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Knatten CK, Dahlseng MO, Perminow G, Skari H, Austrheim AI, Nyenget T, Aabakken L, Schistad O, Stensrud KJ, Bjørnland K. Push-PEG or Pull-PEG: Does the Technique Matter? A Prospective Study Comparing Outcomes After Gastrostomy Placement. J Pediatr Surg 2024; 59:1879-1885. [PMID: 38604831 DOI: 10.1016/j.jpedsurg.2024.03.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 03/04/2024] [Accepted: 03/17/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Push-PEG (percutaneous endoscopic gastrostomy) with T-fastener fixation (PEG-T) allows one-step insertion of a balloon tube or button, and avoids contamination of the stoma by oral bacteria. However, PEG-T is a technically more demanding procedure with a significant learning curve. The aim of the present study was to compare outcomes after PEG-T and pull-PEG in a setting where both procedures were well established. MATERIALS AND METHODS The study is a prospective cohort study including all patients between 0 and 18 year undergoing PEG-T and pull-PEG between 2017 and 2020 at a combined local and tertiary referral center. Complications and parent reported outcomes were recorded during hospital stay, after 14 days and 3 months postoperatively. RESULTS 82 (93%) of eligible PEG-T and 37 (86%) pull-PEG patients were included. The groups were not significantly different with regard to age or weight. Malignant disorders and heart conditions were more frequent in the pull-PEG group, whilst neurodevelopmental disorders were more frequent in the PEG-T group (p < 0.001). 54% in both groups had a complication within 2 weeks. Late complications (between 2 weeks and 3 months postoperatively) occurred in 63% PEG-T vs 62% pull-PEG patients (p = 0.896). More parents in the pull-PEG group (49%) reported that the gastrostomy tube restricted their child's activity, compared to PEG-T (24%) (p = 0.01). At 3 months follow-up, more pull-PEG patients (43%) reported discomfort from the gastrostomy compared to PEG-T (21%) (p = 0.03). CONCLUSION Overall complication rates were approximately similar, but pull-PEG was associated with more discomfort and restriction of activity. LEVELS OF EVIDENCE Treatment study level II.
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Affiliation(s)
| | | | - Gøri Perminow
- Department of Pediatrics, Oslo University Hospital, Norway
| | - Hans Skari
- Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, Norway
| | | | - Tove Nyenget
- Department of Pediatrics, Oslo University Hospital, Norway
| | - Lars Aabakken
- Department of Gastroenterology, Oslo University Hospital, Norway; University of Oslo, Norway
| | - Ole Schistad
- Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, Norway
| | - Kjetil Juul Stensrud
- Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, Norway
| | - Kristin Bjørnland
- Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, Norway; University of Oslo, Norway
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Dahlseng MO, Skari H, Perminow G, Kvello M, Nyenget T, Schistad O, Stensrud KJ, Bjornland K, Knatten CK. Reduced complication rate after implementation of a detailed treatment protocol for percutaneous endoscopic gastrostomy with T-fastener fixation in pediatric patients: A prospective study. J Pediatr Surg 2022; 57:396-401. [PMID: 35487796 DOI: 10.1016/j.jpedsurg.2022.03.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 03/23/2022] [Accepted: 03/26/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Percutaneous endoscopic gastrostomy with push technique (PEG-T) is increasingly used in pediatric patients. In a retrospective study of PEG-T (cohort 1) we reported frequent complications related to T-fasteners and tube dislodgment. The aim of this study was to assess complications after implementation of a strict treatment protocol, and to compare these with the previous retrospective study. MATERIALS AND METHODS The study is a prospective study of PEG-T placement performed between 2017 and 2020 (cohort 2) in pediatric patients (0-18 years). Complications were recorded during hospital stay, fourteen days and three months postoperatively, graded according to the Clavien-Dindo classification and categorized as early (<30 days) or late (>30 days). RESULTS In total 82 patients were included, of which 52 (60%) had neurologic impairments. Median age and weight were 2.0 years [6 months-18.1 years] and 13.4 kg [3.5-51.5 kg], respectively. There was a significant reduction in median operating time from 28 min [10-65 min] in cohort 1 to 15 min [6-35 min] in cohort 2 (p<0.001), number of patients with early tube dislodgement (cohort 1: 9 (10%) vs cohort 2: 1 (1%), p = 0.012), and number of patients with late migrated T-fasteners (cohort 1: 11 (13%) vs cohort 2: 1 (1%), p = 0.004). CONCLUSION We experienced less migrated T-fasteners and tube dislodgment after implementation of strict treatment protocol. LEVEL OF EVIDENCE Treatment study level III.
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Affiliation(s)
- Magnus Odin Dahlseng
- Department of Pediatrics, Oslo Universitetssykehus, Ullevål Sykehus, Barne- og Ungdomsklinikken, Oslo University Hospital, PB 4956 Nydalen, Oslo 0424, Norway.
| | - Hans Skari
- Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, Norway
| | - Gøri Perminow
- Department of Pediatrics, Oslo Universitetssykehus, Ullevål Sykehus, Barne- og Ungdomsklinikken, Oslo University Hospital, PB 4956 Nydalen, Oslo 0424, Norway
| | - Morten Kvello
- Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, Norway; Department of Gynecology and Obstetrics, Sørlandet Sykehus Kristiansand, Norway
| | - Tove Nyenget
- Department of Pediatrics, Oslo Universitetssykehus, Ullevål Sykehus, Barne- og Ungdomsklinikken, Oslo University Hospital, PB 4956 Nydalen, Oslo 0424, Norway
| | - Ole Schistad
- Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, Norway
| | - Kjetil Juul Stensrud
- Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, Norway
| | - Kristin Bjornland
- Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, Norway; University of Oslo, Norway
| | - Charlotte Kristensen Knatten
- Department of Pediatrics, Oslo Universitetssykehus, Ullevål Sykehus, Barne- og Ungdomsklinikken, Oslo University Hospital, PB 4956 Nydalen, Oslo 0424, Norway
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McSweeney ME, Mitchell PD, Smithers CJ, Doherty A, Perkins J, Rosen R. A Retrospective Review of Primary Percutaneous Endoscopic Gastrostomy and Laparoscopic Gastrostomy Tube Placement. J Pediatr Gastroenterol Nutr 2021; 73:586-591. [PMID: 34259651 DOI: 10.1097/mpg.0000000000003236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The laparoscopic-assisted gastrostomy tube placement (LAP) has increasingly become the preferred method for placing gastrostomy tubes in infants and children. The goal of this retrospective review was to examine our institutional experiences with our transition from the percutaneous endoscopic gastrostomy (PEG) procedure to LAP technique. METHODS All patients undergoing primary PEG or LAP gastrostomy at Boston Children's Hospital between January 2010 and June 2015 were identified. The primary aim was to compare complication rates within the first 6 months after tube placement; differences in total hospital procedural costs, hospital resource utilization, and postoperative gastroesophageal reflux disease were examined. RESULTS Nine hundred and eighty-seven patients (442 PEG and 545 LAP gastrostomy tubes) were included. No differences in total complications within 6 months were seen. Patients undergoing PEG placement had more gastrostomy-related complications (PEG 30 [6.7%] vs LAP 13 [2.4%], P = 0.0007) and cellulitis (PEG 23 [5.1%] vs LAP 2 [0.4%], P = 0.03) within the first week of placement. Patients undergoing LAP procedures had more granulation tissue episodes (PEG 19 [4.4%] vs LAP 107 [19.8%], P = 0.005). No differences in emergency room visits, hospital readmissions, or postoperative gastroesophageal reflux disease were seen, although transition to a gastrojejunal tube was higher in patients undergoing LAP procedure (PEG 20 patients [4.6%] vs LAP 51 patients [9.5%], P = 0.0008). CONCLUSIONS Total complications were similar between patients undergoing PEG versus LAP gastrostomy tube placement. Patients with the PEG procedure had more complications within the first week of placement versus patients with the LAP procedure had more granulation skin complications.
