Long-term outcomes of infants and children undergoing percutaneous endoscopy gastrostomy tube placement

Impact of Immunosuppression on Complication Rates in Pediatric Gastrostomy Tube Placement

INTRODUCTION

Immunosuppressed children are vulnerable to post-operative complications. The purpose of this study is to determine if children who are immunosuppressed at gastrostomy tube (G-tube) placement experience higher rates of post-operative complications than children with normal immune function.

METHODS

Children ≤18 years-old who underwent G-tube placement at a high-volume tertiary children's hospital between June 2019-April 2022 were retrospectively identified. Patients who received chemotherapy or post-transplantation immunosuppressive therapy ≤3 months before or 30 days after G-tube placement were identified as the immunosuppressed cohort and 30-day postoperative complication rates were compared. Subset analysis was performed for immunosuppressed children who were neutropenic in the perioperative period.

RESULTS

Thirty-one (5.6 %) of 553 children who underwent G-tube placement were immunosuppressed. Immunosuppressed patients were older (median [IQR] 48 [19-156] months vs. 9 [4-31] months, p < 0.001). The majority underwent laparoscopic placement (71.1 %). There were significantly more PEG placements in the immunosuppressed cohort (22.6 % vs. 4.4 %, p < 0.001). There was no difference in 30-day complication rate between the immunosuppressed and immunocompetent cohorts (29.0 % vs. 34.5 %, p = 0.53); however, there was a higher rate of return to OR for the immunosuppressed cohort (9.7 % vs. 2.7 %, p = 0.03). Subset analysis of the high-risk neutropenic subgroup (n = 13, 41.9 %) revealed no difference in complication rates compared to the non-neutropenic immunosuppressed subgroup.

CONCLUSION

G-tube placement in immunosuppressed patients, including those with perioperative neutropenia, appears to be safe with a comparable safety profile to G-tube placement in children with normal immune function, with the exception of a higher rate of return to the OR within 30 days.

STUDY TYPE

Treatment study.

LEVEL OF EVIDENCE

Level III.

Gastrostomy in Children: A 5-Year Single Tertiary Center Experience

Background and Objectives: Pediatric patients with complex medical conditions, including neurological impairments, genetic syndromes, dysphagia, and malnutrition, often face feeding difficulties that require enteral nutrition support. The optimal technique for gastrostomy tube (GT) placement in children remains unclear, with options such as laparoscopic gastrostomy and percutaneous endoscopic gastrostomy (PEG) being compared in previous studies. This study evaluates outcomes, including complications and caregiver satisfaction, associated with different GT placement techniques in pediatric patients, focusing on the impact of concomitant anti-reflux surgery (fundoplication). Materials and Methods: This retrospective analysis of 71 children (34 with anti-reflux surgery [Group 1], 37 without [Group 2]) undergoing GT placement between 2019 and 2024. Data included demographics, procedural details, complications, and caregiver satisfaction assessed via the Structured Satisfaction Questionnaire with Gastrostomy Feeding (SAGA-8). Results: A total of 71 patients (34 in Group 1, 37 in Group 2) were included in the final analysis. The mean age at the time of the procedure was 5.0 ± 1.1 years, with cerebral palsy being the most common underlying condition. Laparoscopic GT was performed in 97% of cases (69/71), with two percutaneous endoscopic gastrostomy (PEG) placements. Common complications included suppuration (32.35% Group 1 vs. 21.62% Group 2, p = 0.88) and infection (5.88% vs. 2.70%, p = 0.67). There were no significant differences between groups in terms of complication rates, although patients in Group 1 had longer hospitalization durations (7.51 ± 3.56 days vs. 4.22 ± 2.13 days, p < 0.005). Caregiver satisfaction, as assessed by the SAGA-8, was high, with 84.5% of families reporting positive outcomes. Factors influencing satisfaction included previous aspiration pneumonia and the use of home blenderized diets post-discharge. Conclusions: Both laparoscopic and PEG techniques are associated with low complication rates and high caregiver satisfaction in pediatric patients requiring gastrostomy placement. The laparoscopic approach may be preferred for patients undergoing concomitant fundoplication.

Cost Analysis of Avoiding Gastrostomy Tube in Robin Sequence Neonates that Undergo Mandibular Distraction

OBJECTIVES/HYPOTHESIS

To evaluate costs associated with perioperative gastrostomy tube (G-tube) placement for neonates with Robin sequence (PRS) that undergo mandibular distraction osteogenesis (MDO).

METHODS

Retrospective chart review was performed to examine the medical records of neonates with RS who received treatment at our institution between 2012 and 2021. Patients under 6 months of age that underwent MDO for RS were included. Billing records of hospital costs over a 2-year period were analyzed.

RESULTS

The study included 26 total patients with 11 in the MDO-only group, 9 in G-tube after MDO group, and 6 in G-tube before MDO group. There was a significant difference (p < 0.001) in total hospital costs between groups with MDO-only group averaging $119,532 (SD ± 33,503), the G-tube after MDO group averaging $245,315 (SD ± 102,327), and G-tube before MDO group averaging $252,300 (SD ± 84,990). Multiple linear regression was performed controlling for genetic syndrome and birth weight, which still showed a statistically significant difference in total cost between the MDO-only group and G-tube after MDO (p = 0.006), and between the MDO-only group and G-tube prior to MDO (p = 0.01). There was a significant difference in costs between all three groups for total inpatient/outpatient costs with MDO-only group averaging $78,502 (SD ± 30,953), the G-tube after MDO group averaging $176,125 (SD ± 84,315), and the G-tube prior to MDO group averaging $156,309 (SD ± 95,746).

CONCLUSIONS

MDO performed without perioperative G-tube placement may reduce charges by >$100,000. The associated improvement of dysphagia after MDO surgery and potential for avoiding a G-tube has tremendous downstream cost and social benefits for families.

LEVEL OF EVIDENCE

NA Laryngoscope, 135:1192-1198, 2025.

Long-Term Outcomes of Children Receiving Percutaneous Endoscopic Gastrostomy Feeding

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

Gastrostomy tube feeding in children: a single-center experience

BACKGROUND

Despite the widespread use of percutaneous endoscopic gastrostomy (PEG) in pediatric populations, there is a paucity of data on the indications and outcomes of this procedure in Switzerland. This manuscript presents our experience with PEG indication, outcomes, and related complications in children.

