Advertisement

Quality Improvement Guidelines for Pediatric Gastrostomy and Gastrojejunostomy Tube Placement

Published:October 13, 2014DOI:https://doi.org/10.1016/j.jvir.2014.08.002

      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 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 face-to-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 morbidity and high success rates that can be carried out with the use of local anesthesia and sedation (
      • Chait P.G.
      • Weinberg J.
      • Connolly B.L.
      • et al.
      Retrograde percutaneous gastrostomy and gastrojejunostomy in 505 children: a 4 1/2-year experience.
      ,
      • Malden E.S.
      • Hicks M.E.
      • Picus D.
      • Darcy M.D.
      • Vesely T.M.
      • Kleinhoffer M.A.
      Fluoroscopically guided percutaneous gastrostomy in children.
      ). 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 < 1.5 kg is well described (
      • Chait P.G.
      • Weinberg J.
      • Connolly B.L.
      • et al.
      Retrograde percutaneous gastrostomy and gastrojejunostomy in 505 children: a 4 1/2-year experience.
      ,
      • Malden E.S.
      • Hicks M.E.
      • Picus D.
      • Darcy M.D.
      • Vesely T.M.
      • Kleinhoffer M.A.
      Fluoroscopically guided percutaneous gastrostomy in children.
      ,
      • Laffan E.E.
      • McNamara P.J.
      • Amaral J.
      • et al.
      Review of interventional procedures in the very low birth-weight infant (<1.5 kg): complications, lessons learned and current practice.
      ,
      • King S.J.
      • Chait P.G.
      • Daneman A.
      • Pereira J.
      Retrograde percutaneous gastrostomy: a prospective study in 57 children.
      ,
      • Towbin R.B.
      • Ball Jr, W.S.
      • Bissett 3rd, G.S.
      Percutaneous gastrostomy and percutaneous gastrojejunostomy in children: antegrade approach.
      ,
      • Cory D.A.
      • Fitzgerald J.F.
      • Cohen M.D.
      Percutaneous nonendoscopic gastrostomy in children.
      ). 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 (
      • Chait P.G.
      • Weinberg J.
      • Connolly B.L.
      • et al.
      Retrograde percutaneous gastrostomy and gastrojejunostomy in 505 children: a 4 1/2-year experience.
      ).
      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 (
      • Chait P.
      • Baskin K.M.
      • Temple M.
      • Connolly B.
      Pediatric gastrointestinal interventions.
      ).
      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 (
      • Itkin M.
      • DeLegge M.H.
      • Fang J.C.
      • 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).
      ). This communication to the gastrointestinal tract can be percutaneous or through natural orifices (
      • Itkin M.
      • DeLegge M.H.
      • Fang J.C.
      • 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).
      ). 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 (
      • Itkin M.
      • DeLegge M.H.
      • Fang J.C.
      • 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).
      ). Percutaneous gastrojejunostomy is the creation of access to the jejunum via the stomach through a small incision in the abdominal wall (
      • Itkin M.
      • DeLegge M.H.
      • Fang J.C.
      • 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).
      ).
      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 (
      • Itkin M.
      • DeLegge M.H.
      • Fang J.C.
      • 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).
      ).
      Gastropexy is the tacking or securing of the anterior gastric wall to the anterior abdominal wall (
      • Itkin M.
      • DeLegge M.H.
      • Fang J.C.
      • 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).
      ), 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) (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 < 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 (
      • Lewis E.C.
      • Connolly B.
      • Temple M.
      • et al.
      Growth outcomes and complications after radiologic gastrostomy in 120 children.
      ,
      • Norman K.
      • Pichard C.
      • Lochs H.
      • Pirlich M.
      Prognostic impact of disease-related malnutrition.
      ). 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 (
      • Itkin M.
      • DeLegge M.H.
      • Fang J.C.
      • 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).
      ,
      • Patrick P.G.
      • Marulendra S.
      • Kirby D.F.
      • DeLegge M.H.
      Endoscopic nasogastric-jejunal feeding tube placement in critically ill patients.
      ). These tubes, which are usually inserted for < 6 weeks, keep the gastroesophageal junction open, increasing the risk of gastroesophageal reflux and aspiration (
      • Lewis E.C.
      • Connolly B.
      • Temple M.
      • et al.
      Growth outcomes and complications after radiologic gastrostomy in 120 children.
      ); cause impairment of oral feeding; cause irritation of the nasal mucosa; and are a considerable cosmetic and social handicap (
      • Lewis E.C.
      • Connolly B.
      • Temple M.
      • et al.
      Growth outcomes and complications after radiologic gastrostomy in 120 children.
      ). 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) (
      • George D.L.
      • Falk P.S.
      • Umberto Meduri G.
      • et al.
      Nosocomial sinusitis in patients in the medical intensive care unit: a prospective epidemiological study.
      ). 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 (
      • Lewis E.C.
      • Connolly B.
      • Temple M.
      • et al.
      Growth outcomes and complications after radiologic gastrostomy in 120 children.
      ,
      • Ching Y.A.
      • Gura K.
      • Modi B.
      • Jaksic T.
      Pediatric intestinal failure: nutrition, pharmacologic, and surgical approaches.
      ). In addition, long-term use of total parenteral nutrition in children can lead to cholestatic liver disease and liver failure requiring liver transplantation (
      • Lewis E.C.
      • Connolly B.
      • Temple M.
      • et al.
      Growth outcomes and complications after radiologic gastrostomy in 120 children.
      ,
      • Zambrano E.
      • El-Hennawy M.
      • Ehrenkranz R.A.
      • Zelterman D.
      • Reyes-Mugica M.
      Total parenteral nutrition induced liver pathology: an autopsy series of 24 newborn cases.
      ,
      • Quigley E.M.
      • Marsh M.N.
      • Shaffer J.L.
      • Markin R.S.
      Hepatobiliary complications of total parenteral nutrition.
      ). 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 (
      • Itkin M.
      • DeLegge M.H.
      • Fang J.C.
      • 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).
      ). To receive a G tube, a child must have normal or near-normal gastric and small bowel motility, and gastric anatomy must be adequate (
      • Itkin M.
      • DeLegge M.H.
      • Fang J.C.
      • 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).
      ). 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 (
      • Macagno F.
      • Demarini S.
      Techniques of enteral feeding in the newborn.
      ).