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Affiliation(s)
| | - Paul D Mitchell
- Clinical Research Center, Boston Children's Hospital, Boston, MA
| | - C Jason Smithers
- Department of General Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Ashley Doherty
- Information Services, Boston Children's Hospital, Boston, MA
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Wiernicka A, Matuszczyk M, Szlagatys-Sidorkiewicz A, Zagierski M, Toporowska-Kowalska E, Gębora-Kowalska B, Popińska K, Sibilska M, Grzybowska-Chlebowczyk U, Więcek S, Hapyn E, Blimke-Kozieł K, Kierkuś J. Analysis of frequency and risk factors for complications of enteral nutrition in children in Poland after percutaneous endoscopic gastrostomy placement. Nutrition 2021; 89:111265. [PMID: 34082251 DOI: 10.1016/j.nut.2021.111265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 03/08/2021] [Accepted: 03/29/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The aim of the study was to assess the complication rate and identify whether age, nutritional status, and history of respiratory aspiration prior to percutaneous endoscopic gastrostomy (PEG) are risk factors for post-PEG placement complications in Polish children. In addition, the safety of two enteral feeding methods (3 h vs. 8 h) after PEG insertion in children was compared. METHODS Children with clinical indications for PEG placement were recruited from six medical centers in Poland to participate in the study. The patients were centrally randomized to receive the first bolus feed via a feeding tube at 3 h (group 1) or 8 h (group 2) after PEG placement. The preprocedural preparation, postoperative care, and resumption of feeding were performed on all of patients in accordance with the study protocol. Patients were followed for 12 mo. RESULTS Of the 97 randomized patients, 49 were assigned to group 1 and 48 to group 2. Full feed after PEG placement was achieved within 24 to 48 h in most cases (74% vs. 82%). There were no differences between the groups regarding the number of early mild (31.3% vs. 31.3%) and serious (2.1% vs 8.3%) complications or the duration of hospitalization after PEG placement (P > 0.05). The most common serious complication after PEG placement was accidental displacement of PEG. Most reported late complications were mild. The results of the regression analysis indicate no statistically significant effect of age, body mass index standard deviation score, white blood cell count, serum albumin level, and respiratory aspiration in the medical history on the occurrence of mild and severe complications. CONCLUSIONS The early initiation of post-PEG feeding was not associated with an increase in the number of complications. Most complications after the PEG procedure were mild. Age, serum albumin level, white blood cells, body mass index standard deviation score, and a history of aspiration to the respiratory tract were not confirmed as a risk factor for post-PEG complications in children.
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Affiliation(s)
- Anna Wiernicka
- Department of Gastroenterology, Hepatology, Feeding Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland.
| | - Małgorzata Matuszczyk
- Department of Gastroenterology, Hepatology, Feeding Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | | | - Maciej Zagierski
- Department of Pediatrics, Gastroenterology, Allergology and Nutrition, Medical University of Gdańsk, Gdańsk, Poland
| | | | - Beata Gębora-Kowalska
- Department of Alergology, Gastroenterology and Nutrition, Medical University, Łódź, Poland
| | - Katarzyna Popińska
- Department of Pediatrics, Nutrition and Metabolic Disorders, The Children's Memorial Health Institute, Warsaw, Poland
| | - Marta Sibilska
- Department of Pediatrics, Nutrition and Metabolic Disorders, The Children's Memorial Health Institute, Warsaw, Poland
| | | | - Sabina Więcek
- Department of Pediatrics, Medical University of Silesia, Katowice, Poland
| | - Ewa Hapyn
- Department of Pediatrics and Gastroenterology, Area Hospital in Toruń, Poland
| | | | - Jarosław Kierkuś
- Department of Gastroenterology, Hepatology, Feeding Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
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Zenitani M, Nose S, Sasaki T, Oue T. Safety and efficacy of laparoscopy-assisted percutaneous endoscopic gastrostomy in infants and small children weighing less than 10 kg: A comparison with larger patients. Asian J Endosc Surg 2021; 14:44-49. [PMID: 32319215 DOI: 10.1111/ases.12803] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 02/18/2020] [Accepted: 03/23/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Laparoscopy-assisted percutaneous endoscopic gastrostomy (LAPEG) can reduce the risk of percutaneous endoscopic gastrostomy-related complications, such as intra-abdominal organ injury, and determine the optimal position for placement of the gastrostomy tube. We first employed LAPEG 10 years ago but limited its application to elderly patients. Indications for LAPEG have now expanded to small children. This retrospective study aimed to determine the feasibility of LAPEG in children weighing <10 kg. METHODS Our LAPEG procedure for small children involves three essential techniques: gastric insufflation with CO2 to prevent intestinal dilation, a T-fastener device to overcome the difficulties of gastropexy, and primary placement of a button gastrostomy to create less torque than tube gastrostomy at the insertion site and to prevent early tube dislodgement. The medical records of 48 patients with physical and mental disabilities who underwent LAPEG between 2010 and 2018 were evaluated. The outcomes of LAPEG in patients weighing <10 kg (group A, n=11) and ≥10 kg (group B, n=37) were compared. RESULTS The LAPEG procedure was completed in all cases without intraoperative complications or open conversion. The median bodyweight of group A was 6.3 kg (range, 3.6-8.2 kg). None of the patients in group A developed postoperative complications such as stomal infection or dislodgement. The operative time was significantly shorter in group A than in group B (P < .05). CONCLUSION By improving surgical techniques for small children, our LAPEG procedure might be feasible and safe for treating children weighing <10 kg, including those weighing as little as 3.6 kg.
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Affiliation(s)
- Masahiro Zenitani
- Department of Pediatric Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Satoko Nose
- Department of Pediatric Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Takashi Sasaki
- Division of Pediatric Surgery, Department of Surgery, Kindai University Faculty of Medicine, Osaka, Japan
| | - Takaharu Oue
- Department of Pediatric Surgery, Hyogo College of Medicine, Nishinomiya, Japan
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Variability in the Method of Gastrostomy Placement in Children. CHILDREN-BASEL 2020; 7:children7060053. [PMID: 32492791 PMCID: PMC7346129 DOI: 10.3390/children7060053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 04/17/2020] [Accepted: 05/28/2020] [Indexed: 11/24/2022]
Abstract
Although gastrostomy placement is one of the most common procedures performed in children, the optimal technique remains unclear. The purpose of this study was to evaluate variability in the method of gastrostomy tube placement in children in the United States. Patients <18 years old undergoing percutaneous endoscopic gastrostomy (PEG) or surgical gastrostomy (SG) (including open or laparoscopic) from 1997 to 2012 were identified using the Kids’ Inpatient Database. Method of gastrostomy placement was evaluated using a multivariable mixed-effects logistic regression model with a random intercept term and a patient-age random-effect term. A total of 67,811 gastrostomy placements were performed during the study period. PEG was used in 36.6% of entries overall and was generally consistent over time. PEG placement was less commonly performed in infants (adjusted odds ratio [aOR] 0.30, 95%CI 0.26–0.33), children at urban hospitals (aOR: 0.38, 95%CI 0.18–0.82), and children cared for at children’s hospitals (aOR 0.57, 95%CI 0.48–0.69) and was more commonly performed in children with private insurance (aOR 1.17, 95%CI 1.09–1.25). Dramatic variability in PEG use was identified between centers, ranging from 0% to 100%. The random intercept and slope terms significantly improved the model, confirming significant center-level variability and increased variability among patients <1 year old. These findings emphasize the need to further evaluate the safest method of gastrostomy placement in children, in particular among the youngest patients in whom practice varies the most.
