Gastrostomy with antireflux properties

A comparison of laparoscopic and open Nissen fundoplication and gastrostomy placement in the neonatal intensive care unit population

INTRODUCTION

The aim of this study was to compare outcomes after laparoscopic and open techniques for Nissen fundoplication and gastrostomy placement in the neonatal intensive care unit (NICU) population.

METHODS

The medical records for NICU inpatients who underwent laparoscopic and open Nissen fundoplication and gastrostomy placement from August 2002 to August 2008 were reviewed after Institutional Review Board approval. Each technique was compared with regard to operative time, estimated blood loss, postoperative 24-hour narcotic requirements, time to goal feeds, and complication rates. Analysis of variance was used to determine statistical significance. Data are quoted as mean +/- SEM.

RESULTS

Fifty-seven NICU patients underwent fundoplication and gastrostomy placement (25 laparoscopic and 32 open). The time to goal feeds was significantly shorter for the laparoscopic group (4.3 +/- 0.4 vs 6.1 +/- 0.6 days, P = .04). The 24-hour postoperative narcotic requirement was significantly lower in the laparoscopic group (0.24 +/- 0.05 vs 0.55 +/- 0.08 mg/kg, P = .007). Operation times (111 +/- 5 [open] vs 113 +/- 5 minutes, P = .76) and estimated blood loss (13 +/- 2 [open] vs 11 +/- 1 mL, P = .33) were comparable for both groups.

CONCLUSION

Laparoscopic and open techniques for Nissen fundoplication with gastrostomy placement are safe and appropriate treatment methods with equivalent operating times for the treatment of gastroesophageal reflux in the NICU population.

Percutaneous endoscopic gastrostomy buttons in children: superior to tubes

BACKGROUND

There is a paucity of literature comparing outcomes of percutaneous endoscopic gastrostomy (PEG) tubes vs PEG buttons. Primary PEG buttons offer an advantage of being a single-step low-profile enteral access device with potentially fewer complications.

METHODS

A retrospective review of patients undergoing PEG tubes and buttons (January 2006-August 2007) was performed. Power analysis demonstrated that 105 patients in each group were needed. Patient characteristics were collected in each group and evaluated by chi(2) and t tests. P values of less than .05 were considered significant.

RESULTS

A total of 223 children having undergone PEG (110 tubes, 113 buttons) were identified. No differences were found in operative time, intraoperative complications, clogging, breakage, infections, emergency department visits, or hospital readmissions. However, children undergoing PEG button placement were more likely to spend only one night in the hospital vs PEG tube (60% vs 25%, respectively; P < .001). In addition, PEG buttons had fewer dislodgements (4 vs 15; P < .05).

CONCLUSION

The PEG buttons are less likely to become dislodged than PEG tubes. Infection rates were not found to be different between groups. Children with PEG buttons were more likely to be discharged earlier than children with PEG tubes. Primary PEG buttons are clinically comparable to PEG tubes with less concern for dislodgements.

Esophageal Atresia: Migration of the gastrostomy tube into the bronchus

A 2-day-old baby boy, 38 weeks gestation, weight 2000 g was brought due to hypersalivation and imperforate anus with gasless abdomen on plain X-ray. He underwent a gastrostomy tube insertion and colostomy. In contrast study of the stomach, on the 5th postoperative day, the dye spilled into the tracheo bronchial tree and the catheter was seen, entering the right main bronchus. The patient underwent right thoracotomy and the presence of fistula and catheter were confirmed. The fistula and distal esophagus were closed and fixed to the prevertebral fascia because of a long gap. He is under follow-up and recieving home care for a later delayed primary anastomosis.

Effects of Stamm Gastrostomy on Gastric Emptying Rate in Rats

AIM

Although frequency of gastroesophageal reflux (GER) increases after gastrostomy, the role of gastric emptying in GER has not been evaluated. In this study, we examined the effects of Stamm gastrostomy on gastric emptying rate in rats and whether Stamm gastrostomy induces GER or not.

METHODS

Sprague-Dawley rats were divided into three groups. Stamm gastrostomy was done in the first group (SG). Sham operation was carried out in group 2 and the 3rd group served as control. Gastric emptying was assessed using both liquid and solid meals in each group at postoperative 14th day. For solid meal emptying, after fasting of 16 h, the rats were fed for 3 h and gastric emptying rate was measured at the fifth hour. Methylcellulose was used for emptying of liquids and it was given after the animals were fasted for 16 h and gastric emptying rate was measured 30 min later. Histological evaluation for GER was performed in all groups.

