Do gastrostomies close spontaneously? A review of the fate of gastrostomies following successful renal transplantation in children

Gastrocutaneous fistulae in children - A systematic review and meta-analysis of epidemiology and treatment options

BACKGROUND

Gastrostomy tubes are a common adjunct to the care of vulnerable pediatric patients. This study systematically evaluates the epidemiology and risk-factors for gastrocutaneous fistulae (GCF) after gastrostomy removal in children and reviews treatment options focusing on nonoperative management (NOM).

METHODS

After protocol registration (CRD-42017059565), multiple databases were searched. Studies describing epidemiology in children and GCF treatment at any age were included. Critical appraisal was performed (MINORS risk-of-bias assessment tool). One-sided meta-analysis was executed to estimate efficacy of therapeutic adjuncts using a random-effects model.

RESULTS

Sixteen articles evaluating pediatric GCF were identified. 44% defined GCF as persistence >1month which occurred in 31±7% of cases. Risk factors for pediatric GCF include age at gastrostomy, timing of removal, open technique, and fundoplication. Mean MINORS score was 0.60±0.16. Seventeen additional studies were identified reporting 142 patients undergoing NOM (endoscopic, systemic, and local therapies), and one pediatric comparative study was identified. Overall aggregate proportion of GCF closure after any NOM is 77% (80% success rate in local/systemic therapies; 75% success rate in endoscopic approaches). No adverse events were reported.

CONCLUSION

Persistent GCF complicates the management of gastrostomies in 1/3 of children with predictable risk factors. Several treatment options exist that obviate the need for general anesthesia. Their efficacy is unclear. Further prospective investigations are clearly warranted.

LEVEL OF EVIDENCE

III - Systematic Review and Meta-Analysis Based on Retrospective Case Control Studies.

Factors Affecting Spontaneous Closure of Gastrocutaneous Fistulae After Removal of Gastrostomy Tubes in Children With Intestinal Failure

BACKGROUND

Children with intestinal failure (IF) frequently require gastrostomy tubes (GTs) for long-term nutrition support. Risk factors for persistent gastrocutaneous fistulae (GCFs) in pediatric patients with IF are largely unknown but may include underlying nutrition status and duration of indwelling GT.

MATERIALS AND METHODS

Records of patients with IF having undergone GT removal and allowed a trial at spontaneous closure were reviewed. Nonparametric continuous variables were analyzed using the Wilcoxon rank sum test. Post hoc analysis was performed to identify the optimal threshold of GT duration predicting probability of spontaneous closure identified using receiver operating characteristic curve analysis.

RESULTS

Fifty-nine children with IF undergoing GT removal were identified. Spontaneous closure occurred in 36 (61%) sites, while 23 (39%) underwent operative closure at a median 67 days after GT removal. The duration of indwelling GT was significantly shorter in the spontaneous closure group (11.5 vs 21 months, P = .002). Of 33 GT indwelling for ≤ 18 months, 28 (85%) closed spontaneously, compared with only 9 of 26 (35%) with duration >18 months (P < .001). With GCF persisting beyond 7 days, only 21% (6/28) of sites closed spontaneously, but this dropped to 6% (1/18) of cases with concurrent GT duration >18 months.

CONCLUSIONS

Of the risk factors evaluated, only prolonged GT duration was associated with an increased likelihood of failure to close spontaneously. It is significantly less likely in pediatric patients with IF in whom GCF persists >7 days, particularly if the duration of GT is >18 months. Relatively earlier operative closure should be considered in this group.

Persistent gastrocutaneous fistula: factors affecting the need for closure

PURPOSE

The occurrence of gastrocutaneous fistula (GCF) is a well-known complication after gastrostomy tube placement. We explore multiple factors to ascertain their impact on the rate of persistent GCF formation.

METHODS

We retrospectively reviewed patient records for all gastrostomies (GT) constructed at our institution from 2007 to 2011. Association of GCF with method of placement, concomitant fundoplication, neurologic findings, duration of therapy, and demographics was evaluated using logistic regression.