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Abstract
BACKGROUND/AIM Percutaneous endoscopic gastrostomy tube (PEG) has replaced the standard open surgical gastrostomy for enteral nutrition. However, several complications were reported, especially in children less than 10 kg. Our objective was to report the outcomes of percutaneous endoscopic gastrostomy in children according to their weight. PATIENTS AND METHODS 163 children had PEG tube insertion in our tertiary referral hospital from January 2007 to March 2019. Patients were divided into two groups according to the weight; group I (less than 10 kg; n = 112) and group II (more than 10 kg; n = 51). Comparisons were made between the two groups for incidence of postoperative complications, the need for reintervention, 30-day, and 1-year mortality. RESULTS There were 51 males (45.5%) in group I and 27 in group II (52.9%) (P = 0.38). The mean weight at the time of endoscopy was 5.9 ± 1.53 and 17.3 ± 8.23 kg and the mean American Society of Anesthesiologists (ASA) score was 2.6 ± 0.67 and 2.43 ± 0.57 in group I and II, respectively (P = 0.101). The most common associated condition was cerebral palsy (50 (44.6%) and 24 (47.1%) in group I and II, respectively; P = 0.77). The mean operative time was 30.28 ± 11.57 min in group I and 33.62 ± 23.36 min in group II (P = 0.221). Skin complications were the most commonly encountered complications of PEG, and 49% (n = 48) required the removal and replacement of the tube under general anesthesia in group I and 41% (n = 21) in group II (P = 0.84). There was no significant difference in the complication between groups. CONCLUSION : PEG is a safe technique in children less than 10 kg, and the complications rate is comparable with older children. The use of positive transillumination and small needle for measuring the distance between the skin and the stomach enhances the safety of the procedure. PEG should be considered in children less than 10 kg who need supportive or continuous enteral nutrition for different reasons.
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Affiliation(s)
- Osama A. Bawazir
- Department of Surgery, Faculty of Medicine in Umm Al-Qura University at Makkah, Makkah, Saudi Arabia,Address for correspondence: Dr. Osama A. Bawazir, Department of Surgery, Faculty of Medicine, Umm Al.Qura University, P.O. Box 715, Makkah 21955, Saudi Arabia. King Faisal Specialist Hospital and Research Centre, Dept. of Surgery, Jeddah, KSA. E-mail: ;
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Howard C, Macken WL, Connolly A, Keegan M, Coghlan D, Webb DW. Percutaneous endoscopic gastrostomy for refractory epilepsy and medication refusal. Arch Dis Child 2019; 104:690-692. [PMID: 30833283 DOI: 10.1136/archdischild-2018-315629] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 02/12/2019] [Accepted: 02/14/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Current guidelines for percutaneous endoscopic gastrostomy (PEG) placement focus largely on maintaining enteral feeding when oral feeding is no longer possible or adequate with an emphasis on nutrition and quality of life (QOL). Previous publications have also alluded to potential benefits in medication adherence, for example, in children with HIV, renal disease and neurodisability. We describe a cohort of children with refractory epilepsy who refused oral medication and in whom PEG tube placement was initiated for the purpose of drug administration. DESIGN We identified children from the medical records of two tertiary paediatric units over a 9-year period who had PEG tube placement for administration of antiepileptic drug (AED) therapy and collected demographic and clinical details from chart reviews. We assessed parent-reported changes in seizure control and QOL using a structured questionnaire. RESULTS Ten patients met the inclusion criteria. All families reported an improvement in ease of administering medications and eight reported a significant improvement in QOL. Nine children had a decrease in seizure frequency (lasting more than 12 months) following PEG tube placement, including two who underwent surgical intervention for their epilepsy during that period. Four had either a decrease in the number of drugs administered or their doses and four went on to receive fluids and nutrition through their tube on a regular basis. Seven reported PEG complications, which did not require removal of the PEG. CONCLUSIONS This case series of children with resistant epilepsy demonstrates improvement in seizure control and QOL following PEG tube placement for AED administration.
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Affiliation(s)
- Caoimhe Howard
- Department of Neurology, Our Lady's Children's Hospital, Dublin, Ireland.,Department of Paediatrics, Adelaide and Meath Hospital Dublin, incorporating the National Children's Hospital, Dublin, Ireland
| | - William L Macken
- Department of Neurology, Our Lady's Children's Hospital, Dublin, Ireland
| | - Ann Connolly
- Department of Paediatrics, Adelaide and Meath Hospital Dublin, incorporating the National Children's Hospital, Dublin, Ireland
| | - Maria Keegan
- Department of Neurology, Our Lady's Children's Hospital, Dublin, Ireland
| | - David Coghlan
- Department of Paediatrics, Adelaide and Meath Hospital Dublin, incorporating the National Children's Hospital, Dublin, Ireland
| | - David W Webb
- Department of Neurology, Our Lady's Children's Hospital, Dublin, Ireland.,Department of Paediatrics, Adelaide and Meath Hospital Dublin, incorporating the National Children's Hospital, Dublin, Ireland
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Safety and Efficacy of Bedside Percutaneous Endoscopic Gastrostomy Placement in the Neonatal Intensive Care Unit. J Pediatr Gastroenterol Nutr 2018; 67:40-44. [PMID: 29401084 DOI: 10.1097/mpg.0000000000001906] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE The aim of the study is to describe the safety and efficacy of bedside percutaneous endoscopic gastrostomy (PEG) placement in a level 3 neonatal intensive care unit (NICU). METHODS A retrospective chart review was performed on 106 infants with a birthweight ≤6 kg receiving bedside PEG placement at Johns Hopkins All Children's Hospital between 2007 and 2013. Preprocedure, postprocedure, and demographic data were collected. The main safety outcome was postprocedure complication rate and the main efficacy outcome was time to initiate feeds and time on respiratory support. RESULTS The mean birth weight and mean gestational age of our population at the time of procedure were 2.2 kg and 33 weeks, respectively. There were 9 total complications (8.5%) with major complications being only 2 (1.8%). There were no instances of blood stream infections. The mean length of time to initiate feeds was 1.2 days (standard deviation [SD] = 1.2). Ninety-three percent of patients were extubated within 24 hours. CONCLUSIONS Bedside PEG placement is safe with minimal complications. It is associated with little need for ventilator support and allows for early re-initiation of feeds and early success at reaching goal feedings.
