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

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.

Pediatric Craniofacial Tumor Reconstruction

Effective management of pediatric craniofacial tumors requires coordinated input from medical, oncologic, and surgical specialties. Reconstructive algorithms must consider limitations in pediatric donor tissue and account for future growth and development. Immediate reconstruction is often focused on filling dead space, protecting underlying structures, and ensuring skeletal symmetry. Staged reconstruction occurs after the patient has reached skeletal maturity and is focused on restoring permanent dentition. Reconstructive options vary depending on the location, size, and composition of resected tissue. Virtual surgical planning (VSP) reduces the complexity of pediatric craniofacial reconstruction and ensures more predictable outcomes.

[The Need of Evidence-Based Treatment of Early-Onset Feeding Tube Dependency: A Pico- Framework Based Analytic Review of Clinical Features and Treatment of Feeding Tube Dependency]

Feeding Tube Dependency is a constant increasing perinatal mental health condition, with estimated 350 new cases per year in Germany.The early onset feeding tube dependency is the consequence of a generalized food aversion. To establish an evidence-based nationwide treatment plan, relevant research from the past twenty years were narratively reviewed. Feeding tube dependency is an international increasingmental health condition, with a high symptom persistence and a low spontaneous remission. The generalized food aversion would prevent the transition to oral feeding.The treatment protocols, supported by the German Health System, based on low-frequency individual treatment and intensive inpatient treatments are not supported by the most recent evidence. In treatment outcome research more promising and effective programs can be distinguished from ineffective programs. As a result, treatment which are designed as intensive treatment, home-based or inpatient and are psychodynamicbased are most effective. Day-clinic and behavioral modification programs are not or low in treatment effectiveness.The German Health System approach to assist families with feeding tube dependency is not evidence-based. A new structure of treatment is imperatively required.

Advances and challenges of gastrostomy insertion in children

When oral feeding cannot provide adequate nutritional support to children, enteral tube feeding becomes a necessity. The overall aim is to ultimately promote appropriate growth, improve the patient's quality of life and increase carer satisfaction. Nasogastric tube feeding is considered appropriate on a short-term basis. Alternatively, gastrostomy feeding offers a more convenient and safer feeding option especially as it does not require frequent replacements, and carries a lower risk of complications. Gastrostomy tube feeding should be considered when nasogastric tube feeding is required for more than 2-3 wk as per the ESPEN guidelines on artificial enteral nutrition. Several techniques can be used to insert gastrostomies in children including endoscopic, image guided and surgical gastrostomy insertion whether open or laparoscopic. Each technique has its own advantages and disadvantages. The timing of gastrostomy insertion, device choice and method of insertion is dependent on the local expertise, patient requirements and family preference, and should be individualized with a multidisciplinary team approach. We aim to review gastrostomy insertion in children including indications, contraindications, history of gastrostomy, insertion techniques and complications.

The Community Cost of Maintaining Gastrostomies in Pediatric Patients

The use of gastrostomies in children is increasing and their need for long-term management following insertion presents a potentially significant financial and resource challenge to local healthcare systems.

Objectives

The aim of this study was to determine the yearly cost of maintaining a gastrostomy in a pediatric patient.

Methods

A retrospective, bottom-up cost-analysis was conducted in a cohort of 180 patients with gastrostomies aged 0-19 years. One in 5 patients were randomly selected for individual cost analysis (n = 36). Their electronic health record was interrogated from the period of March 1, 2019-March 1, 2020. Costs included in the analysis were staff contact time from the community nursing and nutrition teams, and equipment costs.

Results

The mean cost of maintaining a pediatric gastrostomy across all ages was £709.87 (SD 403.18) per year. Mean annual cost varied by age, underlying diagnosis, and gastrostomy device, but this variation was only statistically significant for the type of device, with Mic-Key buttons having a mean annual cost of £834.66 (SD 307.85), Mini buttons £799.06 (SD 395.01), and percutaneous endoscopic gastrostomy tubes £279.34 (SD 297.45; P = 0.004).

Conclusion

The mean cost of maintaining a gastrostomy in a pediatric patient is just over £700 per year. The cost is the highest as a child enters adulthood. Button devices have higher maintenance costs compared with percutaneous endoscopic gastrostomy tubes.

Comparison of general endotracheal anesthesia versus sedation without endotracheal intubation during initial percutaneous endoscopic gastrostomy insertion for infants: A retrospective cohort study

BACKGROUND

Critical airway incidents are a major cause of morbidity and mortality during anesthesia. Delayed management of airway obstruction quickly leads to severe complications due to the reduced apnea tolerance in infants and neonates. The decision of whether to intubate the trachea during anesthesia is therefore of great importance, particularly as an increasing number of procedures are performed outside of the operating room.

AIM

In this retrospective cohort study, we evaluated airway management for infants below 6 months of age undergoing percutaneous endoscopic gastrostomy insertion. We compared demographic, procedural, and health outcome-related data for infants undergoing percutaneous endoscopic gastrostomy insertion under general endotracheal anesthesia (n = 105) to those receiving monitored anesthesia care (n = 44) without endotracheal intubation.

METHODS

A retrospective chart review was completed for all infants <6 months of age who underwent percutaneous endoscopic gastrostomy insertion in our institution's endoscopy suite between January 2002 and January 2017. Descriptive statistics summarized numeric variables using medians and corresponding ranges (minimum-maximum), and categorical variables using frequencies and percentages. Differences in study outcomes between patients undergoing general anesthesia or monitored anesthesia care were evaluated with univariate quantile or Firth logistic regression for numerical and categorical outcomes, respectively. Results are presented as β [95% confidence interval] or odds ratio [95% confidence interval] along with corresponding p-values.

