Gastrostomy Placement and Management in Children: A Single-Center Experience

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.

Pediatric gastrostomy tube referral patterns and postoperative use: A single-center experience

OBJECTIVES

Practice variability exists regarding the timing of gastrostomy tube (GT) placement in patients unable to maintain adequate oral nutrition. We sought to assess patient factors predictive of longer surgical GT use to inform patient selection.

METHODS

We conducted a single-center, retrospective cohort study including children ≤18 years who underwent surgical GT placement from June 1, 2018 to June 1, 2021 at a children's hospital. Bivariate and logistic regression analyses were performed to assess the impact of referral patterns, operative indications, and patient comorbidities on the length of GT use.

RESULTS

Four hundred fifty-eight children underwent GT placement. Median age at placement was 5 months (interquartile range [IQR]: 2-12) and 52% were male. Fifty-six percent were referred from a neonatal intensive care unit;/cardiovascular intensive care unit provider before initial hospital discharge and 19% were outpatient referrals. Forty-six percent were premature and 50% exhibited oropharyngeal dysphagia. The median duration of nasogastric (NGT) feeding before GT placement was 36.5 days (IQR: 16-64). In those with GT removal (n = 140), the median duration of use was 269 days (IQR: 144-474), with 23% of the cohort no longer utilizing the GT within 12 months of placement. Patients with congenital lung disease (odds ratio [OR]: 3.03, p = 0.002) and genetic anomalies excluding isolated Trisomy 21 (OR: 3.57, p = 0.003) were more likely to require prolonged GT use.

CONCLUSIONS

Nearly a quarter of children attain full oral feeding within a year of GT placement. The identified factors predictive of prolonged GT use suggest early placement in these patients. Continuing NGT feeds in other patients may decrease the morbidity of unnecessary GT placement.

The effects of gastrojejunostomy tube placement on pulmonary and gastrointestinal complications following spinal fusion for neuromuscular scoliosis

To evaluate whether preoperative conversion from a gastrostomy tube (G-tube) to a gastrojejunostomy tube (GJ-tube) decreases short-term postoperative aspiration pneumonia and gastrointestinal complications in children with neuromuscular scoliosis. We conducted a retrospective chart review from January 2006 to October 2021 of pediatric patients who had neuromuscular scoliosis and were fed with a G-tube before spinal fusion. Eligible patients were divided into two groups based on whether they were converted to a GJ-tube preoperatively. Preoperative characteristics and 30-day postoperative outcomes were compared between groups using Chi-square tests. Of 261 eligible patients, 205 were converted to a GJ-tube, while 56 underwent spinal fusion with a G-tube. Common complications following G-tube to GJ-tube conversion were feeding intolerance (25.2%), GJ-tube malfunction (17.7%), and at least one episode of vomiting (17.4%). Within 30 days of discharge, 12.5% of GJ-tube patients and 11.5% of G-tube patients experienced aspiration pneumonia ( P  = 0.85). The GJ-tube group received postoperative tube feeds 7 hours earlier than the G-tube group on average (51.6 h vs. 44.5 h, P  = 0.02). Within 30 days of discharge, one (0.5%) patient from the GJ-tube group died of gastrointestinal complications unrelated to conversion and two (3.6%) patients in the G-tube group died from aspiration pneumonia ( P  = 0.12). Results suggest that there were no appreciable differences in outcomes between patients converted to a GJ-tube preoperatively compared to those who continued to use a G-tube. However, preoperative characteristics indicate that a higher number of complex patients were converted to a GJ-tube, indicating potential selection bias in this retrospective sample. Level of evidence: Level III.

Simultaneous surgery for gastrostomy and laryngotracheal separation in a patient with Tay‒Sachs disease

Genetic testing identified novel compound heterozygous missense variants in the HEXA gene (NM_00520.6: c.775A>C and NM_000520.6: c.508C>T) in a 16-month-old girl diagnosed with Tay‒Sachs disease. The patient gradually became unable to consume food orally. She suffered severe aspiration pneumonia and underwent gastrostomy and laryngotracheal separation at 2 years and 4 months of age. Despite an initially good prognosis, she died at 3 years of age.

