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Aumar M, Lalanne A, Guimber D, Coopman S, Turck D, Michaud L, Gottrand F. Influence of Percutaneous Endoscopic Gastrostomy on Gastroesophageal Reflux Disease in Children. J Pediatr 2018; 197:116-120. [PMID: 29655862 DOI: 10.1016/j.jpeds.2018.02.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 01/12/2018] [Accepted: 02/01/2018] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To determine if gastroesophageal reflux disease (GERD) is present at long-term follow-up after percutaneous endoscopic gastrostomy (PEG), and to identify factors associated with the occurrence or aggravation of GERD after PEG placement. STUDY DESIGN This prospective, observational study was conducted in our single tertiary center over a 13-year period (gastrostomy performed from 1990 to 2003 and follow-up to 2015). Every child who underwent PEG in our center (N = 368) from 1990 to 2003 was eligible. GERD was defined by clinical manifestations requiring antisecretory or prokinetic treatment, occurrence of a GERD-related complication, or the need for antireflux surgery. Outcomes among patients without antireflux surgery were also assessed. Multivariate analysis was used to identify factors aggravating GERD after PEG placement. RESULTS A total 326 patients (89%; 56% with a neurologic impairment) were studied with a median follow-up after 3.5 years (range, 2.0-13.5 years). After PEG placement, GERD appeared in 11% of patients and was aggravated in 25% of patients with preexisting GERD. Factors associated with GERD worsening after PEG placement were neurologic impairment and preexisting GERD. Only 53 patients (16%) required antireflux surgery, among whom 22 required surgery in the year after PEG. Neurologic impairment was the only factor significantly associated with the need for antireflux surgery. CONCLUSIONS GERD predominantly remains clinically controlled after PEG placement. Routine antireflux surgery at the time of PEG placement is not justified.
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Affiliation(s)
- Madeleine Aumar
- CHU Lille, University of Lille, Reference Center for Congenital and Malformative Esophageal Diseases (CRACMO), Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Jeanne de Flandre, Lille University Children's Hospital, Lille, France.
| | - Arnaud Lalanne
- CHU Lille, University of Lille, Reference Center for Congenital and Malformative Esophageal Diseases (CRACMO), Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Jeanne de Flandre, Lille University Children's Hospital, Lille, France
| | - Dominique Guimber
- CHU Lille, University of Lille, Reference Center for Congenital and Malformative Esophageal Diseases (CRACMO), Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Jeanne de Flandre, Lille University Children's Hospital, Lille, France
| | - Stéphanie Coopman
- CHU Lille, University of Lille, Reference Center for Congenital and Malformative Esophageal Diseases (CRACMO), Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Jeanne de Flandre, Lille University Children's Hospital, Lille, France
| | - Dominique Turck
- CHU Lille, University of Lille, Reference Center for Congenital and Malformative Esophageal Diseases (CRACMO), Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Jeanne de Flandre, Lille University Children's Hospital, Lille, France
| | - Laurent Michaud
- CHU Lille, University of Lille, Reference Center for Congenital and Malformative Esophageal Diseases (CRACMO), Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Jeanne de Flandre, Lille University Children's Hospital, Lille, France
| | - Frédéric Gottrand
- CHU Lille, University of Lille, Reference Center for Congenital and Malformative Esophageal Diseases (CRACMO), Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Jeanne de Flandre, Lille University Children's Hospital, Lille, France
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Stone B, Hester G, Jackson D, Richardson T, Hall M, Gouripeddi R, Butcher R, Keren R, Srivastava R. Effectiveness of Fundoplication or Gastrojejunal Feeding in Children With Neurologic Impairment. Hosp Pediatr 2017; 7:140-148. [PMID: 28159744 DOI: 10.1542/hpeds.2016-0126] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVES Gastroesophageal reflux (GER), aspiration, and secondary complications lead to morbidity and mortality in children with neurologic impairment (NI), dysphagia, and gastrostomy feeding. Fundoplication and gastrojejunal (GJ) feeding can reduce risk. We compared GJ to fundoplication using first-year postprocedure reflux-related hospitalization (RRH) rates. METHODS We identified children with NI, dysphagia requiring gastrostomy tube feeding and GER undergoing initial GJ placement or fundoplication from January 1, 2007 to December 31, 2012. Data came from the Pediatric Health Information Systems augmented by laboratory, microbiology, and radiology results. GJ placement was ascertained using radiology results and fundoplication by International Classification of Diseases, Ninth Revision, Clinical Modification codes. Subjects were matched within hospital using propensity scores. The primary outcome was first-year postprocedure RRH rate (hospitalization for GER disease, other esophagitis, aspiration pneumonia, other pneumonia, asthma, or mechanical ventilation). Secondary outcomes included failure to thrive, death, repeated initial intervention, crossover intervention, and procedural complications. RESULTS We identified 1178 children with fundoplication and 163 with GJ placement, matching 114 per group. Matched sample RRH incident rate per child-year (95% confidence interval) for GJ was 2.07 (1.62-2.64) and for fundoplication 1.67 (1.28-2.18), P = .19. Odds of death were similar between groups. Failure to thrive, repeat of initial intervention, and crossover intervention were more common in the GJ group. CONCLUSIONS In children with NI, GER, and dysphagia: fundoplication and GJ feeding have similar RRH outcomes. Either intervention can reduce future aspiration risk; the choice can reflect non-RRH-related complication risks, caregiver preference, and clinician recommendation.
