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Roy SM, Rafferty D, Trejo A, Hamilton L, Bohonowych JE, Strong TV, Ambartsumyan L, Cantu S, Scheimann A, Duis J. Feeding tube use and complications in Prader-Willi syndrome: Data from the Global Prader-Willi Syndrome Registry. Am J Med Genet A 2024; 194:e63546. [PMID: 38303141 DOI: 10.1002/ajmg.a.63546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 01/11/2024] [Accepted: 01/15/2024] [Indexed: 02/03/2024]
Abstract
Guidance on indications for, and types of, feeding tubes recommended in Prader-Willi syndrome (PWS) is needed. A Global PWS Registry survey was developed to investigate nasogastric (NG) and gastrostomy (G) tube use and associated complications. Of 346 participants, 242 (69.9%) had NG-tubes, 17 (4.9%) had G-tubes, and 87 (25.1%) had both NG- and G-tubes. Primary indication for placement was "feeding difficulties and/or poor weight gain" for both NG- (90.2%) and G-tubes (71.2%), while "aspiration/breathing difficulties" was the procedural indication for 6.4% of NG-tubes and 23.1% of G-tubes. NG-tubes were generally removed by age 6 months (NG Only: 82.9%; NG/G: 98.8%), while G-tubes were often removed by age 2 years (G Only: 85.7%; NG/G: 70.5%). The severe complication rate from G-tubes was 31.7% and from NG-tubes was 1.2%. Overall, caregivers indicated the presence of an NG- or G-tube had a positive effect on quality of life. Feeding difficulties in PWS are largely managed by NG-tube alone. The severe complication rate from G-tubes was about 25 times higher than from NG-tubes; yet, G-tube placement rates have generally increased. G-tube placement puts individuals with PWS at risk for anesthesia and surgery-related complications and should be considered judiciously by a multidisciplinary team.
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Affiliation(s)
- Sani M Roy
- Cook Children's Medical Center, Fort Worth, Texas, USA
| | | | - Amy Trejo
- Cook Children's Medical Center, Fort Worth, Texas, USA
| | - Luke Hamilton
- Cook Children's Medical Center, Fort Worth, Texas, USA
| | | | | | | | - Samson Cantu
- Cook Children's Medical Center, Fort Worth, Texas, USA
| | - Ann Scheimann
- The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Texas Children's Hospital, Houston, Texas, USA
| | - Jessica Duis
- Children's Hospital Colorado, Aurora, Colorado, USA
- SequenceMD, Denver, Colorado, USA
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Elmahdi A, Eisa M, Martindale R, Omer E. Persistent Ostomy Following Percutaneous Endoscopic Gastrostomy Removal: Treatment Strategies. Curr Gastroenterol Rep 2024; 26:53-56. [PMID: 38194110 DOI: 10.1007/s11894-023-00912-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2023] [Indexed: 01/10/2024]
Abstract
PURPOSE OF REVIEW The purpose of this article is to review available literature on management of persistent ostomy following PEG tube removal. We will discuss the incidence of persistent gastrocutaneous fistula (GCF) following PEG tube removal, risk factors for their development, and management strategies that have been proposed and their efficacy. RECENT FINDINGS The use of over the scope clips (OTSC) have evolved recently in the management of gastrointestinal bleeding, perforation, and fistula closures. OTSC has become more readily available and proven to be effective and safe. Suturing devices have shown promising results. Persistent gastrocutaneous fistula following PEG removal is a rare yet serious complication that can lead to continuous skin irritation and leakage of gastric contents and acid. There are several postulated risk factors but the most important of these is duration of placement. Management can include medical therapy which has recently been shown to be somewhat effective, endoscopic therapy and surgery as a last resort. Overall, the data on GCFs is limited and further study with larger sample size is needed.
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Affiliation(s)
- Alsiddig Elmahdi
- Virginia Commonwealth University Health Systems, Richmond, VA, USA
| | - Mohamed Eisa
- Allegheny Center for Digestive Health, Allegheny Health Network, Pittsburgh, PA, USA
| | - Robert Martindale
- Department of Surgery, Oregon Health Sciences University, Portland, OR, USA
| | - Endashaw Omer
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, 530 S Jackson St ACB bldg 3rd floor, 40202, Louisville, KY, USA.
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Jackson JE, Theodorou CM, Vukcevich O, Brown EG, Beres AL. Patient selection for pediatric gastrostomy tubes: Are we placing tubes that are not being used? J Pediatr Surg 2022; 57:532-537. [PMID: 34229875 DOI: 10.1016/j.jpedsurg.2021.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 04/12/2021] [Accepted: 06/04/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Identifying pediatric patients who may benefit from gastrostomy tube (GT) placement can be challenging. We hypothesized that many GTs would no longer be in use after 6 months. METHODS Inpatient GT placements in patients < 18 years old at a tertiary children's hospital from 9/2014 to 2/2020 were included. The primary outcome was GT use <6 months (short-term). Secondary outcomes included age at placement, indication for GT, and operations for GT-related issues. RESULTS Fifteen percent (22/142) of GTs were used for <6 months post-operatively. The median duration of short-term GT use was 1.6 months (IQR 0.9-3.4 months). Short-term GTs were more likely to be placed in patients with traumatic brain injury (TBI) (18.2% vs. 4.2%, p = 0.03) and adolescents (≥12 years old, 22.7% vs. 4.0%, p = 0.005). Gastrocutaneous fistula closure was required in 33.3% of short-term patients who had their GTs removed (n = 6/18), with median total hospital charges of $29,989 per patient. CONCLUSION Fifteen percent of pediatric GTs placed as inpatients were used for <6 months, more commonly among adolescents and in TBI patients. One-third of patients with short-term GTs required gastrocutaneous fistula closure. Adolescents and TBI patients may benefit from consideration of short-term nasogastric tube (NGT) feeds rather than surgical GT placement. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Jordan E Jackson
- University of California-Davis, Department of Surgery, Sacramento, CA, USA.
