Infracolic Gastrostomy: Food for Thought

- Review the anatomy relevant to infracolic gastrostomy (ICG)

- Understand the unique risks associated with ICG

- Review the literature relevant to ICG

- Reflect on the procedural steps for ICG based on the literature and institutional experience

Background: Debate exists surrounding the safety of infracolic gastrostomy. There is a paucity of literature on this topic and it has not been addressed in several large society guidelines. In contrast to standard gastrostomy insertion, an infracolic approach requires additional consideration due to the unique risks associated with transgression of multiple additional tissue planes, including the greater omentum, transverse mesocolon and gastrocolic ligament. In particular, there is an increased theoretical risk of vascular or colonic injury.

Clinical Findings/Procedure Details: MEDLINE, EMBASE and PubMed searches were performed. Systematic literature review found 12 published cases of ICG in total across 3 studies (follow-up range 7 days to 54 months). Variable techniques were used however there was reportedly no significant morbidity and no mortality across these studies. This may suggest that the perceived risks have been historically overestimated. Significant selection and reporting biases are acknowledged which are difficult to control for in retrospective studies of this type.

Reflecting on our institutional experience of over 8,000 gastrostomies during the last 10 years, ICG is rarely required. Some interventional radiologists would choose this approach when no other safe access can be identified whilst others may consider this a contraindication or consider endoscopic assistance to facilitate a traditional supra-colic approach.

To gauge IR practice patterns of this approach, an online poll of 54 interventionalists highlighted similar contrasting opinions in practise, with 43% who would proceed with ICG when required, 28% against this approach and 24% uncertain when presented with this clinical scenario.

Conclusion and/or Teaching Points: Following review of the current literature and our own institutional experience, the clinical conundrum persists. Limited available evidence and experience suggest that ICG may be performed safely but operators must be conscious of the risks and unique anatomical considerations involved. Whilst it is difficult to draw any meaningful conclusions, we hope this literature summary and reflection on institutional experience provides a synthesis of what we know so far, to inform operators’ decision making.