RESULTS

Both groups were similar in distribution of age, race, and gender. However, patients selected for general anesthesia had lower median body weights (3.9 kg [range: 2.0-6.7] vs. 4.4 kg [range: 2.6-6.9]), higher percentages of cardiac (95.2% vs. 84.1%), and/or neurologic comorbidities (74.3% vs. 56.8%) and were more frequently given American Society of Anesthesiologists level IV classifications (41.9% vs. 29.6%) indicating that these infants may have had more severe disease than patients selected for monitored anesthesia care. Three monitored-anesthesia-care patients required intraoperative conversion to general anesthesia. General anesthesia patients experienced greater odds of intraoperative hypoxemia (45.2% vs. 29.0%; odds ratio: 2.0 [0.9-4.3], p-value: .09) and required postoperative airway intervention more frequently than monitored-anesthesia-care patients (13.03% vs. 2.3%; odds ratio: 4.6 [0.8-25.6], p-value: .08). Procedure times were identical in both groups (6 min), but general anesthesia resulted in longer median anesthesia times (44 min [range: 22-292] vs. 12 min [range:19-136]; β:13 [95% 6.9-19.1], p-value: < .001).

CONCLUSION

Study results suggest that providers selected general anesthesia over monitored anesthesia care for infants and neonates with low body weights, cardiac comorbidities, and neurologic comorbidities. Increased rates of airway intervention, and increased length of stay may be at least partially related to more severe patient comorbidity, as indicated by higher American Society of Anesthesiologists classifications. However, due to the exploratory nature of these analyses, further confirmatory studies are needed to evaluate the impact of airway selection during PEG on postoperative patient outcomes.

Pediatric Buried Bumper Syndrome: Diagnostic Validity of Transabdominal Ultrasound and Artificial Intelligence

PURPOSE

 Buried bumper syndrome (BBS) is a severe complication of percutaneous endoscopic gastrostomy (PEG) resulting from overgrowth of gastric mucosa and penetration of the inner holding plate into the gastric wall. The aim of this study was to evaluate the diagnostic value of transabdominal ultrasound (US) in comparison to an artificial intelligence (AI) model for the diagnosis of BBS in children.

MATERIALS AND METHODS

 In this monocentric retrospective study, pediatric US data concerning BBS from a ten-year period (2009-2019) were analyzed. US findings were compared to a clinical multiparameter-based AI model and reference standard endoscopy. Clinical risk factors for the occurrence of pediatric BBS were determined.

RESULTS

 In n = 121 independent examinations of n = 82 patients, the placement of the inner holding plate of the PEG was assessed by US. In n = 18 cases BBS was confirmed. Recall and precision rates were 100 % for US and 88 % for the AI-based assessment. Risk factors for the occurrence of BBS were mobilization problems of the PEG (r_s = 0.66, p < 0.001), secretion/exudation (r_s = 0.29, p = 0.002), time between 1^st PEG placement and US (r_s = 0.38, p < 0.001), and elevated leukocyte count (r_s = 0.24, p = 0.016).

CONCLUSION

 Transabdominal US enables correct, rapid, and noninvasive diagnosis of BBS in pediatric patients. Preceding AI models could aid during diagnostic workup. To avoid unnecessary invasive procedures, US could be considered as a primary diagnostic procedure in suspected BBS. .

Effectiveness and Complication Rate of Percutaneous Endoscopic Gastrostomy Placement in Pediatric Oncology Patients

PURPOSE

Malnutrition is a significant issue for pediatric patients with cancer. We sought to evaluate the effectiveness and complication rate of percutaneous endoscopic gastrostomy (PEG) placement in pediatric oncology patients.

METHODS

A retrospective chart review was performed on 49 pediatric oncology patients undergoing PEG placement at Johns Hopkins All Children's Hospital between 2000 and 2016. Demographic and clinical characteristics, complications, absolute neutrophil count at time of PEG placement and at time of complications, length of stay, and mortality were identified. Weight-for-age Z-scores were evaluated at time of- and six months post-PEG placement.

RESULTS

The overall mean weight-for-age Z-score improved by 0.73 (p<0.0001) from pre- (-1.11) to post- (-0.38) PEG placement. Improvement in Z-score was seen in patients who were malnourished at time of PEG placement (1.14, p<0.0001), but not in those who were not malnourished (0.32, p=0.197). Site infections were seen in 12 (24%), buried bumper syndrome in five (10%), and tube dislodgement in one (2%) patient. One patient (2%) with fever was treated for possible peritonitis. There were no cases of other major complications, including gastric perforation, gastrocolic fistula, clinically significant bleeding, or PEG-related death documented.

CONCLUSION

Consistent with previous studies, our data suggests a relationship between site complications (superficial wound infection, buried bumper syndrome) and neutropenia. Additionally, PEG placement appears to be an effective modality for improving nutritional status in malnourished pediatric oncology patients. However, larger prospective studies with appropriate controls and adjustment for potential confounders are warranted to confirm these findings.

A Retrospective Review of Primary Percutaneous Endoscopic Gastrostomy and Laparoscopic Gastrostomy Tube Placement

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.

Percutaneous endoscopic gastrostomy in children: A single center experience in Saudi Arabia

OBJECTIVES

To evaluate the demographic data and complications in children who had undergone percutaneous endoscopic gastrostomy (PEG) over 9 years period.

METHODS

The demographic data, complications, length of hospital admission related to PEG insertion and follow-up findings of 39 patients who had undergone percutaneous endoscopic gastrostomy using the standard pull-through technique between 2011 and 2020 were examined. The study took place at the Gastroenterology Division, Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia RESULTS: The most common indications of feeding with a gastrostomy tube include neurological diseases (n=30, 76.9%), followed by metabolic disorders (n=3, 7.69%), chronic diarrhea (n=2, 5.1%), chronic kidney diseases (n=2, 5.1%), cystic fibrosis (n=1, 2.56%), feeding aversion fibrosis (n=1, 2.56%). Out of the 39 patients, 20 (51%) did not have any complications. However, minor complication are expected. Most common complications included local infection (n=14, 35.89%) followed by granulation tissue (n=6, 15.38%), "buried bumper syndrome" developed in one.