RESULTS

GER was observed pathophysiologically in 5 of the 7 rats in SG group. Gastric emptying rates of liquid and solid meals were found to be similar in control, SG or sham groups.

CONCLUSION

Surgical gastrostomy does not affect the gastric emptying of solid and liquid meals in rats. Other mechanisms should be considered in the development of GER observed following gastrostomy.

Minimally invasive surgery in neonates

Minimally invasive surgery (MIS) has been one of the most important developments in surgery in the last century. By reducing the incision to small puncture wounds, morbidity, pain, adhesions and scarring are reduced. Due to their small size, neonates have not benefited from the advances in endoscopic surgery as rapidly as their adult counterparts. In the last 5 years, miniaturization of instruments and the development of sophisticated new techniques have enabled paediatric surgeons to apply endoscopic surgery to neonates. MIS is now being performed in both the neonatal chest and abdomen. This article reviews these new developments and discusses the potential for even further improvements in neonatal surgery in the future.

Quantitative and qualitative analysis of gastroesophageal reflux after percutaneous endoscopic gastrostomy

BACKGROUND/PURPOSE

Percutaneous endoscopic gastrostomy (PEG) is of great benefit to a defined population of children, but gastrostomy has been implicated in causation or exacerbation of gastroesophageal reflux (GER). The aim of this study was to quantitatively and qualitatively analyze the effect of PEG on GER.

METHODS AND MATERIAL

Sixty-four children mean age 6.7 +/- 4.2 years, most of whom were impaired neurologically were evaluated for GER after PEG between 1998 and 2000. Twenty-four-hour pH monitoring was used for quantitative assessment. Qualitative analysis was by interview to record the following: vomiting, choking, chest infection, and weight gain.

RESULTS

Twenty-four hour pH monitoring was performed 9.4 +/- 1.2 weeks after PEG. Patients underwent follow-up for 18 +/- 6 months. Seventy-two percent who did not have reflux before PEG remained reflux free. Fourteen percent who had GER before PEG continued to have reflux (P <.05). Only 5% of patients without GER before PEG had reflux afterward, and 3% of patients with preexisting GER deteriorated (P >.05). Six percent of patients with preexisting GER improved post-PEG. Of the 14 patients (22%) who had or continued to have reflux after PEG, 11 of 14 (79%) underwent antireflux surgery, and 21% were managed successfully by intensive medical treatment and change of feeding regimen. Only 6% experienced difficulties and complications with the device. Forty-eight percent of patients did not vomit pre- or postoperation. In 16%, vomiting improved post-PEG, whereas 14% experienced minor deterioration (1 to 2 vomits per month). Major deterioration was experienced by 22%. Weight gain occurred in 77%, and in 23% there was no loss of weight. There was an overall improvement in quality of life in 88% after PEG. Overall improvement in quality of life post-PEG, post-antireflux surgery and post-intensive medical management for pathologic GER was 94%.

CONCLUSIONS

(1) PEG did not precipitate or exacerbate GER quantitatively or qualitatively in the majority of children. (2) A normal 24-hour pH study predicted a favourable outcome after PEG. (3) An abnormal preoperation pH study predicted persistence or worsening reflux after PEG, but not all of these patients required an antireflux procedure. (4) GER is not a contraindication to PEG, the overall benefits of which outweigh the risks.

Diagnosis and treatment of feeding disorders in children with developmental disabilities

OBJECTIVES

To determine the results of diagnostic evaluation and the effects of nutritional intervention on energy consumption, weight gain, growth, and clinical status of children with neurodevelopmental disabilities and suspected feeding disorders.

METHODS

We studied 79 children with moderate to severe motor or cognitive dysfunction (male:female, 38:41; age, 5.8 +/- 3.7 years) who were referred for diagnosis and treatment of feeding or nutritional problems. Initial assessments included a 3-day calorie intake record, videofluoroscopic swallowing study (VFSS), 24-hour intraesophageal pH monitoring, milk scintigraphy, and esophagogastroduodenoscopy.