METHODS

This single-center retrospective study included patients < 18 years old who underwent PEG placement between 2007 and 2016. We retrieved demographics, PEG indications, associated comorbidities, pre-placement workup, growth parameters up to 12 months, and associated complications.

RESULTS

Eighty-one patients were included, with a median age of 7 years. Common indications included inadequate caloric intake (85%), failure to thrive, and feeding difficulties. Neurological conditions (46%) were the most commonly associated comorbidity. Thirty-six patients (44%) underwent a pH study before PEG placement. There were significant increases in z-scores for weight (p < 0.002) and body mass index (p < 0.001) 12 months after PEG placement. Minor complications were relatively frequent (n = 55, 68%), mainly granulation tissue or local erythema. Two patients had major complications.

CONCLUSION

PEG is a safe technique for providing long-term enteral nutrition in children, with neurological disease being the most common clinical indication. Our experience demonstrated significant weight gain in children after one year of PEG, with frequent but well-controlled complications.

Pre-Operative Characteristics Helping to Avoid Gastrostomy Tube After Mandibular Distraction in Neonates With Pierre-Robin Sequence: A Institutional Case-Series and Review of the Literature

OBJECTIVE

to investigate the ability of mandibular distraction osteogenesis (MDO) to avoid gastrostomy tube (G-tube).

DATA SOURCES

PubMed, EBSCOhost, Cochrane, and Embase.

REVIEW METHODS

We retrospectively reviewed the number of MDO cases performed at our institution for patients with Robin Sequence (RS) over the past 10 years. In our institutional review, patients were excluded if they had a G-tube already placed at the time of surgery. We also performed a systematic review of the literature. Articles were excluded if they did not detail feeding outcomes after MDO, or if MDO was performed on patients that did not have RS.

RESULTS

In our systematic review, 12 articles were included that comprised a total of 209 neonates with RS that underwent MDO. A total of 174 (83.3%) patients avoided a G-tube once MDO was performed. A total of 14 patients met the inclusion criteria at our institution. Of the 14 RS patients, 9 (64%) avoided having a G-tube placed and all (14/14) avoided tracheostomy. The average birth weight of patients avoiding a G-tube was 3.11 kg compared to 2.25 kg (P = .045) in the group requiring a G-tube. In the group avoiding a G-tube, the average weight at time of operation was 3.46 kg compared to 2.83 kg (P = .037) in the group requiring a G-tube.

CONCLUSION

MDO may be considered as a surgical option to prevent G-tube placement for neonates with non-syndromic RS who have difficulty with PO feeding but whose airway obstruction is not severe enough to require respiratory support. Based on our institutional experience, a minimum weight of 3.00 kg correlated with higher success rates of PO intake and avoiding a G-tube.

Complications after pediatric percutaneous endoscopic gastrostomy: comparison of the push and pull technique

Purpose

Various complications are associated with percutaneous endoscopic gastrostomy (PEG) procedures in children. The push technique is being increasingly used, but its complications are insufficiently characterized. We aimed to assess all complications related to PEG procedures and compare the safety of the pull and push techniques.

Methods

Retrospective review of consecutive pediatric patients who underwent PEG between 2002 and 2020.

Results

In total, 216 children underwent 217 PEG procedures. The push technique was used in 138 (64%) cases, and the pull technique in 79 (36%) cases. The median follow-up time was 6.1 (0.1-18.3) years. The complication rate was high (57%) and patients experienced complications years after the procedure. Overall, 51% and 67% of patients experienced complications in the push and pull groups, respectively. The rates of minor and major complications were higher in the pull group than in the push group (63% vs 48%, p=0.028; and 11% vs 6%, p=0.140, respectively). Reoperation was also more common in the pull group (17% vs 7%, p=0.020).

Conclusions

The overall complication rate of PEG procedures is high. Fortunately, most complications are mild and do not require reoperations. The increasing push technique appears to be safer than the traditional pull technique. Significant long-term morbidity is related to gastrostomies in children.

Changes in Medical Charges Following Intensive Multidisciplinary Intervention for Pediatric Gastrostomy Tube Dependence

OBJECTIVE

Intensive multidisciplinary intervention (IMI) is the most evidence-based approach to treat pediatric feeding disorders. The goal of this exploratory study was to assess changes in health care charges for patients with gastrostomy tube dependence following participation in IMI compared to a waitlist control.

METHODS

Medical charges were assessed for 9 families who participated in IMI compared to 6 control families on a multi-year waitlist for IMI. The IMI and control groups were compared on raw charges submitted as well as individual year-over-year changes in medical charges.

RESULTS

The IMI group decreased health care charges by 71% on average in the year following IMI compared to the control group increasing charges by 22% over the same period.

CONCLUSIONS

IMI also holds potential cost-savings in the year following treatment compared to children who do not receive treatment and adds to previous research focusing on long-term cost effectiveness of IMI.

Complications of one-step button percutaneous endoscopic gastrostomy in children

To assess the complications of one-step button percutaneous endoscopic gastrostomy (B-PEG) and determine risk factors for developing stomal infections or gastropexy complications. A retrospective study of 679 children who underwent a B-PEG procedure in a single tertiary care center over a 10-year period to December 2020 was conducted. Patient characteristics, early complications (occurring ≤ 7 days after the procedure), late complications (> 7 days after the procedure), and outcomes were collected from medical records. A list of potential risk factors, including age at procedure, prematurity, underlying neurological disease, and undernutrition, was determined a priori. At least 1 year of follow-up was available for 513 patients. Median follow-up duration was 2.8 years (interquartile range 1.0-4.9 years). Major complications were rare (< 2%), and no death was related to B-PEG. Early complications affected 15.9% of the study population, and 78.0% of children presented late complications. Development of granulation tissue was the most common complication followed in frequency by tube dislodgment and T-fastener complications. Only 24 patients (3.5%) presented stomal infections. Young age at the time of PEG placement (odds ratio (OR) 2.34 [1.03-5.30], p = .042) was a risk factor for developing peristomal infection. T-fastener migration occurred in 17.3% of children, and we found underlying neurological disease was a protective factor (OR 0.59 [0.37-0.92], p = .019).  Conclusion: B-PEG is a safe method and associated with a low rate of local infection. However, T-fasteners are associated with significant morbidity and require particular attention in young and premature infants. What is Known: • Percutaneous endoscopic gastrostomy (PEG) is the preferred method to provide long-term enteral nutrition in children to prevent malnutrition. The Pull-PEG method is still the most commonly used with complications , such as stomal infection. Since its description, only a few studies have reported postoperative complications of one-step button PEG (B-PEG). What is New: • T-fastener complications were not rare, and underlying neurologic disease was a protective factor. A very low rate of stomal infection was described, and young age at the time of PEG placement was a risk factor. The B-PEG is a safe method with fewer major complications than P-PEG in children.