CONCLUSION

Percutaneous endoscopic gastrostomy tube is the desirable method for patients who are unable to feed orally, feeding is not adequate for demands, has special feeding requirements, or swallowing dysfunction. The technique has become more widespread because of its simplicity, safety, and low cost. Major complications are rare. The procedure is safe and effective and could be carried out by pediatric gastroenterologists after training.

Long-term outcome and efficiency of symptom-selective approach to assess gastroesophageal reflux prior to gastrostomy in neurologically impaired children

PURPOSE

To evaluate the necessity of preoperative screening for gastroesophageal reflux (GER) prior to gastrostomy in neurologically impaired children.

METHODS

Medical records of neurologically impaired children, who have undergone laparoscopic gastrostomy between January, 2004 and June, 2018, were retrospectively reviewed. Before the year of 2014, all patients who required gastrostomy had been routinely screened for GER pre-operatively, but after the year of 2014, only the ones with GER-related symptoms were tested. The characteristics and outcomes of Routine Screening (RS) and Selective Screening (SS) periods were compared.

RESULTS

There were 55 and 54 patients in the RS and SS periods, respectively. Demographics, primary pathologies, and mean follow-up durations (> 2 years) were similar. The rate of GER screening was significantly lower in the SS period (29.6% vs. 63.6%). The rate of Laparoscopic Nissen Fundoplication (LNF) combined with gastrostomy was significantly lower in the SS period (14.8% vs. 38.2%). During follow-up, the rates of new-onset GER symptoms (13% vs. 11.7%) and LNF requirement later on (6.5% vs. 8.8%) were statistically similar between the two periods.

CONCLUSION

Routine screening for GER is not necessary prior to gastrostomy in neurologically impaired children. Symptom-selective screening algorithm is safe and efficient in the long term.

Children's Perspectives on Mealtimes When Living with a Gastrostomy Tube: A Qualitative Study

PURPOSE

To explore children's experiences of mealtimes when living with a gastrostomy tube.

DESIGN AND METHODS

The study used a qualitative descriptive design framed within ecocultural theory. Seven children, three girls and four boys, aged 6-12 years with long-term health conditions and a gastrostomy tube participated in individual interviews. The interviews were qualitatively analysed by means of systematic text condensation.

RESULTS

Four main categories comprised the findings of the children's mealtimes experiences: "Stable in form, open to variation," "An individual, and a shared activity," "An object that needs to be dealt with" and "A part of me." A complex picture emerged, where the children experienced nutrition, whether through the gastrostomy tube or orally, as necessary for a healthy body, although this did not suffice to make the mealtime experience positive.

CONCLUSIONS

Regardless of the children's amount of oral intake, everyday mealtimes were valued as opportunities for social interaction and experienced as a predictable, routine activity no different from the mealtimes of other families. The accounts illustrated that in many situations the children knew precisely what they needed and did not need, what they liked and disliked and why.

PRACTICE IMPLICATIONS

Healthcare professionals should take children's knowledge into consideration to a greater extent when planning follow-up and intervention. The study illuminates that children can take an active part in their healthcare when offered flexible and carefully designed communication material, even in the presence of communicative and/or intellectual disability.

Analysis of frequency and risk factors for complications of enteral nutrition in children in Poland after percutaneous endoscopic gastrostomy placement

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.

Percutaneous Endoscopic Gastrostomy Enhances Interstage Growth in Infants With Hypoplastic Left Heart Syndrome

OBJECTIVES

Infants with hypoplastic left heart syndrome undergoing staged palliation commonly experience chronic growth failure and malnutrition. Greater patient weight at stage 2 palliation (Glenn) is thought to be associated with improved perioperative outcomes. We aimed to compare weight for age z score and interstage growth velocity in children with and without a percutaneous endoscopic gastrostomy prior to Glenn and hypothesize that those with a percutaneous endoscopic gastrostomy experience-enhanced interstage growth and reduced malnutrition rates.

DESIGN

Single-center, retrospective cohort study.

SETTING

A total of 259-bed, quaternary, pediatric referral center.

PATIENTS

Infants with hypoplastic left heart syndrome from 2007 to 2016 with and without percutaneous endoscopic gastrostomy insertion after initial palliation (Norwood).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Primary outcomes were weight for age z score (at birth, Norwood, Norwood discharge, and Glenn), interstage growth velocity, and moderate-to-severe malnutrition (weight for age z score<-2) rates. Secondary outcomes were lengths of stay, mechanical ventilation rates after Glenn, and mortality. Statistical analyses included chi-square, Wilcoxon rank-sum, student's t, paired testing, and exploratory logistic regression. Of the 69 infants studied, 47 (68%) had percutaneous endoscopic gastrostomy insertion at a median of 156 (interquartile range, 115-158) days prior to Glenn. Among children with and without percutaneous endoscopic gastrostomy, we observed no differences in demographics, comorbidities, cardiothoracic surgical times, postoperative Glenn outcomes (length of stay, mechanical ventilation rate, peak 24-hr lactate, nitric oxide use, extracorporeal life support rate, or mortality), weight for age z score at birth, and weight for age z score at Norwood. At the time of percutaneous endoscopic gastrostomy insertion, weight for age z score was -2.5 ± 1.3 and subsequent growth velocity increased from 8 ± 7 to 40 ± 59 g/d (p < 0.01). From Norwood discharge to the date of Glenn, weight for age z score increased in infants with percutaneous endoscopic gastrostomy (-2.5 ± 1.1 to -1.5 ± 1.4 [p < 0.01]) with a large reduction in moderate-to-severe malnutrition rates (76-36%; p < 0.01). In general, weight for age z score at the time of Glenn was associated with reduced postoperative mortality (odds ratio, 0.3; 95% CI, 0.09-0.95; p = 0.04).

