Retrograde percutaneous gastrostomy: a prospective study in 57 children

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.

Peritonitis following percutaneous gastrostomy tube insertions in children

BACKGROUND

Percutaneous retrograde gastrostomy has a high success rate, low morbidity, and can be performed under different levels of sedation or local anesthesia in children. Despite its favourable safety profile, major complications can occur. Few studies have examined peritonitis following percutaneous retrograde gastrostomy in children.

OBJECTIVE

To identify potential risk factors and variables influencing the development and early diagnosis of peritonitis following percutaneous retrograde gastrostomy.

MATERIALS AND METHODS

We conducted a retrospective case-control study of children who developed peritonitis within 7 days of percutaneous retrograde gastrostomy between 2003 and 2012. From the 1,504 patients who underwent percutaneous retrograde gastrostomy, patients who developed peritonitis (group 1) were matched by closest date of procedure to those without peritonitis (group 2). Peritonitis was defined according to recognized clinical criteria. Demographic, clinical, procedural, management and outcomes data were collected.

RESULTS

Thirty-eight of 1,504 children (2.5%; 95% confidence interval, 1.8-3.5) who underwent percutaneous retrograde gastrostomy developed peritonitis ≤7 days post procedure (group 1). Fever (89%), irritability (63%) and abdominal pain (55%) occurred on presentation of peritonitis. Group 1 patients were all treated with antibiotics; 41% underwent additional interventions: tube readjustments (8%), aspiration of pneumoperitoneum (23%), laparotomy (10%) and intensive care unit admission (10%). In group 1, enteral feeds started on average 3 days later and patients were discharged 5 days later than patients in group 2. There were two deaths not directly related to peritonitis. Neither age, gender, weight, underlying diagnoses nor operator was identified as a risk factor.

CONCLUSION

Peritonitis following percutaneous retrograde gastrostomy in children occurs in approximately 2.5% of cases. No risk factors for its development were identified. Medical management is usually sufficient for a good outcome. Patients with peritonitis are delayed starting feeds and have a hospital stay that is an average of 5 days longer than those without.

Characteristics and outcomes of children with enterostomy feeding tubes: A study of 325 children

OBJECTIVES

To examine the characteristics and outcomes of children with gastrostomy and gastrojejunostomy tubes inserted before age three years, and to identify the factors that predict removal of the enterostomy tubes within 12 months of insertion.

DESIGN

Case review of a consecutive sample of 325 medical records.

SETTING

A tertiary care paediatric hospital that is situated in a large metropolitan area.

PATIENTS

All outpatients and inpatients from birth to 36 months of age who had an enterostomy tube inserted from 1994 to 1996.

METHODS

No direct intervention was provided. In the subgroup of 203 patients with a follow-up period of at least 12 months after tube insertion, children whose tubes were removed within 12 months of insertion were compared with children who continued to receive tube feedings for 12 months or longer.

RESULTS

At the time of tube insertion, the median age of patients was six months; 47% of the children for whom data were available were failing to thrive. Although 66 (21%) of 321 patients for whom data were available had their tubes removed, only 25 of the 203 (12%) patients with a follow-up period of 12 months or more had their tubes removed within 12 months of insertion. Children whose tubes were removed less than 12 months after insertion differed from children whose tubes were not removed with respect to medical diagnosis (no children with cerebral palsy had their tubes removed versus 33% of children with cancer who had their tube removed). Most children with failure to thrive at the time of tube insertion were also failing to thrive at the time of tube removal.

CONCLUSION

Children with cerebral palsy are not likely to have enterostomy tubes removed within one year of insertion.

Safety and effectiveness of radiologic percutaneous gastrostomy and gastro jejunostomy in children with cardiac disease

OBJECTIVE

The purpose of our study was to evaluate the safety and effectiveness of radiologic percutaneous gastrostomy and gastrojejunostomy for providing nutritional support in children with cardiac disease.

MATERIALS AND METHODS

Retrospective chart review of 58 children with cardiac disease who underwent radiologic percutaneous gastrostomy from November 2001 to June 2005 was conducted. Patient data were collected until January 2007. The patients' weights were collected at the time of insertion and 6, 12, 18, and 24 months after insertion, and weight-for-age z-scores were calculated.

RESULTS

The mean weight-for-age z-score increased from -2.79 at the time of radiologic percutaneous gastrostomy insertion to -2.33 (p = 0.05) at 6 months after insertion, -1.89 (p = 0.001) at 12 months, -1.65 (p = 0.0002) at 18 months, and -1.40 (p = 0.0004) at 24 months. Repeated measures regression analysis showed a significant increase in weight-for-age z-score over time (p < 0.0001), with an estimated mean increase in weight-for-age z-score of 0.055 per month. No mortality was associated with the insertion or usage of radiologic percutaneous gastrostomy. Major complications included intestinal perforation (3.4%) and aspiration pneumonia (12.1%).

