Growth outcomes and complications after radiologic gastrostomy in 120 children

Long-Term Outcomes of Children Receiving Percutaneous Endoscopic Gastrostomy Feeding

Background and Objectives: Data regarding long-term outcomes of gastrostomy-fed children is scarce. The aim of the study was to analyze the long-term follow-up of children receiving percutaneous endoscopic gastrostomy (PEG) in terms of nutritional outcomes, hospitalization, and fundoplication rates. Materials and Methods: The medical records of gastrostomy-fed children who underwent PEG placement between January 2002 and June 2022 and subsequently attended primary care clinics of the Clalit Health Services (CHS) in Northeastern Israel, were reviewed in this retrospective cohort study. Results: A total of 372 gastrostomy tubes (GT) were placed, 88% of the children had neuro-developmental impairment. During the median follow-up of 64 months, 230 patients (62%) had frequent recurrent hospitalizations defined as at least two hospitalizations per year on average. Hospitalizations were due to respiratory infections in 52%. Among 322 patients who underwent iron status work-up, (64%) and (31%) had iron deficiency (ID) and ID anemia, respectively. Laboratory monitoring of other micronutrient levels was limited but showed that 25/73 (34%) had vitamin D deficiencies, without significant association with recurrent hospitalization (p > 0.1). A total of 12% of the patients underwent subsequent fundoplication. Conclusions: This study confirmed the durability of gastrostomy tube feeding in children with neurological impairment, noting a low prevalence of fundoplication but a high rate of hospitalizations, primarily due to respiratory infections. Regular assessment of micronutrient deficiencies, particularly vitamin D, is recommended for these patients.

Iatrogenic vascular complications of non-vascular percutaneous abdominal procedures

PURPOSE

The purpose of this paper is to compile and present all of the reported vascular complications that resulted from common non-vascular abdominal procedures in the literature. Non-vascular procedures include, though are not limited to, percutaneous abscess/fluid collection drainage (PAD), percutaneous nephrostomy (PN), paracentesis, percutaneous transhepatic cholangiography (PTC)/percutaneous biliary drainage (PBD), percutaneous biliary stone removal, and percutaneous radiologic gastrostomy (PG)/percutaneous radiologic gastrojejunostomy (PG-J). By gathering this information, radiologists performing these procedures can be aware of the associated vascular injuries, as well as take steps to minimize risks.

METHODS

A literature review was conducted using the PubMed database to catalog relevant articles, published in the year 2000 onward, in which an iatrogenic vascular complication occurred from the following non-vascular abdominal procedures: PAD, PN, paracentesis, PTC/PBD, percutaneous biliary stone removal, and PG/PG-J. Biopsy and tumor ablation were deferred from this article.

RESULTS

214 studies met criteria for analysis. 28 patients died as a result of vascular complications from the analyzed non-vascular abdominal procedures. Vascular complications from paracentesis were responsible for 19 patient deaths, followed by four deaths from PTC/PBD, three from biliary stone removal, and two from PG.

CONCLUSION

Despite non-vascular percutaneous abdominal procedures being minimally invasive, vascular complications still can arise and be quite serious, even resulting in death. Through the presentation of vascular complications associated with these procedures, interventionalists can improve patient care by understanding the steps that can be taken to minimize these risks and to reduce complication rates.

Paediatric gastrostomy stoma complications and treatments: A rapid scoping review

AIMS AND OBJECTIVES

To provide a scoping review of the types of treatments used to address paediatric skin-related stoma complications specific to infection, hypergranulation and gastric leakage, and explore their effectiveness and indications for use.

BACKGROUND

Stoma-related complications can be a common occurrence for children with gastrostomy (G) and gastrojejunostomy (GJ) tubes. Nurses require guidance to inform decision-making of the broad spectrum of treatments used in clinical practice.

DESIGN

A scoping review using a rapid review approach.

