title: Transmural migration of gastrostomy tube retention discs.
abstract: BACKGROUND
  Accidental dislodgment is one of the most frequent causes of avoidable cost and consternation related to gastrostomy tubes. The Sacks-Vine gastrostomy tube, inserted in an antegrade fashion by a percutaneous technique, is extremely stable due to the construction of its disc retention device. However, transmural migration of the retention disc is a known severe delayed complication associated with this tube.
  
  
  OBJECTIVE
  To review the presentation, diagnosis, and treatment of transmural migration of gastrostomy retention discs, to propose a mechanism for the progressive development of this complication, and to recommend a method for preventing its occurrence.
  
  
  METHODS
  From January 1991 to October 1999, pediatric interventional radiologists at two children's hospitals performed 300 antegrade gastrostomy and gastrojejunostomy primary insertion procedures. A "push-pull" variation of the antegrade approach used for 44 of these insertions is excluded from further analysis. Of the remaining 256 procedures, 5 boys and 3 girls with a mean age of 5.1 years (range 0.8-19 years) were identified from review of the prospectively gathered procedural database with significant complications related to the disc retention component of their gastrostomy tubes. A retrospective analysis was conducted of their medical records, diagnostic imaging, and interventional and surgical findings.
  
  
  RESULTS
  Transmural migration was diagnosed on average 36 months after insertion (16-48 months). The diagnosis was made incidentally during endoscopy (n=1) or fluoroscopy (n=5) in six asymptomatic patients, and during barium enema to explore feculent vomiting and halitosis in two symptomatic patients. Migration of the retention disc fell along a continuum from intramural (n=4) to transmural and intracolonic (n=4), with gastric mucosal erosion, extensive granulation and inflammation in all eight patients. Although there was no evidence of free air in any patient, a gastrocolic fistula was demonstrated in four patients and a gastrocolocutaneous fistula in two of four patients with complete transmural migration. Surgical resection of the disc, gastrostomy, and fistula repair if needed was successfully performed in all patients.
  
  
  CONCLUSIONS
  Gastrostomy tubes with an internal retention disc are at risk for progressive disc migration into and through the gastric wall, resulting in irretrievable fixation and potential fistula formation. This severe delayed complication results from prolonged traction on the retention disc. Transmural migration may be avoided through improved tube care education, daily disc mobilization, and earlier disc retrieval.
authors.affiliation: Department of Radiology, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA. cahill@email.chop.edu
authors.forename: Anne Marie
authors.initials: AM
authors.lastname: Cahill
authors.forename: Kevin M
authors.initials: KM
authors.lastname: Baskin
authors.forename: Robin D
authors.initials: RD
authors.lastname: Kaye
authors.forename: Charles R
authors.initials: CR
authors.lastname: Fitz
authors.forename: Richard B
authors.initials: RB
authors.lastname: Towbin
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D003108:Colonic Diseases / Q000209:etiology; D005260:Female; D005548:Foreign-Body Migration / Q000175:diagnosis*; D005747:Gastric Fistula / Q000209:etiology; D005774:Gastrostomy / Q000009:adverse effects / Q000295:instrumentation*; D006801:Humans; D007223:Infant; D007412:Intestinal Fistula / Q000209:etiology; D007441:Intubation, Gastrointestinal / Q000009:adverse effects / Q000295:instrumentation*; D008297:Male; D013270:Stomach