Complications of retained internal bolster after pediatric percutaneous endoscopic gastrostomy

The "cut and push" method of removing percutaneous endoscopic gastrostomy tube is not safe in paediatric patients

PURPOSE

A "cut and push" (CP) approach has been described in the literature for removal of percutaneous endoscopic gastrostomy (PEG) tubes. The aim of this study is to investigate the safety profile of this method in children.

METHOD

Our study included all children who underwent CP procedure for either removal or replacement of Freka PEG tube at our centre between January 2016 and August 2021. Parents contacted to establish if the internal component had been seen in the stools post-procedure. If not seen, a plain film of chest, abdomen and pelvis was arranged followed by computerised tomography (CT) scan. The presence of the internal component as a retained foreign body on imaging was evaluated along with any complication.

RESULTS

Of the 27 patients included, six (22.2%) patients had the internal component seen in the stool. Five (18.5%) patients in total had a retained internal component with three (11.1%) patients had major complications requiring complex surgical interventions, and two (7.4%) patients required endoscopic retrieval.

CONCLUSION

Our study reports more severe complications that required complex surgical interventions compared to the previous studies. We believe that this method of removal is not safe in children and should be abandoned. Also, patients with Down syndrome might be at higher risk of retention and complications.

‘Cut and push’ as an alternative to endoscopic retrieval of PEG type gastrostomy tubes

PURPOSE

Percutaneous Endoscopically placed Gastrostomy (PEG) tubes are frequently used in children. The traditional endoscopic method to remove/change the PEG device requires general anaesthesia in children. A minimally invasive alternative is the 'Cut and Push' method (C&P): avoiding the risks/wait times of general anaesthesia and reducing resource burden. Data regarding the safety/effectiveness of C&P in children are lacking with concerns raised about the possibility of gastrointestinal obstruction.

METHODS

We retrospectively reviewed all cases of PEG removal / change to button in children (< 18 years) between December 2020 and January 2022. Cases were identified from a prospectively maintained database and all cases of C&P included. Parents/carers were asked if the child had suffered any complications following C&P and if flange was visualised in stools.

RESULTS

During the time period, 27 PEGs were either removed or changed to button via C&P. The average waiting time for C&P was 14.29 days, significantly shorter than the minimum 6-month waiting time for elective endoscopy. Our evaluation revealed no complications of C&P at median 70 days (range 25-301). In three cases the flange was visualised in the stool, at 2 days, 3 days and 5 weeks following C&P respectively.

DISCUSSION

These data support the available literature suggesting C&P is an effective means to facilitate minimally invasive and prompt PEG removal/change to button in children. We recommend minimum weight and age parameters for this procedure and further evaluation of the safety and resource implications of this technique.

Replacing gastrostomy tubes with collapsible bumpers in pediatric patients: Is it safe to "cut" the tube and allow the bumper to pass enterally?

PURPOSE

The "cut and push" technique for removal of percutaneous endoscopic gastrostomy (PEG) tubes with collapsible bumpers offers an alternative to the standard traction method of removal. This study compared the outcomes of these techniques.

METHODS

We completed a research ethics board-approved retrospective cohort study, identifying all patients less than 18years of age who underwent PEG tube removal at a children's hospital between December 2013 and December 2016. Outcomes included need for sedation and complications.

RESULTS

We identified 127 children who had PEG tubes removed. Significantly fewer children required sedation with the cut and push group (1.1% vs. 60.6%, p≤0.001). Ten complications occurred, including 9 in the cut and push group (9.6% vs. 3%, p=0.23). Mean age at time of complication was significantly younger in the cut and push group (2.2 vs. 6.3years p=0.004).

CONCLUSION

This is the largest reported series comparing the cut and push vs. traction removal methods. The cut and push technique significantly reduced the need for procedural sedation but was associated with increased risk of complications. While these data suggest that the technique is safe in older children, caution should be taken in younger children who appear to be more likely to vomit the residual bumper.

LEVELS OF EVIDENCE

Level III-Treatment study, Retrospective comparative study.

Adverse events associated with percutaneous enteral access

Placement of percutaneous endoscopic gastrostomy or jejunostomy is a safe procedure with low periprocedural mortality, but overall mortality rates are high because of underlying disease conditions. These procedures are also associated with postprocedure complications. The clinically significant adverse events related to the procedures include infection (at tube site and peritonitis), bleeding, and aspiration. More rare associated events include buried bumpers, injury to adjacent viscera with subsequent fistula formation, and tumor seeding. There is a lack of guidelines about these procedures other than those concerning the use of antibiotics and the management of antithrombotics and anticoagulation before the procedure.

Hidden treasure in an endoscopically retrieved oesophageal trichobezoar

A 12-year-old girl with Smith-Lemli-Opitz syndrome and gastrostomy dependency presented with multiple episodes of coffee ground vomits. An upper gastrointestinal endoscopy revealed a trichobezoar in the lower oesophagus, with a 'hidden treasure'-a retained end of a G tube at the core. Endoscopic retrieval led to resolution of symptoms. Literature is scant with only one previous report of an oesophageal trichobezoar. Techniques of removal of percutaneous endoscopic gastrostomy in children are reviewed. The pathogenesis, preventative measures and management for oesophageal trichobezoars are discussed.