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Aumar M, Lalanne A, Guimber D, Coopman S, Turck D, Michaud L, Gottrand F. Influence of Percutaneous Endoscopic Gastrostomy on Gastroesophageal Reflux Disease in Children. J Pediatr 2018; 197:116-120. [PMID: 29655862 DOI: 10.1016/j.jpeds.2018.02.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 01/12/2018] [Accepted: 02/01/2018] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To determine if gastroesophageal reflux disease (GERD) is present at long-term follow-up after percutaneous endoscopic gastrostomy (PEG), and to identify factors associated with the occurrence or aggravation of GERD after PEG placement. STUDY DESIGN This prospective, observational study was conducted in our single tertiary center over a 13-year period (gastrostomy performed from 1990 to 2003 and follow-up to 2015). Every child who underwent PEG in our center (N = 368) from 1990 to 2003 was eligible. GERD was defined by clinical manifestations requiring antisecretory or prokinetic treatment, occurrence of a GERD-related complication, or the need for antireflux surgery. Outcomes among patients without antireflux surgery were also assessed. Multivariate analysis was used to identify factors aggravating GERD after PEG placement. RESULTS A total 326 patients (89%; 56% with a neurologic impairment) were studied with a median follow-up after 3.5 years (range, 2.0-13.5 years). After PEG placement, GERD appeared in 11% of patients and was aggravated in 25% of patients with preexisting GERD. Factors associated with GERD worsening after PEG placement were neurologic impairment and preexisting GERD. Only 53 patients (16%) required antireflux surgery, among whom 22 required surgery in the year after PEG. Neurologic impairment was the only factor significantly associated with the need for antireflux surgery. CONCLUSIONS GERD predominantly remains clinically controlled after PEG placement. Routine antireflux surgery at the time of PEG placement is not justified.
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Affiliation(s)
- Madeleine Aumar
- CHU Lille, University of Lille, Reference Center for Congenital and Malformative Esophageal Diseases (CRACMO), Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Jeanne de Flandre, Lille University Children's Hospital, Lille, France.
| | - Arnaud Lalanne
- CHU Lille, University of Lille, Reference Center for Congenital and Malformative Esophageal Diseases (CRACMO), Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Jeanne de Flandre, Lille University Children's Hospital, Lille, France
| | - Dominique Guimber
- CHU Lille, University of Lille, Reference Center for Congenital and Malformative Esophageal Diseases (CRACMO), Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Jeanne de Flandre, Lille University Children's Hospital, Lille, France
| | - Stéphanie Coopman
- CHU Lille, University of Lille, Reference Center for Congenital and Malformative Esophageal Diseases (CRACMO), Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Jeanne de Flandre, Lille University Children's Hospital, Lille, France
| | - Dominique Turck
- CHU Lille, University of Lille, Reference Center for Congenital and Malformative Esophageal Diseases (CRACMO), Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Jeanne de Flandre, Lille University Children's Hospital, Lille, France
| | - Laurent Michaud
- CHU Lille, University of Lille, Reference Center for Congenital and Malformative Esophageal Diseases (CRACMO), Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Jeanne de Flandre, Lille University Children's Hospital, Lille, France
| | - Frédéric Gottrand
- CHU Lille, University of Lille, Reference Center for Congenital and Malformative Esophageal Diseases (CRACMO), Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Jeanne de Flandre, Lille University Children's Hospital, Lille, France
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Fernandes AR, Elliott T, McInnis C, Easterbrook B, Walton JM. Evaluating complication rates and outcomes among infants less than 5kg undergoing traditional percutaneous endoscopic gastrostomy insertion: A retrospective chart review. J Pediatr Surg 2018; 53:933-936. [PMID: 29506815 DOI: 10.1016/j.jpedsurg.2018.02.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 02/01/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE Percutaneous endoscopic gastrostomy (PEG) enables enteral nutrition for patients with inadequate oral intake. Laparoscopic guidance of PEG insertion is used for high-risk populations, including in infants less than 5kg at insertion. This study aimed to assess complication rates with traditional PEG tube insertion in infants less than 5kg at a single tertiary care center. METHODS A retrospective review of patients less than 5kg who underwent PEG insertion was conducted. PEG insertion-related complications, up to four years following insertion, were collected. Outcomes were reported as counts and percentages, or median with minimum and maximum values. RESULTS 480 pediatric gastrostomy procedures between January 1, 2009 and February 1, 2017, were screened, with 129 included for analysis. Median weight at PEG insertion was 3800g. Superficial surgical site infection (SSI) occurred in 6 (4.7%) patients, and 1 (0.8%) required readmission for intravenous antibiotics. One (0.8%) required endoscopic management for retained foreign body, 1 (0.8%) required operative management for gastrocolic fistula, and 1 (0.8%) for persistent gastrocutaneous fistula. No deep space SSI, procedure-related hemorrhage requiring readmission or transfusion, buried bumper syndrome, or procedure-related mortality occurred. CONCLUSION Traditional PEG tube insertion in infants less than 5kg results in complication rates comparable to pediatric literature standards. LEVEL OF EVIDENCE Level II, retrospective prognosis study.
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Affiliation(s)
| | - Tessa Elliott
- McMaster Pediatric Surgery Research Collaborative, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Carter McInnis
- McMaster Pediatric Surgery Research Collaborative, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Bethany Easterbrook
- McMaster Pediatric Surgery Research Collaborative, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - J Mark Walton
- McMaster Children's Hospital, Hamilton, Ontario, Canada; McMaster Pediatric Surgery Research Collaborative, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
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12
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Why wait: early enteral feeding after pediatric gastrostomy tube placement. J Pediatr Surg 2018; 53:656-660. [PMID: 28689884 DOI: 10.1016/j.jpedsurg.2017.06.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 05/22/2017] [Accepted: 06/15/2017] [Indexed: 12/26/2022]
Abstract
PURPOSE Early initiation of feedings after gastrostomy tube (GT) placement may reduce associated hospital costs, but many surgeons fear complications could result from earlier feeds. We hypothesized that, irrespective of placement method, starting feedings within the first 6h following GT placement would not result in a greater number of post-operative complications. METHODS An IRB-approved retrospective review of all GTs placed between January 2012 and December 2014 at three academic institutions was undertaken. Data was stratified by placement method and whether the patient was initiated on feeds at less than 6h or after. Baseline demographics, operative variables, post-operative management and complications were analyzed. Descriptive statistics were used and P-values <0.05 were considered significant. RESULTS One thousand and forty-eight patients met inclusion criteria. GTs were inserted endoscopically (48.9%), laparoscopically (44.9%), or via an open approach (6.2%). Demographics were similar in early and late fed groups. When controlling for method of placement, those patients who were fed within the first 6h after gastrostomy placement had shorter lengths of stay compared to those fed greater than 6h after placement (P<0.05). Total post-operative outcomes were equivalent between feeding groups for all methods of placement (laparoscopic (P=0.87), PEG (P=0.94), open (P=0.81)). CONCLUSIONS Early initiation of feedings following GT placement was not associated with an increase in complications. Feeds initiated earlier may shorten hospital stays and decrease overall hospital costs. TYPE OF STUDY Multi-institutional retrospective. LEVEL OF EVIDENCE III.
