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Ascencio A, Fingland S, Diaz-Miron J, Weber N, Hills-Dunlap J, Partrick D, Acker SN. Operative Complications Following Gastrostomy Tube Placement After Cardiac Surgery During Infancy. J Surg Res 2024; 296:203-208. [PMID: 38281355 DOI: 10.1016/j.jss.2023.12.030] [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: 03/01/2023] [Revised: 11/27/2023] [Accepted: 12/23/2023] [Indexed: 01/30/2024]
Abstract
INTRODUCTION Gastrostomy tube (GT) placement is common in infants following repair of congenital heart defects. We aimed to determine rate of operative complications and predictors of short-term GT use to counsel parents regarding the risks and benefits of GT placement. METHODS We reviewed infants aged <1 y with congenital heart disease who underwent GT placement after cardiac surgery between 2018 and 2021. Demographics and clinical data were collected and analyzed. Comparisons were made between infants who required the GT for more than 1 y and those who required the GT for less than 1 y. RESULTS One hundred thirty three infants were included; 35 (26%) suffered one or more complication including wound infection (4, 3%), granulation tissue (3, 2%), tube dislodgement (10), leakage from the tube (9), unplanned emergency department visit (15), and unplanned readmission (1). Thirty-four infants used the GT for feeds for 1 y or less (26%) including 17 (13%) who used it for 3 mo or less. Fifty-six infants had their GT removed during the study period (42%), 20 of whom required gastrocutaneous fistula closure (36%). Thirty-three infants had a GT placed on or before day of life 30, 17 (52%) used the GT for less than 1 y, and 10 (31%) used it for 3 mo or less. CONCLUSIONS GT placement is associated with a relatively high complication and reoperation rate. GT placement in infants aged less than 30 d is associated with shorter duration of use. Risks, benefits, and alternatives such as nasogastric tube feeds should be discussed in the shared decision-making process for selected infants.
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Affiliation(s)
- Andy Ascencio
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Stephanie Fingland
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Jose Diaz-Miron
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Nell Weber
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Jonathan Hills-Dunlap
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - David Partrick
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Shannon N Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO.
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Bawazir O, Banaja AM, Bawazir R, Bawazir AO. Percutaneous endoscopic gastrostomy in children: A tertiary center experience. Asian J Endosc Surg 2022; 15:524-530. [PMID: 35146931 DOI: 10.1111/ases.13040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 12/23/2021] [Accepted: 01/26/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Percutaneous endoscopic gastrostomy (PEG) is a common procedure in children. The outcomes of PEG could be affected by the associated disease. We aimed to evaluate the outcomes and safety of PEG tube placement in a tertiary care center with special attention to patients with cardiac disease, ventriculoperitoneal (VP) shunt, or peritoneal dialysis (PD) catheter. METHODS This retrospective study included 113 pediatric patients who had PEG tube insertion from 2011 to 2021. Eighteen patients (15.93%) had cardiac disease, five patients (4.42%) had PD catheters, and three patients (2.65%) had VP shunt. RESULTS The median age was 3 years (interquartile range: 1-6), and females represented 55% of our patients. The weight ranged from 2.57 to 60 kg, and the most common indication for insertion was neurological disease (n = 56; 49.56%). The median operative time was 30 (20-45) minutes. Pneumonia and vomiting were the most frequent complications (n = 20, 17.7%). Thirty-day mortality occurred in four patients (3.54%) and 1-year mortality in 10 patients (8.85%). Nine patients (7.96%) required fundoplication, and four patients (3.53%) had tube removal and reinsertion. There was no association between weight and postoperative complications (odds ratio: 0.97; P = .48). There were no differences in postoperative complications among patients with cardiac diseases, PD catheters, and VP shunts. No complications were reported in patients with VP shunt. One patient with cardiac disease and one patient with PD catheter required fundoplication. Removal and reinsertion were needed in one patient with a PD catheter. CONCLUSION PEG is feasible in low-weight infants with a low complication rate. The complication rate is low in patients with VP shunt, PD catheter, and cardiac patients.