| | | | - Olivia Vukcevich
- University of California-Davis, Department of Surgery, Sacramento, CA, USA
| | - Erin G Brown
- University of California-Davis, Department of Surgery, Sacramento, CA, USA
| | - Alana L Beres
- University of California-Davis, Department of Surgery, Sacramento, CA, USA
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Mullens CL, Twist J, Bonasso PC, Parrish DW. The PEET procedure: Punch Excision of Epithelialized Tracts for gastrocutaneous fistula closure. J Pediatr Surg 2021; 56:1900-1903. [PMID: 34226051 DOI: 10.1016/j.jpedsurg.2021.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/29/2021] [Accepted: 06/04/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Persistent Gastrocutaneous Fistula (GCF) is common problem encountered in the pediatric population. Several management options for intervening on pediatric persistent GCF have been described and range from open surgical management to medical management. Here we describe a novel adaptation on a previously described technique that utilizes a punch biopsy to excise the GCF we have coined as Punch Excision of Epithelialized Tracts (PEET). METHODS The steps to this procedure include passing a punch biopsy tool over a Foley catheter. The catheter is inserted into the GCF tract, the balloon is inflated, the catheter is retracted against the abdominal wall, and the punch biopsy instrument is pushed through the skin and subcutaneous tissue circumferentially excising the tract. RESULTS Four patients at our institution have undergone GCF excision using the PEET approach. Mean duration of the GCF in our four patients was 9 months. Mean follow-up after GCF excision using the PEET approach was 7.8 months. No patients in the cohort had any post-operative complications including surgical site wound infection, emergency department visits, or re-hospitalizations related to their surgical care. CONCLUSION Based on our preliminary findings in this small patient cohort, we believe the PEET approach for managing persistent pediatric GCF has short-term efficacy and has the potential upside of utilizing fewer hospital resources to perform the procedure in a time-efficient manner.
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Affiliation(s)
| | - Joanna Twist
- West Virginia University School of Medicine, Morgantown, WV, USA
| | - Patrick C Bonasso
- West Virginia University School of Medicine, Department of Surgery, Division of Pediatric Surgery, Morgantown, WV, USA
| | - Dan W Parrish
- West Virginia University School of Medicine, Department of Surgery, Division of Pediatric Surgery, Morgantown, WV, USA
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Zheng HB, Len M, Pattamanuch N. Effective Use of Topical Sucralfate in the Conservative Management of Expanded Gastrostomy Tract Reduction. JPGN REPORTS 2021; 2:e111. [PMID: 37205946 PMCID: PMC10191476 DOI: 10.1097/pg9.0000000000000111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 05/27/2021] [Indexed: 05/21/2023]
Abstract
Sucralfate is a common medication used to treat duodenal ulcers, gastric ulcers, and gastritis. The off-label use of topical sucralfate has been described in the literature to induce wound healing in epithelial injury. Yet, current literature lacks clinical depictions in the application of sucralfate to treat a common gastrostomy tube complication, that of a dilated gastrostomy site. We present a case report of a medically complex pediatric patient where topical sucralfate was applied to reduce the size of a large gastrostomy stomal defect. Sucralfate was used to reduce healing time and allow introduction of a new gastrostomy device through the same stomal opening without the need for additional procedures or surgeries.
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Affiliation(s)
- Hengqi Betty Zheng
- From the Division of Pediatric Gastroenterology and Hepatology, University of Washington, Seattle Children’s Hospital, Seattle, WA
| | - Mary Len
- From the Division of Pediatric Gastroenterology and Hepatology, University of Washington, Seattle Children’s Hospital, Seattle, WA
| | - Nicole Pattamanuch
- From the Division of Pediatric Gastroenterology and Hepatology, University of Washington, Seattle Children’s Hospital, Seattle, WA
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6
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Liu X, Yang Z, He S, Wang G. Percutaneous endoscopic gastrostomy. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2021. [DOI: 10.18528/ijgii210015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Xudong Liu
- Department of Endoscopy, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhengqiang Yang
- Department of Radiology Intervention, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shun He
- Department of Endoscopy, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Guiqi Wang
- Department of Endoscopy, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Gkolfakis P, Arvanitakis M, Despott EJ, Ballarin A, Beyna T, Boeykens K, Elbe P, Gisbertz I, Hoyois A, Mosteanu O, Sanders DS, Schmidt PT, Schneider SM, van Hooft JE. Endoscopic management of enteral tubes in adult patients - Part 2: Peri- and post-procedural management. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53:178-195. [PMID: 33348410 DOI: 10.1055/a-1331-8080] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
ESGE recommends the "pull" technique as the standard method for percutaneous endoscopic gastrostomy (PEG) placement.Strong recommendation, low quality evidence.ESGE recommends the direct percutaneous introducer ("push") technique for PEG placement in cases where the "pull" method is contraindicated, for example in severe esophageal stenosis or in patients with head and neck cancer (HNC) or esophageal cancer.Strong recommendation, low quality evidence.ESGE recommends the intravenous administration of a prophylactic single dose of a beta-lactam antibiotic (or appropriate alternative antibiotic, in the case of allergy) to decrease the risk of post-procedural wound infection.Strong recommendation, moderate quality evidence.ESGE recommends that inadvertent insertion of a nasogastric tube (NGT) into the respiratory tract should be considered a serious but avoidable adverse event (AE).Strong recommendation, low quality evidence.ESGE recommends that each institution should have a dedicated protocol to confirm correct positioning of NGTs placed "blindly" at the patient's bedside; this should include: radiography, pH testing of the aspirate, and end-tidal carbon dioxide monitoring, but not auscultation alone.Strong recommendation, low quality evidence.ESGE recommends confirmation of correct NGT placement by radiography in high-risk patients (intensive care unit [ICU] patients or those with altered consciousness or absent gag/cough reflex).Strong recommendation, low quality evidence.ESGE recommends that EN may be started within 3 - 4 hours after uncomplicated placement of a PEG or PEG-J.Strong recommendation, high quality evidence.ESGE recommends that daily tube mobilization (pushing inward) along with a loose position of the external PEG bumper (1 - 2 cm from the abdominal wall) could mitigate the risk of development of buried bumper syndrome.Strong recommendation, low quality evidence.
