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Major C, Hall NJ. The Insertion and Management of Gastrostomies in Children in the United Kingdom - A Survey of Practice. J Pediatr Surg 2024; 59:1531-1537. [PMID: 38735807 DOI: 10.1016/j.jpedsurg.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 12/14/2023] [Accepted: 04/15/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND Gastrostomy insertion is one of the most frequently performed procedures by specialist paediatric surgeons. We aimed to determine practice across the United Kingdom (UK) and in particular to identify areas where there was consistency or variation in practice between practitioners and centres. METHODS A structured survey was distributed to all consultant practitioners who insert gastrostomies in the UK. Practice surrounding a range of aspects of gastrostomy care including insertion technique, device use, post-operative management and subsequent care were determined. RESULTS Of total 135 practitioners who insert gastrostomies, responses were received from 103 (76%) with responses received from all UK centres. There was variation between centres in the provision of pre-operative information, and between practitioners in preferred device, insertion techniques, post-operative feeding practice and change/removal procedures. The most frequently preferred device for primary gastrostomy insertion was a Freka® PEG (36%) button device (30%), CorFlo™ PEG (21%), or G-tube (10%). Laparoscopy was always used when inserting either PEG or button device by over 50% of respondents and selectively used by the majority of the remainder. Feeds were started between 1 and 24 h post-insertion, most practitioners (64%) plan a minimum one night hospital stay but a third plan for more than one night. CONCLUSION There is considerable variation in practice for most stages of the pathway for children having a gastrostomy. Further work is warranted to understand the relationship between different practices and patient outcomes, resource use and cost and subsequently to develop best practice guidelines. LEVEL OF EVIDENCE: 3
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Affiliation(s)
- Christina Major
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
| | - Nigel J Hall
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK; University Surgery Unit, Faculty of Medicine, University of Southampton, Southampton, UK.
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2
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Chaparro-Zaraza DF, Pinilla-Orejarena AP, Otoya-Castrillón JP, Chacón-Valenzuela D, Quintero-Olarte JJ, Cifuentes-Rincón AB, Quesada-Uribe BF, Durán-Hernandez A, Bermon A, Manrique-Hernandez EF. Evaluating the use of laparoscopic gastrostomy in children with congenital heart disease in Colombia: a retrospective analysis. Front Pediatr 2024; 12:1405793. [PMID: 38938503 PMCID: PMC11208668 DOI: 10.3389/fped.2024.1405793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 06/04/2024] [Indexed: 06/29/2024] Open
Abstract
Introduction Congenital Heart Disease (CHD) is the most common congenital disorder and a leading cause of infant mortality. Despite improved survival rates, patients with CHD often face malnutrition due to increased metabolic demands, feeding difficulties, and gastrointestinal dysfunction. Malnutrition in CHD is linked to poor short and long-term clinical outcomes. Gastrostomy (GT) is frequently used for long-term enteral support, and laparoscopic GT (LGT) has demonstrated advantages in children without CHD. This study evaluated a modified Georgeson's percutaneous LGT technique and its perioperative complications in children with CHD. Methods We performed an analytical retrospective cohort study from 2018 to 2022, including patients younger than 24 months with a diagnosis of CHD who underwent LGT. The primary outcome evaluated was the presence of complications during surgery and the first thirty postoperative days. Complications were graded using Clavien-Dindo's (CD) classification. Sociodemographic, clinical, and procedure-related variables were collected. A bivariate analysis was performed using STATA 15, and a p < 0.05 was considered statistically significant. Results Seventy-eight patients were eligible (male 56.41%, Median age 129.5 days, weight: 4.83 kg). The median surgery time was 35 min. The complication rate was 24.36%. The most frequent complications were GT site infection (10.26%), followed by leakage (8.97%) and granuloma formation (6.41%). Conversion to open surgery was significantly associated with postoperative complications (p = 0.002). Conclusion This modified technique is well-tolerated in children with CHD, demonstrating a low rate of CD grade 3A/3B complications and no grade 4 or 5 complications.