CONCLUSIONS

Infants undergoing palliation for hypoplastic left heart syndrome with percutaneous endoscopic gastrostomy insertion prior to Glenn had improved growth velocity and dramatically reduced rates of moderate-to-severe malnutrition rates (40% reduction). In addition, we noted weight for age z score at when Glenn was associated with improved postoperative Glenn survival. No complications from percutaneous endoscopic gastrostomy were noted. Placement of a percutaneous endoscopic gastrostomy improved weight for age z score, enhanced interstage growth, and reduced malnutrition rates for this at-risk population of malnourished children.

Laparoscopic Gastrostomy Placement in Children Has Few Major, but Many Minor Early Complications

INTRODUCTION

 Laparoscopic gastrostomy (LAPG) is an increasingly popular alternative to more traditional gastrostomy techniques. This study evaluates early postoperative complications following LAPG and investigates risk factors for gastrostomy complications.

MATERIALS AND METHODS

 Retrospective study of patients <16 years undergoing LAPG from 2005 to 2018. Early postoperative complications (<30 days) were grouped as gastrostomy-related or general and graded according to the Clavien-Dindo classification for surgical complications.

RESULTS

 A total of 104 patients, of which 54 (52%) had neurological impairment (NI), were included. Median age and weight were 1.2 years (1 day-15.2 years) and 8.9 kg (3.4-36), respectively. Operating time was median 37 minutes (19-86) and shorter in the second half of the patients (46 vs. 35 minutes, p = 0.04). A total of 40 (38%) patients experienced 53 gastrostomy-related complications. Of these, seven complications needed surgical treatment; severe leakage (2), too short gastrostomy button (1), feeding difficulties (1), gastric outlet obstruction (1), omentum trapped in umbilical port sutures (1), and suspected fascial defect (1). Stoma infection and granulation tissue were reported in 13 and 12%, respectively. Tube dislodgement occurred in six patients and was managed with bedside reinsertion in all. Gastrostomy-related complications were less frequent in NI patients (46 vs 22%, p = 0.01).

CONCLUSION

 LAPG is a safe procedure with few major complications, but a high rate of minor complications. Operating time declined during the study period, and NI patients had fewer gastrostomy-related complications.

Gastrostomy and quality of life in children with intellectual disability: a qualitative study

OBJECTIVE

Children with intellectual disability and marked feeding difficulties may undergo gastrostomy insertion to assist with their nutritional and medication needs. Use has increased recently for younger children, and it is intended to provide long-term support. This study explored the perceived value of gastrostomy for the quality of life (QOL) of children with intellectual disabilities and their families.

METHODS

Twenty-one primary caregivers of children with intellectual disability aged 2-18 years participated in semistructured telephone interviews. Data were analysed using directed content analysis, and data were coded to existing QOL domains relevant to children with intellectual disability and their families.

RESULTS

Benefits in each of the child and family QOL domains were represented in the interview data. For children, the impacts of gastrostomy for the physical health domain were predominant, supplemented by experiences of value for emotional well-being, social interactions, leisure activities and independence. For families, gastrostomy was integrated into multiple aspects of QOL relating to family interactions, parenting, resources and supports, health and safety, and advocacy support for disability. Shortcomings related to difficulties with equipment and complications.

CONCLUSIONS

Our comprehensive overview of the value of gastrostomy for children with intellectual disability and their families was classified within a QOL framework. Gastrostomy was mainly supportive over long time periods across many QOL domains. Findings will be of use to patient counselling and education and the development of family support resources.

Gastrostomy tube insertion in children with developmental or acquired disorders: a register-based study

AIM

To describe trends in gastrostomy tube insertion in children with developmental or acquired disorders in Sweden and assess their demographic characteristics.

METHOD

Children aged 0 to 18 years with gastrostomy tube insertions recorded between 1998 and 2014 were identified in the Swedish National Patient Register. Associations between disorder type and year of surgery, as well as age at surgery, were analysed using linear regression analyses. The association between disorder type and mortality 2 years from gastrostomy tube insertion was also analysed using logistic regression analysis.

RESULTS

The data for 4112 children (2182 males, 1930 females), with a median age of 2 years (interquartile range=1-8y), were analysed. Children who presented with developmental disorders were the largest group (n=3501, 85%). The most common diagnosis in children with developmental disorders was cerebral palsy (n=165, 4%). In children with acquired disorders, acute lymphoblastic leukaemia (n=117, 3%) was the most common diagnosis. Gastrostomy tube insertions increased from 1998 to 2014, with the greatest increase in children with developmental disorders, who were younger than children with acquired disorders when the gastrostomy tube was first inserted. Age at tube insertion decreased in both groups during the study period. Mortality was higher in children with acquired disorders, suggesting that gastrostomy tube insertion should be part of a palliative care approach.

INTERPRETATION

Child characteristics differed depending on whether the underlying disorder was developmental or acquired, suggesting a need for clinical health care guidelines related to the specific goals of gastrostomy tube insertion.

WHAT THIS PAPER ADDS

Gastrostomy tube insertions increased by 140% from 1998 to 2014 in Sweden. The age of children with developmental disorders decreased by 1 month per year during the study period. Children presenting with developmental disorders were younger than children with acquired disorders when the gastrostomy tube was first inserted. Mortality was higher in children with acquired disorders.