Efficacy of enteral feeding by gastrostomy tube placement in patients with Lennox-Gastaut syndrome on body weight and days of hospitalization: A retrospective case series

BACKGROUND

Lennox-Gastaut syndrome (LGS) is a severe form of drug-resistant epilepsy that begins during childhood and frequently leads to significant neurological impairments. Patients with LGS are likely to receive improper oral nutrition because of issues such as dysphagia and aspiration risk, potentially resulting in long-term tube feeding and eventual gastrostomy tube placement. Therefore, we investigated the effects of gastrostomy tube placement on nutrition outcomes and frequency of hospitalization in LGS.

METHODS

We retrospectively examined 67 patients diagnosed with LGS who had undergone gastrostomy tube placement between January 2005 and August 2022. Comprehensive clinical data and complications arising from the procedure were collected. Patients' nutrition condition and frequency of hospitalizations were analyzed before and after gastrostomy tube placement.

RESULTS

Gastrostomy tube placement was performed for the following reasons: high risk of aspiration (50 out of 67, 74.6%), dysphagia (13 out of 67, 25.4%), persistent nasogastric tube feeding (2 out of 67, 3.0%), and severe malnutrition (2 out of 67, 3.0%). After the procedure, z scores for weight-for-age improved significantly, shifting from -3.35 ± 3.57 to -2.54 ± 2.70 over a 2-year interval (P < 0.001). Additionally, the total days of hospitalization and days of hospitalization due to respiratory symptoms reduced significantly from 41.94 ± 51.76 to 15.27 ± 26.68 (P < 0.001) and from 23.75 ± 36.92 to 10.52 ± 22.98 (P = 0.009), respectively. Among the patients, 50 (74.6%) experienced complications resulting from gastrostomy, with a relatively small proportion of major complications (11 out of 67, 16.4%) and no mortality.

CONCLUSION

Gastrostomy tube placement is a relatively safe procedure with favorable effects on nutrition status and hospitalization rates in patients with LGS.

Experiences of Parents and Caregivers of Children Who Underwent Gastrostomy Tube Insertion

Gastrostomy feeding is a route of enteral nutrition for children with feeding difficulties. This study investigated caregiver experiences of the transition to gastrostomy feeding. A survey was administered to caregivers of children <18 years in a major pediatric center in Ireland. Experiences of decision-making, support, and adjusting to tube feeding were examined. Seventy-six caregivers participated. Median satisfaction with the information provided by the hospital was high. Almost half (48%) spoke to another caregiver of a child with a gastrostomy prior to their own child's gastrostomy insertion and most (88%) felt reassured by this. Concerns following insertion included managing the tube and their child's oral intake and feelings about the tube. The oral intake of 83% of children who had some intake prior to gastrostomy insertion did not change or increased following insertion. Most (89%) would make the same decision to insert the tube. Feelings associated with the transition included relief and stress. Gastrostomy tube insertion presents logistical and psychosocial challenges for caregivers. Peer support from other caregivers may alleviate some of these challenges.

Exploring parental thoughts and clinical experiences on blended food in a paediatric population, a qualitative study

Background

There's a growing interest in blended food (BF) as an alternative to commercial food (CF) for tube-fed children. Thus, we investigated parental and medical experiences with BF as an option for tube feeding in children.

Methods

In this cross-sectional study, all patients were already using BF, chosen by parents. In March 2022, all patients using BF provided consent and completed a questionnaire assessing their experiences. Medical data were collected retrospectively from patient charts, including biometric changes, dietary adjustments, and nutritional status. A non-validated parent satisfaction score was computed from 17 questions, rated on a scale from one to five. A score of ≥ 51 points, indicating an average score of > 3 per question, was deemed indicative of a positive parental experience with BF.