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Affiliation(s)
- Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Edward J Despott
- Royal Free Unit for Endoscopy and Centre for Gastroenterology, UCL Institute for Liver and Digestive Health, The Royal Free Hospital, London, United Kingdom
| | - Asuncion Ballarin
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Torsten Beyna
- Department of Gastroenterology and Therapeutic Endoscopy, Evangelisches Krankenhaus Düsseldorf, Germany
| | - Kurt Boeykens
- Nutrition Support Team, AZ Nikolaas Hospital, Moerlandstraat 1, 9100, Sint-Niklaas, Belgium
| | - Peter Elbe
- Department of Upper Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Ingrid Gisbertz
- Department of Gastroenterology, Bernhoven Hospital, Uden, the Netherlands
| | - Alice Hoyois
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Ofelia Mosteanu
- Department of Gastroenterology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - David S Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital & University of Sheffield, United Kingdom
| | - Peter T Schmidt
- Department of Medicine (Solna), Karolinska Institutet, Stockholm, Sweden.,Department of Medicine, Ersta Hospital, Stockholm, Sweden
| | - Stéphane M Schneider
- Université Côte d'Azur, Centre Hospitalier Universitaire de Nice, Gastroentérologie et Nutrition, Nice, France
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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Abstract
Various approaches for enteral access exist, but because there is no single best approach it should be tailored to the needs of the patient. This article discusses the various enteral access techniques for nasoenteric tubes, gastrostomy, gastrojejunostomy, and direct jejunostomy as well as their indications, contraindications, and pitfalls. Also discussed is enteral access in altered anatomy. In addition, complications associated with these endoscopic techniques and how to either prevent or properly manage them are reviewed.
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Currais P, Faias S, Francisco F, Sousa L, Gramacho J, Pereira AD. Gastrocutaneous fistulas after PEG removal in adult cancer patients: frequency and treatment options. Surg Endosc 2020; 35:2211-2216. [PMID: 32394169 DOI: 10.1007/s00464-020-07627-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 05/04/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION AND AIMS PEG removal in head and neck cancer patients (HNCPs) is performed after treatment, in case of disease remission and after adequate oral intake is resumed. The PEG tract usually closes spontaneously within 2-3 days. Persistent gastrocutaneous fistula (GCF) is a rare complication after PEG tube removal and is characterized by the persistence of gastric leakage through the fistulous tract for more than 1 month. Our main goal was to access the incidence and the success of a treatment algorithm for GCF in HNCPs. METHODS Retrospective unicentric study of HNCPs referred for PEG removal between 2014 and 2018. The patients with GCF were selected and their sequential treatment was reviewed. RESULTS In 331 patients with PEGs removed, 19 (5.7%) GCFs were documented. Medical therapy (4-8 weeks) was performed with clinical success (definitive closure of the GCF) in 12 (63.2%) patients. The remaining seven patients required endoscopic or surgical treatment. In four, endoscopic treatment had technical and clinical success (in three patients with fulguration of the gastric leak edges with argon plasma coagulation, silver nitrate in the path and external orifice, and closure of the internal orifice with hemoclips and in one with an over-the-scope-clip). Only three patients underwent surgery, one due to clinical failure of sequential endoscopic therapy and two had direct surgery. CONCLUSION GCF occurs rarely after PEG removal in HNCPs. Medical therapy is usually effective and should be maintained for at least 8 weeks. Endoscopic therapy is an effective second-line option with and surgery rarely required.
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Affiliation(s)
- P Currais
- Gastroenterology Department - Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal. .,Serviço de Gastrenterologia, Instituto Português de Oncologia de Lisboa Francisco Gentil, Rua Professor Lima Basto, 1099-023, Lisbon, Portugal.
| | - S Faias
- Gastroenterology Department - Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal
| | - F Francisco
- Gastroenterology Department - Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal
| | - L Sousa
- Gastroenterology Department - Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal
| | - J Gramacho
- Gastroenterology Department - Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal
| | - A Dias Pereira
- Gastroenterology Department - Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal
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Outpatient curettage and electrocautery as an alternative to primary surgical closure for pediatric gastrocutaneous fistulae. J Surg Res 2018; 229:96-101. [DOI: 10.1016/j.jss.2018.03.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 02/21/2018] [Accepted: 03/15/2018] [Indexed: 11/23/2022]
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Einhorn LM, Taicher BM, Greene NH, Reinstein LJ, Jooste EH, Campbell MJ, Machovec KA. Percutaneous endoscopic gastrostomy vs surgical gastrostomy in infants with congenital heart disease. Paediatr Anaesth 2018; 28:612-617. [PMID: 29882315 DOI: 10.1111/pan.13416] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/04/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Infants with congenital heart disease often require feeding tube placement to supplement oral intake. Gastrostomy tubes may be placed by either surgical or percutaneous endoscopic methods, but there is currently no data comparing outcomes of these procedures in this population. AIMS The aim of our retrospective study was to investigate the perioperative outcomes between the 2 groups to determine if there are clinically significant differences. METHODS We reviewed the charts of all infants with congenital heart disease at a single academic institution having isolated surgical or percutaneous endoscopic gastrostomy tube placement from January 2011 to December 2015. Anesthetic time, defined by cumulative minimum alveolar concentration hours of exposure to volatile anesthetic, was the primary outcome. Operative time, intraoperative complications, and postoperative intensive care admissions were secondary outcomes. RESULTS One hundred and one infants with congenital heart disease were included in this study. Anesthetic exposure was shorter in the endoscopic group than the surgical group (0.20 MAC-hours vs 0.56 MAC-hours, 95% confidence interval 0.23, 0.49, P < .001). Average operative times were also shorter in the endoscopic gastrostomy vs the surgical group (8 ± 0.7 minutes vs 35 ± 1.3 minutes, 95% confidence interval 23.7, 31.0, P < .001). Adjusting for prematurity and preoperative risk category, the surgical group was associated with a 3.45 fold increase in the likelihood of a higher level of care postoperatively (95% confidence interval 1.20, 9.90, P = .02). CONCLUSION In infants with congenital heart disease, percutaneous endoscopic gastrostomy placement is associated with reduced anesthetic exposure and fewer postoperative intensive care unit admissions compared to surgical gastrostomy.