       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 (
      • Itkin M.
      • DeLegge M.H.
      • Fang J.C.
      • 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).
      ). 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 (
      • Hsu C.W.
      • Sun S.F.
      • Lin S.L.
      • et al.
      Duodenal versus gastric feeding in medical intensive care unit patients: a prospective, randomized, clinical study.
      ,
      • Heyland D.K.
      • Drover J.W.
      • MacDonald S.
      • Novak F.
      • Lam M.
      Effect of postpyloric feeding on gastroesophageal regurgitation and pulmonary microaspiration: results of a randomized controlled trial.
      ). 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 (
      • Felsher J.
      • Chand B.
      • Ponsky J.
      Decompressive percutaneous endoscopic gastrostomy in nonmalignant disease.
      ). Some GJ tube systems have two ports and can be used for concurrent jejunal feeding and gastric decompression (
      • Itkin M.
      • DeLegge M.H.
      • Fang J.C.
      • 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).
      ). 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 (
      • Baskin K.M.
      • Hogan M.J.
      • Sidhu M.K.
      • 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.
      ,
      • Hogan M.J.
      • Marshalleck F.E.
      • Sidhu M.K.
      • et al.
      Quality improvement guidelines for pediatric abscess and fluid drainage.
      ). 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 < 6 weeks, placement of a nasogastric or nasojejunal feeding tube should be considered (
      • Itkin M.
      • DeLegge M.H.
      • Fang J.C.
      • 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).
      ). 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 (
      • Malloy P.C.
      • Grassi C.J.
      • Kundu S.
      • et al.
      Consensus guidelines for periprocedural management of coagulation status and hemostasis risk in percutaneous image-guided interventions.
      ). The following procedures should be followed:
      • 1.
        Correct international normalized ratio to ≤ 1.5.
      • 2.
        Ensure platelet count is > 50,000.
      • 3.
        Withhold clopidogrel for 5 days before the procedure.
      • 4.
        Do not withhold aspirin.
      • 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 (
      • Hogan M.J.
      • Marshalleck F.E.
      • Sidhu M.K.
      • et al.
      Quality improvement guidelines for pediatric abscess and fluid drainage.
      ).
      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 (
      • Chait P.G.
      • Weinberg J.
      • Connolly B.L.
      • et al.
      Retrograde percutaneous gastrostomy and gastrojejunostomy in 505 children: a 4 1/2-year experience.
      ). 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 (
      • Sidhu M.
      • Strauss K.J.
      • Connolly B.
      • et al.
      Radiation safety in pediatric interventional radiology.
      ,
      • Hall E.J.
      Radiation biology for pediatric radiologists.
      ,
      • Stecker M.S.
      • Balter S.
      • Towbin R.B.
      • et al.
      Guidelines for patient radiation dose management.
      ,
      • Govia K.
      • Connolly B.L.
      • Thomas K.E.
      • Gordon C.L.
      Estimates of effective dose to pediatric patients undergoing enteric and venous access procedures.
      ,
      National Research Council
      Health Risks from Exposure to Low Levels of Ionizing Radiation: BEIR VII Phase 2.
      ). 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 (
      • Pearce M.S.
      • Salotti J.A.
      • Little M.P.
      • et al.
      Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study.
      ). 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 (
      • Govia K.
      • Connolly B.L.
      • Thomas K.E.
      • Gordon C.L.
      Estimates of effective dose to pediatric patients undergoing enteric and venous access procedures.
      ). The stochastic radiation risks of fatal malignancy associated with enteric procedures in children are low (1–10 per 10,000) (
      • Govia K.
      • Connolly B.L.
      • Thomas K.E.
      • Gordon C.L.
      Estimates of effective dose to pediatric patients undergoing enteric and venous access procedures.
      ). 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 (
      • Govia K.
      • Connolly B.L.
      • Thomas K.E.
      • Gordon C.L.
      Estimates of effective dose to pediatric patients undergoing enteric and venous access procedures.
      ,
      • Brenner D.
      • Elliston C.
      • Hall E.
      • Berdon W.
      Estimated risks of radiation-induced fatal cancer from pediatric CT.
      ).
      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 (
      • Govia K.
      • Connolly B.L.
      • Thomas K.E.
      • Gordon C.L.
      Estimates of effective dose to pediatric patients undergoing enteric and venous access procedures.
      ). 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 (
      • Govia K.
      • Connolly B.L.
      • Thomas K.E.
      • Gordon C.L.
      Estimates of effective dose to pediatric patients undergoing enteric and venous access procedures.
      ). 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.

      Sedation and Anesthesia

      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 (
      • Nseir S.
      • Zerimech F.
      • Jaillette E.
      • Artru F.
      • Balduyck M.
      Microaspiration in intubated critically ill patients: diagnosis and prevention.
      ). 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 (
      • Chait P.G.
      • Weinberg J.
      • Connolly B.L.
      • et al.
      Retrograde percutaneous gastrostomy and gastrojejunostomy in 505 children: a 4 1/2-year experience.
      ,
      • Towbin R.B.
      • Ball Jr, W.S.
      • Bissett 3rd, G.S.
      Percutaneous gastrostomy and percutaneous gastrojejunostomy in children: antegrade approach.
      ). It is nevertheless concerning that a large minority of sedations performed by nonanesthesiologists from multiple specialties do not follow published guidelines (
      • Langhan M.L.
      • Mallory M.
      • Hertzog J.
      • Lowrie L.
      • Cravero J.
      Physiologic monitoring practices during pediatric procedural sedation: a report from the Pediatric Sedation Research Consortium.
      ).
      “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 non-anesthesia providers, patient safety is of utmost concern” (
      • Bui A.H.
      • Urman R.D.
      Clinical and safety considerations for moderate and deep sedation.
      ).
      Light sedation, analgesia, and anxiolysis in general refer to a condition in which the patient is relaxed (eg, using oral benzodiazepines or < 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 anesthesia alone; Chait et al (
      • Chait P.G.
      • Weinberg J.
      • Connolly B.L.
      • et al.
      Retrograde percutaneous gastrostomy and gastrojejunostomy in 505 children: a 4 1/2-year experience.
      ) 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 (
      • Chait P.G.
      • Weinberg J.
      • Connolly B.L.
      • et al.
      Retrograde percutaneous gastrostomy and gastrojejunostomy in 505 children: a 4 1/2-year experience.
      ). 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” (
      • Friedman J.N.
      • Ahmed S.
      • Connolly B.
      • Chait P.
      • Mahant S.
      Complications associated with image-guided gastrostomy and gastrojejunostomy tubes in children.
      ).
      Beyond light sedation, the spectrum from moderate and deep sedation to general anesthesia is semantically and clinically uncertain (
      • Green S.M.
      • Mason K.P.
      Stratification of sedation risk—a challenge to the sedation continuum.
      ). 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 (
      • Rex D.K.
      Effect of the Centers for Medicare & Medicaid Services policy about deep sedation on use of propofol.
      ). 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 (
      • Green S.M.
      • Mason K.P.
      Stratification of sedation risk—a challenge to the sedation continuum.
      ), despite recognition that properly trained nonanesthesiologists, including radiologists and interventional radiologists, can and do safely and effectively employ strategies for deep sedation in children (
      • Moran T.C.
      • Kaye A.D.
      • Mai A.H.
      • Bok L.R.
      Sedation, analgesia, and local anesthesia: a review for general and interventional radiologists.
      ,

      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.