Results

Nine children receiving BF were identified (median age: 4.7 years; weight: 14.9 kg; 66% male). All parents were satisfied with BF, reflected in the parent satisfaction score. Parents cited reduced feeding-related discomforts as the main reason for switching to BF. Weight (+0.3 SD) and length (+0.5 SD) showed positive changes. None discontinued BF, though modifications were made for five patients by the dietician. Nutritional deficiencies, mainly iron with or without zinc deficiency, were observed in four patients, with uncertain onset due to lack of pre-BF laboratory testing.

Conclusions

In this small BF cohort overseen by an experienced multidisciplinary team, BF was well tolerated, resulting in high parental satisfaction and maintaining good nutritional status.

Gastrostomy Tubes: Indications, Types, and Care

Gastrostomy tube insertion has become a more common practice in pediatric patients. An increasing number of children both in health-care facilities and at home are relying on temporary or long-term enteral feeding. Gastrostomy tube placement can be accomplished by various methods and by a variety of specialists. Despite the overall safety of these procedures, both early and late complications can occur. It is important for pediatricians and pediatric subspecialists to be familiar with and aware of the indications, safety, and management of gastrostomies. This paper provides a comprehensive overview of the topic.

Prophylactic anti-reflux procedure for children undergoing laparoscopic gastrostomy: Rethinking of the routine practice

AIM

Laparoscopic gastrostomy is a frequently performed procedure in children requiring long-term enteral nutrition. The role of prophylactic anti-reflux surgery during gastrostomy placements is controversial. The current study aims to evaluate the role of prophylactic anti-reflux procedures during gastrostomy placement.

METHODS

A retrospective single-center analysis of all children without reflux receiving laparoscopic gastrostomy from January 2005 through December 2021 was performed. Demographics and clinical outcomes were compared between patients receiving gastrostomy placement alone and patients receiving gastrostomy with prophylactic anti-reflux surgery.

RESULTS

A total of 79 patients had a confirmed absence of reflux by a 24-h pH/impedance study before operation. Thirty-six of these patients underwent prophylactic anti-reflux surgery (PAR) while 43 received gastrostomy (PG) alone. The operative time and conversion rate were significantly higher in the PAR group (140.5 ± 67.5 vs. 80.2 ± 66.8 min, p = 0.0001 and 8.3% vs. 0%, p = 0.04). There were no major complications in either group. De novo reflux was detected in five patients (11.6%) in the PG group. None of these patients progressed to require anti-reflux surgery.

CONCLUSION

The occurrence of de novo reflux after laparoscopic gastrostomy was low and could be managed without anti-reflux surgery. A routine pre-operative pH study is helpful for appropriate patient selection to avoid unnecessary anti-reflux surgery, which lengthens operative time and increases the conversion rate.

Outcomes of laparoscopic gastrostomy in children with and without the use of a modified T-fastener technique

BACKGROUND

Laparoscopic gastrostomy is commonly performed for durable enteral access in children. T-fasteners have been used intraoperatively to achieve a secure gastropexy, traditionally using external bolsters. We compare the safety profile of a modified paired T-fastener technique to standard laparoscopic-assisted suture gastropexy.

METHODS

A retrospective matched case-control study was performed of pediatric patients who underwent laparoscopic gastrostomy at a single center from 2015 to 2021. In the paired T-fastener group, pairs of T-fasteners were passed into the stomach in a square configuration, allowing the suture pairs to be tied subcutaneously. This cohort was matched in a 1:2 fashion with age, sex, and body mass index or weight-matched controls who underwent laparoscopic gastrostomy with buried transabdominal gastropexy.

RESULTS

Thirty patients underwent laparoscopic gastrostomy using the paired T-fastener technique and were matched to 60 controls. There was no significant difference in median operative time or 30-day complication rates between the groups, but the paired T-fastener technique significantly reduced the number of trocars required, and it was used for patients with thicker abdominal walls.