Complications of percutaneous endoscopic gastrostomy in children: results of an Italian multicenter observational study

BACKGROUND

Percutaneous endoscopic gastrostomy is the preferred way to achieve an artificial feeding route for patients requiring long-term enteral nutrition. Although the procedure is well-standardized, it carries early and late complications.

AIM

To establish the mortality and morbidity of this technique in a large cohort of children.

METHODS

A multi-centre prospective clinical data collection from children undergoing percutaneous endoscopic gastrostomy tube implantation has been conducted from January 2004 to December 2007. Previous abdominal surgery was the only exclusion criterion. Follow-up visits were carried out at 1, 3, 6, 12, and 24 months after the procedure.

RESULTS

239 children (males, 55.2%; mean age 6.05±6.1years) were enrolled from nine tertiary Italian centres. Major complications occurred in 8 patients (3.3%). The cumulative incidence of complications was 47.7% at 24 months. The presence of thoraco-abdominal deformity was an independent predictor of complications at 12 months. No risk factors were identified in association to complications during the 1st tube replacement.

CONCLUSION

In children undergoing percutaneous endoscopic gastrostomy placement minor complications are common, while severe morbidities are rare. Accurate follow up is essential to recognize every complication, in particular when risk factors such as thoraco-abdominal deformity exist.

Traction removal of percutaneous endoscopic gastrostomy devices in children

BACKGROUND

There are few published data on non-endoscopic removal of percutaneous endoscopic gastrostomy devices in children.

AIMS

To describe prospective data acquired for traction removal of percutaneous endoscopic gastrostomy devices at a single pediatric center over a 5-year period.

METHODS

Data were obtained from endoscopy records, computerized hospital patient information systems and case note analysis. The device that could be removed by traction was the Corflo (Merck) 12-Fr percutaneous endoscopic gastrostomy tube with a collapsible internal retention dome. All procedures were performed under general anesthesia.

RESULTS

Between 2002-2006, 220 children underwent percutaneous endoscopic gastrostomy removals (166 by traction, 51 endoscopically and 3 Foley catheter to button conversions). The median duration between percutaneous endoscopic gastrostomy insertion and low profile button device substitution was 0.83 years (0.12-3.86). Complications from traction removal included internal retention dome separation in two cases (allowed to pass per rectum, uneventfully), failure to a insert a low profile button device needing percutaneous endoscopic gastrostomy reinsertion, enterocutaneous fistula requiring surgical closure in one patient and laparoscopy for suspected low profile button device misplacement in one instance. The material cost of endoscope disinfection (£10) and disposable usage (£80) avoided by traction removal was calculated at £90 per procedure.

CONCLUSION

No mortality occurred as a result of the traction removal of percutaneous endoscopic gastrostomy tubes. Laparoscopy for suspected low profile button device misplacement was needed in one case (0.60%). Traction removal of percutaneous endoscopic gastrostomy tubes was generally safe and a cost-saving procedure in our experience.

A simple adjunct for safer change of PEG

Percutaneous endoscopic gastrostomy (PEG) is a procedure commonly performed in children who require long-term enteral nutritional support. Although simple, PEG insertion carries the risk of severe and potentially life-threatening complications. Attention to detail is paramount in preventing such complications. Removal is also associated with complications. We describe a simple and inexpensive technique, just requiring a loop nylon suture, which is a useful adjunct to standard endoscopic removal or change of PEG. This modified technique is particularly useful in the untoward event of gastric separation from the anterior abdominal wall during gastrostomy tract dilatation or insertion of the new button device.

Complications of removing percutaneous endoscopic gastrostomy tubes in children

BACKGROUND

Little information has been reported regarding the frequency and type of complications arising from removal of percutaneous endoscopic gastrostomy (PEG) tubes in children.

METHODS

The records of 397 patients who had PEG tubes placed from 1993 through 1998 were reviewed for complications after removal. Data collected included length of time the tube was in place, age of the patient at insertion, type of tube removed, and patient diagnosis.

RESULTS

Fifty-four children had the PEG tube removed by traction or endoscopy. The only complication was persistent leaking through a gastrocutaneous fistula in 13 patients (24%). Leaking ceased in 6 children coincident with H2-antagonist therapy and silver nitrate cautery, and surgical closure of the fistula was required in 7 patients. Comparison of these 7 children with those who did not require surgery (n = 47) showed a longer duration of tube placement (mean +/- SE of 20.6+/-3.6 months, range 11-31 months vs. 11.1+/-1.3 months, range 1-35 months; P<0.05). Further analysis showed no child with a PEG tube removed before 11 months (n = 23) after insertion required surgery, whereas 7 (23%) of 31 children with a PEG tube removed after 11 or more months required surgery. Age at insertion, type of feeding device removed, and patient diagnoses were not different between the two groups.

CONCLUSIONS

These data indicate that persistent leaking necessitating surgical closure of a gastrocutaneous fistula does not occur in children with a PEG tube removed within 11 months of insertion. In contrast, 23% of children with a PEG tube removed 11 or more months after insertion require surgery. In patients identified as candidates for tube removal, this time frame may be important in clinical decision making.