Factors Associated With Gastrostomy Tube Complications in Infants With Congenital Heart Disease

INTRODUCTION

Children with congenital heart disease (CHD) often experience feeding intolerance due to aspiration, inability to tolerate feed volume, or reflux within the first few months of life, requiring a surgically placed gastrostomy tube (GT) for durable enteral access. However, complications such as GT dislodgement, cellulitis, and leakage related to GT use are common. GT-related complications can lead to unscheduled pediatric surgery clinic or emergency room (ER) visits, which can be time consuming for the family and increase overall healthcare costs. We sought to identify factors associated with GT complications within 2 wk after GT surgery and 1-y after discharge home following GT placement in infants with CHD.

METHODS

We performed a retrospective cohort study using the Society of Thoracic Surgeons database and electronic medical records from a tertiary children's hospital. We identified infants <1 y old underwent CHD surgery followed by GT surgery between September 2013-August 2018. Demographics, pre-operative feeding regimen, comorbidities, and GT-related utilization were measured. Postoperative GT complications (e.g., GT cellulitis, leakage, dislodgement, obstruction, and granulation tissue) within 2 wk after the GT surgery and an unplanned pediatric surgery clinic or ER visit within 1-y after discharge home were captured. Bivariate comparisons and multivariable logistic regression evaluated factors associated with GT complications and unplanned clinic or ER visits. A Kaplan-Meier failure curve examined the timing of ER/clinic visits.

RESULTS

Of 152 infants who underwent CHD then GT surgeries, 66% (N = 101) had postoperative GT complications. Overall, 83 unscheduled clinic visits were identified after discharge, with 37% (N = 31) due to concerns about granulation tissue. Of 137 ER visits, 48% (N = 66) were due to accidental GT dislodgement. Infants who were hospitalized for ≥2 wk after GT surgery had more complications than those discharged home within 2 wk of the GT surgery (40.6% versus 15.7%, P = 0.002). Infants receiving oral nutrition before CHD surgery (38.6% versus 60%, P=<0.001) or with single ventricle defects (19.8% versus 37.3%, P = 0.02) had fewer GT complications. After adjusting for type of cardiac anomaly, infants receiving oral nutrition prior to CHD surgery had a decreased likelihood of GT complications (odds ratio OR 0.46; 95% confidence intervals CI:0.23-0.93). A Kaplan-Meier failure curve demonstrated that 50% of the cohort experienced a complication leading to an unscheduled ER/clinic visit within 6 mo after discharge.

CONCLUSIONS

Unplanned visits to the ER or pediatric surgery clinic occur frequently for infants with CHD requiring a surgically placed GT. Oral feedings before cardiac surgery associated with fewer GT complications. Prolonged hospitalization associated with more GT complications. Optimizing outpatient care and family education regarding GT maintenance may reduce unscheduled visits for this high-risk, device-dependent infant population.

Gastrostomy Tube Use in Pediatrics: A Systematic Review

CONTEXT

Despite frequency of gastrostomy placement procedures in children, there remains considerable variability in preoperative work-up and procedural technique of gastrostomy placement and a paucity of literature regarding patient-centric outcomes.

OBJECTIVES

This review summarizes existing literature and provides consensus-driven guidelines for patients throughout the enteral access decision-making process.

DATA SOURCES

PubMed, Google Scholar, Medline, and Scopus.

STUDY SELECTION

Included studies were identified through a combination of the search terms "gastrostomy," "g-tube," and "tube feeding" in children.

DATA EXTRACTION

Relevant data, level of evidence, and risk of bias were extracted from included articles to guide formulation of consensus summaries of the evidence. Meta-analysis was conducted when data afforded a quantitative analysis.

EVIDENCE REVIEW

Four themes were explored: preoperative nasogastric feeding tube trials, decision-making surrounding enteral access, the role of preoperative imaging, and gastrostomy insertion techniques. Guidelines were generated after evidence review with multidisciplinary stakeholder involvement adhering to GRADE methodology.

RESULTS

Nearly 900 publications were reviewed, with 58 influencing final recommendations. In total, 17 recommendations are provided, including: (1) tTrial of home nasogastric feeding is safe and should be strongly considered before gastrostomy placement, especially for patients who are likely to learn to eat by mouth; (2) rRoutine contrast studies are not indicated before gastrostomy placement; and (3) lLaparoscopic placement is associated with the best safety profile.

LIMITATIONS

Recommendations were generated almost exclusively from observational studies and expert opinion, with few studies describing direct comparisons between GT placement and prolonged nasogastric feeding tube trial.

CONCLUSIONS

Additional patient- and family-centric evidence is needed to understand critical aspects of decision-making surrounding surgically placed enteral access devices for children.