      ).
      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 (
      • Hertzog J.H.
      • Havidich J.E.
      Non-anesthesiologist-provided pediatric procedural sedation: an update.
      ). 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” (
      • Neuhauser C.
      • Wagner B.
      • Heckmann M.
      • Weigand M.A.
      • Zimmer K.P.
      Analgesia and sedation for painful interventions in children and adolescents.
      ).
      Deep sedation for procedures such as gastrostomy can be safely performed outside the operating room by nonanesthesiologists even in moderately high-risk pediatric patients (
      • Wengrower D.
      • Gozal D.
      • Gozal Y.
      • et al.
      Complicated endoscopic pediatric procedures using deep sedation and general anesthesia are safe in the endoscopy suite.
      ). At this time, there are no specific published guidelines for deep sedation per se. Nevertheless, existing guidelines for sedation by nonanesthesiologists (
      American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists.
      Practice guidelines for sedation and analgesia by non-anesthesiologists.
      ,
      • Cote C.J.
      • Wilson S.
      Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update.
      ) 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 side-stream capnography) is also recommended for moderate or deep sedation for early detection of microalveolar hypoventilation and prevention of hypoxemia (
      • Lightdale J.R.
      • Goldmann D.A.
      • Feldman H.A.
      • Newburg A.R.
      • DiNardo J.A.
      • Fox V.L.
      Microstream capnography improves patient monitoring during moderate sedation: a randomized, controlled trial.
      ,

      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.

      ).
      It is also essential that sedation providers properly recognize patients at high risk for sedation complications (
      • Neuhauser C.
      • Wagner B.
      • Heckmann M.
      • Weigand M.A.
      • Zimmer K.P.
      Analgesia and sedation for painful interventions in children and adolescents.
      ), 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
      • 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 (
      • Mason K.P.
      Pediatric procedures in interventional radiology.
      ).

      Patient Care Issues

      Especially in young children, maintaining the appropriate environment, particularly with regard to ambient temperature, is of paramount importance (
      • Hogan M.J.
      • Marshalleck F.E.
      • Sidhu M.K.
      • et al.
      Quality improvement guidelines for pediatric abscess and fluid drainage.
      ). 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 < 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 (
      • Hogan M.J.
      • Marshalleck F.E.
      • Sidhu M.K.
      • et al.
      Quality improvement guidelines for pediatric abscess and fluid drainage.
      ,
      • Mason K.P.
      Pediatric procedures in interventional radiology.
      ). 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 (
      • Itkin M.
      • DeLegge M.H.
      • Fang J.C.
      • 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).
      ). 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 (
      • Chait P.G.
      • Weinberg J.
      • Connolly B.L.
      • et al.
      Retrograde percutaneous gastrostomy and gastrojejunostomy in 505 children: a 4 1/2-year experience.
      ). Large gastric varices make the procedure hazardous, although simultaneous endoscopic control has been described (
      • Chait P.
      • Baskin K.M.
      • Temple M.
      • Connolly B.
      Pediatric gastrointestinal interventions.
      ). 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 (
      • Itkin M.
      • DeLegge M.H.
      • Fang J.C.
      • 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).
      ). 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 (
      • Sane S.S.
      • Towbin A.
      • Bergey E.A.
      • et al.
      Percutaneous gastrostomy tube placement in patients with ventriculoperitoneal shunts.
      ). 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 (
      • Chait P.G.
      • Weinberg J.
      • Connolly B.L.
      • et al.
      Retrograde percutaneous gastrostomy and gastrojejunostomy in 505 children: a 4 1/2-year experience.
      ). Morbid obesity is a relative contraindication because shifting of the panniculus in the postoperative period may dislodge the G tube from the stomach (
      • Itkin M.
      • DeLegge M.H.
      • Fang J.C.
      • 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).
      ). 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 (
      • Itkin M.
      • DeLegge M.H.
      • Fang J.C.
      • 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).
      ). Antegrade techniques have a reported incidence of 5.4%–30% of peristomal infections (
      • McClave S.A.
      • Chang W.K.
      Complications of enteral access.
      ). 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 (
      • Lipp A.
      • Lusardi G.
      Systemic antimicrobial prophylaxis for percutaneous endoscopic gastrostomy.
      ). In contrast, one of the advantages of the transabdominal, or retrograde, route is that it does not expose the 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 (
      • Shastri Y.M.
      • 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.
      ).