CONCLUSION

We demonstrate the modified paired T-fastener technique as a safe, efficient means of gastropexy in pediatric laparoscopic gastrostomy. The paired T-fastener approach eliminates external bolsters, reduces additional trocars, and may be advantageous for thicker abdominal walls while maintaining a similar complication profile to standard laparoscopic gastrostomy.

Complications of percutaneous endoscopic gastrostomy in children: a single-center experience

Purpose: Percutaneous endoscopic gastrostomy is the most preferred method for feeding in children with intact gastrointestinal system functions when oral nutrition is insufficient due to neurological, neuromuscular, or oncological diseases. This study aimed to evaluate the indications for percutaneous endoscopic gastrostomy and associated complications in the patients we followed up. Materials and Methods: In this descriptive study, the records of 130 patients who underwent percutaneous endoscopic gastrostomy for nutritional support between January 1st 2013- December 30th 2020 were retrospectively reviewed. Demographic data, indications, complications, and follow-up periods of the patients were examined. Results: Of the patients, 75 were male and 55 were female. The mean age of the patients was 48 months (min 1 month-max 211 months). The evaluation of the patients with percutaneous endoscopic gastrostomy in terms of diagnosis revealed that 95 patients required nutritional support due to neuromotor retardation associated with neurological disease, 19 patients due to central nervous system tumor, and 13 patients due to metabolic disease. Considering complications, the most frequent minor complication was leakage in 11of the 33 patients, while the most frequent major complication was colonic fistulation in 6 of the 9 patients. Two patients required open surgery in the early period due to intra abdominal leak. Conclusion: Although enteral nutrition with a percutaneous endoscopic gastrostomy tube seems to be an appropriate and reliable method to meet the nutritional needs of pediatric patients who have normal digestive system functions but cannot be fed orally due to swallowing disorders, it is necessary to pay attention to its complications like any surgical procedure.

Complications of Percutaneous and Surgical Gastrostomy Placements in Children: a Single-Centre Series

Gastrostomy placement is a standard procedure for children requiring enteral feeding for more than 3-6 weeks. Various techniques have been described (percutaneous endoscopic, laparoscopy, and laparotomy), and many complications have been reported. In our center, gastrostomy placement is performed either percutaneously by pediatric gastroenterologists, by laparoscopy/laparotomy by the visceral surgery team, or jointly, that is laparoscopic-assisted percutaneous endoscopic gastrostomy. This study aims to report all complications and identify risk factors and ways to prevent them.

Methods

This is a monocentric retrospective study including children younger than 18 years who underwent gastrostomy placement (percutaneous or surgical) between January 2012 and December 2020. Complications that occurred up to 1 year after placement were collected and classified according to their time of onset, degree of severity, and management. A univariate analysis was conducted to compare the groups and the occurrence of complications.

Results

We established a cohort of 124 children. Sixty-three (50.8%) presented a concomitant neurological disease. Fifty-nine patients (47.6%) underwent endoscopic placement, 59 (47.6%) surgical placement, and 6 (4.8%) laparoscopic-assisted percutaneous endoscopic gastrostomy. Two hundred and two complications were described, including 29 (14.4%) major and 173 (85.6%) minor. Abdominal wall abscess and cellulitis were reported 13 times. Patients who underwent surgical placement presented more complications (major and minor combined) with a statistically significant difference compared with the endoscopic technique. Patients with a concomitant neurological disease had significantly more early complications in the percutaneous group. Patients with malnutrition had significantly more major complications requiring endoscopic or surgical management.

Conclusion

This study highlights a significant number of major complications or complications requiring additional management under general anesthesia. Children with a concomitant neurological disease or malnutrition are at greater risk of severe and early complications. Infections remain a frequent complication, and prevention strategies should be reviewed.

Complications of Gastrostomy and Gastrojejunostomy: The Prevalence in Children

Purpose

This study aimed to provide an overview of the prevalence of the complications of a gastrostomy or a gastrojejunostomy with a low-profile gastric tube in children. The study also examined the effect of presence of the gastrostomy tube on the prevalence of complications.