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Affiliation(s)
- Lisa M Einhorn
- Pediatric Division, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Brad M Taicher
- Pediatric Division, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Nathaniel H Greene
- Pediatric Division, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Leon J Reinstein
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Edmund H Jooste
- Pediatric Division, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Michael J Campbell
- Division of Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Kelly A Machovec
- Pediatric Division, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
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12
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St-Louis E, Safa N, Guadagno E, Baird R. Gastrocutaneous fistulae in children - A systematic review and meta-analysis of epidemiology and treatment options. J Pediatr Surg 2018; 53:946-958. [PMID: 29506816 DOI: 10.1016/j.jpedsurg.2018.02.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 02/01/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND Gastrostomy tubes are a common adjunct to the care of vulnerable pediatric patients. This study systematically evaluates the epidemiology and risk-factors for gastrocutaneous fistulae (GCF) after gastrostomy removal in children and reviews treatment options focusing on nonoperative management (NOM). METHODS After protocol registration (CRD-42017059565), multiple databases were searched. Studies describing epidemiology in children and GCF treatment at any age were included. Critical appraisal was performed (MINORS risk-of-bias assessment tool). One-sided meta-analysis was executed to estimate efficacy of therapeutic adjuncts using a random-effects model. RESULTS Sixteen articles evaluating pediatric GCF were identified. 44% defined GCF as persistence >1month which occurred in 31±7% of cases. Risk factors for pediatric GCF include age at gastrostomy, timing of removal, open technique, and fundoplication. Mean MINORS score was 0.60±0.16. Seventeen additional studies were identified reporting 142 patients undergoing NOM (endoscopic, systemic, and local therapies), and one pediatric comparative study was identified. Overall aggregate proportion of GCF closure after any NOM is 77% (80% success rate in local/systemic therapies; 75% success rate in endoscopic approaches). No adverse events were reported. CONCLUSION Persistent GCF complicates the management of gastrostomies in 1/3 of children with predictable risk factors. Several treatment options exist that obviate the need for general anesthesia. Their efficacy is unclear. Further prospective investigations are clearly warranted. LEVEL OF EVIDENCE III - Systematic Review and Meta-Analysis Based on Retrospective Case Control Studies.
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Affiliation(s)
- Etienne St-Louis
- Division of Pediatric Surgery, McGill University Health Centre, Montreal, Quebec, Canada; Division of General Surgery, McGill University Health Centre, Montreal, Quebec, Canada.
| | - Nadia Safa
- Division of General Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Elena Guadagno
- Medical Library, McGill University Health Centre, Montreal, Quebec, Canada
| | - Robert Baird
- Department of Pediatric General and Thoracic Surgery, British Columbia Children's Hospital, Vancouver, British Columbia V6H 3V4, Canada
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Alshafei A, Deacy D, Antao B. Risk Factors for a Persistent Gastrocutaneous Fistula Following Gastrostomy Device Removal: A Tertiary Center Experience. J Indian Assoc Pediatr Surg 2017; 22:220-225. [PMID: 28974874 PMCID: PMC5615896 DOI: 10.4103/jiaps.jiaps_205_16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
AIM The aim of this study is to identify the risk factors for a persistent gastrocutaneous fistula (GCF) after gastrostomy device (GD) removal in children. MATERIALS AND METHODS A retrospective analysis of 59 patients that underwent GD insertion and removal over an 11-year period (2005-2015). Patients were divided into two Groups (A and B) according to persistence or closure of the gastrocutaneous tract. Data included patient demographics, comorbidities, age at insertion, gastrostomy site infections, size and type of device, duration of placement, and method of insertion and removal. Statistical analysis was done using Chi-square test and ANOVA test where P < 0.05 was considered statistically significant. RESULTS A total of 34 patients (Group A) developed a GCF post-GD removal. The gastrostomy tract closed spontaneously in 25 patients (Group B). Underlying comorbidities did not influence spontaneous closure. Younger age at insertion (<2 years), longer duration of device placement, open gastrostomy insertion, upsizing the GD, changing a gastrostomy tube to a button, and site infections were significant risk factors for a persistent GCF. CONCLUSIONS Risk analysis of persistent GCF is important for patient counseling before removal or replacement of the GD. We have identified a number of potentially reversible risk factors for a persistent GCF and have made recommendations accordingly.
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Affiliation(s)
- Abdulrahman Alshafei
- Department of Paediatric Surgery, Our Lady's Children's Hospital, Crumlin, Dublin 12, Ireland
| | - Dawn Deacy
- Department of Paediatric Surgery, Our Lady's Children's Hospital, Crumlin, Dublin 12, Ireland
| | - Brice Antao
- Department of Paediatric Surgery, Our Lady's Children's Hospital, Crumlin, Dublin 12, Ireland
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Hucl T, Spicak J. Complications of percutaneous endoscopic gastrostomy. Best Pract Res Clin Gastroenterol 2016; 30:769-781. [PMID: 27931635 DOI: 10.1016/j.bpg.2016.10.002] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 09/18/2016] [Accepted: 10/02/2016] [Indexed: 01/31/2023]
Abstract
Percutaneous endoscopic gastrostomy (PEG) has become the method of choice for mid-to long-term enteral feeding. The majority of complications that occur are minor, but the rare major complications may be life threatening. Some complications occur soon after tube placement, others develop later, when the gastrostomy tract has matured. Older patients with comorbidities and infections appear to be at a greater risk of developing complications. Apart from being aware of indications and contraindications, proper technique of PEG placement, including correct positioning of the external fixation device, and daily tube care are important preventive measures. Adequate management of anticoagulation and antithrombotic agents is important to prevent bleeding, and administration of broad spectrum antibiotics prior to the procedure helps prevent infectious complications. Early recognition of complications enables prompt diagnosis and effective therapy.