      Procedure

      There are two techniques for placing percutaneous G tubes in children—the transoral, or antegrade, and the transabdominal, or retrograde, technique (
      • Chait P.G.
      • Weinberg J.
      • Connolly B.L.
      • et al.
      Retrograde percutaneous gastrostomy and gastrojejunostomy in 505 children: a 4 1/2-year experience.
      ,
      • Towbin R.B.
      • Ball Jr, W.S.
      • Bissett 3rd, G.S.
      Percutaneous gastrostomy and percutaneous gastrojejunostomy in children: antegrade approach.
      ,
      • Lewis E.C.
      • Connolly B.
      • Temple M.
      • et al.
      Growth outcomes and complications after radiologic gastrostomy in 120 children.
      ,
      • Friedman J.N.
      • Ahmed S.
      • Connolly B.
      • Chait P.
      • Mahant S.
      Complications associated with image-guided gastrostomy and gastrojejunostomy tubes in children.
      ,
      • Sane S.S.
      • Towbin A.
      • Bergey E.A.
      • et al.
      Percutaneous gastrostomy tube placement in patients with ventriculoperitoneal shunts.
      ,
      • Rosenberg J.
      • Amaral J.G.
      • Sklar C.M.
      • et al.
      Gastrostomy and gastrojejunostomy tube placements: outcomes in children with gastroschisis, omphalocele, and congenital diaphragmatic hernia.
      ). 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 (
      • Chait P.G.
      • Weinberg J.
      • Connolly B.L.
      • et al.
      Retrograde percutaneous gastrostomy and gastrojejunostomy in 505 children: a 4 1/2-year experience.
      ,
      • Towbin R.B.
      • Ball Jr, W.S.
      • Bissett 3rd, G.S.
      Percutaneous gastrostomy and percutaneous gastrojejunostomy in children: antegrade approach.
      ,
      • Sane S.S.
      • Towbin A.
      • Bergey E.A.
      • et al.
      Percutaneous gastrostomy tube placement in patients with ventriculoperitoneal shunts.
      ), 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 (
      • Chait P.
      • Baskin K.M.
      • Temple M.
      • Connolly B.
      Pediatric gastrointestinal interventions.
      ), 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 (
      • Marx M.V.
      • Williams D.M.
      • Perkins A.J.
      • et al.
      Percutaneous feeding tube placement in pediatric patients: immediate and 30-day results.
      ). 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 (
      • Towbin R.B.
      • Ball Jr, W.S.
      • Bissett 3rd, G.S.
      Percutaneous gastrostomy and percutaneous gastrojejunostomy in children: antegrade approach.
      ,
      • Sane S.S.
      • Towbin A.
      • Bergey E.A.
      • et al.
      Percutaneous gastrostomy tube placement in patients with ventriculoperitoneal shunts.
      ). 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 (
      • Laasch H.U.
      • Wilbraham L.
      • Bullen K.
      • et al.
      Gastrostomy insertion: comparing the options—PEG.
      ). 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 (
      • Towbin R.B.
      • Ball Jr, W.S.
      • Bissett 3rd, G.S.
      Percutaneous gastrostomy and percutaneous gastrojejunostomy in children: antegrade approach.
      ,
      • Lipp A.
      • Lusardi G.
      Systemic antimicrobial prophylaxis for percutaneous endoscopic gastrostomy.
      ). 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 (
      • Towbin R.B.
      • Ball Jr, W.S.
      • Bissett 3rd, G.S.
      Percutaneous gastrostomy and percutaneous gastrojejunostomy in children: antegrade approach.
      ,
      • Laasch H.U.
      • Wilbraham L.
      • Bullen K.
      • et al.
      Gastrostomy insertion: comparing the options—PEG.
      ).
      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 (
      • Itkin M.
      • DeLegge M.H.
      • Fang J.C.
      • 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).
      ,
      • Coleman C.C.
      • Coons H.G.
      • Cope C.
      • et al.
      Percutaneous enterostomy with the Cope suture anchor.
      ). Use of this technique in infants weighing 800 g has been described (
      • Chait P.
      • Baskin K.M.
      • Temple M.
      • Connolly B.
      Pediatric gastrointestinal interventions.
      ). 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 (
      • Chait P.G.
      • Weinberg J.
      • Connolly B.L.
      • et al.
      Retrograde percutaneous gastrostomy and gastrojejunostomy in 505 children: a 4 1/2-year experience.
      ,
      • Itkin M.
      • DeLegge M.H.
      • Fang J.C.
      • 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).
      ). 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: < 10 kg, 8.5-F; 10–25 kg, 10-F; > 25 kg, 12-F (
      • Chait P.G.
      • Weinberg J.
      • Connolly B.L.
      • et al.
      Retrograde percutaneous gastrostomy and gastrojejunostomy in 505 children: a 4 1/2-year experience.
      ). 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) (
      • Chait P.G.
      • Weinberg J.
      • Connolly B.L.
      • et al.
      Retrograde percutaneous gastrostomy and gastrojejunostomy in 505 children: a 4 1/2-year experience.
      ). The 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 (
      • Foster A.
      • Given M.
      • Thornton E.
      • et al.
      Removal of T-fasteners 2 days after gastrostomy is feasible.
      ).
      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 (
      • Chait P.G.
      • Weinberg J.
      • Connolly B.L.
      • et al.
      Retrograde percutaneous gastrostomy and gastrojejunostomy in 505 children: a 4 1/2-year experience.
      ). 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 (
      • Chait P.G.
      • Weinberg J.
      • Connolly B.L.
      • et al.
      Retrograde percutaneous gastrostomy and gastrojejunostomy in 505 children: a 4 1/2-year experience.
      ).
      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 (
      • Chait P.G.
      • Weinberg J.
      • Connolly B.L.
      • et al.
      Retrograde percutaneous gastrostomy and gastrojejunostomy in 505 children: a 4 1/2-year experience.
      ,
      • Malden E.S.
      • Hicks M.E.
      • Picus D.
      • Darcy M.D.
      • Vesely T.M.
      • Kleinhoffer M.A.
      Fluoroscopically guided percutaneous gastrostomy in children.
      ,
      • King S.J.
      • Chait P.G.
      • Daneman A.
      • Pereira J.
      Retrograde percutaneous gastrostomy: a prospective study in 57 children.
      ,
      • Towbin R.B.
      • Ball Jr, W.S.
      • Bissett 3rd, G.S.
      Percutaneous gastrostomy and percutaneous gastrojejunostomy in children: antegrade approach.
      ,
      • Lewis E.C.
      • Connolly B.
      • Temple M.
      • et al.
      Growth outcomes and complications after radiologic gastrostomy in 120 children.
      ,
      • Sane S.S.
      • Towbin A.
      • Bergey E.A.
      • et al.
      Percutaneous gastrostomy tube placement in patients with ventriculoperitoneal shunts.
      ,
      • Rosenberg J.
      • Amaral J.G.
      • Sklar C.M.
      • et al.
      Gastrostomy and gastrojejunostomy tube placements: outcomes in children with gastroschisis, omphalocele, and congenital diaphragmatic hernia.
      ,
      • Nah S.A.
      • Narayanaswamy B.
      • Eaton S.
      • et al.
      Gastrostomy insertion in children: percutaneous endoscopic or percutaneous image-guided?.
      ,
      • Albanese C.T.
      • Towbin R.B.
      • Ulman I.
      • Lewis J.
      • Smith S.D.
      Percutaneous gastrojejunostomy versus Nissen fundoplication for enteral feeding of the neurologically impaired child with gastroesophageal reflux.
      ). Rosenberg et al (
      • Rosenberg J.
      • Amaral J.G.
      • Sklar C.M.
      • et al.
      Gastrostomy and gastrojejunostomy tube placements: outcomes in children with gastroschisis, omphalocele, and congenital diaphragmatic hernia.
      ), 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).
      Table 1Success Rates and Thresholds for G Tube or GJ Tube Placement in Children
      AuthorYearNo. CasesSuccess Rate (%)
      Towbin et al (
      • Towbin R.B.
      • Ball Jr, W.S.
      • Bissett 3rd, G.S.
      Percutaneous gastrostomy and percutaneous gastrojejunostomy in children: antegrade approach.
      )
      198824100
      Malden et al (
      • Malden E.S.
      • Hicks M.E.
      • Picus D.
      • Darcy M.D.
      • Vesely T.M.
      • Kleinhoffer M.A.
      Fluoroscopically guided percutaneous gastrostomy in children.
      )
      199227100
      King et al (
      • King S.J.
      • Chait P.G.
      • Daneman A.
      • Pereira J.
      Retrograde percutaneous gastrostomy: a prospective study in 57 children.
      )
      19935798.3
      Albanese et al (
      • Albanese C.T.
      • Towbin R.B.
      • Ulman I.
      • Lewis J.
      • Smith S.D.
      Percutaneous gastrojejunostomy versus Nissen fundoplication for enteral feeding of the neurologically impaired child with gastroesophageal reflux.
      )
      19934498
      Chait et al (
      • Chait P.G.
      • Weinberg J.
      • Connolly B.L.
      • et al.
      Retrograde percutaneous gastrostomy and gastrojejunostomy in 505 children: a 4 1/2-year experience.
      )
      199651198.8
      Sane et al (
      • Sane S.S.
      • Towbin A.
      • Bergey E.A.
      • et al.
      Percutaneous gastrostomy tube placement in patients with ventriculoperitoneal shunts.
      )
      1998205100
      Lewis et al (
      • Lewis E.C.
      • Connolly B.
      • Temple M.
      • et al.
      Growth outcomes and complications after radiologic gastrostomy in 120 children.
      )
      2008120100
      Rosenberg et al (
      • Rosenberg J.
      • Amaral J.G.
      • Sklar C.M.
      • et al.
      Gastrostomy and gastrojejunostomy tube placements: outcomes in children with gastroschisis, omphalocele, and congenital diaphragmatic hernia.
      )
      20083794.7
      Nah et al (
      • Nah S.A.
      • Narayanaswamy B.
      • Eaton S.
      • et al.
      Gastrostomy insertion in children: percutaneous endoscopic or percutaneous image-guided?.
      )
      201019399
      GJ tube = gastrojejunostomy tube; G tube = gastrostomy tube.
      Table 2Success Rate and Threshold
      OutcomeSuggested Threshold Value (%)
      Successful placement of percutaneous G tube95%
      G tube = gastrostomy tube.