Methods

In this cross-sectional study, parents were invited to complete an online questionnaire. Children aged 0-16 years with a low-profile gastrostomy or gastrojejunostomy tube were included in the study.

Results

A total of 67 complete surveys were conducted. The mean age of the included children was seven years. The most common complications during the past week, were skin irritation (35.8%), abdominal pain (34.3%), and the formation of granulation tissue (29.9%). The most common complications during the past six months were skin irritation (47.8%), vomiting (43.4%), and abdominal pain (38.8%). Most complications occurred within the first year after gastrojejunostomy placement and gradually decreased as the duration since the placement of the gastrojejunostomy tube increased. The prevalence of severe complications was rare. Parental confidence in caring for the gastrostomy positively correlated with increases in the duration of the gastrostomy tube. Even so, parental confidence in the care of the gastrostomy tube was reduced in some parents more than a year after its placement.

Conclusion

The prevalence of gastrojejunostomy complications in children is relatively high. The incidences of severe complications after the placement of a gastrojejunostomy tube were rare in this study. A lack of confidence in the care of the gastrostomy tube was noted in some parents more than a year after its placement.

Clinical management and diagnosis of CLN2 disease: consensus of the Brazilian experts group

Neuronal ceroid lipofuscinosis type 2 (CLN2) is a rare neurodegenerative genetic disease that affects children in early life. Its classic form is rapidly progressive, leading to death within the first 10 years. The urge for earlier diagnosis increases with the availability of enzyme replacement therapy. A panel of nine Brazilian child neurologists combined their expertise in CLN2 with evidence from the medical literature to establish a consensus to manage this disease in Brazil. They voted 92 questions including diagnosis, clinical manifestations, and treatment of the disease, considering the access to healthcare in this country. Clinicians should suspect CLN2 disease in any child, from 2 to 4 years old, with language delay and epilepsy. Even though the classic form is the most prevalent, atypical cases with different phenotypes can be found. Electroencephalogram, magnetic resonance imaging, molecular and biochemical testing are the main tools to investigate and confirm the diagnosis. However, we have limited access to molecular testing in Brazil, and rely on the support from the pharmaceutical industry. The management of CLN2 should involve a multidisciplinary team and focus on the quality of life of patients and on family support. Enzyme replacement therapy with Cerliponase α is an innovative treatment approved in Brazil since 2018; it delays functional decline and provides quality of life. Given the difficulties for the diagnosis and treatment of rare diseases in our public health system, the early diagnosis of CLN2 needs improvement as enzyme replacement therapy is available and modifies the prognosis of patients.

Continuous Glucose Monitoring in Enterally Fed Children with Severe Central Nervous System Impairment

Children with severe central nervous system (CNS) impairment are at risk of developing various degrees of nutritional deficit that require long-term nutritional intervention. Interventions are most often implemented through enteral nutrition (EN) using commercially manufactured feeds administered via gastro/jejunostomy or nasogastric or nasojejunal tubes. The modality of feeding-continuous feeding or bolus feeding-is dependent on the function of the gastrointestinal tract, particularly the efficiency of gastric emptying. In the literature, the relationship between this type of nutrition and the occurrence of hyperglycaemia is often discussed. In addition, children with chronic neurological diseases are vulnerable to disorders of many mechanisms of neurohormonal counter-regulation related to carbohydrate management, and due to limited verbal and logical contact, it is difficult to recognise the symptoms of hypoglycaemia in such patients. We aimed to assess the carbohydrate metabolism in children with severe CNS impairment, with enteral nutrition delivered via nasogastric, nasoenteral, or percutaneous tubes, based on continuous glycaemic monitoring (CGM) and the measurement of glycated haemoglobin (HbA1c) levels.