A Literature Review of Percutaneous Endoscopic Gastrostomy: Dealing With Complications

Sufficient energy and essential nutrients are vital for normal growth and development in childhood. Ideally, nutrition should be provided orally. However, if the gastrointestinal system is functional, enteral tube feeding can be used when nutritional requirements cannot be provided orally, thus providing nutritional benefits and enabling positive disease management in pediatric patients. Postoperative care in children allows monitoring of the position and functionality of the tube; performing nutrition intolerance, growth, hydration, and nutritional assessments; and performing metabolic and complication follow-ups. Tube feeding in pediatric patients is beneficial and has positive effects in controlling and managing diseases and providing appropriate nutrition in children. However, in postoperative patients, it is important to prevent potential complications, which can be classified into 5 groups: mechanical, gastrointestinal, metabolic, infectious, and pulmonary complications. Important points for managing complications include having enteral nutrition practices based on evidence-based guidelines, sharing outcomes with nurses working in clinical settings, creating enteral feeding guides in clinical settings, providing patients/patients' family with training in line with these guides, and maintaining follow-ups at home. This literature review discusses complications and practices regarding the management of complications after percutaneous endoscopic gastrostomy.

Percutaneous Endoscopic Gastrostomy After Cardiothoracic Surgery in Children Less Than 2 Months Old: An Assessment of Long-Term Malnutrition Status and Gastrostomy Outcomes

OBJECTIVES

Infants with critical congenital heart disease undergoing cardiothoracic surgery commonly experience chronic malnutrition and growth failure. We sought to determine whether placement of a percutaneous endoscopic gastrostomy was associated with reduced moderate-severe malnutrition status and to describe percutaneous endoscopic gastrostomy-related clinical and safety outcomes in this population.

DESIGN

Single-center, retrospective cohort study.

SETTING

Two hundred fifty-nine-bed, tertiary care, pediatric referral center.

PATIENTS

Children with congenital heart disease less than 2 months old undergoing cardiothoracic surgery from 2007 to 2013 with and without percutaneous endoscopic gastrostomy.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Primary outcomes were weight for age z scores during hospitalization, at 6 months, and 1 year after cardiothoracic surgery. Secondary outcomes were frequency of percutaneous endoscopic gastrostomy revision, percutaneous endoscopic gastrostomy complications, and mortality. Statistical analyses included Wilcoxon rank-sum, Fisher exact, and Student t tests. Two hundred twenty-two subjects met study criteria, and 77 (35%) had percutaneous endoscopic gastrostomy placed at a mean of 45 ± 31 days after cardiothoracic surgery. No differences were noted for demographics, comorbidities, and weight for age z score at birth and at the time of cardiothoracic surgery. The percutaneous endoscopic gastrostomy cohort had greater Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery risk category (4 [4-5] vs 4 [2-4]) and length of stay (71 d [49-101 d] vs 26 d [15-42 d]). Mean weight for age z score at the time of percutaneous endoscopic gastrostomy was -2.8 ± 1.3. Frequency of moderate-severe malnutrition (weight for age z score, ≤ -2) was greater in children with percutaneous endoscopic gastrostomy at discharge (78% vs 48%), 6 months (61% vs 16%), and 1 year (41% vs 2%). Index mortality was lower in children with percutaneous endoscopic gastrostomy at 30 days (8% vs 0%) and hospital discharge (19% vs 4%). However, no mortality differences were observed after discharge. Growth velocity after percutaneous endoscopic gastrostomy was greater (44 ± 19 vs 10 ± 9 g/d). Children tolerated percutaneous endoscopic gastrostomy without hemodynamic compromise, minor percutaneous endoscopic gastrostomy complications, and anticipated percutaneous endoscopic gastrostomy revisions. Children without mortality had percutaneous endoscopic gastrostomy removal at a median duration of 253 days (133-545 d). Children with univentricular physiology had improved in-hospital mean growth velocity (6.3 vs 24.4 g/d; p < 0.01) and reduced 1-year rate moderate-severe malnutrition (66.7% vs 36.9%; p < 0.01) after percutaneous endoscopic gastrostomy placement.

CONCLUSIONS

Percutaneous endoscopic gastrostomy placement was well tolerated and associated with improved postoperative growth velocity in children with critical congenital heart disease undergoing cardiothoracic surgery less than 2 months old. These findings were also noted in our subanalysis of children with univentricular physiology. Persistent rates of moderate-severe malnutrition were noted at 1-year follow-up. Although potential index mortality benefit was observed, definitive data are still needed.

Comparison of the Laparoscopic and Open Methods of Gastrostomy at Neonates and Infants Up To Three Months of Age

Background: An open surgical intervention is a common approach for gastrostomy tube placement in neonates and infants. Also available, however less often used, is a laparoscopic technique for low-profile gastrostomy tube (button) placement. In this study we compare the pre-, intra-, and post-procedural outcomes of each technique. Methods: We retrospectively evaluated all open and laparoscopically inserted gastrostomies at our department from January 2002 to December 2016 and compared them in terms of operative parameters and outcomes. Results: In the study interval, 44 open and 90 laparoscopically placed low-profile (button) gastrostomies were performed. There were no significant differences in gender distribution, mean age (42.54 versus 34.16 days), and mean weight (3311 versus 3476 g). The frequency of concomitant Nissen fundoplication was higher in the laparoscopy group (18% versus 47%; P < .05). The duration of G-tube placement by laparotomy was significantly longer (mean difference 16 minutes), than by laparoscopy, as were time periods between G-tube insertion and the onset of first feeding (mean differences 8.4 and 19.6 hours, respectively). Children in the laparoscopy group spent nearly 15 fewer days in the hospital than those who received a G-tube by laparotomy (29.0 versus 13.9; P < .05). Major complications were observed in 3 (6.82%) patients in the laparotomy group in the form of gastric content leak into the abdominal cavity and resulting peritonitis; complications were lower in the laparoscopy group (68.18% versus 13.33%; P = .03). Conclusions: Compared with open gastrostomy, the laparoscopic approach appears to be advantageous with respect to procedural duration, initiation of feedings, hospitalization duration, and rate of complications. Another difference was the frequency of concomitant Nissen fundoplication. Further prospective studies may determine the role of these patient-specific factors regarding who benefits most from the laparoscopic technique.

