Lesser curvature gastrostomy reduces the incidence of postoperative gastroesophageal reflux

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.

Percutaneous endoscopic gastrostomy (PEG) does not worsen vomiting in children

PURPOSE

We aimed to evaluate the rate and examine potential predictors of subsequent anti-reflux procedures in a population undergoing percutaneous endoscopic gastrostomy (PEG) insertion.

MATERIALS

We retrospectively reviewed the pre- and post-operative clinical course of patients undergoing PEG insertion over a 10-year period with respect to indication, underlying co-morbidity, and GER investigation and management.

RESULTS

We reviewed data on 170 patients. Neurological disability (e.g., cerebral palsy) was the most common underlying condition in those undergoing PEG insertion (n = 104) followed by cystic fibrosis (n = 29). Oropharyngeal dysphagia and failure to thrive were the commonest indications for PEG. Eight patients (4.7%) reported increased frequency of vomiting after PEG, 6 (75%) of whom had a pre-operative diagnosis of GER. Two (25%) patients from this sub-group subsequently required anti-reflux surgery. Patient's with neurological disease were not at increased risk of new-onset GER or increased vomiting following PEG insertion compared to those with non-neurological conditions (p = 0.259). In total, 8 (4.7%) and 7 (4.1%) patients underwent fundoplication and gastrojejunal tube insertion, respectively.

CONCLUSIONS

PEG insertion does not appear to induce symptomatic gastro-oesophageal reflux in the majority of children, suggesting that in the majority of cases, a concurrent anti-reflux procedure is unnecessary. Parents should be counseled accordingly.

The relationship between percutaneous endoscopic gastrostomy and gastro-oesophageal reflux disease in children: a systematic review

BACKGROUND

The relationship between percutaneous endoscopic gastrostomy (PEG) insertion and gastro-oesophageal reflux disease (GERD) is widely disputed in the current literature. The aim of this systematic review is to examine the available evidence documenting the association between PEG and GERD.

METHODS

The following databases were searched: MEDLINE (1950 to week 2, January 2011), PubMed, ISI Web of Knowledge (1898 to week 2, January, 2011), EMBASE (1980 to week 2, January 2011) and The Cochrane Central Register of Controlled Trials (CENTRAL) using the terms "gastroesophageal reflux", "gastroesophageal disease", "GERD", "GERD", "GER", "GER" and "percutaneous endoscopic gastrostomy", "PEG", "gastrostomy". In addition, the reference lists of all included studies were reviewed for relevant citations. Studies examining children pre and post insertion of PEG for GERD and written in English language were included. Data extraction was performed by two authors, and the methodology and statistical analysis of each study were assessed.

RESULTS

Eight studies were included in this systematic review. Two reported increased incidence of GERD after PEG. However, neither was of high methodological quality. The remaining six reported no change or decreased GERD. Nonetheless, few demonstrated rigorous methodology.

CONCLUSIONS

The current evidence examining the effect of PEG insertion on GERD has been inconsistent and is not of high quality and therefore is unconvincing, preventing a definitive conclusion. Overall, the available literature on this topic does not demonstrate a causal effect of PEG insertion on GERD.

Percutaneous Endoscopic Gastrostomy Prevents Gastroesophageal Reflux in Patients with Nasogastric Tube Feeding: A Prospective Study with 24-Hour pH Monitoring

Background/Aims

Percutaneous endoscopic gastrostomy (PEG) has been widely used for patients with swallowing dysfunction. However, its beneficial effects in the treatment of gastroesophageal reflux (GER) are controversial. The aim of this study was to evaluate the effect of PEG on the prevention of GER in patients with nasogastric tube (NGT) feeding.

Methods

Continuous 24-hour pH monitoring was performed prospectively in 21 patients receiving NGT feeding before and 7.3±2.2 days after PEG placement to compare the severity of GER.

Results

We studied 21 patients with a mean age of 59.8±14.1 years. The mean duration of NGT placement was 5.8±5.4 months. The causes of swallowing dysfunction included cerebral infarction, cerebral hemorrhage and other central nervous system (CNS) lesions. When all of the patients were considered, there were no significant differences in reflux parameters after PEG placement compared to before PEG placement. However, all seven patients who had preexisting GER showed significant improvement (p<0.05) of the reflux parameters, including the frequency of acid reflux, duration of acid reflux, total time with a pH below 4.0 and the fraction of time with a pH below 4.0, after PEG placement.

Conclusions

PEG might prevent GER in patients receiving NGT feeding, especially in those patients with GER.

No increase in gastroesophageal reflux after laparoscopic gastrostomy in children

The objective of the study was to assess the influence of a laparoscopic video-assisted gastrostomy on acid gastroesophageal reflux (GER). A prospective uncontrolled study included 23 neurologically disabled children, from 10 months to 15 years of age, all with severe nutritional problems and in need of a gastrostomy. They all had a history of clinical GER problems including vomiting, choking and chest infections. A 24-h pH monitoring was used for a quantitative assessment of GER the day before surgery and 12+/-3 months (7-22 months) postoperatively. The gastrostomy was placed on the anterior wall of the stomach near the lesser curvature. The main outcome measure was the comparison of the pre- and postoperative 24-h pH monitoring and the reflux index (RI), i.e. the percentage of time with pH below 4. The results showed a non-significant reduction of RI from 6.8+/-4.5 preoperatively to 3.7+/-2.0 postoperatively. We conclude that a gastrostomy using the video-assisted technique and placing the stoma on the anterior wall of the stomach close to the lesser curvature does not cause aggravation of acid reflux.