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Affiliation(s)
- Osama Bawazir
- Department of Surgery Faculty of Medicine, Umm Al-Qura University at Makkah, Makkah, Saudi Arabia.,Consultant Pediatric Surgery and Pediatric Urology, Department of Surgery, King Faisal Specialist Hospital & Research Center, Jeddah, Saudi Arabia
| | - Abdulaziz M Banaja
- Department of Pediatric Surgery, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Razan Bawazir
- King Saud Bin Abdulaziz University for Health Sciences,College of Medicine-Jeddah, College Of Medicine, Jeddah, Saudi Arabia
| | - Abdullah Osama Bawazir
- King Saud Bin Abdulaziz University for Health Sciences,College of Medicine-Jeddah, College Of Medicine, Jeddah, Saudi Arabia
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Stephenson KJ, Bonasso PC, Vasquez IL, Burford JM, Wyrick DL, Bhavaraju A, Dassinger MS. An Evaluation of Pediatric Gastrocutaneous Fistula Closure Through the Punch Excision of Epithelized Tract Procedure. Am Surg 2022; 88:1822-1826. [PMID: 35420922 DOI: 10.1177/00031348221084945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Persistent gastrocutaneous fistulae frequently complicate gastrostomy tube placement. A minimally invasive technique for tract closure employing balloon catheter retraction and punch excision of the epithelized tract (PEET) was recently reported. We hypothesized the PEET technique of closure would lead to decreased complications without an increased incidence of recurrence. METHODS We conducted a single-center retrospective cohort study evaluating children who underwent gastrocutaneous fistula (GCF) closure 1/1/2018-12/31/2021, comparing patients who underwent the PEET procedure to those repaired with layered closure. Procedure duration and outcomes were additionally compared to the 2018-2019 National Surgical Quality Improvement Program (NSQIP) Participant Use File (PUF) database. RESULTS Sixty-two children underwent operative GCF closure, including 25 with PEET and 37 traditional layered closure. Procedural time was significantly decreased employing PEET (14 vs 26 minutes, P < .0001), less than half the national median by the NSQIP PUF database of 292 GCF closures (14 vs 34.5 minutes, P < .0001). Those repaired with the PEET method experienced no episodes of recurrence, surgical site infection, readmission, reoperation, or mortality within 30 days of the procedure. Conversely, in traditional closure, there was a 24.3% complication rate, including 7 surgical site infections, 1 readmission, and 2 unplanned reoperations. National procedural complication rate by NSQIP PUF was 5.5%, with a 4.8% rate of surgical site infection, .3% reoperation incidence, and .3% mortality. DISCUSSION Our study suggests GCF closure employing the PEET procedure is a safe, more efficient method of tract closure than the traditional layered closure technique.
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Affiliation(s)
- Krista J Stephenson
- Department of Pediatric Surgery, 14423Arkansas Children's Hospital, Little Rock, AR, USA
| | - Patrick C Bonasso
- Department of Pediatric Surgery, 14423Arkansas Children's Hospital, Little Rock, AR, USA
| | - Isabel L Vasquez
- Department of Surgery, 366944Arkansas Children's Research Institute, Little Rock, AR, USA
| | - Jeffrey M Burford
- Department of Pediatric Surgery, 14423Arkansas Children's Hospital, Little Rock, AR, USA
| | - Deidre L Wyrick
- Department of Pediatric Surgery, 14423Arkansas Children's Hospital, Little Rock, AR, USA
| | - Avi Bhavaraju
- Department of Trauma and Acute Care Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Melvin S Dassinger
- Department of Pediatric Surgery, 14423Arkansas Children's Hospital, Little Rock, AR, 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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Ishikawa Y, Nishikawa K, Fukushima N, Takahashi K, Hasegawa Y, Yuda M, Tanishima Y, Ikegami T. Assessment of button-type jejunostomy for nutritional management after esophagectomy in 201 cases. Int J Clin Oncol 2021; 26:2224-2228. [PMID: 34463868 DOI: 10.1007/s10147-021-02022-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 08/23/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND Many surgeons preferably place a trans-nasal feeding tube or a feeding enterostomy for post-operative nutritional management after esophagectomy. Various types of tubes (such as nasogastric, transgastric, transduodenal, or transjejunal tubes) have been used for enteral feeding; however, the appropriate enteral feeding routes have not yet been proposed. Therefore, this study aimed to evaluate the feasibility and safety of button-type jejunostomy. METHODS We reviewed 201 patients who underwent esophagectomy with placement of a button-type jejunostomy at the Jikei University Hospital (Tokyo, Japan) between 2008 and 2019. The analyzed variables included clinicopathological characteristics, operative data, jejunostomy-related characteristics, and postoperative complications. Postoperative bodyweight loss was examined 6 months and 1 year after the operation. RESULTS Refractory enterocutaneous fistula and bowel obstruction occurred in 13 (6.5%) and 14 (7.0%) patients, respectively. The body mass index at button-type jejunostomy removal was significantly lower and the duration of button-type jejunostomy placement was significantly longer in patients with a refractory enterocutaneous fistula (p = 0.023 and p < 0.001, respectively). Bowel obstruction was significantly more likely to develop in patients with a non-squamous cell carcinoma (p = 0.021) and in patients who underwent open abdominal procedures (p < 0.001). After 1 year, the median bodyweight losses were 12.1% and 15.6% in patients with short and long jejunostomy placement durations (p = 0.642), respectively. CONCLUSION A button-type jejunostomy is durable and allows easy self-management for maintaining the bodyweight without any adverse events. However, it is strongly recommended that the button be removed within a year to prevent refractory enterocutaneous fistula formation.