Epidemiology of gastrostomy insertion for children and adolescents with intellectual disability

The largest group of recipients of pediatric gastrostomy have neurological impairment with intellectual disability (ID). This study investigated trends in first gastrostomy insertion according to markers of disadvantage and ID etiology. Linked administrative and health data collected over a 32-year study period (1983-2014) for children with ID born between 1983 and 2009 in Western Australia were examined. The annual incidence rate change over calendar year was calculated for all children and according to socioeconomic status, geographical remoteness, and Aboriginality. The most likely causes of ID were identified using available diagnosis codes in the linked data set. Of 11,729 children with ID, 325 (2.8%) received a first gastrostomy within the study period. The incidence rate was highest in the 0-2 age group and there was an increasing incidence trend with calendar time for each age group under 6 years of age. This rate change was greatest in children from the lowest socioeconomic status quintile, who lived in regional/remote areas or who were Aboriginal. The two largest identified groups of ID were genetically caused syndromes (15.1%) and neonatal encephalopathy (14.8%).Conclusion: Gastrostomy is increasingly used in multiple neurological conditions associated with ID, with no apparent accessibility barriers in terms of socioeconomic status, remoteness, or Aboriginality. What is Known: • The use of gastrostomy insertion in pediatrics is increasing and the most common recipients during childhood have neurological impairment, most of whom also have intellectual disability (ID). What is New: • Nearly 3% of children with ID had gastrostomy insertion performed, with the highest incidence in children under 3 years of age. • Gastrostomy use across different social groups was equitable in the Australian setting.

Complications in children with percutaneous endoscopic gastrostomy (PEG) placement

INTRODUCTION

The aim of this study was to analyze the complication rates and mortality in association with different operative techniques of percutaneous endoscopic gastrostomy (PEG), age, underlying diseases and other risk factors. Moreover, analysis of the indications of PEG insertion and the underlying comorbidities was also performed.

METHODS

This study performs a literature analysis of PEG-related complications in children. Literature was searched on PubMed^® (1994-2017) using terms "percutaneous endoscopic gastrostomy", "complications", "mortality" and "children".

RESULTS

Eighteen articles with 4631 patients were analyzed. The mean age was 3 years (0-26 years). Operative techniques were: pull technique in 3507 (75.7%), 1 stage PEG insertion in 449 (9.7%), introducer technique in 435 (9.4%), image-guided technique in 195 (4.2%) and laparoscopic-assisted PEG in 45 (1.6%). Most frequent indications for PEG insertion were dysphagia (n = 859, 32.6%), failure to thrive (n = 723, 27.5%) and feeding difficulties (n = 459,17.4%). Minor complications developed in n1518 patients (33%), including granulation  (n = 478, 10.3%), local infection (n = 384, 8.3%) and leakage (n = 279, 6%). In 464 (10%) patients, major complications occurred; the most common were systemic infection (n = 163, 3.5%) and cellulitis (n = 47, 1%). Severe complication like perforation occurred in less than 0.3%. Patients with lethal outcomes (n = 7, 0.15%) had severe comorbidities; and the cause of mortality was sepsis in all cases. Prematurity or young age did not affect complication rate. Patients with ventriculoperitoneal (VP) shunt had higher risk of major complications. In high-risk patients, laparoscopic-assisted PEG insertion had less major and severe complication than traditional pull technique.

CONCLUSIONS

PEG is a safe operative technique; although minor complications are relatively common and occur in up to 1/3 of patients, there is a fairly low rate of severe complications. Two-thirds of PEG patients have at least one comorbidity. Patients with VP shunt have higher risk of major complications. In high-risk patients, laparoscopic-assisted PEG is recommended.

Clinical and Psychosocial Factors Associated With Patient Experience in Pediatrics

OBJECTIVE

To identify clinical and psychosocial factors associated with patient experience with care.

METHODS

We analyzed patient experience surveys, corresponding clinical and psychosocial the data of 1567 encounters using survey-weighted multivariate logistic regression analysis with willingness to recommend the facility as outcome variable.

RESULTS

Parents are less likely to recommend the facility if there were custody issues with the child during their stay, if the child has history of chronic medical condition, and if the child is male with odds ratio and corresponding 95% confidence interval of 0.38 [0.21, 0.69], 0.43 [0.24, 0.80], and 0.67 [0.45, 0.99] respectively. Parents of older patients (1-year difference) and parents of low socioeconomic status are more likely to recommend the facility (1.05 [1.01, 1.09] and 2.74 [1.72, 4.37] respectively).

CONCLUSIONS

Clinical and psychosocial factors significantly affect patient experience scores together with parent perception of provider-family communication and relationship, and hospital environment conducive for children.

Safety and Efficacy of Bedside Percutaneous Endoscopic Gastrostomy Placement in the Neonatal Intensive Care Unit

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.

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.

Initial experience with percutaneous endoscopic gastrostomy with T-fastener fixation in pediatric patients

BACKGROUND AND STUDY AIMS

 Insertion of a percutaneous endoscopic gastrostomy (PEG) with push-through technique and T-fastener fixation (PEG-T) has recently been introduced in pediatric patients. The T-fasteners allow a primary insertion of a balloon gastrostomy. Due to limited data on the results of this technique in children, we have investigated peri- and postoperative outcomes after implementation of PEG-T in our department.

PATIENTS AND METHODS

 This retrospective chart review included all patients below 18 years who underwent PEG-T placement from 2010 to 2014. Main outcomes were 30-day postoperative complications and late gastrostomy-related complications.