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Affiliation(s)
- Bryan Stone
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah;
| | - Gabrielle Hester
- Hospital Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - Daniel Jackson
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Troy Richardson
- Biostatistics, Children's Hospital Association, Overland Park, Kansas
| | - Matt Hall
- Biostatistics, Children's Hospital Association, Overland Park, Kansas
| | | | - Ryan Butcher
- Biomedical Informatics, University of Utah, Salt Lake City, Utah
| | - Ron Keren
- Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Rajendu Srivastava
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah.,Institute for Healthcare Leadership, Intermountain Healthcare, Salt Lake City, Utah
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Concomitant Fundoplication With Gastrostomy: A Two-State Comparison Showing Continued Use of Reflux Medications. J Pediatr Gastroenterol Nutr 2016; 63:e163-e168. [PMID: 27070655 DOI: 10.1097/mpg.0000000000001211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES We sought to determine whether practice differences for fundoplication exist between 2 geographically distinct states, and to determine the reflux medication use pattern associated with concomitant fundoplication. METHODS A retrospective observational cohort study of children in Colorado (CO) and North Carolina (NC) insured by Medicaid from 2006 to 2008. Children who received a surgical gastrostomy during the study period were included, and our primary outcome measure was the performance of a concomitant gastric fundoplication. Thirty-day prescription fills for reflux medications were examined before and after gastrostomy procedure. RESULTS We examined 969 surgical gastrostomy admission in both states over the 3-year study period (CO, n = 341 and NC, n = 628). Patients in each state had similar age (median age, 6 months, P = 0.97). Use of pH probe (CO: 15%, NC: 11%) and diagnosis of reflux (CO: 84%, NC: 72%) differed in each state. Concomitant fundoplication was performed in 60% of patients in CO and 43% in NC (P < 0.01). Age less than 6 months was associated with an increased adjusted odds of fundoplication in CO (OR 9.77, CI, 3.91, 24.43), but less so in NC (OR 2.73, CI, 1.48, 5.04). Among patients undergoing gastrostomy, the proportion of patients on reflux medication 4 to 6 months post-discharge did not differ between those receiving fundoplication and those that did not in either state. CONCLUSIONS Rates of concomitant fundoplication varied in the 2 states despite patients having similar demographic and clinical characteristics. Antireflux surgery was not associated with a reduction in reflux medications in either state.
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Kvello M, Åvitsland TL, Knatten CK, Pripp AH, Aabakken L, Emblem R, Bjørnland K. Trends in the use of gastrostomies at a tertiary paediatric referral centre. Scand J Gastroenterol 2016; 51:625-32. [PMID: 26679498 DOI: 10.3109/00365521.2015.1123288] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The aims of this study were to describe the population of paediatric patients undergoing gastrostomy placement at a Norwegian tertiary referral centre and to investigate trends over time in patient characteristics and operative technique. MATERIALS AND METHODS Patients <15 years of age getting a primary gastrostomy from 1994 to 2012 were included in this retrospective observational study. Patient data were collected from medical records and the National Registry. RESULTS Six-hundred forty-nine patients with a median age of 1.2 years [gestational week 30-14.9 years] were included. Neurological disorders (ND) was the most common underlying group of diagnosis (n = 311, 48%), followed by cardiac disease 104 (16%), congenital anomalies 85 (13%), respiratory disease 43 (7%), malignancy 29 (5%), and others 77 (12%). At follow-up, 162 (25%) patients were dead. A percutaneous endoscopic technique (PEG) was used in 401 (62%) patients, open surgery (OPEN) in 201 (31%) and laparoscopy (LAP) in 47 (7%). The number of gastrostomies per year more than doubled during the period (p < 0.001). More patients with cardiac disease and congenital anomalies were given a gastrostomy during the last years (all p < 0.05), whereas the number of patients with ND remained stable. Furthermore, there has been a decrease in median age and an increase in the number of PEG and LAP (p < 0.05). CONCLUSION The number of gastrostomy insertions has increased from 1994 to 2012. NDs is the most common underlying diagnosis in patients receiving a gastrostomy, PEG is the most common technique and patient characteristics have changed during the study period.