RESULTS

Nine hundred fifty patients had GTs placed, of which 148 patients had GTs removed and 47 (32%) of 148 required surgical closure secondary to persistent GCF. Laparoscopic and open procedures comprised 79 (53%) of 148 and 69 (47%) of 148, respectively. Seventeen (22%) patients in the laparoscopic group developed persistent GCF, compared to 30 (43%) in the open group (P=0.035, OR=2.52). Seventy-one patients had concomitant Nissen fundoplication. Thirty-one (44%) developed GCF, compared to 16 (21%) without a Nissen (P=0.002, OR=4.94). Patients with button in place for 303 days had persistent GCF incidence of 23%, compared to 45% at 540 days (P<0.001, OR=3.51) and 50% at 850 days (P=0.011, OR=4.51). Patients with device placed at 1.8 months of age were more likely to develop GCF compared to those with device placed at 8.9 months of age (P=0.017, OR=2.35).

CONCLUSION

Open operations, concurrent Nissen and younger age at placement were all statistically significant factors causing persistent GCF.

Incidence and predictors of gastrocutaneous fistula in the pediatric patient

Background/Purpose. To determine the incidence, predictors, and outcomes of repair of gastrocutaneous fistulae (GCF) in pediatric patients. Methods. Patients were identified through a medical records search of all gastrostomy insertions performed from 1997–2007. Results. Of 1083 gastrostomies, 49 had GCF closure. Gastrostomy indications were reflux/aspiration (30/43 [70%]) and feeding intolerance/failure to thrive (7/43 [16%]). Gastrostomies were performed as open surgical procedures (84%) with fundoplication (66% of all cases) at an age of 0.5 ± 0.57 (median ± inter-quartile range) years. Gastrostomies were removed in outpatient settings when no longer used and were present for 2.3 ± 2.2 years, and GCF persisted for 2.0 ± 3.0 months. GCF were closed by laparotomy and stapling. GCF closure length of stay was 2.0 ± 3.3 days. Complications occurred in 6/49 patients and included infection/fever (4/6) and localized skin redness/breakdown (2/6). Conclusions. From our collected data, GCFs occur at a frequency of 4.5% and persist for 2.0 ± 3.0 months until closed. Given the complicated medical histories of patients and relatively high rate of postoperative infection/reaction (12.2%), GCF closure is not a benign, “uncomplicated” procedure. Further information describing factors determining which patients develop GCF requiring closure is needed.

Nutrition in children with CRF and on dialysis

The objectives of this study are: (1) to understand the importance of nutrition in normal growth; (2) to review the methods of assessing nutritional status; (3) to review the dietary requirements of normal children throughout childhood, including protein, energy, vitamins and minerals; (4) to review recommendations for the nutritional requirements of children with chronic renal failure (CRF) and on dialysis; (5) to review reports of spontaneous nutritional intake in children with CRF and on dialysis; (6) to review the epidemiology of nutritional disturbances in renal disease, including height, weight and body composition; (7) to review the pathological mechanisms underlying poor appetite, abnormal metabolic rate and endocrine disturbances in renal disease; (8) to review the evidence for the benefit of dietetic input, dietary supplementation, nasogastric and gastrostomy feeds and intradialytic nutrition; (9) to review the effect of dialysis adequacy on nutrition; (10) to review the effect of nutrition on outcome.

Percutaneous endoscopic gastrostomy in children: a safe technique with major symptom relief and high parental satisfaction

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is widely used for establishing enteral feeding. The aim of this study was to assess immediate and long-term results after PEG insertion.

PATIENTS AND METHODS

A total of 121 children were retrospectively reviewed. Median age was 2.4 years (range, 4 months-13.2 years) at the time of PEG insertion. Patient morbidity, indications for PEG, preoperative findings and perioperative complications were registered retrospectively. Parents/caregivers of 85 children were interviewed for long-term results.

