A gastrostomy is an opening through the abdominal wall into the stomach. A feeding device is inserted through this opening, which allows your child to be fed directly into his or her stomach, bypassing the mouth and throat.
People who have difficulties feeding can benefit from a gastrostomy. There are many reasons why someone might have difficulties feeding, including neurological (nervous system) disorders and gastrointestinal (digestive system) disorders. Some people also have difficulty swallowing, which increases the chance that they will accidentally breathe in food (aspirate). Your doctor will explain to you the specific reasons why your child needs a gastrostomy.
What are the advantages of having a gastrostomy?
Gastrostomies are often useful for children who need to be fed slowly, or have had problems with feeding by nasogastric tube in the past. Overnight feeds are regarded as safer using a gastrostomy than a naso-gastric tube.
Some families find a gastrostomy more acceptable than a naso-gastric tube as it can be hidden under clothing, is less likely to be pulled out accidentally and does not irritate the skin of the face. A gastrostomy can be a permanent or temporary measure, as it can be removed when your child no longer needs it.
What different types of gastrostomy are there?
Gastrostomies differ mainly in the way that they are inserted. At GOSH, they can be inserted using one of four different methods:
- Radiologically inserted gastrostomy (RIG)
- Percutaneous endoscopic gastrostomy (PEG)
- Laparoscopic gastrostomy
- Open surgical gastrostomy
At GOSH, children almost always have a general anaesthetic for gastrostomy insertion, whichever method is used.
The method used to insert a gastrostomy depends on many factors, including your child’s weight, medical condition, and previous or planned abdominal surgery. Your child’s doctor will explain why a particular method has been chosen as best for your child. This information only explains about radiologically inserted gastrostomies (RIG). Information about the other methods of insertion is available. Please ask your doctor or nurse for further details.
Regardless of the method of insertion, the same device is usually used initially. This consists of a thin, plastic tube secured inside the stomach by a plastic disc. The tube is brought out through a small incision (cut) in the abdomen and secured by a triangular plastic anchor.
Once this type of tube has been in place for three months or more, it can be changed to a more discreet device, such as a button. More details about buttons follow later in this information sheet.
What is a radiologically inserted gastrostomy (RIG)?
A radiologically inserted gastrostomy uses x-rays and other imaging techniques to insert the gastrostomy device. It is carried out by an interventional radiologist (doctor specialising in scans and imaging to perform procedures), usually in the radiology or x-ray department.
What happens before the gastrostomy is inserted?
The evening before the procedure, your child will need to swallow some barium, usually in the form of a milkshake. Alternatively, it can be given through a naso-gastric tube. Barium is a chalky liquid that shows up well on x-rays. By the next day, the barium will have travelled through the digestive system to the large intestine, so that this is very clear on the x-rays used during gastrostomy insertion. This helps the radiologist to insert the gastrostomy tube safely.
As your child will be having a general anaesthetic for the gastrostomy insertion, it is very important that his or her stomach is as empty as possible on the day of the procedure, as this reduces the risk of vomiting during and after the anaesthetic. If someone vomits during an anaesthetic, there is a chance that the stomach contents could get into the lungs, damaging them. Your child’s nurse will explain exactly what time your child can last eat or drink before the procedure, but as a general rule, the following applies.
Food and milk:
Breast-fed babies
Give them their last feed four hours before the procedure is scheduled
Bottle-fed babies and children
Give them their last milk feed, food or milk drink six hours before the procedure is scheduled
Clear fluids:
All babies and children can have a drink of water or weak squash, but no fizzy drinks, until two hours before the procedure is scheduled.
Please follow these instructions carefully, otherwise your child’s procedure may be delayed or even cancelled.
The doctors will explain the procedure in more detail, discuss any worries you may have and ask you to give permission for the procedure by signing a consent form. Another doctor will visit you to explain about the anaesthetic.
What does the procedure involve?
Your child will be taken to the Interventional Radiology Suite and given the general anaesthetic, either as an injection or by breathing gas in through a face mask.