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Affiliation(s)
- Morten Kvello
- a Institute of Clinical Medicine, University of Oslo , Oslo , Norway ;,b Department of Gastrointestinal and Paediatric Surgery , Oslo University Hospital, Rikshospitalet , Norway
| | - Tone Lise Åvitsland
- a Institute of Clinical Medicine, University of Oslo , Oslo , Norway ;,b Department of Gastrointestinal and Paediatric Surgery , Oslo University Hospital, Rikshospitalet , Norway
| | - Charlotte Kristensen Knatten
- a Institute of Clinical Medicine, University of Oslo , Oslo , Norway ;,b Department of Gastrointestinal and Paediatric Surgery , Oslo University Hospital, Rikshospitalet , Norway
| | - Are Hugo Pripp
- c Oslo Centre of Biostatistics and Epidemiology, Oslo University Hospital , Oslo , Norway
| | - Lars Aabakken
- a Institute of Clinical Medicine, University of Oslo , Oslo , Norway ;,d Department of Gastroenterology , Oslo University Hospital, Rikshospitalet , Norway
| | - Ragnhild Emblem
- a Institute of Clinical Medicine, University of Oslo , Oslo , Norway ;,b Department of Gastrointestinal and Paediatric Surgery , Oslo University Hospital, Rikshospitalet , Norway
| | - Kristin Bjørnland
- a Institute of Clinical Medicine, University of Oslo , Oslo , Norway ;,b Department of Gastrointestinal and Paediatric Surgery , Oslo University Hospital, Rikshospitalet , Norway
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Gastroesophageal Reflux Burden, Even in Children That Aspirate, Does Not Increase Pediatric Hospitalization. J Pediatr Gastroenterol Nutr 2016; 63:210-7. [PMID: 26794490 PMCID: PMC4917472 DOI: 10.1097/mpg.0000000000001092] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Gastroesophageal reflux is common but remains a controversial disease to diagnose and treat and little is known about the role of reflux testing in predicting clinical outcomes, particularly in children at risk for extraesophageal reflux complications. The aim of this study was to determine if rates of hospitalization were affected by reflux burden even after adjusting for aspiration risk. METHODS We prospectively recruited, between 2009 and 2014, a cohort of pediatric patients with suspected extraesophageal reflux disease who were referred for reflux testing and underwent both multichannel intraluminal impedance with pH (pH-MII) and modified barium swallow studies. A subset of patients also underwent bronchoalveolar lavage with pepsin analysis. We determined their rates of hospitalization for a minimum of 1 year following pH-MII testing. RESULTS We prospectively enrolled 116 pediatric patients who presented for care at Boston Children's Hospital and underwent both pH-MII and modified barium swallow studies. There was no statistically significant relationship between reflux burden measured by pH-MII or bronchoalveolar pepsin and total number of admissions or number of admission nights even after adjusting for aspiration status (P > 0.2). There were no statistically significant relationships between reflux burden by any method and the number or nights of urgent pulmonary admissions before or after adjusting for aspiration risk (P > 0.08). CONCLUSIONS Even in aspirating children, reflux burden did not increase the risk of hospitalization. Based on these results, routine reflux testing cannot be recommended even in aspirating children, because the results do not impact clinically significant outcomes.