      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 (
      • Sane S.S.
      • Towbin A.
      • Bergey E.A.
      • et al.
      Percutaneous gastrostomy tube placement in patients with ventriculoperitoneal shunts.
      ). It is also recognized that 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.
      Table 3Major Complication Rate after G Tube or GJ Tube Placement in Children
      AuthorYearNo. CasesMajor Complication Rate within 30 Days (%)
      Towbin et al (
      • Towbin R.B.
      • Ball Jr, W.S.
      • Bissett 3rd, G.S.
      Percutaneous gastrostomy and percutaneous gastrojejunostomy in children: antegrade approach.
      )
      1988240
      Malden et al (
      • Malden E.S.
      • Hicks M.E.
      • Picus D.
      • Darcy M.D.
      • Vesely T.M.
      • Kleinhoffer M.A.
      Fluoroscopically guided percutaneous gastrostomy in children.
      )
      1992270
      King et al (
      • King S.J.
      • Chait P.G.
      • Daneman A.
      • Pereira J.
      Retrograde percutaneous gastrostomy: a prospective study in 57 children.
      )
      1993570
      Marx et al (
      • Marx M.V.
      • Williams D.M.
      • Perkins A.J.
      • et al.
      Percutaneous feeding tube placement in pediatric patients: immediate and 30-day results.
      )
      1996613.3
      Chait et al (
      • Chait P.G.
      • Weinberg J.
      • Connolly B.L.
      • et al.
      Retrograde percutaneous gastrostomy and gastrojejunostomy in 505 children: a 4 1/2-year experience.
      )
      19965110.39
      Sane et al (
      • Sane S.S.
      • Towbin A.
      • Bergey E.A.
      • et al.
      Percutaneous gastrostomy tube placement in patients with ventriculoperitoneal shunts.
      )
      19982059
      Friedman et al (
      • Friedman J.N.
      • Ahmed S.
      • Connolly B.
      • Chait P.
      • Mahant S.
      Complications associated with image-guided gastrostomy and gastrojejunostomy tubes in children.
      )
      20042085
      Lewis et al (
      • Lewis E.C.
      • Connolly B.
      • Temple M.
      • et al.
      Growth outcomes and complications after radiologic gastrostomy in 120 children.
      )
      20081204.2
      Rosenberg et al (
      • Rosenberg J.
      • Amaral J.G.
      • Sklar C.M.
      • et al.
      Gastrostomy and gastrojejunostomy tube placements: outcomes in children with gastroschisis, omphalocele, and congenital diaphragmatic hernia.
      )
      2008375
      Nah et al (
      • Nah S.A.
      • Narayanaswamy B.
      • Eaton S.
      • et al.
      Gastrostomy insertion in children: percutaneous endoscopic or percutaneous image-guided?.
      )
      20101933
      GJ tube = gastrojejunostomy tube; G tube = gastrostomy tube.
      Complications may be defined as major or minor depending on management, hospital stay, and outcome in accordance with the SIR Clinical Practice Guidelines (
      • Lewis E.C.
      • Connolly B.
      • Temple M.
      • et al.
      Growth outcomes and complications after radiologic gastrostomy in 120 children.
      ,
      • Sacks D.
      • McClenny T.E.
      • Cardella J.F.
      • Lewis C.A.
      Society of Interventional Radiology clinical practice guidelines.
      ). Complications occur in approximately 5% of patients (
      • Chait P.G.
      • Weinberg J.
      • Connolly B.L.
      • et al.
      Retrograde percutaneous gastrostomy and gastrojejunostomy in 505 children: a 4 1/2-year experience.
      ,
      • Malden E.S.
      • Hicks M.E.
      • Picus D.
      • Darcy M.D.
      • Vesely T.M.
      • Kleinhoffer M.A.
      Fluoroscopically guided percutaneous gastrostomy in children.
      ,
      • King S.J.
      • Chait P.G.
      • Daneman A.
      • Pereira J.
      Retrograde percutaneous gastrostomy: a prospective study in 57 children.
      ,
      • Towbin R.B.
      • Ball Jr, W.S.
      • Bissett 3rd, G.S.
      Percutaneous gastrostomy and percutaneous gastrojejunostomy in children: antegrade approach.
      ,
      • Lewis E.C.
      • Connolly B.
      • Temple M.
      • et al.
      Growth outcomes and complications after radiologic gastrostomy in 120 children.
      ,
      • Friedman J.N.
      • Ahmed S.
      • Connolly B.
      • Chait P.
      • Mahant S.
      Complications associated with image-guided gastrostomy and gastrojejunostomy tubes in children.
      ,
      • Sane S.S.
      • Towbin A.
      • Bergey E.A.
      • et al.
      Percutaneous gastrostomy tube placement in patients with ventriculoperitoneal shunts.
      ,
      • Rosenberg J.
      • Amaral J.G.
      • Sklar C.M.
      • et al.
      Gastrostomy and gastrojejunostomy tube placements: outcomes in children with gastroschisis, omphalocele, and congenital diaphragmatic hernia.
      ,
      • Nah S.A.
      • Narayanaswamy B.
      • Eaton S.
      • et al.
      Gastrostomy insertion in children: percutaneous endoscopic or percutaneous image-guided?.
      ). Published complication rates and suggested thresholds include the following (Table 4).
      Table 4Published Complication Rates and Suggested Thresholds
      Specific Major ComplicationRate (%)Suggested Threshold (%)
      Death (
      • Lewis E.C.
      • Connolly B.
      • Temple M.
      • et al.
      Growth outcomes and complications after radiologic gastrostomy in 120 children.
      )
      0.05–0.91
      Blood loss requiring transfusion (
      • Lewis E.C.
      • Connolly B.
      • Temple M.
      • et al.
      Growth outcomes and complications after radiologic gastrostomy in 120 children.
      ,
      • Marx M.V.
      • Williams D.M.
      • Perkins A.J.
      • et al.
      Percutaneous feeding tube placement in pediatric patients: immediate and 30-day results.
      )
      0.5–1.73
      Extraluminal G tube placement (
      • Chait P.G.
      • Weinberg J.
      • Connolly B.L.
      • et al.
      Retrograde percutaneous gastrostomy and gastrojejunostomy in 505 children: a 4 1/2-year experience.
      )
      0.20.5
      Bowel transgression (
      • Chait P.G.
      • Weinberg J.
      • Connolly B.L.
      • et al.
      Retrograde percutaneous gastrostomy and gastrojejunostomy in 505 children: a 4 1/2-year experience.
      )
      0.20.5
      Peritonitis (
      • Lewis E.C.
      • Connolly B.
      • Temple M.
      • et al.
      Growth outcomes and complications after radiologic gastrostomy in 120 children.
      ,
      • Friedman J.N.
      • Ahmed S.
      • Connolly B.
      • Chait P.
      • Mahant S.
      Complications associated with image-guided gastrostomy and gastrojejunostomy tubes in children.
      )
      1.8–35
      Subcutaneous abscess (
      • Friedman J.N.
      • Ahmed S.
      • Connolly B.
      • Chait P.
      • Mahant S.
      Complications associated with image-guided gastrostomy and gastrojejunostomy tubes in children.
      )
      25
      Septicemia (
      • Lewis E.C.
      • Connolly B.
      • Temple M.
      • et al.
      Growth outcomes and complications after radiologic gastrostomy in 120 children.
      ,
      • Friedman J.N.
      • Ahmed S.