Percutaneous Endoscopic Gastrostomy Tubes Can Be Considered Safe in Children: A Single-Center 11-Year Retrospective Analysis

Background and Objectives: When the human body is disabled to naturally ingest food through the mouth, enteral or parenteral nutritional support should be started. Percutaneous gastrostomy (PEG) is a flexible feeding tube that is inserted into the stomach through the abdominal wall in patients who will need long-term enteral nutrient intake. The aim of this study is to analyze clinical characteristic of children at the time of PEG placement as well as to determine indications, complications and outcomes associated with PEG at the Department of Pediatrics of the University Hospital of Split. Materials and Methods: Retrospective analysis of the medical records of patients treated from 2010 to 2020 was performed. The following data were collected from medical records: age, gender, information about nasogastric feeding before PEG placement, indication for PEG insertion, duration of PEG, procedure-related complications and treatment outcomes. Malnutrition was determined according to the z-score range for BMI for age and sex. According to the indication for PEG placement, patients were divided into five categories: central nervous system (CNS) diseases, neuromuscular diseases, genetic disorders, metabolic diseases, and group of children with polytrauma. Results: A total of 40 patients with median age of 110 months were included in study. At the time of PEG placement, most patients had deviations in body weight and height compared to expected values for age and sex. The most common underlying diagnoses were diseases of the central nervous system. Minor complications were found in 13 (35%) of patients. One patient (2.7%) developed major complication (gastrocolic fistula) and consequently underwent reoperation. The median duration of PEG in patients with complications before the need for replacement was 27 months, and in patients without complications, 43 months. Conclusions: Negative deviations of z-score body weight, body height, and body mass index could indicate the need for possible earlier placement of PEG. PEG can be considered as a safe therapeutic option in children since PEG-related complications, mostly in minor forms, were found in a small number of patients.

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: An Update to the ESPGHAN Position Paper

BACKGROUND

The European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) position paper from 2015 on percutaneous endoscopic gastrostomy (PEG) required updating in the light of recent clinical knowledge and data published in medical journals since 2014.

METHODS

A systematic review of medical literature from 2014 to 2020 was carried out. Consensus on the content of the manuscript, including recommendations, was achieved by the authors through electronic and virtual means. The expert opinion of the authors is also expressed in the manuscript when there was a lack of good scientific evidence regarding PEGs in children in the literature.

RESULTS

The authors recommend that the indication for a PEG be individualized, and that the decision for PEG insertion is arrived at by a multidisciplinary team (MDT) having considered all appropriate circumstances. Well timed enteral nutrition is optimal to treat faltering growth to avoid complications of malnutrition and body composition. Timing, device choice and method of insertion is dependent on the local expertise and after due consideration with the MDT and family. Major complications such as inadvertent bowel perforation should be avoided by attention to good technique and by ensuring the appropriate experience of the operating team. Feeding can be initiated as early as 3 hours after tube placement in a stable child with iso-osmolar feeds of standard polymeric formula. Low-profile devices can be inserted initially using the single-stage procedure or after 2-3 months by replacing a standard PEG tube, in those requiring longer-term feeding. Having had a period of non-use and reliance upon oral intake for growth and weight gain-typically 8-12 weeks-a PEG may then safely be removed after due consultation. In the event of non-closure of the fistula the most successful method for closing it, to date, has been a surgical procedure, but the Over-The-Scope-Clip (OTSC) has recently been used with considerable success in this scenario.

CONCLUSIONS

A multidisciplinary approach is mandatory for the best possible treatment of children with PEGs. Morbidity and mortality are minimized through team decisions on indications for insertion, adequate planning and preparation before the procedure, subsequent monitoring of patients, timing of the change to low-profile devices, management of any complications, and optimal timing of removal of the PEG.

What Is the Correct Way to Manage Children Requiring Gastrostomy? Single Center Experience

Children with complex medical issues often present different comorbidities that cause feeding difficulties. Gastrostomy is often helpful, and should be performed when nutritional supplementation is necessary for longer than 6 weeks. Recently, different techniques have been used for gastrostomy in children. The authors report on their experiences regarding the diagnostic and therapeutic management of children requiring gastrostomy. All patients managed in the last 10 years were reviewed, retrospectively. Everyone underwent investigation to exclude gastroesophageal reflux disease (GERD). A total of 148 patients: 111 cases (75%) were neurologically impaired patients, 18 (12%) had complex heart disease, 10 (6%) had metabolic diseases, 4 (3%) had fibrosis cystic, 4 (3%) had muscle disease, and one had chromosomopathy. After investigation, 49 patients had GERD. PEG was performed in 101 cases (68%), laparo-assisted gastrostomy was performed in 44 cases (29.7%), open gastrostomy was performed in three cases. At follow-up, all patients reported weight gain, but 13 cases had major complications. Currently, the surgeon has the possibility of choosing between several safe techniques for gastrostomy. In our experience, PEG is the most useful technique for patients without GERD, while a laparo-assisted technique is better for patients who require laparoscopic fundoplication.

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.

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.

An Economic Analysis of Intensive Multidisciplinary Interventions for Treating Medicaid-Insured Children with Pediatric Feeding Disorders

Background. Intensive multidisciplinary intervention (IMI) represents a well-established treatment for pediatric feeding disorders (PFDs), but program availability represents an access care barrier. We develop an economic analysis of IMI for weaning from gastronomy tube (G-tube) treatment for children diagnosed with PFDs from the Medicaid programs' perspective, where Medicaid programs refer to both fee-for-service and managed care programs. Methods. The 2010-2012 Medicaid Analytic eXtract claims provided health care data for children aged 13 to 72 months. An IMI program provided data on average admission costs. We employed a finite-horizon Markov model to simulate PFD treatment progression assuming 2 treatment arms: G-tube only v. IMI targeting G-tube weaning. We compared the expenditure differential between the 2 arms under varying time horizons and treatment effectiveness. Results. Overall Medicaid expenditure per member per month was $6814, $2846, and $1550 for the study population of children with PFDs and G-tube treatment, the control population with PFDs without G-tube treatment, and the no-PFD control population, respectively. The PFD-diagnosed children with G-tube treatment only had the highest overall expenditures across all health care settings except psychological services. The expenditure at the end of the 8-year time horizon was $405,525 and $208,218 per child for the G-tube treatment only and IMI arms, respectively. Median Medicaid expenditure was between 1.7 and 2.2 times higher for the G-tube treatment arm than for the IMI treatment arm. Limitations. Data quality issues could cause overestimates or underestimates of Medicaid expenditure. Conclusions. This study demonstrated the economic benefits of IMI to treat complex PFDs from the perspective of Medicaid programs, indicating this model of care not only holds benefit in terms of improving overall quality of life but also brings significant expenditure savings in the short and long term.

Survival of children and adolescents with intellectual disability following gastrostomy insertion

BACKGROUND

Positive health outcomes have been observed following gastrostomy insertion in children with intellectual disability, which is being increasingly used at younger ages to improve nutritional intake. This study investigated the effect of gastrostomy insertion on survival of children with severe intellectual disability.