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Goldin AB, Heiss KF, Hall M, Rothstein DH, Minneci PC, Blakely ML, Browne M, Raval MV, Shah SS, Rangel SJ, Snyder CL, Vinocur CD, Berman L, Cooper JN, Arca MJ. Emergency Department Visits and Readmissions among Children after Gastrostomy Tube Placement. J Pediatr 2016; 174:139-145.e2. [PMID: 27079966 DOI: 10.1016/j.jpeds.2016.03.032] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 01/25/2016] [Accepted: 03/10/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To define the incidence of 30-day postdischarge emergency department (ED) visits and hospital readmissions following pediatric gastrostomy tube (GT) placement across all procedural services (Surgery, Interventional-Radiology, Gastroenterology) in 38 freestanding Children's Hospitals. STUDY DESIGN This retrospective cohort study evaluated patients <18 years of age discharged between 2010 and 2012 after GT placement. Factors significantly associated with ED revisits and hospital readmissions within 30 days of hospital discharge were identified using multivariable logistic regression. A subgroup analysis was performed comparing patients having the GT placed on the date of admission or later in the hospital course. RESULTS Of 15 642 identified patients, 8.6% had an ED visit within 30 days of hospital discharge, and 3.9% were readmitted through the ED with a GT-related issue. GT-related events associated with these visits included infection (27%), mechanical complication (22%), and replacement (19%). In multivariable analysis, Hispanic ethnicity, non-Hispanic black race, and the presence of ≥3 chronic conditions were independently associated with ED revisits; gastroesophageal reflux and not having a concomitant fundoplication at time of GT placement were independently associated with hospital readmission. Timing of GT placement (scheduled vs late) was not associated with either ED revisits or hospital readmission. CONCLUSIONS GT placement is associated with high rates of ED revisits and hospital readmissions in the first 30 days after hospital discharge. The association of nonmodifiable risk factors such as race/ethnicity and medical complexity is an initial step toward understanding this population so that interventions can be developed to decrease these potentially preventable occurrences given their importance among accountable care organizations.
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Affiliation(s)
- Adam B Goldin
- Department of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA.
| | - Kurt F Heiss
- Emory University, Children's Healthcare of Atlanta, Atlanta, GA
| | - Matt Hall
- Children's Hospital Association, Overland Park, KS
| | | | - Peter C Minneci
- The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | | | - Marybeth Browne
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Mehul V Raval
- Emory University, Children's Healthcare of Atlanta, Atlanta, GA
| | - Samir S Shah
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Shawn J Rangel
- Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | - Loren Berman
- Nemours-Alfred I. DuPont Hospital for Children, Wilmington, DE
| | - Jennifer N Cooper
- The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Marjorie J Arca
- Medical College of Wisconsin/Children's Hospital of Wisconsin, Milwaukee, WI
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Estimating Adverse Events After Gastrostomy Tube Placement. Acad Pediatr 2016; 16:129-35. [PMID: 26306663 DOI: 10.1016/j.acap.2015.05.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Revised: 05/06/2015] [Accepted: 05/07/2015] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Gastrostomy feeding tube placement in children is associated with a high frequency of adverse events. This study sought to preoperatively estimate postoperative adverse events in children undergoing gastrostomy feeding tube placement. METHODS This was an observational study of children who underwent gastrostomy with or without fundoplication at 1 of 50 participating hospitals, using 2011-2013 data from the American College of Surgeons' National Surgical Quality Improvement Program Pediatric. The outcome was the occurrence of any postoperative complications or mortality at 30 days after gastrostomy tube placement. The preoperative clinical characteristics significantly associated with occurrence of adverse events were included in a multivariate logistic model. The area under the receiver operating characteristic curve was computed to assess model performance and split-set validated. RESULTS A total of 2817 children were identified as having undergone gastrostomy tube placement. The unadjusted rate of adverse events within 30 days after gastrostomy tube placement was 11%. Thirteen predictor variables were identified. Notable preoperative variables associated with a greater than 75% increase in adverse event rate were preoperative sepsis/septic shock (odds ratio [OR], 10.76, 95% confidence interval [CI], 3.84-30.17), central nervous system tumor (OR, 3.36; 95% CI, 1.42-7.95), the primary procedure as indicated by the current procedural terminology (CPT) linear risk variable (OR, 1.93; 95% CI, 1.50-2.49), severe cardiac risk factors (OR, 1.88; 95% CI, 1.17-3.03), and preoperative seizure history (OR, 1.90; 95% CI, 1.38-2.62). The area under the receiver operating characteristic curve was 0.71 with the derivation data set and 0.71 upon split-set validation. CONCLUSIONS Preoperatively estimating postoperative adverse events in children undergoing gastrostomy tube placement is feasible.