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Affiliation(s)
- Tomas Hucl
- Department of Gastroenterology and Hepatology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.
| | - Julius Spicak
- Department of Gastroenterology and Hepatology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
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Fernandez-Pineda I, Sandoval JA, Jones RM, Boateng N, Wu J, Rao BN, Davidoff AM, Shochat SJ. Gastrostomy Complications in Pediatric Cancer Patients: A Retrospective Single-Institution Review. Pediatr Blood Cancer 2016; 63:1250-3. [PMID: 26960180 PMCID: PMC5704922 DOI: 10.1002/pbc.25968] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 02/16/2016] [Indexed: 01/14/2023]
Abstract
BACKGROUND Complications in pediatric cancer patients after a gastrostomy (GT) placement have not been widely investigated. We aimed to evaluate the complication rate and nature of complications in this specific population. PROCEDURE Medical records of pediatric cancer patients having a GT placed at our institution from 1998 to 2013 were retrospectively reviewed. Variables analyzed included gender, age, diagnosis, surgical procedure, GT device, duration of GT usage, absolute neutrophil count (ANC) level at surgery, and complications. RESULTS One hundred seventy-one patients (92 males, 79 females), median age of 6 years (range, 0.2-21), who underwent 181 procedures (110 open, 59 endoscopic, and 12 laparoscopic) were identified. Diagnosis included central nervous system tumor (n = 101), solid tumor (n = 45), and leukemia/lymphoma (n = 25). A GT tube was used in 139 procedures and a GT button in 42. Median ANC level at procedure was 3,300/mm(3) (range, 0-38,988). Median duration of GT usage was 8 months (range, 0.2-142). One hundred seventy-seven complications occurred in 106 patients (61.9%) and were categorized as perioperative (<1 month after surgery, 20.3%) and late (>1 month after surgery, 79.7%). Major complications included 42 (23.7%) GT site infections and four (2.2%) intrabdominal complications. The most common minor complication was granulation tissue (28.8%). Younger age at procedure was associated with complications (P = 0.048) and an open technique was associated with GT site infection (P = 0.003). No statistical significance was observed between complications and gender, diagnosis, GT device, duration of GT usage, and ANC at procedure. CONCLUSIONS Younger patients were more likely to have complications, and GT site infections were more common after open GT procedures.
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Affiliation(s)
| | - John A. Sandoval
- Department of Surgery, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Reagan M. Jones
- Department of Surgery, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Nana Boateng
- Department of Biostatistics, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Jianrong Wu
- Department of Biostatistics, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Bhaskar N. Rao
- Department of Surgery, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Andrew M. Davidoff
- Department of Surgery, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Stephen J. Shochat
- Department of Surgery, St Jude Children’s Research Hospital, Memphis, Tennessee,Correspondence to: Stephen J. Shochat, Department of Surgery, St. Jude Children’s Research Hospital, Memphis, Tennessee 38105.
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Abstract
PURPOSE The incidence of persistent gastrocutaneous fistula (GCF) after removal of gastrostomy tubes in pediatric patients is estimated to be up to 44 %. Our aim was to review the outcomes of GCF closure by an endoscopic technique that utilizes cautery and endoclips. METHODS A retrospective analysis of patients who underwent endoscopic treatment for persistent GCF from January 2010 to September 2013 was performed. This technique utilized esophagogastroduodenoscopy with cauterization of the fistula track and endoclipping of the gastric mucosa. RESULTS Sixteen patients underwent endoscopic treatment for persistent GCF. Mean age at time of endoscopy was 7.5 ± 5.5 (1.1-17) years. Gastrostomy tubes were in place for mean of 5.4 ± 5.2 (0.5-14.2) years prior to removal. The average time from gastrostomy tube removal to first endoscopic clipping was 6.7 ± 9 (0.1-28.9) months. Seven patients (44 %) had successful closure after one endoclipping procedure. Six patients underwent a second endoclipping procedure, with three successful closures. Four patients (25 %) required surgical closure for persistent fistulas and 2 (13 %) have continued drainage. CONCLUSIONS While endoscopy with cautery and endoclipping proves to be safe, many patients require multiple procedures and may require surgical closure. Patient selection and refinement of this technique may improve outcomes.
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Kim JS, Baik JH, Lim SH, Hong BY, Jo L. Conversion of Percutaneous Endoscopic Gastrostomy to Gastrojejunostomy Under Fluoroscopic Guidance for Treatment of Gastrocutaneous Fistula. Ann Rehabil Med 2015; 39:133-7. [PMID: 25750883 PMCID: PMC4351485 DOI: 10.5535/arm.2015.39.1.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 07/14/2014] [Indexed: 11/05/2022] Open
Affiliation(s)
- Joon-Sung Kim
- Department of Rehabilitation Medicine, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Jun Hyun Baik
- Department of Radiology, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Seong Hoon Lim
- Department of Rehabilitation Medicine, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Bo Young Hong
- Department of Rehabilitation Medicine, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Leechan Jo
- Department of Rehabilitation Medicine, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
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Wright R, Abrajano C, Koppolu R, Stevens M, Nyznyk S, Chao S, Bruzoni M, Wall J. Initial results of endoscopic gastrocutaneous fistula closure in children using an over-the-scope clip. J Laparoendosc Adv Surg Tech A 2014; 25:69-72. [PMID: 25531644 DOI: 10.1089/lap.2014.0379] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Gastrocutaneous fistula (GCF) occurs commonly in pediatric patients after removal of long-term gastrostomy tubes. Although open repair is generally successful, endoscopic approaches may offer benefits in terms of incisional complications, postoperative pain, and procedure time. In addition, endoscopic approaches may offer particular benefit in patients with varied degrees of skin irritation or erosion surrounding a GCF, making surgical repair difficult, or patients with significant comorbidities, making minimal intervention and anesthesia time preferable. Over-the-scope (OSC) clips are a new technology that enables endoscopic closure of intestinal fistulas up to 2 cm in diameter. Six pediatric patients underwent endoscopic GCF closure using OSC clips under Institutional Review Board approval. The procedure was technically successful in 5 of 6 cases with an average operating time of 29 minutes. The technical failure required an open revision, whereas all other patients reported full healing of the GCF site at 1 month. All successful cases were performed as outpatients without postoperative narcotics. In addition, all patients reported high satisfaction with the procedure and cosmetic results. Endoscopic GCF closure using an OSC clip is technically feasible in the pediatric population. Based on limited cases with a 1-month follow-up, the functional and cosmetic results of technically successful cases are excellent. Endoscopic GCF closure is a potential alternative to standard surgical closure in patients with skin irritation or erosion and/or significant comorbidities.