RESULTS

 In total, 87 patients were included, and median follow-up time was 2.4 years (1 month - 4.9 years). Median age and weight at PEG-T insertion were 1.9 years (9.4 months - 16.4 years) and 10.4 kg (5.4 - 33.0 kg), respectively. Median operation time was 28 minutes (10 - 65 minutes), and 6 surgeons and 3 endoscopists performed the procedures. During the first 30 days, 54 complications occurred in 41 patients (47 %). Most common were peristomal infections treated with either local antibiotics in 11 patients (13 %) or systemic antibiotics in 11 other patients (13 %). 9 patients (10 %) experienced tube dislodgment. Late gastrostomy-related complications occurred in 33 patients (38 %). The T-fasteners caused early and late complications in 9 (10 %) and 11 patients (13 %), respectively. Of these, 4 patients (5 %) had subcutaneously migrated T-fasteners which were removed under general anesthesia.

CONCLUSION

 We found a high rate of complications after PEG-T. In particular, problems with the T-fasteners and tube dislodgment occurred frequently after PEG-T insertion.

Enteral Nutrition in Pediatric Patients

Pediatric patients require specialized attention and have diverse demands for proper growth and development, and thus need a different approach and interest in nutritional assessment and supply. Enteral nutrition is the most basic and important method of nutritional intervention, and its indications should be identified. Also, the sites, modes, types, and timing of nutritional intervention according to the patient's condition should be determined. In addition, various complications associated with enteral nutrition supply should be identified, and prevention and treatment are required. This approach to enteral nutrition and proper administration can help in the proper growth and recovery of pediatric patients with nutritional imbalances or nutritional needs.

Antibiotic prophylaxis does not reduce the infection rate following percutaneous endoscopic gastrostomy in infants and children

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.

Short article: Buried bumper syndrome in children: incidence and risk factors

OBJECTIVE

Buried bumper syndrome (BBS) is a serious complication in gastrostomy-dependent children. Many need surgical correction. On account of comorbidities, this becomes a high-risk procedure. Our aim was to review the incidence of BBS in children and to identify the risk factors.

PATIENTS AND METHODS

Retrospective review of patients' records over 10 years, 2006-2015, was carried out. Types of tubes, operative interventions, comorbidities and records were noted. Two-tailed Fisher's exact test was used for statistical analysis.

RESULTS

A total of 535 patients were reviewed. Overall, 475 had only percutaneous endoscopic gastrostomy (PEG) and 60 had a jejunal extension with percutaneous endoscopic gastrostomy (PEG-J). Twenty-nine patients (PEG-J - 16/26; PEG - 13/26) had a total of 31 BBS episodes. The overall incidence of BBS in our study was 5.4%. The age at presentation ranged from 1 to 18 years (median 8.6 years). All had significant comorbidities (neurodevelopmental 26/29, cardiorespiratory 14/29, genetic 16/29). Overall, 27/29 had two or more comorbidities. The mean time to development of BBS was 1025±634 days. BBS was found in the second or the subsequent tube in four patients with PEGs (P<0.0004) and in 10 PEG-Js (P<0.0001). Twenty-five patients needed laparotomy. There were no postoperative deaths.

CONCLUSION

In BBS, the two significant risk factors identified were a having PEG-J and two or more previous gastrostomy insertions. Vigilance in documentation and prolonged follow-up to provide regular education to carers can reduce the incidence of this preventable complication.

Complications in pediatric endoscopy

The experience of the "endoscopic community" in pediatric patients is limited, but during recent years increased skills of the endoscopists and technological improvements lead to a standardization of pediatric endoscopy and the development of specialized pediatric endoscopy unit. Adverse events related to diagnostic and therapeutic endoscopy in children are usually rare. Diagnosis, prevention and treatment of complications in pediatric endoscopy is crucial when dealing with benign diseases in children. The complication rate of diagnostic EGD and colonoscopy in children are extremely low. Therapeutic procedures have obviously an increased rate of adverse events. Esophageal dilations are the most common indication for endoscopic therapy in children and can lead to perforations which requires prompt diagnosis and management. Complications of ERCP in pediatric age are similar to those reported in adults. The experience in pediatric emergency endoscopy (mainly foreign body removal) is consolidated and related adverse events extremely rare. Sedation of children during endoscopy maybe needs further evaluation and standardization, to reduce the rate of specific complications.

Does Gastrostomy Placement With Concurrent Fundoplication Increase the Risk of Gastrostomy-related Complications?

OBJECTIVE

To compare the incidence of complications with a primary gastrostomy versus gastrostomy with concurrent fundoplication and evaluating the impact of the method of gastrostomy tube placement. Neurologically impaired children were compared with neurologically normal children. Two low profile devices were compared for longevity.

METHODS

Ninety-eight patients (58 boys, mean age 4.66 years) with 107 gastrostomies inserted between April 2004 and May 2008 were included in this retrospective, single institution audit. Minimum follow-up period was 1 year. Specific complications reviewed were tube and site related. Logistic regression analysis examined the relationship between complications, type of procedure, method of placement, and neurological status. Survival analysis with log-rank test was used to compare the duration of the low-profile devices.

RESULTS

There were 63 primary gastrostomies and 44 with concurrent fundoplication, 71 children were neurologically impaired. Mean (±SD) follow-up time was 35.6 ± 1.4 months. There was a significant association between concurrent gastrostomy insertion with fundoplication and incidence of infection (odds ratio = 2.4, 95% confidence interval (CI) 1.02-5.56, P = 0.02) and excoriation (odds ratio = 2.5, 95% CI 1.09-5.71, P = 0.015). There were no associations between the complications with gastrostomy placement and neurological status. Failure rate of the balloon device was significantly greater than the fixed bolster device with a Hazard Ratio for survival of 3.2 (95% CI 2.2-4.6).