CONCLUSION

Radiologic percutaneous gastrostomy is a safe method for providing long-term nutritional support in children with cardiac disease and is effective for improving growth and nutrition in this group of patients.

Growth outcomes and complications after radiologic gastrostomy in 120 children

BACKGROUND

Enteral feeding is ideal for children with low caloric intake. It can be provided through different methods, including nasogastric, nasojejunal, gastrostomy, or gastrojejunostomy tubes.

OBJECTIVE

To assess growth outcomes of pediatric patients following retrograde percutaneous gastrostomy (RPG) and compare complications with those following other gastrostomy methods.

MATERIALS AND METHODS

We retrospectively reviewed 120 random RPG patients from 2002 to 2003 (mean follow-up, 2.7 years). Patient weights and growth percentiles were recorded at insertion, and at 0-5 months, 6-12 months, and 18-24 months after insertion, and then compared using a Student's t-test. Complications and tube maintenance issues (TMIs) were recorded.

RESULTS

Gastrostomy tube insertion was successful in all 120 patients (59 boys, 61 girls; mean age 4.3 years). The most common underlying diagnosis was neurologic disease (29%, 35/120) and the main indication was inadequate caloric intake (24%, 29/120). Significant increases in growth percentile for the entire population were demonstrated between insertion and 0-5 months (18.7-25.3; P<0.001) and between insertion and 18-24 months (18.7-25.8; P<0.001). In boys and girls significant growth increases occurred between insertion and 0-5 months (boys P=0.004; girls P=0.01). There were 11 major postprocedural complications, 100 minor complications and 169 TMIs.

CONCLUSION

RPG provides long-term enteral nutrition in the pediatric population and increases growth significantly 6 and 24 months after insertion. Minor complications and TMIs are frequent.

Percutaneous radiologic gastrostomy

Gastrostomy is a preferred method of nutrition in patients with impaired ability to eat. Although surgical gastrostomy is a well-established method and has been widely performed in the last century, beginning with early 1980s, percutaneous gastrostomy techniques, either endoscopic or radiologic, has widely gained acceptance. As percutaneous methods have been shown to be an effective, safe, easy to perform and low-cost techniques with low morbidity and mortality rates, nowadays percutaneous gastrostomy is the first method of choice in need of nutrition in patients with functioning gut. In this article authors review the technique of percutaneous radiologic gastrostomy, as well as indications, contraindications, variations of technique, ethical considerations, controversies and comparison with surgical and endoscopic methods.

Imaging and intervention in the gastrointestinal tract in children

Vascular and interventional techniques have become an integral component of modern pediatric healthcare. Minimally invasive procedures of the gastrointestinal tract now comprise a large part of any active pediatric interventional practice. Magnetic resonance cholangiopancreatography offers a reliable, non-invasive means to evaluate patients with possible pancreatic or biliary pathology. This article reviews treatment of esophageal strictures and placement of gastronomy and gastrojejunostomy tubes and discusses new developments. Placement of percutaneous cecostomy tubes is a relatively new procedure that creatively uses the techniques developed for placement of percutaneous gastronomy tubes. This procedure offers significant benefits and lasting positive lifestyle changes for patients suffering from fecal incontinence. Liver biopsy in high-risk patients can be performed safely using measures designed to significantly decrease the risk of post-biopsy hemorrhage, such as track embolization or the transjugular approach.

Substitute decision-making: measuring individually mediated sources of uncertainty

One aspect of O'Connor's Decisional Conflict Scale [O'Connor, A.M., Validation of a decisional conflict scale, Med. Decis. Making 15 (1995) 25-30] is the assessment of selected factors (perceived lack of information, undue social pressure, lack of support from others, and lack of clarity about personal values) that are believed to contribute to decisional uncertainty. This study explored the appropriateness of this uncertainty measure in the substitute decision-making context. Forty-nine mothers deciding on gastrostomy tube insertion for their children completed the scale, and also provided verbal reports about the contributory factors. For each of the four factors, relatively high-, moderate-, and low-scoring sub-groups were identified; then the associated verbal reports were examined for across-sub-group differences. Differences in verbal reports about information (chi 2 = 6.990, P = 0.0082), perceived pressure (chi 2 = 8.377, P = 0.0038), social support (chi 2 = 5.573, P = 0.0182), and perceived gains and losses (chi 2 = 3.85, P = 0.0499; chi 2 = 5.76, P = 0.0164) were observed, implying consistency between quantitative scores and verbal reports. This quantitative/qualitative hybrid approach may be clinically useful for assessing individually mediated factors contributing to decision uncertainty, and for evaluating therapeutic interventions in other substitute decision-making contexts.