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Affiliation(s)
- Robert Wright
- Division of Pediatric Surgery, Lucile Packard Children's Hospital , Stanford, California
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Khan FA, Fisher JG, Sparks EA, Iglesias J, Zurakowski D, Modi BP, Duggan C, Jaksic T. Factors Affecting Spontaneous Closure of Gastrocutaneous Fistulae After Removal of Gastrostomy Tubes in Children With Intestinal Failure. JPEN J Parenter Enteral Nutr 2014; 39:860-3. [PMID: 24993864 DOI: 10.1177/0148607114538058] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 05/07/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Children with intestinal failure (IF) frequently require gastrostomy tubes (GTs) for long-term nutrition support. Risk factors for persistent gastrocutaneous fistulae (GCFs) in pediatric patients with IF are largely unknown but may include underlying nutrition status and duration of indwelling GT. MATERIALS AND METHODS Records of patients with IF having undergone GT removal and allowed a trial at spontaneous closure were reviewed. Nonparametric continuous variables were analyzed using the Wilcoxon rank sum test. Post hoc analysis was performed to identify the optimal threshold of GT duration predicting probability of spontaneous closure identified using receiver operating characteristic curve analysis. RESULTS Fifty-nine children with IF undergoing GT removal were identified. Spontaneous closure occurred in 36 (61%) sites, while 23 (39%) underwent operative closure at a median 67 days after GT removal. The duration of indwelling GT was significantly shorter in the spontaneous closure group (11.5 vs 21 months, P = .002). Of 33 GT indwelling for ≤ 18 months, 28 (85%) closed spontaneously, compared with only 9 of 26 (35%) with duration >18 months (P < .001). With GCF persisting beyond 7 days, only 21% (6/28) of sites closed spontaneously, but this dropped to 6% (1/18) of cases with concurrent GT duration >18 months. CONCLUSIONS Of the risk factors evaluated, only prolonged GT duration was associated with an increased likelihood of failure to close spontaneously. It is significantly less likely in pediatric patients with IF in whom GCF persists >7 days, particularly if the duration of GT is >18 months. Relatively earlier operative closure should be considered in this group.
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Affiliation(s)
- Faraz A Khan
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jeremy G Fisher
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Eric A Sparks
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Julie Iglesias
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - David Zurakowski
- Department of Surgery, Department of Biostatistics, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Biren P Modi
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Christopher Duggan
- Division of Gastroenterology and Nutrition, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Tom Jaksic
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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Closure of a percutaneous endoscopic gastrostomy-associated nonhealing gastrocutaneous fistula using endoscopic hemoclips. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2014; 27:501-2. [PMID: 24078932 DOI: 10.1155/2013/145946] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Persistent gastrocutaneous fistula: factors affecting the need for closure. J Pediatr Surg 2013; 48:2506-10. [PMID: 24314194 DOI: 10.1016/j.jpedsurg.2013.06.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Revised: 05/31/2013] [Accepted: 06/05/2013] [Indexed: 11/22/2022]
Abstract
PURPOSE The occurrence of gastrocutaneous fistula (GCF) is a well-known complication after gastrostomy tube placement. We explore multiple factors to ascertain their impact on the rate of persistent GCF formation. METHODS We retrospectively reviewed patient records for all gastrostomies (GT) constructed at our institution from 2007 to 2011. Association of GCF with method of placement, concomitant fundoplication, neurologic findings, duration of therapy, and demographics was evaluated using logistic regression. RESULTS Nine hundred fifty patients had GTs placed, of which 148 patients had GTs removed and 47 (32%) of 148 required surgical closure secondary to persistent GCF. Laparoscopic and open procedures comprised 79 (53%) of 148 and 69 (47%) of 148, respectively. Seventeen (22%) patients in the laparoscopic group developed persistent GCF, compared to 30 (43%) in the open group (P=0.035, OR=2.52). Seventy-one patients had concomitant Nissen fundoplication. Thirty-one (44%) developed GCF, compared to 16 (21%) without a Nissen (P=0.002, OR=4.94). Patients with button in place for 303 days had persistent GCF incidence of 23%, compared to 45% at 540 days (P<0.001, OR=3.51) and 50% at 850 days (P=0.011, OR=4.51). Patients with device placed at 1.8 months of age were more likely to develop GCF compared to those with device placed at 8.9 months of age (P=0.017, OR=2.35). CONCLUSION Open operations, concurrent Nissen and younger age at placement were all statistically significant factors causing persistent GCF.