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Affiliation(s)
- Yoshitaka Ishikawa
- Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi Minato-ku, Tokyo, 1058461, Japan.
| | - Katsunori Nishikawa
- Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi Minato-ku, Tokyo, 1058461, Japan
| | - Naoko Fukushima
- Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi Minato-ku, Tokyo, 1058461, Japan
| | - Keita Takahashi
- Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi Minato-ku, Tokyo, 1058461, Japan
| | - Yako Hasegawa
- Department of Surgery, Itabashi Chuo Medical Center, 2-12-7 Azusawa Itabashi-ku, Tokyo, 1740051, Japan
| | - Masami Yuda
- Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi Minato-ku, Tokyo, 1058461, Japan
| | - Yuichiro Tanishima
- Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi Minato-ku, Tokyo, 1058461, Japan
| | - Toru Ikegami
- Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi Minato-ku, Tokyo, 1058461, Japan
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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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8
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Khdair Ahmad F, Younes D, Al Darwish MB, Aljubain MA, Dweik M, Alda'as Y. Safety and outcomes of percutaneous endoscopic gastrostomy tubes in children. Clin Nutr ESPEN 2020; 38:160-164. [DOI: 10.1016/j.clnesp.2020.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 04/30/2020] [Accepted: 05/12/2020] [Indexed: 01/14/2023]
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Endoscopy-Assisted Suture of Gastrocutaneous Fistula: A Promising Approach in Pediatric Patients. Am J Gastroenterol 2018; 113:1562-1564. [PMID: 30072775 DOI: 10.1038/s41395-018-0213-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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10
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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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13
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Yap BKY, Nah SA, Chen Y, Low Y. Fundoplication with gastrostomy vs gastrostomy alone: a systematic review and meta-analysis of outcomes and complications. Pediatr Surg Int 2017; 33:217-228. [PMID: 27889821 DOI: 10.1007/s00383-016-4028-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/25/2016] [Indexed: 01/16/2023]
Abstract
PURPOSE We compare the outcomes of fundoplication with gastrostomy vs gastrostomy alone and review the need for subsequent fundoplication after the initial gastrostomy alone. METHODS We searched studies published from 1969 to 2016 for comparative outcomes of concomitant fundoplication with gastrostomy (FGT) vs gastrostomy insertion alone (GT) in children. Gastrostomy methods included open, laparoscopic, and endoscopic procedures. Primary aims were minor and major complications. Secondary aims included post-operative reflux-related complications, fundoplication specific complications, and need for subsequent fundoplication after GT. RESULTS We reviewed 447 studies; 6 observational studies were included for meta-analysis, encompassing 2730 children undergoing GT (n = 1745) or FGT (n = 985). FGT was associated with more minor complications [19.9 vs 11.4%, OR 2.02, 95% confidence interval (CI) 1.43-2.87, p ≤ 0.0001, I 2 = 0%], minor complications requiring revision (6.8 vs 3.0%, OR 2.27, 95% CI 1.28-4.05, p = 0.005, I 2 = 0%), and more overall complications (21.3 vs 12.0%, OR 1.99, 95% CI 1.43-2.78, p < 0.0001, I 2 = 0%). Incidence of major complications (1.8 vs 2.0%, OR 1.39, 95% CI 0.62-3.11, p = 0.42, I 2 = 5%) and reflux-related complications (8.8 vs 10.3%, OR 0.75, 95% CI 0.35-1.68, p = 0.46, I 2 = 0%) in both groups was similar. Incidence of subsequent fundoplication in GT patients was 8.6% (mean). CONCLUSIONS Gastrostomy alone is associated with fewer minor and overall complications. Concomitant fundoplication does not significantly reduce reflux-related complications. As few patients require fundoplication after gastrostomy, current evidence does not support concomitant fundoplication.