CONCLUSIONS

Gastrostomy site-related problems were more common than generally reported. There was a higher incidence of site infection and skin excoriation for gastrostomy placement with concurrent fundoplication. There was no significant difference in complications between the method of gastrostomy placement or neurological status. Balloon devices were changed 3 times more often than bolster retention devices.

Advances in Pediatric Gastrostomy Placement

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.

Percutaneous endoscopic gastrostomy in children: a single center experience

AIM

The aim of this study was to evaluate the demographic data and complication rates in children who had undergone percutaneous endoscopic gastrostomy in a three-year period in our Division of Pediatric Gastroenterology and to interrogate parental satisfaction.

MATERIAL AND METHODS

The demographic data, complications and follow-up findings of the patients who had undergone percutaneous endoscopic gastrostomy between March 2011 and March 2014 were examined retrospectively using medical files.

RESULTS

Forty seven percutaneous endoscopic gastrostomy and percutaneous endoscopic gastrostomy related procedures were performed in 34 children during a three-year period. The median age of the patients was 2.25 years (3 months-16 years, first and third quartiles=1.0-6.0) and the mean body weight was 13.07±8.6 kg (3 kg-47 kg). Before percutaneous endoscopic gastrostomy procedure, the mean weight z score was -2.26±1.2 (-5-0) and the mean height z score was -2.25±0.96 (-3.85-0.98). The follow-up mean height and weight Z scores at the 12(th) month after the percutaneous endoscopic gastrostomy procedure could be reached in 24 patients. A significant increase in the mean weight Z score from -2.41 to -1,07 (p=0.000) and in the mean height Z score from -2.29 to -1.99 (p=0.000) was found one year after percutaneous endoscopic gastrostomy catheter was placed in these 24 patients. Patients with neurological and metabolic diseases constituted the majority (64.7% and 26.5% respectively). Peritoneal leakage of food was detected in one patient and local stoma infections were detected in three patients after the procedure. During the follow up period, "Buried bumper syndrome" was observed in one patient. Following percutaneous endoscopic gastrostomy, the number of patients using anti-reflux medication increased from 16 (47.1%) to 18 (52.9%) (p=0.62). One patient with cerebral palsy who had aspiration pneumonia after percutaneous endoscopic gastrostomy insertion had undergone Nissen fundoplication. Percutaneous endoscopic gastrostomy tube was removed in a patient. The parents had positive views related with percutaneous endoscopic gastrostomy after the procedure.

CONCLUSIONS

Percutaneous endoscopic gastrostomy is a substantially successful and reliable method in infants as well as in children and adolescents. The parents had positive views related with percutaneous endoscopic gastrostomy after the procedure.

Comparison of Two Laparoscopic Techniques for Gastropexy in Children

BACKGROUND

Laparoscopic gastrostomy is a widely used interventional procedure in pediatric surgery. We report comparative data for two endosurgical methods for the fixation of the stomach against the abdominal wall, using the U-stitches technique and the Saf-T-Pexy® (Halyard Health Inc., Alpharetta, GA) system.

MATERIALS AND METHODS

Within the period from January 2012 to June 2014 we performed 24 operations involving laparoscopic placement of a gastrostomy tube using U-stitches (Group I) and 24 operations using the Saf-T-Pexy system (Group II). The two groups of patients were compared in terms of demographics and intraoperative and postoperative results.

RESULTS

No statistical difference (P > .05) was found while comparing the patients' demographics and intra- and postoperative results. The mean duration of the surgical procedure in Group I was 23.75 minutes; in contrast, the mean duration of surgery in Group II was 22.71 minutes (P > .05). The time to first feeding (9.96 hours versus 10.63 hours) and time to full enteral feeding (23.13 hours versus 24.5 hours) were consistent for patients from both groups (P > .05). A similar postoperative duration of stay was recorded for the patients from the comparison groups (7.25 days versus 7.21 days; P > .05). Statistical analysis of the two groups demonstrated a significant difference in the parameters of minor postoperative complications (41.67% versus 8.33%; P < .05).

CONCLUSIONS

Use of the Saf-T-Pexy system is a simple and efficient method for gastropexy involving placement of gastrostomy tubes that significantly reduces the number of postoperative complications.

Risk factors for complications in infants and children with percutaneous endoscopic gastrostomy tubes

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.

[Button gastrostomy in children]

For the period January 2002 to December 2013 it was performed 84 interventions for introduction of gastrostomy tube. The first group included 24 open operations and the second group had 60 laparoscopic operations by using of button devices MIC-KEY (Kimberly-Clark, Roswell, USA) in neonates and infants. Statistically significant difference was not observed during comparison of demographic data of patients. Differences in groups were found in statistical analysis of intra- and postoperative parameters (p<0.05). Mean duration of surgery in the first group was 37.29 min, in the second group - 23.97 min. Time to start of feeding and transition to complete enteral nutrition was less in patients who underwent laparoscopic surgery than after open intervention (10.5 and 19.13 hours, 23.79 and 35.88 hours respectively; p<0.05). It was revealed augmentation of hospital stay in the 1st group in comparison with the 2(nd) group (11.71 and 7.09 days respectively; p<0.05). Frequency of postoperative complications was 18.33% in the 2(nd) group and 24% - in the 1st group (p<0.05). The authors consider that button devices are simply and effective technique of gastrostomy establishment in children. It is associated with minimal surgery duration and allows to start early enteral nutrition in comparison with open techniques.

ESPGHAN position paper on management of percutaneous endoscopic gastrostomy in children and adolescents

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.

Short-Term Complications of Percutaneous Endoscopic Gastrostomy according to the Type of Technique

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.

Single-center experience with 1-step low-profile percutaneous endoscopic gastrostomy in children

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.