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22
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Long-term outcome after percutaneous endoscopic gastrostomy in children. Pediatr Neonatol 2013; 54:326-9. [PMID: 23721827 DOI: 10.1016/j.pedneo.2013.04.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Revised: 11/26/2012] [Accepted: 04/26/2013] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) is widely accepted as the preferred procedure to establish long-term enteral feeding. OBJECTIVE To learn the long-term outcomes of the patients who have undergone PEG placement, we reviewed our experience with children who underwent this procedure in our institute. METHODS A total of 83 pediatric patients (42 males and 41 females), who were aged from 3 months to 20 years, underwent PEG insertion in National Taiwan University Hospital from January 2000 to April 2011. The underlying diseases of the patients receiving PEG were neurological dysfunction (n = 67), metabolic disorders (n = 9), gastrointestinal disease (n = 2), and congenital heart disease (n = 1). This procedure was performed under intravenous sedation or under general anesthesia. Prophylactic antibiotics were administered for 1 day. Tube feeding began 24 hours after the PEG placement. The body weight of the patients was recorded 1 day before PEG placement and at least 6 months after PEG placement. RESULTS The weight-for-age Z-score before and at 6 months after PEG placement were -1.5 ± 2.0 and -0.9 ± 2.1, respectively, which was statistically significant (paired t test, p = 0.006). The catch-up growth was recorded after PEG placement. Complications of PEG in our patients included cellulitis at the gastrostomy wound (n = 14), dislodgement of the tube (n = 17), and persistent gastrocutaneous fistula (n = 3). The PEG tube was removed permanently in seventeen patients because they resumed an adequate oral intake. During the follow-up period, 14 patients died of an underlying disease or infection. CONCLUSION Our experience confirmed that PEG placement is a good long-term route for nutritional supply with no serious complications in children.
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Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) tubes have allowed for a safe and efficient way to feed patients who cannot tolerate oral feeding, yet have a functioning gastrointestinal tract. Gastrocutaneous fistulas (GCF) after PEG removal are an unusual and rare complication in adults and may be in part due to poor tissue healing, delayed gastric emptying, or increased gastric acid production. Various approaches have been reported to treat PEG-related gastric fistulas; however, their success rate is variable and patients frequently require repeat procedures or >1 technique in combination, including acid suppression therapy, silver nitrate ablation of the PEG tract lining, argon plasma coagulation, fibrin glue, and/or endoclipping. Upon our review, there have been no published case series reporting the use of endoscopic banding to close persistent GCFs after PEG removal. STUDY DESIGN Four patients with persistent GCFs after PEG removal were taken for esophagogastroduodenoscopy with banding of the fistula site. This procedure was chosen due to its relative ease of application. Patient follow-up was by telephone within 3 days of having the procedure and then again 1 to 2 weeks afterward, to ensure that there was no persistent leakage through the fistula tract. RESULTS Of the 4 patients who had persistent GCFs after PEG removal, endoscopic banding resulted in complete closure of the fistula in 3 of our 4 patients. In 1 case, banding was unsuccessful secondary to scarring from prior radiation treatment as well as having a previous PEG tube placed 1 inch from the current fistula site. In this case, a second PEG tube was placed through the original PEG stoma, leading to cessation of the gastric leak. The first case resulted in no recurrence after 3 years. The second and third cases have shown no recurrence after 3 months. The fourth case resulted in a second PEG tube to manage persistent drainage through the tract after unsuccessful banding of the site due to complex endoscopic and anatomic issues. CONCLUSIONS Endoscopic closure of a GCF, regardless of technique used, can help avoid surgical intervention. Anatomic changes from any previous treatment modalities may decrease the success rate of fistula banding. However, in our patients, endoscopic banding proved to be a safe and relatively simple alternative in closing persistent GCFs due to prior PEG tubes.
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24
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Abstract
BACKGROUND AND OBJECTIVES Gastrostomy feeding in children is well established for nutritional support. Gastrostomy tubes may be permanent or temporary. After removal, spontaneous closure may occur, but persistence of the tract requires surgical repair. Laparotomy with gastric repair and fascial closure is the standard technique for treatment of a persistent gastrocutaneous fistula. We describe a technique of extraperitoneal excision of the fistulous tract and our results using this method. METHODS We reviewed 21 cases of extraperitoneal gastrocutaneous fistula closure in which a Foley catheter traction technique was used and were performed over the last 8 y. The technique involves insertion of a small Foley catheter with traction applied to the fistulous tract and core excision with electrocautery. Closure of the tract without fascial separation was accomplished and early feedings were allowed. RESULTS Ten males and 11 females underwent closure with this technique. The duration of the gastrostomy ranged from 1 y to 6 y, with a mean of 3.3 y. The time from removal to surgical repair was 3 wk to 1 y, with a mean of 4.3 mo; 15 had gastrostomy alone, and 6 had gastrostomy in combination with Nissen fundoplication. Open gastrostomy had been done in 10 patients and laparoscopic gastrostomy in 11 patients. Half of the patients had an ambulatory procedure. One patient developed a superficial wound infection, and there was 1 recurrence requiring intraperitoneal closure. CONCLUSION Extraperitoneal closure for gastrocutaneous fistula is safe and effective. The technique allows for rapid resumption of feeds and a shortened length of stay. Minimal morbidity occurs with this technique, and it is well tolerated in the pediatric population.
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Affiliation(s)
- Gustavo Stringel
- Department of Pediatrics, NY Medical College, Valhalla, NY 10595, USA.
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Gastrocutaneous fistula from migrated skin staples: an unusual complication of percutaneous endoscopic gastrostomy in a severely burned patient. J Burn Care Res 2012; 33:e252-3. [PMID: 22267058 DOI: 10.1097/bcr.0b013e318248b5d4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bratu I, Bharmal A. Incidence and predictors of gastrocutaneous fistula in the pediatric patient. ISRN GASTROENTEROLOGY 2010; 2011:686803. [PMID: 21991525 PMCID: PMC3168482 DOI: 10.5402/2011/686803] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2010] [Accepted: 10/28/2010] [Indexed: 12/04/2022]
Abstract
Background/Purpose. To determine the incidence, predictors, and outcomes of repair of gastrocutaneous fistulae (GCF) in pediatric patients. Methods. Patients were identified through a medical records search of all gastrostomy insertions performed from 1997–2007. Results. Of 1083 gastrostomies, 49 had GCF closure. Gastrostomy indications were reflux/aspiration (30/43 [70%]) and feeding intolerance/failure to thrive (7/43 [16%]). Gastrostomies were performed as open surgical procedures (84%) with fundoplication (66% of all cases) at an age of 0.5 ± 0.57 (median ± inter-quartile range) years. Gastrostomies were removed in outpatient settings when no longer used and were present for 2.3 ± 2.2 years, and GCF persisted for 2.0 ± 3.0 months. GCF were closed by laparotomy and stapling. GCF closure length of stay was 2.0 ± 3.3 days. Complications occurred in 6/49 patients and included infection/fever (4/6) and localized skin redness/breakdown (2/6). Conclusions. From our collected data, GCFs occur at a frequency of 4.5% and persist for 2.0 ± 3.0 months until closed. Given the complicated medical histories of patients and relatively high rate of postoperative infection/reaction (12.2%), GCF closure is not a benign, “uncomplicated” procedure. Further information describing factors determining which patients develop GCF requiring closure is needed.