      • Connolly B.
      • Chait P.
      • Mahant S.
      Complications associated with image-guided gastrostomy and gastrojejunostomy tubes in children.
      )
      0.9–12
      VP shunt infection (
      • Sane S.S.
      • Towbin A.
      • Bergey E.A.
      • et al.
      Percutaneous gastrostomy tube placement in patients with ventriculoperitoneal shunts.
      )
      910
      G tube = gastrostomy tube; VP = ventriculoperitoneal.
      Marx et al (
      • Marx M.V.
      • Williams D.M.
      • Perkins A.J.
      • et al.
      Percutaneous feeding tube placement in pediatric patients: immediate and 30-day results.
      ) 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 = 5), mild peritonitis treated with 48 hours of intravenous antibiotics (n = 3), pain that required increased ventilatory support in a patient with myopathy (n = 1), collapse of right upper lobe that required vigorous pulmonary toilet (n = 1), and seizure treated with intravenous medication for control (n = 1).
      Malden et al (
      • Malden E.S.
      • Hicks M.E.
      • Picus D.
      • Darcy M.D.
      • Vesely T.M.
      • Kleinhoffer M.A.
      Fluoroscopically guided percutaneous gastrostomy in children.
      ) 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 (
      • Towbin R.B.
      • Ball Jr, W.S.
      • Bissett 3rd, G.S.
      Percutaneous gastrostomy and percutaneous gastrojejunostomy in children: antegrade approach.
      ) 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 (
      • King S.J.
      • Chait P.G.
      • Daneman A.
      • Pereira J.
      Retrograde percutaneous gastrostomy: a prospective study in 57 children.
      ) placed G tubes in 57 children using the retrograde technique. They reported no major and only two minor complications consisting of abdominal tenderness and low-grade fever lasting <48 hours.
      In a large series of 511 patients, Chait et al (
      • Chait P.G.
      • Weinberg J.
      • Connolly B.L.
      • et al.
      Retrograde percutaneous gastrostomy and gastrojejunostomy in 505 children: a 4 1/2-year experience.
      ) 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 (
      • Friedman J.N.
      • Ahmed S.
      • Connolly B.
      • Chait P.
      • Mahant S.
      Complications associated with image-guided gastrostomy and gastrojejunostomy tubes in children.
      ). 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%) (
      • Friedman J.N.
      • Ahmed S.
      • Connolly B.
      • Chait P.
      • Mahant S.
      Complications associated with image-guided gastrostomy and gastrojejunostomy tubes in children.
      ).
      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 (
      • Lewis E.C.
      • Connolly B.
      • Temple M.
      • et al.
      Growth outcomes and complications after radiologic gastrostomy in 120 children.
      ). During that time, 358 tubes were inserted. Complications were divided into early (< 30 d after tube insertion) and late (≥ 30 d after tube insertion) and were determined to be major or minor according to SIR Clinical Practice Guidelines (
      • Sacks D.
      • McClenny T.E.
      • Cardella J.F.
      • Lewis C.A.
      Society of Interventional Radiology clinical practice guidelines.
      ). 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 (
      • Lewis E.C.
      • Connolly B.
      • Temple M.
      • et al.
      Growth outcomes and complications after radiologic gastrostomy in 120 children.
      ). 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 (
      • Sane S.S.
      • Towbin A.
      • Bergey E.A.
      • et al.
      Percutaneous gastrostomy tube placement in patients with ventriculoperitoneal shunts.
      ) 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.
      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 (
      • Chait P.
      • Baskin K.M.
      • Temple M.
      • Connolly B.
      Pediatric gastrointestinal interventions.
      ).
      A unique complication of GJ tubes, which is almost totally confined to feeding tubes with a distal pigtail loop, is intussusception (
      • Friedman J.N.
      • Ahmed S.
      • Connolly B.
      • Chait P.
      • Mahant S.
      Complications associated with image-guided gastrostomy and gastrojejunostomy tubes in children.
      ,
      • Wales P.W.
      • Diamond I.R.
      • Dutta S.
      • et al.
      Fundoplication and gastrostomy versus image-guided gastrojejunal tube for enteral feeding in neurologically impaired children with gastroesophageal reflux.
      ,
      • Connolly B.L.
      • Chait P.G.
      • Siva-Nandan R.
      • Duncan D.
      • Peer M.
      Recognition of intussusception around gastrojejunostomy tubes in children.
      ,
      • Hughes U.M.
      • Connolly B.L.
      • Chait P.G.
      • Muraca S.
      Further report of small-bowel intussusceptions related to gastrojejunostomy tubes.
      ). 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 (
      • Friedman J.N.
      • Ahmed S.
      • Connolly B.
      • Chait P.
      • Mahant S.
      Complications associated with image-guided gastrostomy and gastrojejunostomy tubes in children.
      ,
      • Hughes U.M.
      • Connolly B.L.
      • Chait P.G.
      • Muraca S.
      Further report of small-bowel intussusceptions related to gastrojejunostomy tubes.
      ). 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 (
      • Connolly B.L.
      • Chait P.G.
      • Siva-Nandan R.
      • Duncan D.
      • Peer M.
      Recognition of intussusception around gastrojejunostomy tubes in children.
      ,
      • Hughes U.M.
      • Connolly B.L.
      • Chait P.G.
      • Muraca S.
      Further report of small-bowel intussusceptions related to gastrojejunostomy tubes.
      ).
      Thresholds for major and minor complications are more difficult, considering the conflicting evidence already cited; however, major complications should not occur in > 5% of patients within 30 days of G tube or GJ tube placement, and minor complications should not occur in > 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 (
      • DeLegge M.H.
      • McClave S.A.
      • DiSario J.A.
      • et al.
      Ethical and medicolegal aspects of PEG-tube placement and provision of artificial nutritional therapy.
      ). 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 (
      • Itkin M.
      • DeLegge M.H.
      • Fang J.C.
      • 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).
      ,
      • DeLegge M.H.
      • McClave S.A.
      • DiSario J.A.
      • et al.
      Ethical and medicolegal aspects of PEG-tube placement and provision of artificial nutritional therapy.
      ). 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 (
      • DeLegge M.H.
      • McClave S.A.
      • DiSario J.A.
      • et al.
      Ethical and medicolegal aspects of PEG-tube placement and provision of artificial nutritional therapy.
      ). 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 (
      • Itkin M.
      • DeLegge M.H.
      • Fang J.C.
      • 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).
      ).