RESULTS

These studies demonstrated gastroesophageal reflux (GER) with or without aspiration in 44 of 79 patients (56%), oropharyngeal dysphagia in 21 (27%), and aversive feeding behaviors in 14 (18%). Diagnosis-specific approaches included medical GER therapy in 20 patients (25%), fundoplication plus gastrostomy tube (GT) in 18 (23%), oral supplements in 17 (22%), feeding therapy only in 14 (18%), and GT only in 10 (13%). After 24.6 +/- 3.0 months, relative calorie intake, expressed as intake (kcal/d)/recommended daily allowance (RDA, kcal/d), improved significantly (initial:final = 0.78 +/- 0.36:1.23 +/- 0.27). The z scores increased significantly for both weight (initial:final = -2.80 +/- 1.33:-0.81 +/- 0.69) and height (-3.14 +/- 0.98:-2.00 +/- 0.67). Improved subcutaneous tissue stores were demonstrated by increased thickness of both subscapular skinfolds (change = 71% +/- 26%) and triceps skinfolds (38% +/- 17%). After nutritional intervention, the acute care hospitalization rate, compared with the 2-year period before intervention, decreased from 0.4 +/- 0.18 to 0.15 +/- 0.06 admissions per patient-year and included only 3 admissions (0.02 per patient-year) related to feeding problems.

CONCLUSIONS

In children with developmental disabilities, diagnosis-specific treatment of feeding disorders results in significantly improved energy consumption and nutritional status. These data also indicate that decreased morbidity (reflected by a lower acute care hospitalization rate) may be related, at least in part, to successful management of feeding problems. Our results emphasize the importance of a structured approach to these problems, and we propose a diagnostic and treatment algorithm for children with developmental disabilities and suspected feeding disorders.children, developmental disabilities, fundoplication, gastroesophageal reflux, gastrostomy, hospitalization, nutrition.

Laparoscopic-assisted percutaneous endoscopic gastrostomy

The authors report the successful use of laparoscopic-assisted percutaneous endoscopic gastrostomy (LAPEG) in two children. Attempts at simple percutaneous endoscopic gastrostomy in both patients had failed. Subsequently, LA-PEG was easily accomplished. This technique consisted of a combination of upper gastrointestinal endoscopy and laparoscopy. The gastrostomy was placed under direct vision in the lesser gastric curvature, hence minimizing the risk of developing gastroesophageal reflux.

Comparison of open and laparoscopic gastrostomy and fundoplication in 120 patients

The rapid development and incorporation of minimally invasive surgical techniques has abruptly changed adult surgical practices. These minimally invasive procedures are now being successfully applied to pediatric surgical problems. The anticipated benefits of these techniques include less postoperative pain, quicker return of bowel function, shorter hospital stay, and lower hospital costs, with a quicker return to normal activity. This report compares the first 60 infants and children to undergo laparoscopic gastrostomy and/or fundoplication at our institution with the same number of patients that underwent these procedures in the traditional open fashion. The two groups were similar with respect to age, sex, concurrent illness, presenting symptoms, neurological status, and procedures performed. Patients in the laparoscopic group were found to have shorter mean hospital and postoperative stays and tolerated feeding earlier. The mean hospital stay was 13.8 days for the laparoscopic group versus 16.4 days in the open group. The mean postoperative stay was 6.8 days for the laparoscopic group versus 10.7 days for the open group. The mean postoperative day on which feeding was tolerated was 2.3 in the laparoscopic group versus 4.8 in the open group. Postoperative complications were similar between the two groups. These results seem to reflect the less traumatic nature of the laparoscopic procedures as compared with the open procedures. Laparoscopic fundoplication and gastrostomy is an attractive alternative to open fundoplication and gastrostomy in infants and children.

Gastroesophageal reflux in children

Operations for the control of complicated gastroesophageal reflux in children are commonly performed procedures in large pediatric centers. The comprehensive diagnostic scheme includes radiologic and endoscopic work-up coupled with extended pH probe analysis. Medical therapy remains the principle form of management, with surgery reserved for treatment failure.

Laparoscopic gastrostomy and fundoplication

Laparoscopic gastrostomy and fundoplication are a useful alternative to open fundoplication and gastrostomy in pediatric patients. Laparoscopic fundoplication appears to decrease the length of hospital stay and allow a more rapid recovery.

Gastrostomy techniques and devices

Gastrostomies play an important role in the management of a wide variety of surgical and nonsurgical conditions of childhood. Many techniques and gastrostomy devices are available. In our experience, percutaneous endoscopic gastrostomy has proved safe and effective, and the gastrostomy button has eliminated most of the catheter-related problems. Candidates for gastrostomy, particularly children with foregut dysmotility, must be carefully selected, undergo preoperative studies aimed at determining the degree of gastroesophageal reflux, and have appropriate long-term follow-up. Attention to technical detail is essential to avoid operative complications. A good working relationship between the surgeon, gastroenterologist, nurse, and patient's family is essential to minimize long-term morbidity, particularly stoma-related problems.