METHODS

Working with a multidisciplinary health professional team, search terms were generated. A systematic search of CINAHL, MEDLINE and EMBASE databases was completed, coupled with an Internet search to identify relevant clinical practice guidelines and hand searching of citation lists. Eligible articles were peer-reviewed English publications, focused on paediatric populations aged 18 years and under, dating from 2002-2016 and described complications and treatment approaches related to G- and GJ-tube stomas. Pertinent information was extracted using a standardised template, and a narrative synthesis approach was used to analyse the data.

RESULTS

Twenty-five articles were included in this review. Study designs varied, and complication management was often a secondary focus. A broad spectrum of treatments was used to manage each complication type. There was a lack of consensus on lines of therapy; however, a stepwise approach was often used for complication management, particularly for infections.

CONCLUSIONS

The evidence on the comparative effectiveness of different treatment strategies of skin-related gastrostomy stoma complications in paediatric practice is sparse. Current evidence is generally limited to expert opinions. Future studies examining efficacy of treatments and their indications for use with children are warranted.

RELEVANCE TO CLINICAL PRACTICE

Effective management of skin-related stoma complications is important to maintain health and wellness among children who rely on G- and GJ-tubes for nutrition support.

Effects of Mechanical Complications on Radiation Exposure During Fluoroscopically Guided Gastrojejunostomy Exchange in the Pediatric Population

The purpose of the article is to evaluate the effects of mechanical complications, such as clogging or coiling, of gastrojejunostomy tubes on radiation exposure during exchange in the pediatric population. In this HIPAA-compliant and IRB-approved study, we retrospectively reviewed procedural records for patients undergoing gastrojejunostomy (GJ) tube exchange during a 4-month period in 2014. Success of the procedure, specifications of the tube, age, and sex of the patient as well as radiation exposure during the procedure were included. Radiation exposure was measured in fluoroscopy time and cumulative air kerma. Complications encountered during exchange were also recorded, if available. Patients presenting for gastrostomy to GJ conversions or combined procedures were excluded from the study. Ordinary and mixed effect linear regression models were used to test associations between GJ tube parameters, presence of mechanical complications, and fluoroscopy time and radiation dose. 146 patients undergoing 285 GJ exchanges met inclusion criteria over the 4-month study period (M:F 82:64). All exchanges were successful with 85 demonstrating a form of mechanical complication (44 coiled, 41 clogged). Of the reported GJ tube specifications, only tube length was significantly associated with mechanical complications (p < 0.001). The presence of mechanical complication was significantly associated with increased radiation exposure and fluoroscopy time (p < 0.0001). Mechanical complications of gastrojejunostomy tubes, such as clogging or coiling, are associated with increased radiation exposure during exchange. Strategies to decrease these complications, including re-siting the gastrostomy tract or placement of a surgical jejunostomy in the event of repeated coiling of a tube should be strongly considered.

Peritonitis following percutaneous gastrostomy tube insertions in children

BACKGROUND

Percutaneous retrograde gastrostomy has a high success rate, low morbidity, and can be performed under different levels of sedation or local anesthesia in children. Despite its favourable safety profile, major complications can occur. Few studies have examined peritonitis following percutaneous retrograde gastrostomy in children.

OBJECTIVE

To identify potential risk factors and variables influencing the development and early diagnosis of peritonitis following percutaneous retrograde gastrostomy.

MATERIALS AND METHODS

We conducted a retrospective case-control study of children who developed peritonitis within 7 days of percutaneous retrograde gastrostomy between 2003 and 2012. From the 1,504 patients who underwent percutaneous retrograde gastrostomy, patients who developed peritonitis (group 1) were matched by closest date of procedure to those without peritonitis (group 2). Peritonitis was defined according to recognized clinical criteria. Demographic, clinical, procedural, management and outcomes data were collected.

RESULTS

Thirty-eight of 1,504 children (2.5%; 95% confidence interval, 1.8-3.5) who underwent percutaneous retrograde gastrostomy developed peritonitis ≤7 days post procedure (group 1). Fever (89%), irritability (63%) and abdominal pain (55%) occurred on presentation of peritonitis. Group 1 patients were all treated with antibiotics; 41% underwent additional interventions: tube readjustments (8%), aspiration of pneumoperitoneum (23%), laparotomy (10%) and intensive care unit admission (10%). In group 1, enteral feeds started on average 3 days later and patients were discharged 5 days later than patients in group 2. There were two deaths not directly related to peritonitis. Neither age, gender, weight, underlying diagnoses nor operator was identified as a risk factor.