      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.

      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.

      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 (≤ 23 h) for observation only

       Major Complications

      C. Require major therapy, minor hospitalization (≥ 24 h but < 48 h)
      D. Require major therapy, unplanned increase in level of care, prolonged hospitalization (> 48 h)
      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 (
      • Fink A.
      • Kosecoff J.
      • Chassin M.
      • Brook R.H.
      Consensus methods: characteristics and guidelines for use.
      ,
      • Leape L.L.
      • Hilborne L.H.
      • Park R.E.
      • et al.
      The appropriateness of use of coronary artery bypass graft surgery in New York State.
      ).

      References

        • Chait P.G.
        • Weinberg J.
        • Connolly B.L.
        • et al.
        Retrograde percutaneous gastrostomy and gastrojejunostomy in 505 children: a 4 1/2-year experience.
        Radiology. 1996; 201: 691-695
        • Malden E.S.
        • Hicks M.E.
        • Picus D.
        • Darcy M.D.
        • Vesely T.M.
        • Kleinhoffer M.A.
        Fluoroscopically guided percutaneous gastrostomy in children.
        J Vasc Interv Radiol. 1992; 3: 673-677
        • Laffan E.E.
        • McNamara P.J.
        • Amaral J.
        • et al.
        Review of interventional procedures in the very low birth-weight infant (<1.5 kg): complications, lessons learned and current practice.
        Pediatr Radiol. 2009; 39: 781-790
        • King S.J.
        • Chait P.G.
        • Daneman A.
        • Pereira J.
        Retrograde percutaneous gastrostomy: a prospective study in 57 children.
        Pediatr Radiol. 1993; 23: 23-25
        • Towbin R.B.
        • Ball Jr, W.S.
        • Bissett 3rd, G.S.
        Percutaneous gastrostomy and percutaneous gastrojejunostomy in children: antegrade approach.
        Radiology. 1988; 168: 473-476
        • Cory D.A.
        • Fitzgerald J.F.
        • Cohen M.D.
        Percutaneous nonendoscopic gastrostomy in children.
        AJR Am J Roentgenol. 1988; 151: 995-997
        • Chait P.
        • Baskin K.M.
        • Temple M.
        • Connolly B.
        Pediatric gastrointestinal interventions.
        in: Stringer D.A. Babyn P.S. Pediatric Gastrointestinal Imaging and Intervention. 2nd ed. BC Decker, Hamilton, Ontario2000: 97-160
        • Itkin M.
        • DeLegge M.H.
        • Fang J.C.
        • 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
        • Lewis E.C.
        • Connolly B.
        • Temple M.
        • et al.
        Growth outcomes and complications after radiologic gastrostomy in 120 children.
        Pediatr Radiol. 2008; 38: 963-970
        • Norman K.
        • Pichard C.
        • Lochs H.
        • Pirlich M.
        Prognostic impact of disease-related malnutrition.
        Clin Nutr. 2008; 27: 5-15
        • Patrick P.G.
        • Marulendra S.
        • Kirby D.F.
        • DeLegge M.H.
        Endoscopic nasogastric-jejunal feeding tube placement in critically ill patients.
        Gastrointest Endosc. 1997; 45: 72-76
        • George D.L.
        • Falk P.S.
        • 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
        • Ching Y.A.
        • Gura K.
        • Modi B.
        • Jaksic T.
        Pediatric intestinal failure: nutrition, pharmacologic, and surgical approaches.
        Nutr Clin Pract. 2007; 22: 653-663
        • Zambrano E.
        • El-Hennawy M.
        • Ehrenkranz R.A.
        • 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
        • Quigley E.M.
        • Marsh M.N.
        • Shaffer J.L.
        • Markin R.S.
        Hepatobiliary complications of total parenteral nutrition.
        Gastroenterology. 1993; 104: 286-301
        • Macagno F.
        • Demarini S.
        Techniques of enteral feeding in the newborn.
        Acta Paediatr Suppl. 1994; 402: 11-13
        • Hsu C.W.
        • Sun S.F.
        • Lin S.L.
        • et al.
        Duodenal versus gastric feeding in medical intensive care unit patients: a prospective, randomized, clinical study.
        Crit Care Med. 2009; 37: 1866-1872
        • Heyland D.K.
        • Drover J.W.
        • 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
        • Felsher J.
        • Chand B.
        • Ponsky J.
        Decompressive percutaneous endoscopic gastrostomy in nonmalignant disease.
        Am J Surg. 2004; 187: 254-256
        • Baskin K.M.
        • Hogan M.J.
        • Sidhu M.K.
        • 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
        • Hogan M.J.
        • Marshalleck F.E.
        • Sidhu M.K.
        • et al.
        Quality improvement guidelines for pediatric abscess and fluid drainage.
        J Vasc Interv Radiol. 2012; 23: 1397-1402
        • Malloy P.C.
        • Grassi C.J.
        • 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: S240-S249
        • Sidhu M.
        • Strauss K.J.
        • Connolly B.
        • et al.
        Radiation safety in pediatric interventional radiology.
        Tech Vasc Interv Radiol. 2010; 13: 158-166
        • Hall E.J.
        Radiation biology for pediatric radiologists.
        Pediatr Radiol. 2009; 39: S57-S64
        • Stecker M.S.
        • Balter S.
        • Towbin R.B.
        • et al.
        Guidelines for patient radiation dose management.
        J Vasc Interv Radiol. 2009; 20: S263-S273
        • Govia K.
        • Connolly B.L.
        • Thomas K.E.
        • Gordon C.L.
        Estimates of effective dose to pediatric patients undergoing enteric and venous access procedures.
        J Vasc Interv Radiol. 2012; 23: 443-450
        • National Research Council
        Health Risks from Exposure to Low Levels of Ionizing Radiation: BEIR VII Phase 2.
        The National Academies Press, Washington, DC2006
        • Pearce M.S.
        • Salotti J.A.
        • Little M.P.
        • 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
        • Brenner D.
        • Elliston C.
        • Hall E.
        • Berdon W.
        Estimated risks of radiation-induced fatal cancer from pediatric CT.
        AJR Am J Roentgenol. 2001; 176: 289-296
        • 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
        • Langhan M.L.
        • 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
        • Bui A.H.
        • Urman R.D.
        Clinical and safety considerations for moderate and deep sedation.
        J Med Pract Manage. 2013; 29: 35-41
        • Friedman J.N.
        • Ahmed S.
        • Connolly B.
        • Chait P.
        • Mahant S.
        Complications associated with image-guided gastrostomy and gastrojejunostomy tubes in children.
        Pediatrics. 2004; 114: 458-461
        • Green S.M.
        • Mason K.P.
        Stratification of sedation risk—a challenge to the sedation continuum.
        Paediatr Anaesth. 2011; 21: 924-931
        • Rex D.K.
        Effect of the Centers for Medicare & Medicaid Services policy about deep sedation on use of propofol.
        Ann Intern Med. 2011; 154: 622-626
        • Moran T.C.
        • Kaye A.D.
        • Mai A.H.
        • Bok L.R.
        Sedation, analgesia, and local anesthesia: a review for general and interventional radiologists.
        Radiographics. 2013; 33: E47-E60
      1. 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.