METHODS

We used linked disability and health data of children and adolescents who were born in Western Australia between 1983 and 2009 to compare survival of individuals with severe intellectual disability by exposure to gastrostomy status. For those born in 2000-2009, we employed propensity score matching to adjust for confounding by indication. Effect of gastrostomy insertion on survival was compared by pertinent health and sociodemographic risk factors.

RESULTS

Compared with children born in the 1980s-1990s, probability of survival following first gastrostomy insertion for those born in 2000-2009 was higher (2 years: 94% vs. 83%). Mortality risk was higher in cases than that in their matched controls (hazard ratio 2.9, 95% confidence interval 1.1, 7.3). The relative risk of mortality (gastrostomy vs. non-gastrostomy) may have differed by sex, birthweight and time at first gastrostomy insertion. Respiratory conditions were a common immediate or underlying cause of death among all children, particularly among those undergoing gastrostomy insertion.

CONCLUSIONS

Whilst gastrostomy insertion was associated with lower survival rates than children without gastrostomy, survival improved with time, and gastrostomy afforded some protection for the more vulnerable groups, and earlier use appears beneficial to survival. Specific clinical data that may be used to prioritise the need for gastrostomy insertion may be responsible for the survival differences observed.

Do Antibiotics Reduce the Incidence of Infections After Percutaneous Endoscopic Gastrostomy Placement in Children?

OBJECTIVE

Percutaneous endoscopic gastrostomy (PEG) provides a long-term solution for tube dependency. Pediatric guidelines recommend prophylactic antibiotic treatment (ABT) based on adult studies.

AIM

To compare wound infection and other complications in children receiving a PEG with and without prophylactic ABT.

METHODS

Retrospective study including children 0 to 18 years undergoing PEG placement. Patients with (2010-2013) and without (2000-2010) ABT were compared with respect to the occurrence of wound infection and other complications.

RESULTS

In total, 297 patients were included (median age 2.9 years, 53% boys). Patients receiving ABT per PEG protocol (n = 78) had a similar wound infection rate (17.9% vs 21%, P = 0.625), significantly less fever (3.8% vs 14.6%, P = 0.013), leakage (0% vs 9.1%, P = 0.003) and shorter hospital admission (2 vs 4 days, P = 0.000), but more overgranulation (28.2% vs 8.7%, P = 0.000) compared with those without (n = 219). Patients receiving any ABT, per PEG protocol or clinical indication (n = 115), had similar occurrence of wound infection (19.1% vs 20.9%, P = 0.768), fever (7.8% vs 14.3%, P = 0.100) and leakage (3.5% vs 8.8%, P = 0.096), a significantly shorter hospital admission (3 vs 4 days, P = 0.000), but more overgranulation (21.7% vs 8.8%, P =0.003) compared with those without (n = 182).

CONCLUSIONS

Prophylactic ABT does not seem to reduce the occurrence of wound infection but it might be beneficial with respect to fever, leakage and duration of hospital admission, but not overgranulation. A randomized controlled trial is needed to confirm our results.

New Medical Device Acquisition During Pediatric Severe Sepsis Hospitalizations

OBJECTIVES

Severe sepsis is a significant cause of healthcare utilization and morbidity among pediatric patients. However, little is known about how commonly survivors acquire new medical devices during pediatric severe sepsis hospitalization. We sought to determine the rate of new device acquisition (specifically, tracheostomy placement, gastrostomy tube placement, vascular access devices, ostomy procedures, and amputation) among children surviving hospitalizations with severe sepsis. For contextualization, we compare this to rates of new device acquisition among three comparison cohorts: 1) survivors of all-cause pediatric hospitalizations; 2) matched survivors of nonsepsis infection hospitalizations; and 3) matched survivors of all-cause nonsepsis hospitalization with similar organ dysfunction.

DESIGN

Observational cohort study.

SETTING

Nationwide Readmission Database (2016), including all-payer hospitalizations from 27 states.

PATIENTS

Eighteen-thousand two-hundred ten pediatric severe sepsis hospitalizations; 532,738 all-cause pediatric hospitalizations; 16,173 age- and sex-matched nonsepsis infection hospitalizations; 15,025 organ dysfunction matched all-cause nonsepsis hospitalizations; and all with live discharge.

MEASUREMENTS AND MAIN RESULTS

Among 18,210 pediatric severe sepsis hospitalizations, 1,024 (5.6%) underwent device placement. Specifically, 3.5% had new gastrostomy, 3.1% new tracheostomy, 0.6% new vascular access devices, 0.4% new ostomy procedures, and 0.1% amputations. One-hundred forty hospitalizations (0.8%) included two or more new devices. After applying the Nationwide Readmissions Database sampling weights, there were 55,624 pediatric severe sepsis hospitalizations and 1,585,194 all-cause nonsepsis hospitalizations with live discharge in 2016. Compared to all-cause pediatric hospitalizations, severe sepsis hospitalizations were eight-fold more likely to involve new device acquisition (6.4% vs 0.8%; p < 0.001). New device acquisition was also higher in severe sepsis hospitalizations compared with matched nonsepsis infection hospitalizations (5.1% vs 1.2%; p < 0.01) and matched all-cause hospitalizations with similar organ dysfunction (4.7% vs 2.8%; p < 0.001).

CONCLUSIONS

In this nationwide, all-payer cohort of U.S. pediatric severe sepsis hospitalizations, one in 20 children surviving severe sepsis experienced new device acquisition. The procedure rate was nearly eight-fold higher than all-cause, nonsepsis pediatric hospitalizations, and four-fold higher than matched nonsepsis infection hospitalizations.

Percutaneous endoscopic gastrostomy in children less than 10 kilograms: A comparative study

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.

Risk of Hospitalizations Following Gastrostomy in Children with Intellectual Disability

OBJECTIVE

To examine the frequency of hospital admissions before and after gastrostomy insertion in children with severe intellectual disability.