CONCLUSION

Peritonitis following percutaneous retrograde gastrostomy in children occurs in approximately 2.5% of cases. No risk factors for its development were identified. Medical management is usually sufficient for a good outcome. Patients with peritonitis are delayed starting feeds and have a hospital stay that is an average of 5 days longer than those without.

A Core Outcome Set for Children With Feeding Tubes and Neurologic Impairment: A Systematic Review

CONTEXT

Uncertainty exists about the impacts of feeding tubes on neurologically impaired children. Core outcome sets (COS) standardize outcome selection, definition, measurement, and reporting.

OBJECTIVE

To synthesize an evidence base of qualitative data on all outcomes selected and/or reported for neurologically impaired children 0 to 18 years living with gastrostomy/gastrojejunostomy tubes.

DATA SOURCES

Medline, Embase, and Cochrane Register databases searched from inception to March 2014.

STUDY SELECTION

Articles examining health outcomes of neurologically impaired children living with feeding tubes.

DATA EXTRACTION

Outcomes were extracted and assigned to modified Outcome Measures in Rheumatology 2.0 Filter core areas; death, life impact, resource use, pathophysiological manifestations, growth and development.

RESULTS

We identified 120 unique outcomes with substantial heterogeneity in definition, measurement, and frequency of selection and/or reporting: "pathophysiological manifestation" outcomes (n = 83) in 79% of articles; "growth and development" outcomes (n = 13) in 55% of articles; "death" outcomes (n = 3) and "life impact" outcomes (n = 17) in 39% and 37% of articles, respectively; "resource use" outcomes (n = 4) in 14%. Weight (50%), gastroesophageal reflux (35%), and site infection (25%) were the most frequently reported outcomes.

LIMITATIONS

We were unable to investigate effect size of outcomes because quantitative data were not collected.

CONCLUSIONS

The paucity of outcomes assessed for life impact, resource use and death hinders meaningful evidence synthesis. A COS could help overcome the current wide heterogeneity in selection and definition. These results will form the basis of a consensus process to produce a final COS.

De novo radiologic placement of button gastrostomy: a feasibility study in children with cancer

BACKGROUND

Primary placement of percutaneous radiologic button gastrostomy has been successfully performed in adults but research is lacking as to its success in children during cancer treatment.

OBJECTIVE

To assess the safety and effectiveness of such treatment at a single center.

MATERIALS AND METHODS

We conducted a 3-year retrospective feasibility study reporting on placement procedure, feeding plan, acute complications and effectiveness of this technique based on the evolution of the weight and weight-to-height during a period of 3 months.

RESULTS

Eleven gastrostomies were performed in 11 children and young adults (3-20 years old) during oncological treatment. No major complications occurred. Two patients experienced minor side effects -- local leakage and granulation tissue formation -- both easily treated. In all cases, enteral feeding started within 24 h following the button placement. The patients were able to go home within 72 h. After 1 month, 64% (7/11) had gained weight, 18% (2/11) had maintained weight and 9% (1/11) had lost weight. After 3 months, 73% (8/11) had gained weight and 9% (1/11) had lost weight.

CONCLUSION

The procedure and devices were well tolerated and mostly effective in our cohort.

Preliminary Results of Percutaneous Radiologic Gastrostomy in a Pediatric Population: A Modified Chiba-Needle Puncture Technique With Single Gastropexy

OBJECTIVE

The purpose of this study was to evaluate the technical feasibility, safety, and clinical effectiveness of percutaneous radiologic gastrostomy using a modified Chiba-needle puncture technique with single gastropexy in pediatric patients.

