Radiologically inserted gastrostomy (RIG)

Information about Radiologically inserted gastrostomy (RIG), what they are and how they are inserted. It explains what to expect when your child comes to the Interventional Radiology (IR) department at Great Ormond Street Hospital (GOSH) and what care to expect afterwards.

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 their 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.

A radiologically inserted gastrostomy uses X-rays and other imaging techniques to insert the gastrostomy device. It is carried out by an interventional radiologist – a doctor specialising in scans and imaging to perform procedures– usually in the radiology or X-ray department.

Gastrostomies are often useful for children who need to be fed slowly or have had problems with feeding by naso-gastric (NG) tube in the past.

Overnight feeds are regarded as safer using a gastrostomy than a NG tube. Some families prefer a gastrostomy 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, as it can be removed when your child no longer needs it.

Gastrostomies mainly differ 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.

This leaflet only explains about RIGs, but information about the other methods of insertion is available. Please ask your doctor or nurse or visit our website for further details.

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 which particular method is best for your child.

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 leaflet.

You will already have received information about how to prepare your child for the procedure in your admission letter. You may need to come to GOSH before the procedure so that your child can have a pre-admission assessment to check that they are well enough. This appointment may involve taking blood samples and other tests.

Your child will need to be admitted to a bed on a ward in the hospital. The person bringing your child to the procedure should have ‘parental responsibility’ for them. Parental responsibility refers to the individual who has legal rights, responsibilities, duties, power and authority to make decisions for a child. If the person bringing your child does not have parental responsibility, we may have to cancel the procedure.

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 NG 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 the gastrostomy insertion. This helps the radiologist to insert the gastrostomy tube safely.

An anaesthetist will visit to talk to you about your child’s anaesthetic. The specialist will explain the procedure in more detail, discuss any questions you may have and ask you to sign a consent form giving permission for your child to have the procedure. If your child has any medical problems, please tell the specialists.

Many of the procedures we perform involve the use of X-rays. Legally, we are obliged to ask anyone over the age of 12 whether there is any chance they might be pregnant, and we will also ask for the first date of their last period (if started). This is to protect babies in the womb from receiving unnecessary radiation.

You and your child will then be brought to the IR suite for their anaesthetic and procedure.

Your child needs to be fasted for the procedure for the general anaesthetic.

If your child takes regular medication, please speak to your child’s team about when to stop these before the procedure.

As a general rule:

Food and milk:

• Breast-fed babies- can have their last feed three hours before the procedure. Breast milk is digested faster than solid food or formula.
• Bottle-fed babies and children- can have their last milk feed, food or milk drink, six hours before the procedure. They should not have any food or milk after this time.

Water:

• All babies and children can have a drink of water (but no other fluids), until one hour before the procedure.

It is equally important to keep giving your child food and drink until those times to ensure they remain well-hydrated and get adequate nutrition. This may involve waking your child in the night to give them a drink which we recommend.

Please follow these instructions carefully, otherwise your child’s procedure may be delayed or even cancelled.

Once your child is under general anaesthetic and deeply asleep, their 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 their skin.

The team will then set up X-ray machines around your child so that images of their abdomen can be seen clearly on a screen near the operating table.

An NG tube will be passed into the stomach, if your child does not already have one. An 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. The specialists will use the NG tube to fill the stomach with air so that the stomach is easier to reach from the skin.

Using a series of catheters (thin plastic tube) and guide wires, the gastronomy device will be passed down through the mouth and into the stomach. The interventional radiologist will then carefully place the gastrostomy device through the stomach wall. The internal plastic disc anchors the device to the inside of the stomach wall.

The tube itself is then brought out through a small incision about 10mm long in the abdomen. 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 NG tube is usually removed at this stage.

Your child will be having the procedure under general anaesthetic. Every anaesthetic carries a risk, but this is extremely 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.

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.

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.

The procedure does involve the use of X-rays. The levels that are used are low dose and therefore low risk. If you have any concerns regarding the use of radiation, please discuss this with the person performing your procedure beforehand.

Your child will return to the ward after they have recovered from the general anaesthetic. Some children feel sick and vomit after a general anaesthetic. Your child may have a headache or sore throat or feel dizzy, but these side effects are usually short-lived and not severe.

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 usually pass in a few hours 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 your community team will explain this to you.

Your child will be prescribed a special liquid feed, which contains all or most of the nutrients they need. 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.

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.

The initial gastrostomy tube can stay in place for 18 months 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 the same type or switching to a low-profile button device. 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.

• Your child has a temperature of 38⁰C or higher.
• Your child is in a lot of pain when flushing or feeding down the tube
• Bleeding around the stoma (hole)
• Leaking of feed or stomach contents around the tube.
• The tube becomes blocked or is difficult to flush.

You can call the ward by calling the GOSH switchboard and asking for the ward your child was discharged from.

Telephone: 020 7405 9200

If you are unable to get through, please call NHS111 by dialling 111.