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13
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Miyata S, Dong F, Lebedevskiy O, Park H, Nguyen N. Comparison of operative outcomes between surgical gastrostomy and percutaneous endoscopic gastrostomy in infants. J Pediatr Surg 2017; 52:1416-1420. [PMID: 28139230 DOI: 10.1016/j.jpedsurg.2017.01.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 01/10/2017] [Accepted: 01/14/2017] [Indexed: 01/14/2023]
Abstract
PURPOSE Safety profile of different gastrostomy procedures in small children has not been well studied. This study was conducted to investigate whether complication and mortality rates differ between surgical gastrostomy (G-tube) and percutaneous endoscopic gastrostomy (PEG) in infants and neonates. METHODS In this retrospective study utilizing the Kids' Inpatient Database, all infants who underwent either G-tube or PEG as a sole procedure were identified. Variables included age, gender, race, presence of neurological impairment, prematurity, complex chronic condition, and severity of illness/risk of mortality subclasses. Postoperative complication, reoperation, and mortality rates were compared between G-tube and PEG. A subgroup of neonates was also analyzed. RESULTS A total of 1456 infants were identified (G-tube n=874, PEG n=582). In univariate analysis, the rates of adverse outcomes were not significantly different (G-tube vs PEG complication rate was 7.3% and 6.7%, p=0.65; mortality rate 1.3% and 0.7%, p=0.29, respectively). Adjusted odds ratios (ORs) for complication were 1.07 (G-tube vs PEG, 95% confidence interval [CI] 0.700-1.620) for overall infants and 1.19 (95% CI 0.601-2.350) for the neonatal subgroup. Similarly, adjusted ORs for mortality did not differ significantly both in infants (OR 1.749, 95% CI 0.532-5.755) and in the neonatal subgroup (OR 2.153, 95% CI 0.566-8.165). CONCLUSIONS When G-tube and PEG were performed as the only procedure throughout a hospitalization in infants and neonates, the two techniques had comparable risks of postoperative complications and mortalities. LEVEL OF EVIDENCE Retrospective comparative study, Level III.
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Affiliation(s)
- Shin Miyata
- Department of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, United States; Department of Surgery, Arrowhead Regional Medical Center, Colton, CA, United States.
| | - Fanglong Dong
- Department of Surgery, Arrowhead Regional Medical Center, Colton, CA, United States.
| | - Olga Lebedevskiy
- Department of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, United States; Department of Surgery, Arrowhead Regional Medical Center, Colton, CA, United States.
| | - Hanna Park
- Department of Surgery, Arrowhead Regional Medical Center, Colton, CA, United States.
| | - Nam Nguyen
- Department of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, United States.
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14
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van Els AL, van Driel JJ, Kneepkens CMF, de Meij TGJ. Antibiotic prophylaxis does not reduce the infection rate following percutaneous endoscopic gastrostomy in infants and children. Acta Paediatr 2017; 106:801-805. [PMID: 28130790 DOI: 10.1111/apa.13762] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 12/18/2016] [Accepted: 01/24/2017] [Indexed: 12/29/2022]
Abstract
AIM Percutaneous endoscopic gastrostomy (PEG) is the standard for placing gastrostomy in children needing long-term enteral nutrition, with major and minor complications reported in up to 19% and 47.7% of children, respectively. We reviewed our experience with PEG, concentrating on the efficacy of antibiotic prophylaxis in reducing infectious complications. METHODS We performed a retrospective, single-centre study that comprised all children up to 18 years of age who underwent a first PEG procedure in the VU University Medical Centre, Amsterdam, from 2008 to 2012. All complications up to one month after PEG were recorded. Infection rates with and without antibiotic prophylaxis could be compared as a new protocol requiring the preprocedure administration of cefazolin was not followed consistently. RESULTS We enrolled 129 patients (78 male) with a mean age of 4.9 ± 4.8 years and median age of 2.9 years. Major complications were seen in seven patients (5.4%) and minor complications in 23 patients (17.8%). Antibiotic prophylaxis was administered to 99 of 129 children (76.7%). Infections occurred in 15 of 129 patients (11.6%); 14 of 99 with and 1 of 30 without prophylaxis developed infections (p = 0.106). Peristomal infections were the most frequent complication (10.1%). CONCLUSION Percutaneous endoscopic gastrostomy was a safe procedure and antibiotic prophylaxis did not seem to decrease infectious complications.
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Affiliation(s)
- Anne L. van Els
- Department of Paediatric Gastroenterology; VU University Medical Centre; Amsterdam The Netherlands
| | - J Joris van Driel
- Princess Amalia Children's Centre; Isala Hospital; Zwolle The Netherlands
| | - CM Frank Kneepkens
- Department of Paediatric Gastroenterology; VU University Medical Centre; Amsterdam The Netherlands
| | - Tim G. J. de Meij
- Department of Paediatric Gastroenterology; VU University Medical Centre; Amsterdam The Netherlands
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15
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Landisch RM, Colwell RC, Densmore JC. Infant gastrostomy outcomes: The cost of complications. J Pediatr Surg 2016; 51:1976-1982. [PMID: 27678507 DOI: 10.1016/j.jpedsurg.2016.09.025] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 09/12/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Comparative outcomes of enhanced percutaneous endoscopic gastrostomy (PEG) and laparoscopic gastrostomy (LG) have not been elucidated in infants. We describe the outcomes and procedural episodic expenditures of PEG versus LG in this high-risk population. METHODS One hundred eighty-three gastrostomies in children under 1year were reviewed from our institution spanning 1/2011-6/2015. Pertinent demographics and 3-month complications (mortality, gastrocolic fistula, reoperation, cellulitis, granulation, pneumonia, and tube dislodgement <6weeks) were collected. Facility and professional administrative data was used to conduct a charge and cost analysis of PEG and LG procedures as well as their statistically significant complications. RESULTS Seventy-eight PEG and 105 LG infants were compared. LG infants were significantly younger, had higher ASA class, and increased frequency of cardiopulmonary disease. Significant major complications included a 3.8% incidence of gastrocolic fistula among PEGs (3.8% vs 0%, p=0.04) and 7.6% early tube dislodgements among LG infants (0 vs. 7.6%, p=0.01), resulting in $86,896 of additional charges with PEG complication. Incorporating complication frequency, average charges and variable cost per case were $8964 and $253 greater using PEG. CONCLUSIONS Despite a healthier cohort, infants undergoing enhanced PEG have more morbid and costly complications. LG may be the less burdensome approach to gastrostomy in infants. LEVEL OF EVIDENCE Case-Control Study/Retrospective Comparative Study - Level III.
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Affiliation(s)
- Rachel M Landisch
- Children's Research Institute and Children's Hospital of Wisconsin, Milwaukee, WI 53226; Medical College of Wisconsin, Milwaukee, WI 53226.
| | - Ryan C Colwell
- Children's Research Institute and Children's Hospital of Wisconsin, Milwaukee, WI 53226
| | - John C Densmore
- Children's Research Institute and Children's Hospital of Wisconsin, Milwaukee, WI 53226; Medical College of Wisconsin, Milwaukee, WI 53226
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16
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Resource utilization after implementing a hospital-wide standardized feeding tube placement pathway. J Pediatr Surg 2016; 51:1674-9. [PMID: 27306489 DOI: 10.1016/j.jpedsurg.2016.05.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 04/19/2016] [Accepted: 05/20/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND/PURPOSE Children requiring gastrostomy/gastrojejunostomy tubes (GT/GJ) are heterogeneous and medically complex patients with high resource utilization. We created and implemented a hospital-wide standardized pathway for feeding device placement. This study compares hospital resource utilization before and after pathway implementation. METHODS We performed a retrospective cohort study comparing outcomes through one year of follow-up for consecutive groups of children undergoing GT/GJ placement prepathway (n=298, 1/1/2010-12/31/2011) and postpathway (n=140, 6/1/2013-7/31/2014) implementation. We determined the change in the rate of hospital resource utilization events and time to first event. RESULTS Prior to implementation, 145 (48.7%) devices were placed surgically, 113 (37.9%) endoscopically and 40 (13.4%) using image guidance. After implementation, 102 (72.9%) were placed surgically, 23 (16.4%) endoscopically and 15 (10.7%) using image guidance. Prior to implementation, 174/298 (58.4%) patients required additional hospital resource utilization compared to 60/143 (42.0%) corresponding to a multivariate adjusted 38% reduced risk of a subsequent feeding tube related event. CONCLUSIONS Care of tube-feeding dependent patients is spread among multiple specialists leading to variability in the preoperative workup, intraoperative technique and postoperative care. Our study shows an association between implementation of a standardized pathway and a decrease in hospital resource utilization.