MATERIALS AND METHODS

From July 2006 to December 2013, percutaneous radiologic gastrostomy was performed in 12 children (median age, 21 months; range, 6-46 months). Their stomachs were punctured using a 21-gauge Chiba needle. A single Cope gastrointestinal suture anchor was used for gastropexy, and a tube was inserted through the same tract as the anchor using a 12- or 14-French Dawson-Mueller pigtail drainage catheter. We then evaluated the technical success of the procedure, the number of puncture attempts using a 21-gauge Chiba needle, the procedure time, complications, and treatment of complications.

RESULTS

Percutaneous radiologic gastrostomy was technically successful in all patients. Only a single puncture attempt was required in 10 patients (83%); two attempts were needed in two patients (17%). The average procedure time was 10 minutes 25 seconds (range, 5 minutes 5 seconds to 25 minutes 24 seconds). Pneumoperitoneum requiring tube exchange occurred in two of the 12 patients (17%). Two patients experienced pain immediately after the procedure. Three patients who had esophagogastric reflux after percutaneous radiologic gastrostomy underwent conversion percutaneous radiologic gastrojejunostomy.

CONCLUSION

Percutaneous radiologic gastrostomy using a modified Chiba-needle technique with single gastropexy in pediatric patients is technically feasible and safe.

Long-term outcome of children receiving percutaneous endoscopic gastrostomy feeding

OBJECTIVES

The aim of the present study was to analyze the long-term follow-up of children receiving percutaneous endoscopic gastrostomy (PEG) in terms of survival, nutritional outcome, and weaning from enteral nutrition. The secondary objectives were to evaluate the complications related to PEG and the outcome of patients with neurological disability.

METHODS

The present study was a single-center retrospective study including all of the 368 patients who underwent PEG from 1990 to 2003 in our tertiary hospital.

RESULTS

A total of 368 patients received PEG during the study period. After a median follow-up of 2.4 years (interquartile range 1.4-4.2 years), PEG was in place in 36% and was removed in 27%; 26% of patients were deceased. Two deaths could be directly related to PEG. A statistically significant weight and height catch-up was observed in patients with PEG in place in whom weight/age z score increased from -2.6 to -1.7 (P < 0.01) and height/age z score also increased from -2.1 to -1.6 (P < 0.01). In patients who had their PEG removed weight/age z score increased from -2.5 to -1.6 (P < 0.01) and height/age z score from -2.8 to -1.4 (P = 0.01) at the time of weaning. Early complications occurred in 152 patients, whereas late complications occurred in 191 patients. Most complications were minor (85%). After multivariate analyses, the factors associated with late complications were digestive and ear, nose, and throat (ENT) diseases, age <1 year at the time of PEG placement, and use of PEG longer than 2 years. Early complications were less frequent in patients with respiratory diseases.

CONCLUSIONS

PEG allows nutritional and growth catch-up and is safe in the long term.

Variations in blood glucose levels following gastrostomy tube insertion in a paediatric population

BACKGROUND

Radiologic insertion of a gastrostomy or gastrojejunostomy tube is a common procedure in children. Glucagon is used to create gastric hypotonia, permitting gastric distension and facilitating percutaneous puncture. Glucagon can cause hyperglycaemia and potentially rebound hypoglycaemia. The safety of glucagon and incidence of hypoglycaemia has not been studied following gastrostomy or gastrojejunostomy tube insertion.

OBJECTIVE

To determine variations in blood glucose in children post gastrostomy or gastrojejunostomy tube insertion. Secondarily, to determine the frequency of hypoglycaemia and hyperglycaemia in children who did or did not receive glucagon.

MATERIALS AND METHODS

This is a retrospective observational study of 210 children undergoing percutaneous gastrostomy or gastrojejunostomy tube insertion over a 2-year period. We studied the children's clinical and laboratory parameters. Abnormal blood glucose levels were defined according to age-established norms. We used descriptive statistics and ANOVA.

RESULTS

We analysed 210 children with recorded blood glucose levels. More than 50% of the children were less than the third percentile for weight. In the glucagon group (n = 187) hyperglycaemia occurred in 82.3% and hypoglycaemia in 2.7% (n = 5). In the no glucagon group (n = 23), hyperglycaemia occurred in 43.5% and there were no cases of hypoglycaemia. The peak blood glucose occurred within 2 h, with normalization by 6 h post-procedure. Five children became hypoglycaemic, all received glucagon; 4/5 had weights <3rd percentile. Logistic regression analysis revealed no factors significantly associated with hypoglycaemia.