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Affiliation(s)
| | | | | | - Daniella Chacón-Valenzuela
- Department of Pediatric Surgery, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
- School of Medicine, Universidad Industrial de Santander, Bucaramanga, Colombia
| | | | | | | | - Alvaro Durán-Hernandez
- Department of Pediatric Intensive Care, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
| | - Anderson Bermon
- Department of Epidemiology, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
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Nasher O, Thornber J, Dean J, Goldthorpe J, Rajfeld L, Smith L, Hannon E. The principles of enhanced recovery after percutaneous endoscopic gastrostomy (ERaPEG): a UK tertiary center experience. Pediatr Surg Int 2024; 40:123. [PMID: 38704451 DOI: 10.1007/s00383-024-05693-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2024] [Indexed: 05/06/2024]
Abstract
PURPOSE Enhanced recovery after surgery (ERAS) pathways have been shown to improve surgical outcomes and patient satisfaction. The aim of the study was to assess whether the implementation of a perioperative enhanced recovery after percutaneous endoscopic gastrostomy (ERaPEG) pathway based on ERAS principles was safe, satisfactory to parents and improved outcomes. METHODS Following a quality improvement project, a multimodal ERaPEG pathway was introduced as standard practice within the department and children undergoing elective same-day admission percutaneous endoscopic gastrostomy (PEG) at a single UK tertiary center were prospectively enrolled. Exclusion criteria were patients undergoing other concurrent procedures and those who underwent a laparoscopic assisted/open procedure. Data included patient demographics, underlying diagnosis, indication, length of stay (LOS) and 30-day readmission. Parental experience and satisfaction were determined using a questionnaire including 5-point Likert scales. A retrospective cohort was used for comparison. Data were analyzed using Chi-Square test and Mann-Whitney U tests. RESULTS Ninety-five patients met the inclusion criteria: 50 pre and 45 post the implementation of ERaPEG. Median age was 3 and 2 years, respectively. Neurodisability was the underlying diagnosis in most patients (84%-pre-ERaPEG; 76%-post-ERaPEG). Most common PEG indication was medication/nutritional supplementation (52%-pre-ERaPEG; 51%-post-ERaPEG). The LOS significantly decreased from a median of 51.5 h (pre-ERaPEG) to 32 h (post-ERaPEG) (p < 0.001). Thirty-day readmission rates were similar (6% vs 11%). Most parents felt that the educational material was easy to access and understand. Post-operatively the majority of parents (≥ 80%) were confident in managing the gastrostomy device, setting up/giving the feeds and also felt that the LOS was appropriate. CONCLUSION This study shows that the implementation of an ERaPEG pathway significantly reduced LOS following PEG. In addition, the pathway was satisfactory to parents and offered the benefit of improved resource utilization.
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Affiliation(s)
- Omar Nasher
- Department of Pediatric Surgery, Leeds Children's Hospital, The Leeds Teaching Hospitals NHS Trust, Leeds, UK.
| | - Julia Thornber
- Nutrition & Dietetics, Leeds Children's Hospital, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Joanne Dean
- Department of Pediatric Gastroenterology, Leeds Children's Hospital, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jenny Goldthorpe
- Department of Pediatric Gastroenterology, Leeds Children's Hospital, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Linsay Rajfeld
- Department of Pediatric Gastroenterology, Leeds Children's Hospital, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Liz Smith
- Department of Pediatric Surgery, Leeds Children's Hospital, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Edward Hannon
- Department of Pediatric Surgery, Leeds Children's Hospital, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
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4
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Novak I, Velazco NK. Gastrostomy Tubes: Indications, Types, and Care. Pediatr Rev 2024; 45:175-187. [PMID: 38556513 DOI: 10.1542/pir.2022-005647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Gastrostomy tube insertion has become a more common practice in pediatric patients. An increasing number of children both in health-care facilities and at home are relying on temporary or long-term enteral feeding. Gastrostomy tube placement can be accomplished by various methods and by a variety of specialists. Despite the overall safety of these procedures, both early and late complications can occur. It is important for pediatricians and pediatric subspecialists to be familiar with and aware of the indications, safety, and management of gastrostomies. This paper provides a comprehensive overview of the topic.