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17
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Petrosyan M, Khalafallah AM, Franklin AL, Doan T, Kane TD. Laparoscopic Gastrostomy Is Superior to Percutaneous Endoscopic Gastrostomy Tube Placement in Children Less Than 5 years of Age. J Laparoendosc Adv Surg Tech A 2016; 26:570-3. [PMID: 27268954 DOI: 10.1089/lap.2016.0099] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
PURPOSE Minimally invasive procedures for enteral access in children have evolved over the years, resulting in various techniques of gastrostomy tube placement. The two most common techniques are laparoscopic gastrostomy (LG) and percutaneous endoscopic gastrostomy (PEG). Our study compares the outcomes of both procedures exclusively in children under the age of five. METHODS All procedures relating to enteral access in children <5 years of age were reviewed retrospectively from July 2009 to July of 2014 as approved by our Institutional Review Board. Demographics, techniques, and complications were collected and analyzed. RESULTS Of 293 patients in our study, 150 patients underwent PEG, 75 LG, and 68 LG with Nissen fundoplication (LNG). The most common indication for enteral tube placement was failure to thrive and feeding intolerance. Operative time was less in the PEG group than in the other two groups (P = .001). Overall complication rate was 60% for LG and LNG and 58% for PEG (P = NS). The major complication rate was 3.3% in the PEG group and 0.7% for the LG and LNG groups. There were two deaths in the PEG group. Sixty-eight patients (45.3%) from the PEG group underwent tube changes under anesthesia, requiring additional trip to the operating room with general anesthesia compared with LG and LNG groups (2%) (P = .001). From the PEG group, 134 patients (89%) required many fluoroscopic interventions for tube dislodgments and conversion to gastrojejunostomy tubes for significant reflux and inability to use the gastrostomy (P = .001). CONCLUSION PEG tubes had a higher major complication rate than LG tubes with or without fundoplication in children <5 years of age. Despite longer operative time, LG seems to be the procedure of choice for children of this age for enteral access. Elimination of unnecessary tube changes under anesthesia and the fluoroscopic interventions after the PEG would be beneficial.
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Affiliation(s)
- Mikael Petrosyan
- Department of General and Thoracic Surgery, Children's National Health System , Washington, District of Columbia
| | - Adham M Khalafallah
- Department of General and Thoracic Surgery, Children's National Health System , Washington, District of Columbia
| | - Ashanti L Franklin
- Department of General and Thoracic Surgery, Children's National Health System , Washington, District of Columbia
| | - Tina Doan
- Department of General and Thoracic Surgery, Children's National Health System , Washington, District of Columbia
| | - Timothy D Kane
- Department of General and Thoracic Surgery, Children's National Health System , Washington, District of Columbia
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18
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Fluoroscopy-guided Percutaneous Endoscopic Gastrostomy in Children. Surg Laparosc Endosc Percutan Tech 2016; 26:167-70. [DOI: 10.1097/sle.0000000000000255] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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Suksamanapun N, Mauritz FA, Franken J, van der Zee DC, van Herwaarden-Lindeboom MY. Laparoscopic versus percutaneous endoscopic gastrostomy placement in children: Results of a systematic review and meta-analysis. J Minim Access Surg 2016; 13:81-88. [PMID: 27251841 PMCID: PMC5363129 DOI: 10.4103/0972-9941.181776] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) and laparoscopic-assisted gastrostomy (LAG) are widely used in the paediatric population. The aim of this study was to determine which one of the two procedures is the most effective and safe method. METHODS: This systematic review was conducted according to the preferred reporting items for systematic reviews and meta-analyses statement. Primary outcomes were success rate, efficacy of feeding, quality of life, gastroesophageal reflux and post-operative complications. RESULTS: Five retrospective studies, comparing 550 PEG to 483 LAG placements in children, were identified after screening 2347 articles. The completion rate was similar for both procedures. PEG was associated with significantly more adjacent bowel injuries (P = 0.047), early tube dislodgements (P = 0.02) and complications that require reintervention under general anaesthesia (P < 0.001). Minor complications were equally frequent after both procedures. CONCLUSIONS: Because of the lack of well-designed studies, we have to be cautious in making definitive conclusions comparing PEG to LAG. To decide which type of gastrostomy placement is best practice in paediatric patients, randomised controlled trials comparing PEG to LAG are highly warranted.
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Affiliation(s)
- Nutnicha Suksamanapun
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Femke A Mauritz
- Department of Pediatric Surgery, Wilhelmina Children's Hospital; Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Josephine Franken
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - David C van der Zee
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, Utrecht, The Netherlands
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20
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Abstract
Placement of gastrostomy tubes in infants and children has become increasingly commonplace. A historical emphasis on use of open gastrostomy has been replaced by less invasive methods of placement, including percutaneous endoscopic gastrostomy and laparoscopically assisted gastrostomy procedures. Various complications, ranging from minor to the more severe, have been reported with all methods of placement. Many pediatric patients who undergo gastrostomy tube placement will require long-term enteral therapy. Given the prolonged time pediatric patients may remain enterally dependent, further quality improvement and education initiatives are needed to improve long-term care and outcomes of these patients.
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Affiliation(s)
- Maireade E McSweeney
- Division of Gastroenterology and Nutrition, Department of Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - C Jason Smithers
- Department of General Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
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21
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Gonzalez-Hernandez J, Daoud Y, Fischer AC, Barth B, Piper HG. Endoscopic button gastrostomy: Comparing a sutured endoscopic approach to the current techniques. J Pediatr Surg 2016; 51:72-5. [PMID: 26552896 DOI: 10.1016/j.jpedsurg.2015.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 10/06/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE Button gastrostomy is the preferred feeding device in children and can be placed open or laparoscopically (LBG). Alternatively, a percutaneous endoscopic gastrostomy (PEG) can be placed initially and exchanged for a button. Endoscopic-assisted button gastrostomy (EBG) combines both techniques, using only one incision and suturing the stomach to the abdominal wall. The long-term outcomes and potential costs for EBG were compared to other techniques. METHODS Children undergoing EBG, LBG, and PEG (2010-2013) were compared. Patient demographics, procedure duration/complications, and clinic and emergency room (ER) visits for an eight-week follow-up period were compared. RESULTS Patient demographics were similar (32 patients/group). Mean procedure time (min) for EBG was 38 ± 9, compared to 58 ± 20 for LBG and 31 ± 10 for PEG (p<0.0001). The most common complications were granulation tissue and infection with a trend toward fewer infections in EBG group. Average number of ER visits was similar, but PEG group had fewer clinic visits. 97% of PEG patients had subsequent visits for exchange to button gastrostomy. CONCLUSIONS EBG is safe and comparable to LBG and PEG in terms of complications. It has a shorter procedure time than LBG and does not require laparoscopy, device exchange, or subsequent fluoroscopic confirmation, potentially reducing costs.