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Affiliation(s)
- Brendan K Y Yap
- Department of Pediatric Surgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Shireen Anne Nah
- Department of Pediatric Surgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Yong Chen
- Department of Pediatric Surgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Yee Low
- Department of Pediatric Surgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.
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14
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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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15
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Kapadia MZ, Joachim KC, Balasingham C, Cohen E, Mahant S, Nelson K, Maguire JL, Guttmann A, Offringa M. A Core Outcome Set for Children With Feeding Tubes and Neurologic Impairment: A Systematic Review. Pediatrics 2016; 138:peds.2015-3967. [PMID: 27365302 DOI: 10.1542/peds.2015-3967] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/27/2016] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Uncertainty exists about the impacts of feeding tubes on neurologically impaired children. Core outcome sets (COS) standardize outcome selection, definition, measurement, and reporting. OBJECTIVE To synthesize an evidence base of qualitative data on all outcomes selected and/or reported for neurologically impaired children 0 to 18 years living with gastrostomy/gastrojejunostomy tubes. DATA SOURCES Medline, Embase, and Cochrane Register databases searched from inception to March 2014. STUDY SELECTION Articles examining health outcomes of neurologically impaired children living with feeding tubes. DATA EXTRACTION Outcomes were extracted and assigned to modified Outcome Measures in Rheumatology 2.0 Filter core areas; death, life impact, resource use, pathophysiological manifestations, growth and development. RESULTS We identified 120 unique outcomes with substantial heterogeneity in definition, measurement, and frequency of selection and/or reporting: "pathophysiological manifestation" outcomes (n = 83) in 79% of articles; "growth and development" outcomes (n = 13) in 55% of articles; "death" outcomes (n = 3) and "life impact" outcomes (n = 17) in 39% and 37% of articles, respectively; "resource use" outcomes (n = 4) in 14%. Weight (50%), gastroesophageal reflux (35%), and site infection (25%) were the most frequently reported outcomes. LIMITATIONS We were unable to investigate effect size of outcomes because quantitative data were not collected. CONCLUSIONS The paucity of outcomes assessed for life impact, resource use and death hinders meaningful evidence synthesis. A COS could help overcome the current wide heterogeneity in selection and definition. These results will form the basis of a consensus process to produce a final COS.
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Affiliation(s)
- Mufiza Z Kapadia
- Toronto Outcomes Research in Child Health (TORCH), Child Health Evaluative Sciences,
| | - Kariym C Joachim
- Toronto Outcomes Research in Child Health (TORCH), Child Health Evaluative Sciences
| | - Chrinna Balasingham
- Toronto Outcomes Research in Child Health (TORCH), Child Health Evaluative Sciences
| | - Eyal Cohen
- Division of Paediatric Medicine, Paediatrics Outcomes Research Team, and Institute of Health Policy, Management and Evaluation, and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Ontario, Canada; and
| | - Sanjay Mahant
- Division of Paediatric Medicine, Paediatrics Outcomes Research Team, and Institute of Health Policy, Management and Evaluation, and CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Ontario, Canada; and
| | - Katherine Nelson
- Division of Paediatric Medicine, Institute of Health Policy, Management and Evaluation, and Paediatric Advanced Care Team, Department of Paediatrics, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
| | - Jonathon L Maguire
- Division of Paediatric Medicine, Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, and Department of Paediatrics, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Astrid Guttmann
- Division of Paediatric Medicine, Paediatrics Outcomes Research Team, and Institute of Health Policy, Management and Evaluation, and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Martin Offringa
- Toronto Outcomes Research in Child Health (TORCH), Child Health Evaluative Sciences
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16
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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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17
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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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