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Affiliation(s)
- Inna Novak
- Children's Hospital at Montefiore, Bronx, NY
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Skogar ML, Sundbom M. Time trends and outcomes of gastrostomy placement in a Swedish national cohort over two decades. World J Gastroenterol 2024; 30:1358-1367. [PMID: 38596497 PMCID: PMC11000080 DOI: 10.3748/wjg.v30.i10.1358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/27/2023] [Accepted: 01/31/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) and laparoscopically inserted gastrostomy have become the gold standard for adult patients and children, respectively, requiring long-term enteral nutrition support. Procedure-related mortality is a rare event, often reported to be zero in smaller studies. National data on 30-d mortality and long-term survival rates after gastrostomy placement are scarce in the literature. AIM To study the use of gastrostomies in Sweden from 1998-2019 and to analyze procedure-related mortality and short-term (< 30 d) and long-term survival. METHODS In this retrospective, population-based cohort study, individuals that had received a gastrostomy between 1998-2019 in Sweden were included. Individuals were identified in the Swedish National Patient Register, and survival analysis was possible by cross-referencing the Swedish Death Register. The cohort was divided into three age groups: Children (0-18 years); adults (19-64 years); and elderly (≥ 65 years). Kaplan-Meier with log-rank test and Cox regression were used for survival analysis. RESULTS In total 48682 individuals (52% males, average age 60.9 ± 25.3 years) were identified. The cohort consisted of 12.0% children, 29.5% adults, and 58.5% elderly. An increased use of gastrostomies was observed during the study period, from 13.7/100000 to 22.3/100000 individuals (P < 0.001). The use of PEG more than doubled (about 800 to 1800/year), with a corresponding decrease in open gastrostomy (about 700 to 340/year). Laparoscopic gastrostomy increased more than ten-fold (about 20 to 240/year). Overall, PEG, open gastrostomy, and laparoscopic gastrostomy constituted 70.0% (n = 34060), 23.3% (n = 11336), and 4.9% (n = 2404), respectively. Procedure-related mortality was 0.1% (n = 44) overall (PEG: 0.05%, open: 0.24%, laparoscopic: 0.04%). The overall 30-d mortality rate was 10.0% (PEG: 9.8%, open: 12.4%, laparoscopic: 1.7%) and decreased from 11.6% in 1998-2009 vs 8.5% in 2010-2019 (P < 0.001). One-year and ten-year survival rates for children, adults, and elderly were 93.7%, 67.5%, and 42.1% and 79.9%, 39.2%, and 6.8%, respectively. The most common causes of death were malignancies and cardiovascular and respiratory diseases. CONCLUSION The annual use of gastrostomies in Sweden increased during the study period, with a shift towards more minimally invasive procedures. Although procedure-related death was rare, the overall 30-d mortality rate was high (10%). To overcome this, we believe that patient selection should be improved.
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Affiliation(s)
| | - Magnus Sundbom
- Department of Surgical Sciences, Uppsala University, Uppsala 75185, Sweden
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Takalo M, Iber T, Autio R, Luoto T. Complications after pediatric percutaneous endoscopic gastrostomy: comparison of the push and pull technique. WORLD JOURNAL OF PEDIATRIC SURGERY 2024; 7:e000687. [PMID: 38293648 PMCID: PMC10826555 DOI: 10.1136/wjps-2023-000687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 01/07/2024] [Indexed: 02/01/2024] Open
Abstract
Purpose Various complications are associated with percutaneous endoscopic gastrostomy (PEG) procedures in children. The push technique is being increasingly used, but its complications are insufficiently characterized. We aimed to assess all complications related to PEG procedures and compare the safety of the pull and push techniques. Methods Retrospective review of consecutive pediatric patients who underwent PEG between 2002 and 2020. Results In total, 216 children underwent 217 PEG procedures. The push technique was used in 138 (64%) cases, and the pull technique in 79 (36%) cases. The median follow-up time was 6.1 (0.1-18.3) years. The complication rate was high (57%) and patients experienced complications years after the procedure. Overall, 51% and 67% of patients experienced complications in the push and pull groups, respectively. The rates of minor and major complications were higher in the pull group than in the push group (63% vs 48%, p=0.028; and 11% vs 6%, p=0.140, respectively). Reoperation was also more common in the pull group (17% vs 7%, p=0.020). Conclusions The overall complication rate of PEG procedures is high. Fortunately, most complications are mild and do not require reoperations. The increasing push technique appears to be safer than the traditional pull technique. Significant long-term morbidity is related to gastrostomies in children.
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Affiliation(s)
- Mona Takalo
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Tarja Iber
- Department of Pediatric Surgery, Tampere University Hospital, Tampere, Finland
| | - Reija Autio
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Topi Luoto
- Department of Pediatric Surgery, Tampere University Hospital, Tampere, Finland
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7
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Toker Kurtmen B, Nalli A, Oztan MO, Koyluoglu G. Impact of Scoliosis Severity on Gastrostomy-Related Complications in Children. J Pediatr Gastroenterol Nutr 2023; 77:547-552. [PMID: 37378953 DOI: 10.1097/mpg.0000000000003879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
OBJECTIVES This study aimed to determine the relationship between scoliosis and risk of developing complications in patients who underwent gastrostomy. METHODS Patients who underwent percutaneous endoscopic gastrostomy (PEG) or surgical gastrostomy (SG) between 2012 and 2022 were included. Leakage, discharge, granuloma, and hyperemia were considered minor complications, while visceral injury, ileus, and re-do surgery were considered major complications. The degree of scoliosis was calculated using the Cobb angle. The SG and PEG groups were compared by evaluating the complications and their correlation with scoliosis. RESULTS A total of 104 patients with a mean age of 5.0 ± 5.3 were included; 58% of patients were treated with SG. Patients in the SG group were younger ( P < 0.001). Minor complications were significantly more common in the PEG group ( P = 0.018). There was no difference between the groups in terms of major complications ( P = 1.000). Scoliosis was observed in 32.7% of the patients (n = 34). In the SG group, no correlation was found between the Cobb angle and the frequency of minor ( P = 0.173) or major complications ( P = 0.305). There was no significant difference between the Cobb angles of patients with and without minor complications in the PEG group ( P = 0.478); the Cobb angles of patients with major complications (75°) were significantly higher than those without (36°) ( P = 0.030). CONCLUSION Gastrostomy is important for weight gain and nutritional needs of children. This study showed that the risk of complications in SGs did not correlate with the degree of scoliosis and that the risk of major complications in PEGs increased in patients with a high degree of scoliosis.