MATERIALS AND METHODS

This prospective, observational study included nineteen patients (median (25-75 pc) age: 12.75 (6.17-15.55) years) with permanent CNS damage (Gross Motor Function Classification System V) receiving long-term tube enteral feeding, recruited from two paediatric university nutritional treatment centres. Patients with acute conditions and diagnosed diabetes were excluded. The nutritional status and nutritional support were analysed in all the inpatients in accordance with a uniform protocol. Using the CGM system (Medtronic iPro2), glycaemic curves were analysed, and in addition, HbA1C levels were determined in fourteen patients. CGM results were analysed using GlyCulator2.0. Statistical analysis was performed using the Statistica version 11 software (StatSoft Inc. Tulsa, OK, USA).

RESULTS

More than half (11/19; 58%) of the patients were undernourished (BMI < 3 pc for age and gender), with the stature age being significantly lower than calendar age (5 (4.5-9) vs. 12.75 (6.17-15.55) years; p = 0.0010). The actual caloric intake was 50 (37.7-68.8) kcal/kg (median; 25-75 pc). In patients fed using the bolus method, the number of calories consumed per day was statistically significantly higher than in children subjected to a continuous feeding supply (56.00 (41.00-75.00) vs. 33.40 (26.70-50.00) kcal/kg BW (body weight; p = 0.0159). Decreases in blood glucose levels below the alarm level (<70 mg/dL) were recorded in fifteen patients (78.9%), including two patients with episodes of clinically significant hypoglycaemia (<54 mg/dL). The minimum and maximum glycaemic values recorded in any individual CGM records were 67 mg/dL (median) (minimum: 41 mg/dL; maximum: 77 mg/dL) and 146 (minimum: 114 mg/dL; maximum: 180 g/dL), respectively, for the entire recording. The maximum percentage of glycaemic concentrations > 140 mg/dL (TAR 140) recorded overnight in children with BMI ≥ 3 amounted to 1.6% vs. 0% in undernourished patients (TAR 140: 0.0 (0.00-1.6%) vs. 0% (0.00-0.0%; p = 0.0375); the percentage of glycaemic concentrations <70 mg/dL in the entire recording was comparable (0.77% (0.13-2.2%) vs. 1.8% (0.5-14.4%) vs. p = 0.2629). There was a positive correlation between the mean daily glucose recorded using the CGM method and patients' BMI z-scores (R = 0.48, p = 0.0397). No statistically significant relationship was demonstrated between the occurrence of alarm hypoglycaemia events in the CGM records and undernutrition expressed by BMI z-scores (OR = 1.50 (95%CI: 0.16-13.75), the type of diet (for commercially manufactured OR = 0.36 (95%CI: 0.04-3.52), and the modality of diet delivery (for bolus feeding OR = 2.75 (95%CI: 0.28-26.61).

CONCLUSIONS

In children with chronic OU damage, enteral feeding is associated with a risk of hypoglycaemia, but further studies involving a larger number of patients are needed, and CGM might be a useful tool to estimate the metabolic adequacy of enteral nutritional support in terms of glucose control.

Antibiotic prophylaxis for percutaneous endoscopic gastrostomy in pediatric patients: a meta-analysis

PURPOSE

To investigate if Antibiotic Prophylaxis (AP) can prevent wound and/or systemic infection in pediatric patients who underwent Percutaneous Endoscopic Gastrostomy (PEG).

METHODS

PubMed, Embase, and Cochrane databases were searched for Randomized Controlled Trials (RCT) and Observational Studies that compared AP vs. no Intervention (NI) in children submitted to PEG. Odds ratios (OR) with 95% confidence intervals (CI) were pooled with random-effect models. Quality assessment and risk of bias were performed as outlined by Cochrane recommendations.

RESULTS

Four studies, including one RCT, with a total of 568 patients were included, in which 230 (40.5%) individuals received AP. The use of AP during PEG reduced the incidence of systemic infection (OR 0.46; 95% CI 0.24-0.90; p = 0.02; I² = 0). However, no statistical difference was found for wound infection (OR 0.85; 95% CI 0.43-1.69; p = 0.64; I² = 12%) and for the composite outcome of any kind of infection (OR 0.74; 95% CI 0.13-4.06; p = 0.73; I² = 67%).