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Affiliation(s)
| | - Yahya Daoud
- Department of Surgery, Baylor University Medical Center, Dallas, TX, USA
| | - Anne C Fischer
- Department of Pediatric Surgery, Beaumont Children's Hospital, Royal Oak, MI, USA
| | - Bradley Barth
- Division of Gastroenterology, University of Texas Southwestern/Children's Health, Children's Medical Center, Dallas, TX, USA
| | - Hannah G Piper
- Division of Pediatric Surgery, University of Texas Southwestern/Children's Health, Children's Medical Center, Dallas, TX, USA.
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22
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McSweeney ME, Kerr J, Jiang H, Lightdale JR. Risk factors for complications in infants and children with percutaneous endoscopic gastrostomy tubes. J Pediatr 2015; 166:1514-9.e1. [PMID: 25868432 DOI: 10.1016/j.jpeds.2015.03.009] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 01/26/2015] [Accepted: 03/04/2015] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To identify risk factors associated with percutaneous endoscopic gastrostomy (PEG) tube complications in a large cohort of infants and children. STUDY DESIGN We performed a chart review of 591 pediatric patients undergoing PEG tube placement between 2006 and 2010 at Boston Children's Hospital. Frequency and type of major and minor complications associated with PEG tubes in children were identified. Univariate and multivariate analyses were then conducted to determine potential risk factors for complications. RESULTS A total of 198 PEG-related complications (72 major and 126 minor) were noted in our cohort of 591 patients. Approximately 10.5% of patients experienced at least one major complication and 16.4% experienced at least one minor complication, with the great majority of complications occurring after discharge postplacement. Age <6 months (P = .003), American Society of Anesthesiologists class III (P = .02), and presence of a neurologic disorder (P = .05) were found to be protective against experiencing a major complication, whereas the presence of a ventriculoperitoneal shunt was confirmed to be a risk factor (P = .01) for major complications. CONCLUSION Both minor and major complications are common in children after PEG tube placement, with most complications occurring several months postoperatively. Certain patient factors, including age, neurologic status, and American Society of Anesthesiologists class, may be protective, and the presence of a ventriculoperitoneal shunt may be associate with an increased risk of complications after PEG tube placement.
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Affiliation(s)
- Maireade E McSweeney
- Division of Gastroenterology, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA.
| | - Jessica Kerr
- Division of Gastroenterology, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Hongyu Jiang
- Division of Gastroenterology, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Jenifer R Lightdale
- Pediatric Gastroenterology and Nutrition, UMass Memorial Children's Medical Center, Worcester, MA
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23
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Seifarth FG, Dong ML, Guerron AD, Lozada JS, Magnuson DK. Endoscopic gastrostomy button with double-lasso U-stitch in children. JSLS 2015; 19:e2015.00002. [PMID: 25848198 PMCID: PMC4379868 DOI: 10.4293/jsls.2015.00002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Placement of surgical gastric access is a common operative procedure, with multiple techniques. We describe a cost-effective, safe, and easy-to-perform primary endoscopic gastrostomy button placement in the pediatric population, using a novel double-transcutaneous lasso U-stitch push technique. METHODS This is a retrospective review of a single center's experience of 24 consecutively performed primary gastrostomy button placements in infants and children aged 3 weeks to 20 years, from October 2012 through October 2014. RESULTS The procedure was generally well tolerated, with no intraoperative complications. No conversions to laparoscopic or open procedures were necessary. There were no early tube dislodgements and no postoperative complications within the first 4 weeks. CONCLUSION The endoscopic primary gastrostomy button placement with a transcutaneous lasso U-stitch is a safe, fast, elegant, and cost-effective alternative to a standard percutaneous endoscopic gastrostomy placement.
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Affiliation(s)
- Federico G Seifarth
- Department of Pediatric Surgery, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Matthew L Dong
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Alfredo D Guerron
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jose S Lozada
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - David K Magnuson
- Department of Pediatric Surgery, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
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24
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Engelmann G, Wenning D, Fertig E, Lenhartz H, Hoffmann GF, Teufel U. Antibiotic prophylaxis in the management of percutaneous endoscopic gastrostomy in infants and children. Pediatr Int 2015; 57:295-8. [PMID: 25243971 DOI: 10.1111/ped.12508] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 07/30/2014] [Accepted: 09/11/2014] [Indexed: 01/15/2023]
Abstract
BACKGROUND In randomized controlled trials in adult patients the use of prophylactic broad-spectrum antibiotic reduces the number of insertion site and systemic infections, associated with placement of percutaneous endoscopic gastrostomy (PEG) tubes. For pediatric patients no such trials exist. The aim of this study was to assess the value of antibiotic prophylaxis in PEG placement in pediatric patients. METHODS In a retrospective chart review PEG placement in infants and children performed in a tertiary care center was analyzed. All PEG procedures were performed by an experienced pediatric gastroenterologist using the pull-through technique under general anesthesia. RESULTS A total of 103 procedures were analyzed; 33 patients received antibiotic prophylaxis and 70 did not. Two (6%) of the patients receiving prophylaxis developed local or systemic infections after PEG placement, whereas seven (10%) without prophylaxis suffered from a PEG-related infection. This difference was not significant on chi-squared test (P = 0.5). Sixty patients had a body temperature >38°C within the first 3 days after the PEG procedure. A total of 77% of these patients had no antibiotic prophylaxis. Mean body temperature differed significantly between patients with and without prophylaxis (37.9°C vs. 38.3°C, respectively; P = 0.02). CONCLUSIONS The incidence of PEG-related local or systemic infection after PEG-placement was not significantly different between patients with and without antibiotic prophylaxis, but the latter had a significantly higher mean body temperature after the PEG procedure. Taking elevated mean body temperature as a marker for putative bacteremia it is suggested that antibiotic prophylaxis is indicated in all pediatric patients after PEG placement.
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25
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Viktorsdóttir MB, Óskarsson K, Gunnarsdóttir A, Sigurdsson L. Percutaneous Endoscopic Gastrostomy in Children: A Population-Based Study from Iceland, 1999–2010. J Laparoendosc Adv Surg Tech A 2015; 25:248-51. [DOI: 10.1089/lap.2014.0296] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Kristján Óskarsson
- Department of Pediatric Surgery, Astrid Lindgren Children Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Gunnarsdóttir
- Department of Pediatric Surgery, Astrid Lindgren Children Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Pediatric Surgery, Landspitali University Hospital, Reykjavík, Iceland
| | - Luther Sigurdsson
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin—Madison, Madison, Wisconsin
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26
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Guanà R, Lonati L, Barletti C, Cisarò F, Casorzo I, Carbonaro G, Lezo A, Delmonaco AG, Mussa A, Capitanio M, Cussa D, Lemini R, Schleef J. Gastrostomy Intraperitoneal Bumper Migration in a Three-Year-Old Child: A Rare Complication following Gastrostomy Tube Replacement. Case Rep Gastroenterol 2015; 8:381-6. [PMID: 25565933 PMCID: PMC4280460 DOI: 10.1159/000369964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Feeding gastrostomy is used worldwide for adults and children with feeding impairment to obtain long-term enteral nutrition. Percutaneous endoscopic gastrostomy insertion is considered the gold standard, but after the first months requires gastrostomy tube replacement with a low-profile button. The replacement is known as an easy procedure, but several minor and major complications may occur during and after the manoeuvre. We describe intraperitoneal bumper migration in a 3-year-old boy, a rare complication following gastrostomy tube replacement, and we discuss the recent literature regarding similar cases.