CONCLUSION

Greatest blood glucose variability occurs between 1 h and 3 h post-procedure. Hyperglycaemia is common and more severe with glucagon, and hypoglycaemia rarely occurs. These findings have assisted in developing clinical guidelines for post-percutaneous gastrostomy/gastrojejunostomy tube insertion.

Gastrostomy tube feeding of children with cerebral palsy: variation across six European countries

AIM

To compare the prevalence of gastrostomy tube feeding (GTF) of children with cerebral palsy (CP) in six European countries.

METHOD

Data on 1295 children (754 males, 541 females; mean age 5y 11mo, range 11y 2mo, min 6mo, max 11y 8mo) with CP born from 1999 to 2001 were collected from geographically defined areas in six European countries; four of the areas covered the whole country. Distribution of CP was unilateral 37%, bilateral 51%, dyskinetic 8%, and ataxic 4%. Sixty children were classified in Gross Motor Function Classification System (GMFCS) levels I and II, 6 in level III and 34 in levels IV and Vas Outcome measures were GTF, age at placement, feeding difficulties and the children's height and weight for age standard deviation scores (z-scores).

RESULTS

The use of GTF among all children with CP was highest in western Sweden (22%, 95% confidence interval [CI] 16-29), and lowest in Portugal (6%, 95% CI 3-10), northern England (6%, 95% CI 3-9) and in Iceland (3%, 95% CI 0-13; p<0.001). The difference between areas was greater among children in GMFCS levels IV and V (non-ambulant); in this group, lower height z-scores were more prevalent in the areas with lower prevalence of GTF. The children's age at placement of gastrostomy also varied between areas (p<0.002).

INTERPRETATION

The observed differences in the use of GTF may reflect differences in access to treatment or clinical practice, or both. Our results suggest that the use of GTF may improve growth in height and weight among children with more severely affected gross motor function - the group most likely to have associated feeding difficulties.

A guide to the management of common gastrostomy and gastrojejunostomy tube problems

Gastrostomy (G) and gastrojejunostomy (GJ) tubes are commonly used to enhance nutrition and hydration, and facilitate the administration of medications to children with medically complex conditions. They are considered to be safe and effective interventions for the medical management of these patients; however, they are not without risks. There are common complications associated with G and GJ tubes. Health care providers play an active role in preventing, managing and supporting the patient and parents/caregivers in dealing with these complications. The present article reviews G and GJ tube devices, basic care principles, and how to prevent and manage common complications. Recommendations for how to support and share information with parents/caregivers is provided.

Prospective randomized comparative study of low-profile balloon gastrostomy tubes in children

BACKGROUND

Supplemental enteral nutrition through gastrostomy tubes is well established in children, but prospective studies comparing different tubes remain lacking in this population. The study aimed at comparing different aspects related to the use of low-profile balloon gastrostomy tubes in children.

MATERIALS AND METHODS

The authors prospectively studied the use of 2 tube types--tube A (MIC-Key gastrostomy tube; Ballard Medical Products, Draper, UT) and tube B (MINI One gastrostomy tube; Applied Medical Technology, Brecksville, OH)--in a cohort of children in a crossover study design. Children were randomly assigned to 1 tube type for 4 months, followed by the other tube type for the next 4 months. Patients were evaluated at enrollment and at 4 and 8 months, with monitoring phone calls at 2 and 6 months. Variables measured included caregiver satisfaction, tube-related complications, and device durability.

RESULTS

Twenty-one patients were included in the study. Infection rate (range, 4.8%-5.0%) and overall leakage rate (range, 42.9%-50.0%) were similar in both groups. Trends were noted with other variables measured but without statistical significance. These included lower rates of formula leakage and granulation tissue growth and higher satisfaction scores with tube B and more favorable device durability with tube A.