CONCLUSION

In this pooled analysis of 568 infants who underwent PEG, the use of AP reduced the incidence of systemic infection. Our results were compatible with findings obtained in the adult population. No differences were found regarding wound infection or the composite outcome of any kind of infection.

A Pragmatic Approach to Assessment of Chronic and Recurrent Pain in Children with Severe Neurologic Impairment

The term “severe neurologic impairment” (SNI) is used to describe a group of disorders of the central nervous system which arise in childhood, resulting in motor impairment, cognitive impairment and medical complexity. As a result, much assistance is required with activities of daily living. Since these patients are often unable to self-report pain, or they may exhibit uncommon behaviors when suffering, pain manifestations may go unrecognized. In this article, the basic principles of how to approach pain in children with SNI are discussed.

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.

Management of Postoperative Complications Following Common Pediatric Operations

This review discusses complications unique to pediatric surgical populations. Here the authors focus primarily on five of the most common procedures performed in children: appendectomy, central venous catheterization, pyloromyotomy, gastrostomy, and inguinal/umbilical hernia repair.

Comparing Different Techniques in Children With or Without a Simultaneous Fundoplication: Does the Gastrostomy Technique Matter?

Purpose: To evaluate the results of different gastrostomy techniques and the impact of simultaneous fundoplication. Materials and Methods: The patients who underwent a gastrostomy procedure between 2009 and 2019 in a single tertiary center were evaluated retrospectively. The patients are divided into groups depending on the gastrostomy techniques as open gastrostomy (OG), laparoscopic gastrostomy (LG), percutaneous endoscopic gastrostomy (PEG), and laparoscopy-assisted PEG (LAPEG). Preoperative characteristics and postoperative outcomes are compared among the groups. Results: Two hundred forty-four patients (75, 60, 91, and 18 patients in OG, LG, PEG, and LAPEG groups, respectively) are enrolled in the study. Although rates of minor or major complications did not demonstrate a significant difference among the groups, no major complications were encountered in the LAPEG group, while the lowest minor complications were observed in the PEG group (P > .05). Length of postoperative initiation of enteral feeding and length of hospital stay (LOS) were highest in the OG group (P = .000). Performing a concurrent fundoplication procedure significantly delayed the initiation of enteral feeding and increased the LOS in all of the groups (P < .005). Conclusions: Although PEG is a safe and reproducible technique of gastrostomy in selected patients, LAPEG may expand the boundaries of PEG by reducing the major complication rates. Although simultaneous fundoplication may complicate the perioperative period, it does not have significance on outcomes.

Size Matters: Early Gastrostomy Tube Dislodgment in Children

Background: Gastrostomy tube (g-tube) complications are typically minor and site related with major complications related to dislodgment before tract establishment. With the recent adoption of 12F g-tubes; size of tube has not been evaluated. There is limited research on the efficacy and dislodgment rates of 12 and 14F g-tubes within the early dislodgment window (<42 days postsurgery). Materials and Methods: A retrospective study from June 1, 2013 to May 25, 2020 was performed. A total of 888 patient encounters were identified, with a final data set of 835 being used for analysis. A subset of 21 patients was evaluated based on early dislodgment status. Fisher's exact test and Welch's two-sample test analyses were used to test for significance between groups (P < .05). Results: The early dislodgment rate is low at 2.5% (21/835). There was a significant impact of g-tube size on dislodgment rates. When evaluated by g-tube size, 12F g-tubes are nearly four times more likely to dislodge before 6 weeks than 14F g-tubes. In addition, the average age of 12F patients who dislodged early was significantly lower than that of the population for 14F patients. Conclusions: There is a significant difference in early dislodgment rate and age between the 12F g-tube compared with a 14F. These data suggest a trade-off of the smaller balloon in 12F g-tubes and potential for more limited use in our smallest children.