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.

Influence of percutaneous endoscopic gastrostomy on gastroesophageal reflux: a prospective study in 68 children

BACKGROUND

Among other complications, the development of or an increase of gastroesophageal reflux (GER) is considered to be associated with percutaneous endoscopic gastrostomy (PEG). However, the few studies performed to date show controversial results.

METHODS

Continuous 24-hour pH monitoring was performed prospectively in 68 patients before and at least 3 days after percutaneous endoscopic gastrostomy placement. None of the patients had been treated for gastroesophageal reflux.

RESULTS

The percentage of patients with abnormal test results did not differ significantly before and after PEG insertion (22.1% versus 25%). Nor did the median reflux index change significantly before and after gastrostomy for the whole group of patients (2.6% versus 3.4%). The median reflux index increased significantly (from 1.8 to 5.4) only in patients who underwent PEG implantation in the antrum (n = 9). Clinical signs of GER correlated poorly with the results of pH monitoring.

CONCLUSIONS

Data in this study strongly suggest that, in general, percutaneous endoscopic gastrostomy does not provoke gastroesophageal reflux. Results also indicate that placement in the antrum may be unfavorable.

The development of gastroesophageal reflux after percutaneous endoscopic gastrostomy

The relationship between percutaneous endoscopic gastrostomy (PEG) and subsequent development of gastroesophageal reflux (GER) is complex and not well understood. The authors retrospectively reviewed 82 children over a 5-year period who underwent PEG tube (n = 64) or PEG button (n = 18) placement. Children were evaluated preoperatively for clinical evidence of GER (C-GER) or radiographic GER (R-GER) with upper gastrointestinal contrast study or Tc99m gastric scinitiscan. Seventy-five patients were evaluated for clinical evidence of postoperative GER by direct family contact. Eleven of 39 (28%) patients with no GER preoperatively developed GER postoperatively, eight (20%) of whom required Nissen fundoplication (NF) or gastrojejunostomy (GJ) tube. Ten of 19 (53%) with preoperative C-GER but no R-GER continued to have GER after PEG, but only three required NF or GJ. Only one of nine children who had R-GER only developed clinical GER after PEG placement. Of the eight children with both C-GER and R-GER, only two (25%) required NF or GJ and two (25%) had no postoperative GER. The authors conclude that PEG tubes are useful in infants and children and are associated with a relatively low incidence of postoperative GER. If C-GER is absent, a PEG is a reasonable procedure to consider even in the presence of R-GER.

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.

Morbidity in neurologically impaired children after percutaneous endoscopic versus Stamm gastrostomy

Neurologically impaired children frequently require a feeding gastrostomy. Few reports are available comparing the incidence of postoperative complications and symptomatic gastroesophageal reflux after endoscopic versus operative Stamm gastrostomy in this group of children. We undertook a retrospective study of 63 consecutive neurologically impaired children requiring a feeding gastrostomy, with an average of 23 months of follow-up. No child had symptomatic gastroesophageal reflux. Thirty children had a percutaneous endoscopic gastrostomy and 33 had a Stamm gastrostomy, depending on the preference of the surgeon. The two groups were comparable in age range, cause of neurologic impairment, and indication for gastrostomy. Minor complications occurred in 30%. All three major complications occurred after Stamm gastrostomy, including two postoperative deaths. Symptomatic gastroesophageal reflux developed in 60%. The incidence of fundoplication after gastrostomy was 10% in the percutaneous endoscopic gastrostomy group and 39% after Stamm gastrostomy (p < .025). Morbidity was lower after percutaneous endoscopic gastrostomy than after Stamm gastrostomy in this group of neurologically impaired children. Fundoplication for symptomatic gastroesophageal reflux was infrequent after percutaneous endoscopic gastrostomy and significantly more common after Stamm gastrostomy. Percutaneous endoscopic gastrostomy is recommended as the initial procedure in neurologically impaired children without symptomatic gastroesophageal reflux who require a feeding gastrostomy.

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.

Percutaneous endoscopic gastrostomy

Over the past 5 to 7 years, the veterinary profession has benefitted from our increased ability to provide nutrition to the small animal patient who cannot or will not eat. The adaptation of the percutaneous endoscopic gastrostomy (PEG) for use in the dog and cat deserves a great deal of credit in advancing the level of care we can now give to the chronically ill or critical care patient. The PEG is a relatively simple technique that has proved to be a very cost-efficient way to maintain the nutritional status of the small animal patient. In the author's experience, owner acceptance of using the PEG in the home environment on a chronic basis has been excellent.

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.