CONCLUSION

Both low-profile balloon gastrostomy tubes performed well and had comparable caregiver satisfaction, complications, and overall device durability.

Nonvascular Pediatric Interventional Radiology

Interventional radiology procedures are increasingly in demand in both the adult and pediatric populations. Pediatric procedures mirror many of the adult procedures but with increased complexity due to considerations related to patient size and the requirements for sedation and radiation protection. This article reviews the various nonvascular pediatric interventional procedures and provides information on sedation and radiation protection. The aim is to provide a greater exposure to the possible treatment options for pediatric patients and to facilitate understanding of imaging after various interventions.

Percutaneous gastrostomy tubes in children with Pierre Robin sequence: efficacy, maintenance and complications

BACKGROUND

Children with Pierre Robin sequence (PRS) have significant oropharyngeal abnormalities, with respiratory and feeding difficulties. Gastrostomy tubes (G-tube) provide a means for nutrition.

OBJECTIVE

To evaluate the safety and efficacy of percutaneous G-tube insertion in children with PRS.

MATERIALS AND METHODS

Of 120 children with PRS (1996-2009), 40 were referred for G-tube insertion; clinical details were reviewed in 37/40 children (18M, 19F) at three time periods: (1) pre-G-tube insertion, (2) at G-tube insertion, (3) at G-tube removal.

RESULTS

Pre-G-tube: 32/37 were term infants; 5 were preterm; 16/37 children were ≤ 10th weight percentile. At G-tube insertion, mean age was 66 days, mean weight 4.4 kg (1.1-7.0 kg); 19 dropped ≥10 weight percentiles; 12 tolerated nil by mouth; 2/37 were intubated for the procedure. All G-tubes were successfully placed, with five minor technical issues. Early postprocedure, there were eight minor complications and two dislodgements (classified as major). At G-tube removal mean G-tube dwell time was 2 years, with an average of 3.6 maintenance procedures per child, approximately 3 tube changes/1,000 tube days. At G-tube removal, 76% had maintained or increased weight centiles.

CONCLUSION

G-tubes in PRS provide a safe method for nutrition until children feed adequately by mouth.

Upper gastrointestinal access in children: techniques and outcomes

This article describes the radiologic techniques to obtain upper gastrointestinal access in children with poor oral intake and inadequate nutrition. Our goal is to provide a simple guide of radiologic gastrostomy and gastrojejunostomy procedures, their technical success, and long-term outcomes. Potential complications will be discussed as well as their management. It is important to emphasize that a multidisciplinary approach (pediatrician, dietitian, interventional radiologist, pediatric surgeon) is paramount for appropriate indications and management of patients with gastrostomies and gastrojejunostomies.

Anthropometric growth and utilization of enteral feeding support in pediatric heart transplant recipients

We sought to outline trends in anthropometric growth before and after cardiac transplantation and to document our experience with the use of EFS in this population. A total of 130 patients (59% male) were enrolled and followed for a median of 4.4 yr after transplantation. Negative changes over time in weight z-score (EST: -0.256 [0.160] z/yr, p = 0.01), height z-score (EST: -0.214 [0.096] z/yr, p = 0.03), and BMI z-score (EST: -0.287 [0.161] z/yr, p = 0.07) were observed prior to transplantation. Significant increases in weight z-score (EST: +0.342 [0.143] z/yr, p < 0.001) and BMI z-score (EST: +0.396 [0.140] z/yr, p = 0.005) were seen in the first 18 months following transplantation. No further increases in height, weight, or BMI z-score were seen beyond this. Forty-two (32%) patients received EFS. Prior to transplantation, it was not found to be associated with change in anthropomorphic growth. Post-transplantation exposure to EFS was associated with a faster increase in weight z-score (EST: +0.480 [0.231] z/yr, p = 0.04) and height z-score over time (EST: +0.366 [0.141] z/yr, p = 0.01). Normalization of weight and height z-scores was not achieved during the study follow-up period. This study suggests that further investigation into the role of EFS is warranted to identify strategies to improve growth in pediatric heart transplant recipients.