Current surgical considerations in gastroesophageal reflux disease in infancy and childhood

An understanding of gastroesophageal reflux disease in infants and children by the clinician requires a working knowledge of 18- to 24-hour esophageal pH monitoring and the motility disorders of the esophagus and stomach that may be associated with gastroesophageal reflux disease. The results of surgical therapy for childhood gastroesophageal reflux disease cannot be assessed accurately without this knowledge. Antireflux operations can be tailored to the child's situation, which includes a combination of clinical symptoms and findings on objective tests for reflux and associated alimentary-tract motility disorders. The presence of severe complications from gastroesophageal reflux disease in "asymptomatic" infants and children is a troublesome and not yet fully defined problem. Special areas include the documentation of gastroesophageal reflux disease as a cause of SIDS, the increased reporting of Barrett's esophagus and adenocarcinoma of the esophagus in childhood, and the effect of associated alimentary-tract motility disorders in children with CNS disease who have gastroesophageal reflux disease requiring surgical intervention.

Nissen fundoplication in children with profound neurologic disability. High risks and unmet goals

Anti-reflux procedures have been advocated in children with profound neurologic disability referred for feeding gastrostomy when gastroesophageal reflux is present. Facilitation of care, reduction in pneumonia and vomiting, and improvement in the general health and survival of these children have been major goals of fundoplication and gastrostomy. In large pediatric series, these procedures have been reported to have low risk and negligible mortality rates. Recent reports, however, document an increased incidence of sequelae of fundoplication in children with profound neurologic disability. This paper retrospectively reviews a series of 35 nonverbal, nonambulatory pediatric patients undergoing a total of 39 fundoplications (37 Nissen, 1 Thal, and 1 Belsey) over an 11-year period. Neurologic impairment of 17 (49%) patients was acquired, 13 (37%) congenital, and 5 (14%) due to a syndrome. Perioperative complications occurred in six (17%). Three additional complications led to early postoperative death. A fourth early death was unexplained. Fourteen (40%) had recurrent pneumonia, 11 (31%) recurrent vomiting, 8 (23%) choking-gagging-retching complex, and 3 (9%) bowel obstruction requiring laparotomy. Recurrent gastroesophageal reflux was documented in seven (20%) patients. A second ARP was performed in six (17%). There were 14 (40%) late deaths. Although the major goals of anti-reflux procedure are clearly achieved in many severely impaired children with gastroesophageal reflux, the use of Nissen fundoplication to resolve the complications of swallowing disorders and improve outcome with an acceptably low risk in this complex set of patients does not appear to be established.

Lesser curvature gastrostomy reduces the incidence of postoperative gastroesophageal reflux

Gastrostomy is frequently required in children with neurological impairment and feeding disability. In some centers, concomitant (prophylactic) antireflux procedures are often performed due to the increased risk of occurrence of significant gastroesophageal reflux (GER) after isolated operative or percutaneous endoscopic gastrostomy placement. This has been documented in both experimental and clinical settings. A recent clinical study suggests that placement of a gastrostomy in a lesser curvature location rather than on the greater curvature of the stomach may decrease the incidence of postoperative GER. The purpose of this study is to evaluate this clinical impression. Under ketamine anesthesia and sterile technique, 30 cats underwent laparotomy and placement of a Stamm gastrostomy tube; 15 (group A) were located on the greater curvature of the stomach. Each animal was evaluated postoperatively for the occurrence of GER using upper gastrointestinal contrast study, nuclear medicine gastric scintigraphy (technetium 99m), pH probe/Tuttle test, and lower esophageal sphincter (LES) manometrics. Contrast esophagram with barium demonstrated GER in 3 animals in group A and none in group B (P less than .05). The pH/Tuttle test was positive in 4 animals in group and none in group B (P less than .05). 99mTc gastric scintigraphy (over a 30-minute period) demonstrated GER in 7 cats in group A and in only 1 cat in group B (P less than .05). LES manometric pressures were similar among both groups. This study suggests that a gastrostomy placed in the lesser curvature may reduce the incidence of postgastrostomy GER and obviate the need for a concomitant antireflux procedure in patients with a severe feeding disability but without demonstrable GER during preoperative assessment.