STUDY DESIGN

We conducted a retrospective cohort study using linked health administrative and disability data from Western Australia (WA) and New South Wales (NSW). Children born between 1983 and 2009 in WA and 2002 and 2010 in NSW who had a gastrostomy insertion performed (n = 673 [WA, n = 325; NSW, n = 348]) by the end of 2014 (WA) and 2015 (NSW) were included. Conditional Poisson regression models were used to evaluate the age-adjusted effect of gastrostomy insertion on acute hospitalizations for all-cause, acute lower respiratory tract infections (LRTI), and epilepsy admissions.

RESULTS

The incidence of all-cause hospitalizations declined at 5 years after procedure (WA cohort 1983-2009: incidence rate ratio, 0.70 [95% CI, 0.60-0.80]; WA and NSW cohort 2002-2010: incidence rate ratio, 0.63 [95% CI, 0.45-0.86]). Admissions for acute LRTI increased in the WA cohort and remained similar in the combined cohort. Admissions for epilepsy decreased 4 years after gastrostomy in the WA cohort and were generally lower in the combined cohort. Fundoplication seemed to decrease the relative incidence of acute LRTI admissions in the combined cohort.

CONCLUSIONS

Gastrostomy was associated with health benefits including reduced all-cause and epilepsy hospitalizations, but was not protective against acute LRTI. These decreases in hospitalizations may reflect improved delivery of nutrition and medications.

Pediatric Endoscopy, Update 2020

Optimal management of pediatric endoscopy requires a multidisciplinary approach. In most hospitals, endoscopy in pediatric patients is performed by conventional gastroenterologists and only a few centers have specialized pediatric gastroenterologists. This is due to the fact that the number of pediatric gastroenterologists is limited and not all of them are experienced in endoscopic techniques. However, there are also some pediatric centers offering a high-quality and high-volume endoscopy service provided by very experienced pediatric gastroenterologists. Up to now, the literature on pediatric endoscopy is rather sparse. In this article, we describe current knowledge and practice of endoscopic procedures in pediatric patients, which should be relevant for both the adult and pediatric gastroenterologists.

Pediatric Endoscopy and High-risk Patients: A Clinical Report From the NASPGHAN Endoscopy Committee

Pediatric gastrointestinal endoscopy has been established as safe and effective for diagnosis and management of many pediatric gastrointestinal diseases. Nevertheless, certain patient and procedure factors should be recognized that increase the risk of intra- and/or postprocedural adverse events (AEs). AEs associated with endoscopic procedures can broadly be categorized as involving sedation-related physiological changes, bleeding, perforation, and infection. Factors which may increase patient risk for such AEs include but are not limited to, cardiopulmonary diseases, anatomical airway or craniofacial abnormalities, compromised intestinal luminal wall integrity, coagulopathies, and compromised immune systems. Examples of high-risk patients include patients with congenital heart disease, craniofacial abnormalities, connective tissues diseases, inflammatory bowel disease, and children undergoing treatment for cancer. This clinical report is intended to help guide clinicians stratify patient risks and employ clinical practices that may minimize AEs during and after endoscopy. These include use of CO2 insufflation, endoscopic techniques for maneuvers such as biopsies, and endoscope loop-reduction to mitigate the risk of such complications such as bleeding and intestinal perforation. Endoscopic infection risk and guidance regarding periprocedural antibiotics are also discussed.

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.

Preoperative Educational Intervention Decreases Unplanned Gastrostomy-Related Health Care Utilization

Apprehension in taking independent care of children with medical devices may lead to unnecessary visits to the ED and/or acute clinic (AC). To address these concerns, our institution implemented a gastrostomy tube (GT) class in 2011 for caretakers. We hypothesized that inappropriate GT-related ED/AC visits would be lower in preoperatively educated caregivers. We performed a retrospective cohort study of all patients aged 0 to 18 who received GT (surgical or percutaneous) at our institution between 2006 and 2015 (n = 1340). Class attendance (trained vs untrained) and unscheduled GT-related ED/AC visits one year after GT placement were reviewed. Gastrostomy-related ED/AC visits were classified as appropriate (hospital-based intervention) or inappropriate (site care and education/reassurance). Occurrence of ED/AC visits was compared between trained and untrained cohorts. We found that 59 per cent of patients had an unscheduled GT-related ED/AC visit within one year of placement. The trained cohort had 27 per cent less unplanned ED/AC visits within one year (mean 1.21 (SD 1.82) vs untrained 1.65 (2.24), P < 0.001). On multivariate analysis, GT education independently decreased one-year GT-related health care utilization (Odds Ratio 0.75, 95% Confidence Interval 0.59–0.95). Formal education seems to decrease GT-related health care utilization within one year of placement and should be integrated into a comprehensive care plan to improve caregiver self-efficacy.

Influence of Percutaneous Endoscopic Gastrostomy on Gastroesophageal Reflux Disease in Children

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.

Preoperative Evaluation Is Not Predictive of Transpyloric Feeding Conversion in Gastrostomy-dependent Pediatric Patients

OBJECTIVES

Limited literature exists as to whether preoperative gastrostomy (GT) evaluation may predict which patients will go onto require gastrojejunostomy (GJ) tube feeding. The goal of this study was to compare the preoperative evaluations between patients maintained on GT feeds versus patients who required conversion to GJ feeds.

METHODS

We identified patients at Boston Children's Hospital who underwent GT tube placement and required GJ feeding between 2006 and 2012. GT patients were matched according to age, neurologic, and cardiac status with GJ-converted patients. Preoperative characteristics, rates of total hospitalizations, and respiratory-related admissions were reviewed.

RESULTS

A total of 79 GJ patients (median interquartile range (IQR): age 15 (4.3, 55.7) months; weight 8.8 (4.6, 14.5) kg) were matched with 79 GT patients (median (IQR): age 14.6 (4.7, 55.7) months; weight 8.5 (5, 13.6) kg). Median time from GT to GJ conversion was 8 (IQR 3, 16) months. Both groups had similar rates of successful preoperative nasogastric feeding trials (GT (84.5%) versus GJ (83.1%), P = 1.0), upper gastrointestinal series (GT (89.1%) versus GJ (93.2%), P = 0.73), abnormal videofluoroscopic swallow studies (GT (53.8%) versus GJ (62.2%), P = 0.4), and completion of gastric emptying studies (GT (10.1%) versus GJ (5.1%), P = 0.22). No differences were seen in preoperative hospitalization rates (P = 0.25), respiratory admissions (P = 0.36), although GJ patients had a mean reduction in the number of hospitalization of -1.5 ± 0.5 days, P < 0.001, after conversion.