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Affiliation(s)
- Riccardo Guanà
- Division of Pediatric General Surgery, Regina Margherita Children's Hospital, Turin, Italy
| | - Luca Lonati
- Division of Pediatric General Surgery, Regina Margherita Children's Hospital, Turin, Italy
| | - Claudio Barletti
- Division of Pediatric Gastroenterology, Regina Margherita Children's Hospital, Turin, Italy
| | - Fabio Cisarò
- Division of Pediatric Gastroenterology, Regina Margherita Children's Hospital, Turin, Italy
| | - Ilaria Casorzo
- Division of Pediatric Radiology, Regina Margherita Children's Hospital, Turin, Italy
| | - Giulia Carbonaro
- Division of Pediatric General Surgery, Regina Margherita Children's Hospital, Turin, Italy
| | - Antonella Lezo
- Division of Nutrition, Regina Margherita Children's Hospital, Turin, Italy
| | | | - Alessandro Mussa
- Department of Pediatrics, Regina Margherita Children's Hospital, Turin, Italy
| | - Martina Capitanio
- Division of Pediatric General Surgery, Regina Margherita Children's Hospital, Turin, Italy
| | - Davide Cussa
- Division of Pediatric General Surgery, Regina Margherita Children's Hospital, Turin, Italy
| | - Riccardo Lemini
- Division of Pediatric General Surgery, Regina Margherita Children's Hospital, Turin, Italy
| | - Jürgen Schleef
- Division of Pediatric General Surgery, Regina Margherita Children's Hospital, Turin, Italy
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ESPGHAN position paper on management of percutaneous endoscopic gastrostomy in children and adolescents. J Pediatr Gastroenterol Nutr 2015; 60:131-41. [PMID: 25023584 DOI: 10.1097/mpg.0000000000000501] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVES This European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) position statement provides a comprehensive guide for health care providers to manage percutaneous endoscopic gastrostomy tubes in a safe, effective, and appropriate way. METHODS Relevant literature from searches of PubMed, CINAHL, and recent guidelines was reviewed. In the absence of evidence, recommendations reflect the expert opinion of the authors. Final consensus was obtained by multiple e-mail exchange and during 3 face-to-face meetings of the gastroenterology committee of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. RESULTS Endoscopically placed gastrostomy devices are essential in the management of children with feeding and nutritional problems. The article focuses on practical issues such as indications and contraindications. CONCLUSIONS The decision to place an endoscopic gastrostomy has to be made by an appropriate multidisciplinary team, which then provides active follow-up and care for the child and the device.
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Gang MH, Kim JY. Short-Term Complications of Percutaneous Endoscopic Gastrostomy according to the Type of Technique. Pediatr Gastroenterol Hepatol Nutr 2014; 17:214-22. [PMID: 25587521 PMCID: PMC4291446 DOI: 10.5223/pghn.2014.17.4.214] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Revised: 10/13/2014] [Accepted: 10/17/2014] [Indexed: 01/16/2023] Open
Abstract
PURPOSE The method of percutaneous endoscopic gastrostomy (PEG) tube placement can be divided into the pull and introducer techniques. We compared short-term complications and prognosis between patients who underwent the pull technique and two other types of introducer techniques, the trocar introducer technique and T-fastener gastropexy technique. METHODS Twenty-six patients who underwent PEG were enrolled in this study. We retrospectively investigated the age, sex, body weight, weight-for-age Z-score, underlying diseases, PEG indications, complications, duration of NPO (nil per os), pain control frequency, and duration of antibiotic therapy. The patients were classified into three groups according to the PEG technique. The occurrence of complications was monitored for 10 weeks after the procedure. RESULTS The age, sex, body weight, and weight-for-age Z-score were not significantly between the three groups. Most patients had cerebral palsy and seizure disorders. Dysphagia was the most common indication for PEG. Major complications occurred in 5 (50%), 4 (66.7%), and 0 (0%) patients in group I, II, and III, respectively (p=0.005). Further, peristomal infection requiring systemic antibiotic therapy occurred in 2 (20%), 3 (50%), and 0 (0%) patients in group I, II, and III, respectively (p=0.04). There was no significant difference between the groups with respect to minor complications, duration of NPO, pain control frequency, and duration of antibiotic therapy. CONCLUSION The results indicate that the T-fastener gastropexy technique was associated with the lowest rate of major complications.
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Affiliation(s)
- Mi Hyeon Gang
- Department of Pediatrics, Chungnam National University School of Medicine, Daejeon, Korea
| | - Jae Young Kim
- Department of Pediatrics, Chungnam National University School of Medicine, Daejeon, Korea
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Franken J, Mauritz FA, Suksamanapun N, Hulsker CCC, van der Zee DC, van Herwaarden-Lindeboom MYA. Efficacy and adverse events of laparoscopic gastrostomy placement in children: results of a large cohort study. Surg Endosc 2014; 29:1545-52. [DOI: 10.1007/s00464-014-3839-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 08/19/2014] [Indexed: 11/28/2022]
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Single-center experience with 1-step low-profile percutaneous endoscopic gastrostomy in children. J Pediatr Gastroenterol Nutr 2014; 58:616-20. [PMID: 24378575 DOI: 10.1097/mpg.0000000000000291] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The 1-step low-profile percutaneous endoscopic gastrostomy (1-step PEG) uses a single procedure that allows immediate use of a low-profile device. The aim of the present study was to provide our experience with this device and to analyze complications and outcomes after the initial placement. METHODS We performed a retrospective chart review of pediatric patients with 1-step PEG placement done by our pediatric gastroenterologists between 2006 and June 2011. Patients were studied for a minimum period of 6 months. RESULTS A total of 121 patients were included in our study, with 23% infants. The most common indication for 1-step PEG placement was swallowing dysfunction in children with neurological impairment (49%). Postplacement complications included granulation tissue (52%), cellulitis (23%), leakage (21%), vomiting (17%), tissue breakdown (8%), failed placement (6%), embedded bolster (5%), perforation (0.8%), and bowel obstruction (0.8%). One-step PEG was maintained in 46 patients (38%). In the remaining 75 patients (62%), PEGs were changed to a balloon device in 66 patients and were completely removed in 9 patients. The most common indications for change were damaged PEG (19/75) and issues with size (11/75). The time to change ranged from <1 month to >4 years (14 ± 1.3 months). Sixty-eight percent of 1-step PEG changes/removal was performed with an obturator under brief inhalated anesthesia. CONCLUSIONS The 1-step PEG has complication rates and outcomes comparable with standard PEGs.
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Pediatric endoscopic gastrostomy tubes: outcomes that guide decision making. J Pediatr Gastroenterol Nutr 2014; 58:5-6. [PMID: 24135981 DOI: 10.1097/mpg.0000000000000212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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