        • Hertzog J.H.
        • Havidich J.E.
        Non-anesthesiologist-provided pediatric procedural sedation: an update.
        Curr Opin Anaesthesiol. 2007; 20: 365-372
        • Neuhauser C.
        • Wagner B.
        • Heckmann M.
        • Weigand M.A.
        • Zimmer K.P.
        Analgesia and sedation for painful interventions in children and adolescents.
        Dtsch Arztebl Int. 2010; 107 (I–II, I): 241-247
        • 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
        • 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
        • Cote C.J.
        • 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
        • Lightdale J.R.
        • Goldmann D.A.
        • Feldman H.A.
        • Newburg A.R.
        • DiNardo J.A.
        • Fox V.L.
        Microstream capnography improves patient monitoring during moderate sedation: a randomized, controlled trial.
        Pediatrics. 2006; 117: e1170-e1178
      2. 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.

        • Mason K.P.
        Pediatric procedures in interventional radiology.
        Int Anesthesiol Clin. 2009; 47: 35-43
        • Sane S.S.
        • Towbin A.
        • Bergey E.A.
        • et al.
        Percutaneous gastrostomy tube placement in patients with ventriculoperitoneal shunts.
        Pediatr Radiol. 1998; 28: 521-523
        • McClave S.A.
        • Chang W.K.
        Complications of enteral access.
        Gastrointest Endosc. 2003; 58: 739-751
        • Lipp A.
        • Lusardi G.
        Systemic antimicrobial prophylaxis for percutaneous endoscopic gastrostomy.
        Cochrane Database Syst Rev. 2006; (CD005571)
        • Shastri Y.M.
        • 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
        • Rosenberg J.
        • Amaral J.G.
        • Sklar C.M.
        • et al.
        Gastrostomy and gastrojejunostomy tube placements: outcomes in children with gastroschisis, omphalocele, and congenital diaphragmatic hernia.
        Radiology. 2008; 248: 247-253
        • Marx M.V.
        • Williams D.M.
        • Perkins A.J.
        • et al.
        Percutaneous feeding tube placement in pediatric patients: immediate and 30-day results.
        J Vasc Interv Radiol. 1996; 7: 107-115
        • Laasch H.U.
        • Wilbraham L.
        • Bullen K.
        • et al.
        Gastrostomy insertion: comparing the options—PEG.
        RIG or PIG? Clin Radiol. 2003; 58: 398-405
        • Coleman C.C.
        • Coons H.G.
        • Cope C.
        • et al.
        Percutaneous enterostomy with the Cope suture anchor.
        Radiology. 1990; 174: 889-891
        • 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
        • Nah S.A.
        • Narayanaswamy B.
        • Eaton S.
        • et al.
        Gastrostomy insertion in children: percutaneous endoscopic or percutaneous image-guided?.
        J Pediatr Surg. 2010; 45: 1153-1158
        • Albanese C.T.
        • Towbin R.B.
        • Ulman I.
        • Lewis J.
        • Smith S.D.
        Percutaneous gastrojejunostomy versus Nissen fundoplication for enteral feeding of the neurologically impaired child with gastroesophageal reflux.
        J Pediatr. 1993; 123: 371-375
        • Sacks D.
        • McClenny T.E.
        • Cardella J.F.
        • Lewis C.A.
        Society of Interventional Radiology clinical practice guidelines.
        J Vasc Interv Radiol. 2003; 14: S199-S202
        • Wales P.W.
        • Diamond I.R.
        • 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
        • Connolly B.L.
        • Chait P.G.
        • Siva-Nandan R.
        • Duncan D.
        • Peer M.
        Recognition of intussusception around gastrojejunostomy tubes in children.
        AJR Am J Roentgenol. 1998; 170: 467-470
        • Hughes U.M.
        • Connolly B.L.
        • Chait P.G.
        • Muraca S.
        Further report of small-bowel intussusceptions related to gastrojejunostomy tubes.
        Pediatr Radiol. 2000; 30: 614-617
        • DeLegge M.H.
        • McClave S.A.
        • DiSario J.A.
        • et al.
        Ethical and medicolegal aspects of PEG-tube placement and provision of artificial nutritional therapy.
        Gastrointest Endosc. 2005; 62: 952-959
        • Fink A.
        • Kosecoff J.
        • Chassin M.
        • Brook R.H.
        Consensus methods: characteristics and guidelines for use.
        Am J Public Health. 1984; 74: 979-983
        • Leape L.L.
        • Hilborne L.H.
        • Park R.E.
        • et al.
        The appropriateness of use of coronary artery bypass graft surgery in New York State.
        JAMA. 1993; 269: 753-760