CONCLUSIONS

No differences in preoperative patient characteristics or diagnostic evaluations were seen in GT fed versus GJ converted patients. GJ patients did experience an overall decrease in total admissions after GJ conversion.

Infant Percutaneous Endoscopic Gastrostomy: Risks or Benefits?

BACKGROUND/AIMS

To present a single center's experience with percutaneous endoscopic gastrostomy (PEG) tube placement in infants.

METHODS

Clinical records of infants who underwent PEG tube placement between January 2010 and December 2015 were reviewed. All patients underwent an upper gastrointestinal contrast study and an abdominal ultrasonography before the procedure. PEGs were performed with a 6-mm endoscope using the standard pull-through technique. Data regarding gestational age, birth weight, age and weight, days to feeding start, days to full diet, and complications were reviewed.

RESULTS

Twenty-three patients were included. The most common indication was dysphagia related to hypoxic-ischemic encephalopathy. Median gestational age was 37 weeks (range, 24-41) and median birth weight was 2,605 grams (560-4,460). Patients underwent PEG procedures at a median age of 114 days (48-350); mean weight was 5.1 kg (3.2-8.8). In all patients but one, a 12-Fr tube was positioned. Median feeding start was 3 days (1-5) and on average full diet was achieved 5 days after the procedure (2-11). Six minor complications were recorded and effectively treated in the outpatient clinic; no major complications were recorded.

CONCLUSIONS

PEG is safe and feasible in infants when performed by highly experienced physicians.

Comparison of operative outcomes between surgical gastrostomy and percutaneous endoscopic gastrostomy in infants

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.

Postoperative complications following percutaneous endoscopic gastrostomy are common in children

AIM

Inserting a feeding tube using percutaneous endoscopic gastrostomy may be necessary to ensure that children with eating problems receive sufficient enteral nutrition. The aim of this study was to investigate the perioperative and postoperative complications of percutaneous endoscopic gastrostomy when the pull-through method was the standard procedure.

METHODS

This was a retrospective review of 229 children (50.7% male) who underwent a gastrostomy procedure at Odense University Hospital, Denmark, from January 1, 2000 to December 31, 2012. The median age of the children was 1.6 years (range: 0-14.9), and the follow-up period was 36 months. Complications were graded according to the Clavien-Dindo classification.

RESULTS

A total of 167 postoperative complications occurred in 118 of the 229 patients (51.5%). Of these, 89 were grade 1 complications, 49 were grade 2 complications, and 29 were grade 3b complications. No gastrostomy-related deaths were observed, and no single preoperative risk factor was identified. Perioperative complications were experienced by 2.6% of the patients.

CONCLUSION

Gastrostomy feeding tube placement was associated with a high rate of postoperative complications of various grades when the pull-through method was the standard procedure. A consensus on how to report and grade complications arising from this procedure is warranted.

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.

Fatal Complications after Pediatric Surgical Interventions: Lessons Learned

Placement of catheters, drains, shunts, and tubes in children can lead to serious or even fatal complications at the moment of placement, such as hemorrhage at insertion, or in the longterm, such as infections and migration into adjacent organs. The clinician should always be aware of these potential complications, especially if the child is unwell. For postmortem diagnostic evaluation, either with a computed tomography scan or an invasive autopsy, all tubes, drains, shunts, and/or catheters should be left in situ. We present three cases with fatal complications after the placement of a chest drain, ventriculoperitoneal shunt, and gastrostomy tube.

Comparison of Percutaneous Endoscopic Gastrostomy and Surgical Gastrostomy in Severely Handicapped Children

PURPOSE

Gastrostomy is commonly used procedures to provide enteral nutrition support for severely handicapped patients. This study aimed to identify and compare outcomes and complications associated with percutaneous endoscopic gastrostomy (PEG) and surgical gastrostomy (SG).

METHODS

A retrospective chart review of 51 patients who received gastrostomy in a single tertiary hospital from January 2000 to May 2016 was performed. We analyzed the patients and the complications caused by the procedures.

RESULTS

Among the 51 patients, 26 had PEG and 25 had SG. Four cases in the SG group had fundoplication for gastroesophageal reflux disease. PEG and SG groups were followed up for an average of 29 months and 44 months. Major complications occurred in 19.2% of patients in the PEG group and 20.0% in the SG group, but significant differences between the groups were not observed. Minor complications occurred in 15.4% of patients in the PEG group and 52.0% in the SG group. Minor complications were significantly lower in the PEG group than in the SG group (p=0.006). The average use of antibiotics in the PEG and SG groups was 6.2 days and 15.7 days (p=0.002). Thirteen patients died of underlying disease but not related to gastrostomy, and only one patient died due to complications associated with general anesthesia.

CONCLUSION

The duration of antibiotics use and incidence of minor complications were significantly lower in the PEG group than those in the SG group. Early PEG could be recommended for nutritional supports.

Complications in pediatric enteral and vascular access

Obtaining reliable enteral and vascular access constitutes a significant fraction of a pediatric surgeon׳s job. Multiple approaches are available. Given the complicated nature of this patient population multiple complications can also occur. This article discusses the various techniques and potential complications associated with short- and long-term enteral and vascular access.

Infant gastrostomy outcomes: The cost of complications

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.

Trends in the use of gastrostomies at a tertiary paediatric referral centre

OBJECTIVES

The aims of this study were to describe the population of paediatric patients undergoing gastrostomy placement at a Norwegian tertiary referral centre and to investigate trends over time in patient characteristics and operative technique.

MATERIALS AND METHODS

Patients <15 years of age getting a primary gastrostomy from 1994 to 2012 were included in this retrospective observational study. Patient data were collected from medical records and the National Registry.