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Affiliation(s)
- Ioana Bratu
- Pediatric General Surgery, Department of Surgery, Stollery Children's Hospital, University of Alberta, 2C3.56 WMC, 8440-112 Street, Edmonton, Alberta, Canada T6G 2B7
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Wood J, Leong S, McCarter M, Pearlman N, Stiegmann G, Gonzalez RJ. Endoscopic-assisted closure of persistent gastrocutaneous fistula with a porcine fistula plug: report of a new technique. Surg Innov 2010; 17:53-6. [PMID: 20097672 DOI: 10.1177/1553350609359921] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Persistent gastrocutaneous (GC) fistula is a rare but problematic complication of gastrostomy feeding tube removal. Several techniques for nonoperative fistula closure have been attempted with mixed results. None has proven both satisfactorily simple and consistently effective. The authors present a case of persistent GC fistula treated by a simple outpatient endoscopic-assisted procedure using a porcine anal fistula plug. The procedure requires only basic endoscopic skills, similar to percutaneous gastrostomy tube placement, and it involves minimal operative time and risk to the patient. This technique offers a potential solution to the troublesome problem of persistent GC fistula.
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Affiliation(s)
- James Wood
- University of Colorado at Denver, Aurora, CO, USA
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Abstract
Innovation in endoscope design and application of lessons and techniques from minimally invasive surgery is allowing endoscopists to explore new frontiers in enteral access and meet the demands of an increasingly savvy and aging 'baby boomer' population that has high health care expectations. Another small but very labor intensive group of patients that is contributing both to increased awareness and to the demand for specialized nutrition support services, is made up of patients with intestinal failure. With steadily accruing experience in the care of these patients on long term home parenteral and enteral nutrition, as well as the improved outcomes for intestinal transplantation, these services are poised for exponential growth in coming years. The endoscopist whose practice involves enteral access should be capable of providing the whole gamut of enteral access services allowing individualization of approach to ensure the best possible outcomes for a given patient and indication. Experience with management of the many common complications of enteral access is a pre-requisite for successful long-term outcomes. While it would be desirable that such enteral access be provided within a broader multi-disciplinary model of specialized nutrition support, in the current climate of a tightening health care economy that may be counsel for perfection.
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Avitsland TL, Kristensen C, Emblem R, Veenstra M, Mala T, Bjørnland K. Percutaneous endoscopic gastrostomy in children: a safe technique with major symptom relief and high parental satisfaction. J Pediatr Gastroenterol Nutr 2006; 43:624-8. [PMID: 17130739 DOI: 10.1097/01.mpg.0000229550.54455.63] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) is widely used for establishing enteral feeding. The aim of this study was to assess immediate and long-term results after PEG insertion. PATIENTS AND METHODS A total of 121 children were retrospectively reviewed. Median age was 2.4 years (range, 4 months-13.2 years) at the time of PEG insertion. Patient morbidity, indications for PEG, preoperative findings and perioperative complications were registered retrospectively. Parents/caregivers of 85 children were interviewed for long-term results. RESULTS Perioperative complications were seen in 12%. Twenty-four percent died at a median of 15 months (range, 1.5 months-8 years) after PEG. Eighty-five families were interviewed with a median follow-up time of 5.6 years (range, 1-10 years). A substantial majority (94%) of parents/caregivers reported that the PEG had a positive influence on their child's situation, and 98% would have chosen PEG insertion again. Vomiting/retching improved in 61% of the children, and oral intake enhanced in 43%. Stoma-related complications were frequent (73%). The gastrostomy tube was permanently removed at a median of 3 years (range, 7 months-7.3 years) after PEG placement in 25%. Delayed closure of the gastrocutaneous fistula after gastrostomy removal occurred in 48% of them. Time from insertion to removal was not predictive of delayed closure. CONCLUSION PEG is a safe technique for establishing enteral feeding, even in very sick children. Major complications are rare, although most children experience minor stoma-related problems. Parents/caregivers report that the gastrostomy is of great help for themselves and their child.
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Affiliation(s)
- Tone Lise Avitsland
- University of Oslo, Rikshospitalet-Radiumhospitalet Medical Center, Oslo, Norway
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Teitelbaum JE, Gorcey SA, Fox VL. Combined endoscopic cautery and clip closure of chronic gastrocutaneous fistulas. Gastrointest Endosc 2005; 62:432-5. [PMID: 16111964 DOI: 10.1016/j.gie.2005.04.047] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2005] [Accepted: 04/28/2005] [Indexed: 02/08/2023]
Abstract
BACKGROUND Chronic gastrocutaneous fistula with intermittent drainage is a common outcome after removing long-standing gastrostomy tubes. The standard treatment is surgery with laparotomy and excision of the fistula tract. This study describes the results of an endoscopic closure technique by using a combination of electrocautery and metal clips. METHODS Three patients with gastrocutaneous fistulas (duration 3 months to 3 years) after gastrostomy tube removal were treated endoscopically by electrocautery of the tract and application of metal clips. OBSERVATIONS Treatment resulted in complete fistula closure in two patients and partial closure in a third patient. CONCLUSIONS Combined endoscopic therapy with electrocautery and clipping may be an alternative to surgical closure of chronic gastrocutaneous fistulas.
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Affiliation(s)
- Jonathan E Teitelbaum
- Department of Pediatric Gastroenterology and Nutrition, Monmouth Medical Center, Long Branch, New Jersey, USA
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