Gastrointestinal interventions--emphasis on children

Dosimetric Feasibility of Cone-Beam CT in Pediatric Image-Guided Retrograde Gastrostomy Tube Insertions

Purpose:

Cone-beam computed tomography (CBCT) in interventional radiology allows volumetric imaging with open patient access. This work aimed to assess radiation dose metrics of CBCT in simulated image-guided retrograde gastrostomy (IGRG) tube insertions in pediatric anthropomorphic phantoms and to compare them to measured radiation dose metrics obtained using fluoroscopy during clinical IGRG tube insertions in children.

Methods:

Radiation dose indices obtained from radiation dose structured reports of fluoroscopic IGRG tube insertions were retrospectively evaluated in a consecutive cohort of 30 children. Dose indices were fractionated into 3 clinical stages for each procedure ( planning, insertion, and confirmation). These 3 stages in 30 patients (3 × 30 = 90 patient stages) were compared to dose indices measured from 4 CBCT acquisition protocols acquired in pediatric phantoms.

Results:

The mean proportion of radiation dose during planning, insertion, and confirmation was 35%, 38% and 27%, with mean reference-point air kerma (range) measured to be 1.0 (0.02-6.0) mGy, 0.9 (0.03-4.1) mGy, and 0.7 (0.04-3.7) mGy, respectively. Cone-beam computed tomography dose varied greatly depending on technical parameters and protocol selection, ranging from 0.7 to 39.3 mGy. In 19% of patient stages, the most dose-sparing CBCT protocol evaluated on phantoms delivered less radiation than the radiation dose indices recorded from patient’s fluoroscopy.

Conclusions:

From a dosimetric perspective, radiation delivered in CBCT can vary widely, yet can be appreciably low. With appropriate CBCT protocol selection, the radiation dose delivered may be sufficiently low to warrant consideration for use, if clinically needed during difficult IGRG tube insertions, and satisfy the interventionalist’s benefit–risk assessment.

Gastrointestinal intervention in children

Interventional radiology is a rapidly growing discipline in paediatrics. Many non-vascular interventional techniques may be used in the gastrointestinal tract in children. The technically simpler and more common of these may be adopted by any paediatric radiologist with an interest in interventional radiology. Other rarer and more complex techniques are currently restricted to specialist centres with a higher overall caseload. This review emphasizes the common procedures such as oesophageal dilatation, gastrostomy, insertion of transgastric jejunal feeding tubes and biopsy. Less common salivary, hepatobiliary, pancreatic and intestinal interventions are also described.

Growth outcomes and complications after radiologic gastrostomy in 120 children

BACKGROUND

Enteral feeding is ideal for children with low caloric intake. It can be provided through different methods, including nasogastric, nasojejunal, gastrostomy, or gastrojejunostomy tubes.

OBJECTIVE

To assess growth outcomes of pediatric patients following retrograde percutaneous gastrostomy (RPG) and compare complications with those following other gastrostomy methods.

MATERIALS AND METHODS

We retrospectively reviewed 120 random RPG patients from 2002 to 2003 (mean follow-up, 2.7 years). Patient weights and growth percentiles were recorded at insertion, and at 0-5 months, 6-12 months, and 18-24 months after insertion, and then compared using a Student's t-test. Complications and tube maintenance issues (TMIs) were recorded.

RESULTS

Gastrostomy tube insertion was successful in all 120 patients (59 boys, 61 girls; mean age 4.3 years). The most common underlying diagnosis was neurologic disease (29%, 35/120) and the main indication was inadequate caloric intake (24%, 29/120). Significant increases in growth percentile for the entire population were demonstrated between insertion and 0-5 months (18.7-25.3; P<0.001) and between insertion and 18-24 months (18.7-25.8; P<0.001). In boys and girls significant growth increases occurred between insertion and 0-5 months (boys P=0.004; girls P=0.01). There were 11 major postprocedural complications, 100 minor complications and 169 TMIs.

CONCLUSION

RPG provides long-term enteral nutrition in the pediatric population and increases growth significantly 6 and 24 months after insertion. Minor complications and TMIs are frequent.

Gastrostomy and gastrojejunostomy tube placements: outcomes in children with gastroschisis, omphalocele, and congenital diaphragmatic hernia

PURPOSE

To retrospectively evaluate the technical success, safety, and outcomes of radiologically guided retrograde percutaneous gastrostomy and gastrojejunostomy tube placements in terms of weight gain and growth in children with gastroschisis, omphalocele, and/or congenital diaphragmatic hernia (CDH).

MATERIALS AND METHODS

Research ethics board approval, with waived informed patient consent, was obtained for review of the data of 37 children (17 male, 20 female; age range, 1-20 months; mean age, 4.3 months) in whom gastrostomy or gastrojejunostomy tubes were inserted between 1995 and 2004. Twenty-two patients had CDH, eight had gastroschisis, five had omphalocele, and two had both CDH and omphalocele. The technical success and complications of the procedures were recorded. Tube maintenance problems were analyzed separately from postprocedural complications. Initial and final patient growth percentiles were compared by using a one-sided paired Student t test.

RESULTS

Thirty-six of the 38 procedures performed in the 37 patients were successful. There were three intraprocedural complications (two cases of access difficulty, one case of bleeding) and three major complications (one skin and prosthetic material infection, one track loss during tube replacement, one delayed gastrostomy track closure necessitating surgery). Sixteen patients had at least one minor complication (cellulitis, feeding intolerance, skin-site bleeding, intussusception). Twenty-two patients had at least one tube maintenance problem. All patients gained weight (mean weight gain, 4.7 kg) after the procedure, with a significant increase in growth percentile (average increase, 6.5%; P = .029).

CONCLUSION

Radiologically guided percutaneous gastrostomy and gastrojejunostomy tube placements in children with gastroschisis, omphalocele, and/or CDH are associated with high success rates and low major complication rates. Although tube maintenance problems and minor complications are common, use of gastrostomy and gastrojejunostomy tubes effectively improves nutritional support.

Image-guided interventions in neonates

Minimally invasive interventional radiological procedures can be invaluable in the care of neonates and infants. These procedures have proven to be useful in a wide variety of clinical situations, improving patient care, comfort and safety. Most techniques in adult interventional radiology have been adapted for use in pediatric patients, covering the spectrum of diagnostic and therapeutic intervention. Procedural techniques are similar, but require considerations of patient size, sedation, and support personnel in order to render optimal care. Proper physician training is imperative to provide the necessary confidence and expertise, and post-procedural follow-up is required to maximize positive outcomes. This paper discusses many of the procedures that may be performed in neonates, and offers suggestions and techniques for successful outcomes.