RESULTS

Six-hundred forty-nine patients with a median age of 1.2 years [gestational week 30-14.9 years] were included. Neurological disorders (ND) was the most common underlying group of diagnosis (n = 311, 48%), followed by cardiac disease 104 (16%), congenital anomalies 85 (13%), respiratory disease 43 (7%), malignancy 29 (5%), and others 77 (12%). At follow-up, 162 (25%) patients were dead. A percutaneous endoscopic technique (PEG) was used in 401 (62%) patients, open surgery (OPEN) in 201 (31%) and laparoscopy (LAP) in 47 (7%). The number of gastrostomies per year more than doubled during the period (p < 0.001). More patients with cardiac disease and congenital anomalies were given a gastrostomy during the last years (all p < 0.05), whereas the number of patients with ND remained stable. Furthermore, there has been a decrease in median age and an increase in the number of PEG and LAP (p < 0.05).

CONCLUSION

The number of gastrostomy insertions has increased from 1994 to 2012. NDs is the most common underlying diagnosis in patients receiving a gastrostomy, PEG is the most common technique and patient characteristics have changed during the study period.

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.

Outcomes of Infants With Home Tube Feeding: Comparing Nasogastric vs Gastrostomy Tubes

BACKGROUND

The aim of this study was to determine the tube-related complications and feeding outcomes of infants discharged home from the neonatal intensive care unit (NICU) with nasogastric (NG) tube feeding or gastrostomy (G-tube) feeding.

MATERIALS AND METHODS

We performed a chart review of 335 infants discharged from our NICU with home NG tube or G-tube feeding between January 2009 and December 2013. The primary outcome was the incidence of feeding tube-related complications requiring emergency department (ED) visits, hospitalizations, or deaths. Secondary outcome was feeding status at 6 months postdischarge. Univariate and multivariate analyses were conducted.

RESULTS

There were 322 infants discharged with home enteral tube feeding (NG tube, n = 84; G-tube, n = 238), with available outpatient data for the 6-month postdischarge period. A total of 115 ED visits, 28 hospitalizations, and 2 deaths were due to a tube-related complication. The incidence of tube-related complications requiring an ED visit was significantly higher in the G-tube group compared with the NG tube group (33.6% vs 9.5%, P < .001). Two patients died due to a G-tube-related complication. By 6 months postdischarge, full oral feeding was achieved in 71.4% of infants in the NG tube group compared with 19.3% in the G-tube group ( P < .001). Type of feeding tube and percentage of oral feeding at discharge were significantly associated with continued tube feeding at 6 months postdischarge.

CONCLUSION

Home NG tube feeding is associated with fewer ED visits for tube-related complications compared with home G-tube feeding. Some infants could benefit from a trial home NG tube feeding.

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.

Laparoscopic Gastrostomy Is Superior to Percutaneous Endoscopic Gastrostomy Tube Placement in Children Less Than 5 years of Age

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.

Oral Feeding Reduces Hospitalizations Compared with Gastrostomy Feeding in Infants and Children Who Aspirate

OBJECTIVE

To compare the frequency of hospitalization rates between patients with aspiration treated with gastrostomy vs those fed oral thickened liquids.

STUDY DESIGN

A retrospective review was performed of patients with an abnormal videofluoroscopic swallow study between February 2006 and August 2013; 114 patients at Boston Children's Hospital were included. Frequency, length, and type of hospitalizations within 1 year of abnormal swallow study or gastrostomy tube (g-tube) placement were analyzed using a negative binomial regression model.

RESULTS

Patients fed by g-tube had a median of 2 (IQR 1, 3) admissions per year compared with patients fed orally who had a 1 (IQR 0, 1) admissions per year, P < .0001. Patients fed by gastrostomy were hospitalized for more days (median 24 [IQR 6, 53] days) vs patients fed orally (median 2 [IQR 1, 4] days, [P < .001]). Despite the potential risk of feeding patients orally, no differences in total pulmonary admissions (incidence rate ratio 1.65; 95% CI [0.70, 3.84]) between the 2 groups were found, except patients fed by g-tube had 2.58 times (95% CI [1.02, 6.49]) more urgent pulmonary admissions.

CONCLUSIONS

Patients who underwent g-tube placement for the treatment of aspiration had 2 times as many admissions compared with patients with aspiration who were fed orally. We recommend a trial of oral feeding in all children cleared to take nectar or honey thickened liquids prior to g-tube placement.

Estimating Adverse Events After Gastrostomy Tube Placement

OBJECTIVE

Gastrostomy feeding tube placement in children is associated with a high frequency of adverse events. This study sought to preoperatively estimate postoperative adverse events in children undergoing gastrostomy feeding tube placement.

METHODS

This was an observational study of children who underwent gastrostomy with or without fundoplication at 1 of 50 participating hospitals, using 2011-2013 data from the American College of Surgeons' National Surgical Quality Improvement Program Pediatric. The outcome was the occurrence of any postoperative complications or mortality at 30 days after gastrostomy tube placement. The preoperative clinical characteristics significantly associated with occurrence of adverse events were included in a multivariate logistic model. The area under the receiver operating characteristic curve was computed to assess model performance and split-set validated.

RESULTS

A total of 2817 children were identified as having undergone gastrostomy tube placement. The unadjusted rate of adverse events within 30 days after gastrostomy tube placement was 11%. Thirteen predictor variables were identified. Notable preoperative variables associated with a greater than 75% increase in adverse event rate were preoperative sepsis/septic shock (odds ratio [OR], 10.76, 95% confidence interval [CI], 3.84-30.17), central nervous system tumor (OR, 3.36; 95% CI, 1.42-7.95), the primary procedure as indicated by the current procedural terminology (CPT) linear risk variable (OR, 1.93; 95% CI, 1.50-2.49), severe cardiac risk factors (OR, 1.88; 95% CI, 1.17-3.03), and preoperative seizure history (OR, 1.90; 95% CI, 1.38-2.62). The area under the receiver operating characteristic curve was 0.71 with the derivation data set and 0.71 upon split-set validation.

CONCLUSIONS

Preoperatively estimating postoperative adverse events in children undergoing gastrostomy tube placement is feasible.

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.

Informed Consent for Pediatric Endoscopy

Informed consent and refusal for pediatric procedures involves a process in which the provider, child, and parents/guardians participate. In pediatric gastroenterology, many procedures are considered elective and the process generally begins with an office visit and ends with the signing of the consent document. If the process is emergent then this occurs more expeditiously and a formal consent may not be required. Information about the procedure should be shared in a way that allows a decision-making process to occur for both the parent/guardian and the child, if of assenting age.

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.