciplinary teams to patients, carers and clinical teams is key to an effective shared decision-making process. Any decision should be based on the individual’s values and wishes and should include ‘no treatment’ as an option.²⁵

The life-long consequences for patients, carers and healthcare institutions following the insertion of a gastrostomy are significant. The importance of making and reviewing best interest decisions regularly for individuals who lack mental capacity is fundamental.²⁶

Whilst the Mental Capacity Act 2005²⁷ does not specify any particular individual as having the legal responsibility for decision-making in these circumstances, in practice, this will fall to the individual with overall clinical responsibility for the patient’s care.²⁶ Identifying appropriately experienced clinicians to lead a forum for these decisions and the resources required will vary between settings.