Efficacy and safety of radiologically placed gastrostomy tubes in paediatric haematology/oncology patients

BACKGROUND

The treatment of malnutrition, which is of great concern in paediatric haematology/oncology patients, is fraught with problems. The goals of our study were to document the complications and assess the weight gain with gastrostomy tubes (G-tubes) in this population.

PROCEDURE

Patient data were acquired by retrospective review of all haematology, oncology, and bone marrow transplant (BMT) patients (n = 44) who received radiologically placed G-tubes at our institution over a 4-year period.

RESULTS

Forty-four G-tubes were placed (59% peri-BMT). At tube placement, 55% of patients were malnourished and 45% were nourished. Seventy-five percent of patients had the procedure without general anaesthetic. Localized G-tube-site infection was the most common complication (41%). Major complications occurred in 3 patients; 2 patients experienced localized peritonitis, and 1 patient developed a localized collection of pus in the abdominal wall. There were no G-tube-related deaths. At 1 month after the tube insertion, 39% of patients had gained, 54% maintained, and 7% lost weight. At 3 months, 69% had gained, 28% maintained, and 3% lost weight. There was a statistically significant weight gain from the time of the G-tube placement to both 1 month (P < 0.018) and 3 months (P < 0.0001) after G-tube placement. Patients in all diagnosis categories showed improvement from 1 to 3 months.

CONCLUSIONS

We conclude that retrograde tube placement is safe and can frequently be done without general anaesthetic and that G-tube feeding effectively reverses malnutrition and prevents weight loss in this patient population.

Laparoscopic gastrostomy in children

During a 30-month period, 28 children aged 6 months-15 years underwent fashioning of a laparoscopic gastrostomy. Indications for operation included: feeding difficulties and failure to thrive in neurologically impaired children (13); chronic renal failure (9); and others (6). There were 17 conventional tube and 11 button gastrostomies. Twelve children had insertion of a gastrostomy alone; the others underwent a concomitant laparoscopic Nissen fundoplication (NFP). The average operation time for gastrostomy alone was 65 min (range 35-104) and for gastrostomy plus NFP 155 min (range 130-246). There were no specific laparoscopic complications. Two patients who required large volumes of eternal drugs and peritoneal dialysis from the 1st post-operative day developed minor external leaks from their stomas. It appears that laparoscopy provides for safe and precise positioning of any standard balloon or button gastrostomy. It is a particularly attractive technique for use in patients already undergoing a laparoscopic fundoplication and those in whom other minimally invasive techniques are contraindicated or fail.

Future directions in interventional pediatric radiology

In conclusion, the explosion of interventional radiology and its impact on the pediatric patient have resulted in a completely new approach to the subspecialty of interventional pediatric radiology. The interventional radiologist has become an integral part of the management of patients and has become directly involved in the day-to-day care of patients. The use of interventional MR imaging recently has been described in clinical trial. Open-configuration magnets that allow full access to the patient and are equipped with instrument tracking systems provide an interactive environment in which biopsies, endoscopic procedures, and minimally invasive interventions or surgeries are performed. In addition, thermal ablation and image-based control of energy deposition also can be performed. Among these procedures, noninvasive MR-guided focused ultrasound ablation has the most promising future and may replace some conventional surgery. The merging of new and exciting technologies including MR, ultrasound, CT, and fluoroscopy into an environment in which both surgical and interventional radiologic procedures can be performed with image guidance is the basis of the operating room of the future. The role of the interventional radiologist as both the imager and interventionalist is central to this procedural environment; however, the interventional radiologist must accept all the responsibilities of imaging, therapy, patient care, and associated complications.

Complications and effectiveness of gastrostomy feedings in pediatric cancer patients

PURPOSE

The objective of this study was to assess the complications and efficacy of gastrostomy (GT) feedings in pediatric cancer patients.

PATIENTS AND METHODS

We reviewed the medical records of 33 pediatric cancer patients who received enteral nutrition via a GT.

RESULTS

Median age was 9.4 years (range, 1-19.8 years), and 28 of the 33 patients had solid tumors. Seventeen patients had a significant weight loss (median, 8.5%) and therapy-related weight loss was anticipated in 16 patients. The GT device was placed an average of 5.5 months after diagnosis. Twenty-five patients were fed via a tube and eight via a button device. The tube was placed surgically in 21 cases (including all eight button types) and endoscopically in 12. Nutritional support lasted a median of 9.5 months. One or more complications occurred in 30 patients and were categorized as (a) insertion site reactions (inflammation, 23; infection/colonization, 14; exuberant granulation tissue, 6); (b) mechanical problems (leaking, 3; obstruction, 2; breakage, 1; accidental dislodgement, 2); (c) insertion site bleeding, 8; and (d) feeding intolerance, 12. Only one insertion site cellulitis progressed to a systemic infection. All eight patients with a button GT experienced insertion site complications, with local infection occurring significantly more often in patients with the button than in those with the tube GT. There were no significant associations between insertion technique and type of complication. Twenty-seven patients (82%) achieved or maintained ideal body weight with this intervention.

