Gastrostomy Week – Day 4 – Complications

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You review a patient on the ward for abdo pain and pyrexia, and they have some sort of tube with feeds going into their stomach. You need to call the surgeons for a consult for their abdo pain. But what you call it? Do you know the difference between your PEGs and gastrostomies? Do you understand about tube calibres and lengths? In this four-part series, Camille Wu covers everything the general paediatrician needs to know about enteral feeding via gastrostomies….

See the other posts: Day 1 – why and whenDay 2 – types; Day 3 – devices.

In the previous sections we have learned about gastrostomies including the different types of gastrostomies and the devices. Although gastrostomies are performed regularly, there are potential risks and complications that you need to be aware of.

What are the contraindications for a PEG?

For a PEG, absolute contraindications would be active coagulopathy, or oesophageal obstruction.

For gastrostomies in general, there are no absolute contraindications, but maybe relative ones. And indications for, and timing of, forming one for a particular patient may be a point of debate

What are the risks?

  1. The usual risks associated with giving an anaesthetic.
    • A significant number of patients needing gastrostomies have higher anaesthetic risk factors.
  2. Complications related to the upper endoscopy (if PEG insertion)
    • Including hypoxia, aspiration, haemorrhage, or perforation.
  3. The risks of the gastrostomy procedure itself :
    • colon injury, gastro-colo-cutaneous fistula, small bowel injury, liver injury, or bleeding.
  4. Post-procedural complications include:
    • Abscess, wound infections, herniation, GI bleeding, ileus, or dislodgement.
    • Granulation tissue (can exude fluid, or distort the position of device) (see below), leakage around the device causing dermatitis / excoriation (see below), ill-fitting buttons (eg too tight) that can migrate through the abdominal wall
    • Device failure (blockages, breakages) – some meds can concrete in the device lumen and block it. Meticulous care and maintenance must be observed.
    • Balloon buttons can obstruct the gastric outlet sometimes – make sure the balloon is not over-inflated or being dragged into the pylorus and obstructing it.

granulation tissueexcoriation

 

 

If a device falls out in the first 6 weeks after the gastrostomy was formed, be very careful about reinserting it – undue pressure can separate the stomach away from the anterior abdominal wall.

If the gastrostomy was formed ages ago, it is quite safe to reinsert the device (after checking it’s not broken / balloon not leaking, etc. It’s not sterile anyway, so can be re-used.). If the old device is broken, insert a Foley’s catheter to keep the track open (and prevent it from narrowing down) – secure it to the skin and feeds can be commenced straightaway. This way the child doesn’t have to starve while waiting for their new device.

So, how do you decide which procedure to choose for your patient?

You need to discuss this with the surgeons. It is essentially a technical question, as a PEG and a gastrostomy are just different ways of making the same “hole”.

The decision for the method of formation is made in relation to multiple factors, and should be made in conjunction with patient, their carers / family, paediatrician & surgeon.

 

And finally, the key to making you sound surgically clued-up is…. as a paeds doc talking to the surgeons, don’t call everything a PEG.

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About 

Camille Wu is a paediatric surgeon based at Sydney Children's Hospital.