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.

Point Prevalence of Gastrostomy in a Paediatric Population

OBJECTIVE

The aim of the study was to determine the prevalence of gastrostomy in a paediatric population.

METHODS

A population-based cross-sectional point prevalence study of paediatric gastrostomy was performed. Patients included were ages 0 to 19 years, living within 3 inner-city London boroughs; Southwark, Lambeth, and Lewisham. Patients were identified as having a gastrostomy in situ via Home Enteral Nutrition (HEN) and community nursing databases. Electronic healthcare records were scrutinised to confirm current use of a gastrostomy. The main outcome measures were the point prevalence of gastrostomy in the paediatric population (gastrostomies/100,000 children), primary diagnosis, indication underlying gastrostomy insertion, and age at insertion.

RESULTS

The total population studied was 946,709, of whom 213,920 were of age 0 to 19 years. Of these, 179 had a gastrostomy in situ giving a point prevalence for gastrostomy in the paediatric population of 83.7 (95% confidence interval [CI]: 71.4-96.0)/100,000 children. This varied between age groups: 0 to 4 years: 79.6 (57.3-102.0)/100,000, 5 to 9 years: 116.3 (88.7-143.9)/100,000, 10 to 14: years 87.9 (61.9-113.9)/100,000 and 15 to 19: years 41.4 (22.1-60.1)/100,000. The most common primary diagnoses were neurological disorders (57.1%), and structural abnormalities (16.2%). Unsafe swallow was the most common indication (61%), followed by nutritional or fluid supplementation (28.6%), and behavioural reasons (8.7%). The majority (85.1%) of gastrostomies were inserted under the age of 2 years.

CONCLUSIONS

This is the first UK population-based study of paediatric gastrostomy, identifying a point prevalence of 84/100,000 children. The peak prevalence is in children ages 5 to 9 years. Gastrostomy insertion after a child reaches school age is uncommon.

Gastrostomy Button Placement in Infants With Cyanotic Versus Acyanotic Congenital Heart Disease

BACKGROUND

Infants with congenital heart disease (CHD) may exhibit increased metabolic demands, and many will undergo placement of a gastrostomy to achieve adequate nutritional intake. There is a paucity of data, however, comparing the operative risks and overall complications of gastrostomy placement in cyanotic versus acyanotic infants with CHD. We hypothesized that patients with cyanotic CHD would have a higher rate of gastrostomy-associated complications than infants with acyanotic CHD.

METHODS

We retrospectively reviewed patients who underwent gastrostomy button placement after cardiac surgery for CHD between 2013 and 2018. Patients were stratified into cyanotic CHD and acyanotic CHD cohorts. Patient data were extracted from the Society of Thoracic Surgeons database and merged with clinical data related to gastrostomy placement and complications from chart review. Unadjusted analyses were used to find covariates associated with cyanotic CHD and acyanotic CHD, using a t-test or Wilcoxon rank-sum test for continuous data, depending on normalcy, and χ² or Fisher's exact tests for categorical data depending on the distribution.

RESULTS

There were 257 infants with CHD who underwent gastrostomy placement during the study period, of which 86 had cyanotic CHD. There were no significant differences in baseline weight or preoperative albumin levels between the two groups. Patients with cyanotic CHD had a lower incidence of comorbid syndromes (P = 0.0001), higher Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery scores (P < 0.0001), and higher postoperative mortality rate (P = 0.0189). There was a higher rate of granulation tissue formation in patients with acyanotic CHD (48.5% versus 22.1%, P < 0.0001). There were no differences in other gastrostomy button-related complications, including leakage, wound infection, or dislodgement.

CONCLUSIONS

Patients with acyanotic CHD demonstrated a higher incidence of granulation tissue. We found no difference in gastrostomy-specific complication rates between the two groups, with the notable exception of granulation tissue formation. Based on this study, the diagnosis of cyanotic CHD does not increase the risk of gastrostomy-related complications.