CONCLUSIONS

GT feeding was associated with minor complications, but permitted effective nutritional support for pediatric cancer patients.

Percutaneous feeding tube placement in pediatric patients: immediate and 30-day results

PURPOSE

To evaluate fluoroscopically guided percutaneous feeding tube placement in pediatric patients.

MATERIALS AND METHODS

Sixty-one procedures were performed. Periprocedural care protocol was changed after patient nine. Forty-eight-hour and 30-day outcomes were assessed.

RESULTS

Almost 97% of procedures were successful. The 48-hour major and minor complication rates were 1.9% and 9.6%, respectively, after the initial nine procedures. Risk factors for early complications were the use of the initial care protocol (P < .01) and patient weight below the 50th percentile (P < .05). Major and minor 30-day complication rates were 8.3% and 12.0%, respectively. Risk factors for delayed complications were placement of a gastrojejunostomy tube rather than a gastrostomy tube (P < .05) and immunosuppression (P < .05).

CONCLUSION

Percutaneous feeding tubes can be placed in children with a high rate of technical success. Optimal results require attention to periprocedural care. Morbidity is common during the first month of tube use.

Nonendoscopic antegrade percutaneous gastrostomy: the effect of preplacement gastric insufflation on tube position and intra-abdominal anatomy

Nonendoscopic tube gastrostomy was performed on 47 anesthetized dogs using the technique of Fulton and Dennis with or without gastric insufflation prior to tube placement. Immediately after tube placement, dogs were euthanized and postmortem examinations performed. When gastric insufflation was not performed (group I), gastrostomy tubes penetrated the visceral surface of the stomach in 25% of dogs. The deep leaf of the omentum was interposed between stomach and body wall in the majority of these dogs, exposing other intra-abdominal organs to potential injury. Additionally, displacement and tethering of the spleen cranial to the gastrostomy site were observed in 33% of dogs in group I. Similar results were obtained when preplacement gastric insufflation was performed after the orogastric tube was inserted sufficiently far to displace the stomach laterally against the body wall (group II). In contrast, consistent positioning of gastrostomy tubes through the parietal surface of the stomach was achieved when the stomach was insufflated prior to lateralizing the left abdominal wall with the gastric end of the orogastric tube (group III). It was concluded that the blind percutaneous gastrostomy technique is made safer by insufflating the stomach immediately prior to pushing the gastric wall laterally into contact with the parietal peritoneum.

Weight gain and triceps skinfolds fat mass after gastrostomy placement in children with developmental disabilities

OBJECTIVE

To determine appropriate outcome indicators of nutritional status that are measurable over time after gastrostomy placement in children with severe neurologic impairments.

DESIGN

Twenty-two nonambulatory children met the selection criteria: feeding by gastrostomy of at least 50% of total energy, age between 1 and 12 years, diagnosis of neurologic impairments, and presurgical recommendation for weight gain. Each child served as his or her own control; three assessments were made after gastrostomy placement.

SETTING

Children were seen in specialty outpatient clinics.

STATISTICAL ANALYSES

Scores and Pearson product moment correlations.

RESULTS

Outcomes of gastrostomy placement were (a) increase in actual weight, (b) increase in weight-age equivalent, (c) rate of weight accretion as expected by National Center for Health Statistics growth charts and improved z scores for half of the children, and (d) improvement in triceps skinfolds percentiles for nearly half (n = 10) of the children. The results reflect the heterogeneity of children with severe disabilities. Pearson correlations showed a significant relationship between chronologic age and weight-age equivalent (r = .96), but not for weight for age and weight-age equivalent, or triceps skinfolds fat mass and weight-age equivalent.

CONCLUSIONS/APPLICATIONS

Weight and triceps skinfolds fat mass were appropriate outcome indicators of nutritional status measurable over time. Weight-age equivalent and z scores were more helpful than standard growth plots for interpreting weight gain over time. Our data also support findings that undernutrition limits growth before gastrostomy placement in patients with disabilities. Nutritionists are encouraged to track improvement in nutritional status after gastrostomy placement with measurements of triceps skinfolds fat mass and to use the information to support families facing decisions about the need for this surgery.