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Zaal-Schuller IH, de Vos MA, Ewals FVPM, van Goudoever JB, Willems DL. End-of-life decision-making for children with severe developmental disabilities: The parental perspective. RESEARCH IN DEVELOPMENTAL DISABILITIES 2016; 49-50:235-246. [PMID: 26741261 DOI: 10.1016/j.ridd.2015.12.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 11/28/2015] [Accepted: 12/08/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND AND AIMS The objectives of this integrative review were to understand how parents of children with severe developmental disorders experience their involvement in end-of-life decision-making, how they prefer to be involved and what factors influence their decisions. METHODS AND PROCEDURES We searched MEDLINE, EMBASE, CINAHL and PsycINFO. The search was limited to articles in English or Dutch published between January 2004 and August 2014. We included qualitative and quantitative original studies that directly investigated the experiences of parents of children aged 0-18 years with severe developmental disorders for whom an end-of-life decision had been considered or made. OUTCOMES AND RESULTS We identified nine studies that met all inclusion criteria. Reportedly, parental involvement in end-of-life decision-making varied widely, ranging from having no involvement to being the sole decision-maker. Most parents preferred to actively share in the decision-making process regardless of their child's specific diagnosis or comorbidity. The main factors that influenced parents in their decision-making were: their strong urge to advocate for their child's best interests and to make the best (possible) decision. In addition, parents felt influenced by their child's visible suffering, remaining quality of life and the will they perceived in their child to survive. CONCLUSIONS AND IMPLICATIONS Most parents of children with severe developmental disorders wish to actively share in the end-of-life decision-making process. An important emerging factor in this process is the parents' feeling that they have to stand up for their child's interests in conversations with the medical team.
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Affiliation(s)
- I H Zaal-Schuller
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - M A de Vos
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - F V P M Ewals
- Intellectual Disability Medicine, Department of General Practice, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands.
| | - J B van Goudoever
- Department of Paediatrics, Emma Children's Hospital-Academic Medical Centre, Amsterdam & Department of Paediatrics, VU University Medical Centre, Amsterdam, The Netherlands.
| | - D L Willems
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
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Kakade M, Coyle D, McDowell DT, Gillick J. Percutaneous endoscopic gastrostomy (PEG) does not worsen vomiting in children. Pediatr Surg Int 2015; 31:557-62. [PMID: 25895072 DOI: 10.1007/s00383-015-3707-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/07/2015] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Madhavi Kakade
- Department of Pediatric Surgery, Temple Street Children's University Hospital, Dublin 1, Ireland,
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Papic JC, Finnell SME, Leys CM, Bennett WE, Downs SM. Referring physicians' decision making for pediatric anti-reflux procedures. Surgery 2013; 155:851-9. [PMID: 24787112 DOI: 10.1016/j.surg.2013.12.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 12/10/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Rates of anti-reflux procedures (ARP) vary greatly among pediatric hospitals. How pediatric subspecialists make referral decisions for ARPs has not been described. The aim of this study was to characterize pediatric subspecialists' decision making for referring children for ARPs. METHODS Pediatric subspecialists at a single children's hospital were interviewed about their decision making when referring for ARPs. Qualitative analysis was performed on clinicians' perceptions of the risks and benefits of the treatment options. Clinical algorithms were derived from each interview and were compared using the Clinical Algorithm Nosology. Clinical Algorithm Structural Analysis (CASA) scores were calculated to assess algorithm complexity. Clinical Algorithm Patient Abstraction (CAPA) scores on a scale from 0 (different) to 10 (identical) were generated based on algorithm agreement. RESULTS The interviews yielded 15 algorithms. There was substantial variation in the providers' perceived risks and benefits of the treatment options. CASA scores ranged from 8 to 28 and CAPA scores ranged from 0 to 5.7 (median, 0), indicating great variation in both complexity and patient management. Management variation included testing (33% of algorithms incorporated pH probe test, 67% upper gastrointestinal, and 47% small bowel follow-through), procedure contraindications (33% considered history of gagging a contraindication to ARP), and use of gastrojejunostomy tubes (20% using gastrojejunostomy tube before ARP). CONCLUSION No standards exist for the decision to refer children with gastroesophageal reflux disease for ARP. There is great variation among pediatric subspecialists in their decision making. Differences in providers' perception of the risks and benefits of these procedures contribute to this variation.
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Affiliation(s)
- Jonathan C Papic
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN.
| | - S Maria E Finnell
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN; Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Charles M Leys
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - William E Bennett
- Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN; Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Stephen M Downs
- Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN; Regenstrief Institute, Inc, Indianapolis, IN
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