Once your child is deeply asleep, his or her abdomen will be cleaned with antiseptic solution. An ultrasound scan will be used to locate your child’s liver and its position marked with a pen on his or her skin. The team will then set up x-ray machines around your child so that images of his or her abdomen can be seen clearly on a screen near the operating table.
A naso-gastric tube will be passed into the stomach, if your child does not already have one. A naso-gastric (NG) tube is a thin, plastic tube that is inserted into one of your child’s nostrils, down the back of the throat into the stomach. This is used to fill the stomach with air so that it is easier to reach from the skin. Using a series of catheters and guide wires, the interventional radiologist will place the gastrostomy device through the stomach wall, having pulled it down through the mouth and into the stomach.
The internal plastic disc anchors the device to the inside of the stomach wall, while the tube itself is brought out through a small incision about 10mm long. The triangular plastic anchor rests on the skin of the abdomen to hold the device firmly in place. The free end of the tube is cut to a manageable length, clamped and attached to a feeding connector. The naso-gastric tube is usually removed at this stage.
Are there any risks?
All procedures that break the skin carry a small risk of infection and bleeding. An antibiotic injection is usually given during the procedure to reduce the risk of infection. Every anaesthetic also carries a risk, but this is very small. After effects of an anaesthetic include headache, a sore throat or feeling dizzy or sick, but these are not usually severe and do not last long. The anaesthetist will explain any specific anaesthetic risks for your child when he or she meets you before the procedure.
This particular method of gastrostomy insertion carries some specific risks. There is a very small chance that the large intestine could be damaged during the procedure, but using barium beforehand reduces this risk. If your child has not had barium the night before the procedure, the consultant may cancel the operation as the risk of damaging the large intestine would be too great.
There is a very small possibility that during the procedure, the radiologist will not be able to insert the gastrostomy using this method, in which case your child would need to have it inserted using one of the other methods listed above. This would have to be done on a separate occasion.
What happens after the procedure?
Your child will be taken back to the ward to recover from the anaesthetic and the procedure. He or she may remain a bit sleepy from the anaesthetic for a few hours afterwards but this is normal. Crampy stomach pains can also occur during the first few hours after the procedure. This is caused by the stomach being inflated with air during the procedure. These crampy pains in a few hours usually pass without treatment.
Your child will not be able to have any fluids through the gastrostomy tube for several hours after it has been inserted. The stomach needs this time to settle down and for the tissue to grip tightly around the tube so that stomach contents cannot leak into the abdomen. If stomach contents leak into the abdomen, this can lead to peritonitis, a potentially life threatening infection.
Before the gastrostomy is used and while the feeds are being introduced, your child will have an intravenous infusion (drip) of fluids to give them water and sugar. Once the gastrostomy has had time to rest, your child will start to have liquid feeds through it. This is done very gradually over a period of hours, increasing the amount of feed given each time. The team on the ward and at home will explain this to you.
Your child will be prescribed a special liquid feed, which contains all or most of the nutrients he or she needs. Please talk to your dietitian if you would like to know more about it. Some children can also continue to eat regular food by mouth, using the gastrostomy to ‘top up’ their nutrient levels, but this depends on the reasons why the gastrostomy is required.
Going home
Many children having a radiologically inserted gastrostomy are already inpatients at GOSH receiving treatment for their original medical condition. The ward team will teach you how to look after the gastrostomy, prepare feeds for your child and give them. You may be able to return home once you are confident in using the gastrostomy but this greatly depends on your child’s original medical condition. Your child’s doctor will be able to advise you further on this.
Changing device
The initial gastrostomy tube can stay in place for 18 month to two years, but will need to be replaced at this point, as the plastic tubing becomes worn. Please contact us nearer the time to discuss the device change further.
When the time comes to change the device, you will have the choice of having the tube replaced with another of the same type or switching to a lowprofile button device (pictured left). The low-profile button device is held in place inside the stomach wall using an inflatable balloon and connector sets are used to give feeds. The original longer device will need to be removed in a short procedure under general anaesthetic and replaced with the button, but once the button is in place, it can be changed or replaced easily without the need for an anaesthetic.