RESULTS

Perioperative complications were seen in 12%. Twenty-four percent died at a median of 15 months (range, 1.5 months-8 years) after PEG. Eighty-five families were interviewed with a median follow-up time of 5.6 years (range, 1-10 years). A substantial majority (94%) of parents/caregivers reported that the PEG had a positive influence on their child's situation, and 98% would have chosen PEG insertion again. Vomiting/retching improved in 61% of the children, and oral intake enhanced in 43%. Stoma-related complications were frequent (73%). The gastrostomy tube was permanently removed at a median of 3 years (range, 7 months-7.3 years) after PEG placement in 25%. Delayed closure of the gastrocutaneous fistula after gastrostomy removal occurred in 48% of them. Time from insertion to removal was not predictive of delayed closure.

CONCLUSION

PEG is a safe technique for establishing enteral feeding, even in very sick children. Major complications are rare, although most children experience minor stoma-related problems. Parents/caregivers report that the gastrostomy is of great help for themselves and their child.

Caregiver attitudes towards gastrostomy removal after renal transplantation

Gastrostomy tube (G-tube) removal has been suggested at 3 months following successful renal transplantation (Tx). We noticed a delay in the removal of G-tubes in our pediatric patients following Tx and therefore conducted a cross-sectional single center survey on all renal transplant recipients to assess the causes of delayed G-tube removal. In total, 17 of 23 patients completed the survey, including all patients with G-tubes (n = 10) and seven patients without G-tubes. Median age at Tx of gastrostomy patients was significantly lower than that of patients without a G-tube (median 3.0 yr, range 1.2-4.7 yr vs. median 14 yr, range 6-17 yr, p < 0.0001) and significantly younger than in previous studies on gastrostomies. At the time of the survey, only three of 10 patients had their G-tube removed at 22, 41 and 61 months after Tx at the ages of 3, 5.5 and 9 yr, respectively. The median age at recent follow up of the remaining seven patients was 4.7 yr (range 2.6-8.75 yr). The most important reason for continued use was fluid intake and medication. Results of our survey showed appropriate concern regarding the risk of prolonged use of the gastrostomy. Caregivers felt that benefits of the gastrostomy in the post-transplant period outweighed the risks. Caregivers felt pressured towards removal by the physicians. Our findings support the decision to remove gastrostomies based on individual patient needs and total fluid intake rather than a fixed time following successful Tx.

Combined endoscopic cautery and clip closure of chronic gastrocutaneous fistulas

BACKGROUND

Chronic gastrocutaneous fistula with intermittent drainage is a common outcome after removing long-standing gastrostomy tubes. The standard treatment is surgery with laparotomy and excision of the fistula tract. This study describes the results of an endoscopic closure technique by using a combination of electrocautery and metal clips.

METHODS

Three patients with gastrocutaneous fistulas (duration 3 months to 3 years) after gastrostomy tube removal were treated endoscopically by electrocautery of the tract and application of metal clips.

OBSERVATIONS

Treatment resulted in complete fistula closure in two patients and partial closure in a third patient.

CONCLUSIONS

Combined endoscopic therapy with electrocautery and clipping may be an alternative to surgical closure of chronic gastrocutaneous fistulas.

Analysis of factors affecting the spontaneous closure of a gastrocutaneous fistula

BACKGROUND/PURPOSE

Few reports have documented the rate of persistence of a gastrocutaneous fistula (GCF) after gastrostomy removal or the reason for the persistence of a GCF. The purpose of this report was to analyze a large group of pediatric patients with a persistent GCF to determine the rate of persistence and any factors that correlate with the persistence of a GCF.

METHODS

This was a retrospective review of 1,042 children from The Children's Hospital, Denver, Colorado who had a gastrostomy constructed between 1992 and 2002. The charts of all children with a persistent GCF after gastrostomy catheter removal were analyzed for correlation between 13 clinical parameters and the persistence of a GCF.

RESULTS

There were 150 children with a persistent GCF for an incidence of 34%. Time elapsed between the creation of the GCF and removal of the gastrostomy appliance (< or =8 months versus >8 months) was the only parameter that showed any correlation with persistence of a GCF (P <.05). None of the other parameters studied showed any conclusive correlation with persistence of a GCF.

CONCLUSIONS

Time was the only factor that determined whether a surgically created GCF would persist after removal of a gastrostomy appliance.