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Affiliation(s)
- Bade Toker Kurtmen
- From the Department of Pediatric Surgery, University of Health Sciences, Tepecik Education and Research Hospital, Izmir, Turkey
| | - Aslihan Nalli
- From the Department of Pediatric Surgery, University of Health Sciences, Tepecik Education and Research Hospital, Izmir, Turkey
| | - Mustafa Onur Oztan
- the Department of Pediatric Surgery, Faculty of Medicine, Izmir Katip Celebi University, Izmir, Turkey
| | - Gokhan Koyluoglu
- the Department of Pediatric Surgery, Faculty of Medicine, Izmir Katip Celebi University, Izmir, Turkey
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8
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Scalise PN, Durgin JM, Koo DC, Staffa SJ, Yang A, Kim HB, Demehri FR. Outcomes of laparoscopic gastrostomy in children with and without the use of a modified T-fastener technique. Surgery 2023; 174:698-702. [PMID: 37357096 DOI: 10.1016/j.surg.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/01/2023] [Accepted: 05/24/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Laparoscopic gastrostomy is commonly performed for durable enteral access in children. T-fasteners have been used intraoperatively to achieve a secure gastropexy, traditionally using external bolsters. We compare the safety profile of a modified paired T-fastener technique to standard laparoscopic-assisted suture gastropexy. METHODS A retrospective matched case-control study was performed of pediatric patients who underwent laparoscopic gastrostomy at a single center from 2015 to 2021. In the paired T-fastener group, pairs of T-fasteners were passed into the stomach in a square configuration, allowing the suture pairs to be tied subcutaneously. This cohort was matched in a 1:2 fashion with age, sex, and body mass index or weight-matched controls who underwent laparoscopic gastrostomy with buried transabdominal gastropexy. RESULTS Thirty patients underwent laparoscopic gastrostomy using the paired T-fastener technique and were matched to 60 controls. There was no significant difference in median operative time or 30-day complication rates between the groups, but the paired T-fastener technique significantly reduced the number of trocars required, and it was used for patients with thicker abdominal walls. CONCLUSION We demonstrate the modified paired T-fastener technique as a safe, efficient means of gastropexy in pediatric laparoscopic gastrostomy. The paired T-fastener approach eliminates external bolsters, reduces additional trocars, and may be advantageous for thicker abdominal walls while maintaining a similar complication profile to standard laparoscopic gastrostomy.
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Affiliation(s)
- P Nina Scalise
- Department of Surgery, Boston Children's Hospital, MA. https://twitter.com/NinaScaliseMD
| | - Jonathan M Durgin
- Department of Surgery, Boston Children's Hospital, MA. https://twitter.com/JonDurginMD
| | - Donna C Koo
- Department of Surgery, Boston Children's Hospital, MA. https://twitter.com/DonnaKooMD
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, MA
| | | | - Heung Bae Kim
- Department of Surgery, Boston Children's Hospital, MA. https://twitter.com/heungbaekim
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Popescu M, Mutalib M. Rate of paediatric gastrostomy insertion in England and relationship to epidemiology of cerebral palsy. Frontline Gastroenterol 2023; 14:399-406. [PMID: 37581183 PMCID: PMC10423607 DOI: 10.1136/flgastro-2022-102356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 04/24/2023] [Indexed: 08/16/2023] Open
Abstract
Background and objectives Gastrostomy tubes are commonly used to provide an alternative route for enteral nutrition. Most of the gastrostomies are inserted in children with cerebral palsy. Previous studies have shown an increase in insertion rate, however, epidemiological studies reveal a stasis in prevalence of cerebral palsy. We aimed to provide an up-to-date rate of gastrostomy insertion in children in England over a 20-year period and systematically review the prevalence of cerebral palsy to ascertain an epidemiological explanation for insertion trends. Methods Retrospective search of Hospital Episode Statistic, a database held diagnosis and procedural code from all England National Health Service hospitals from 2000 to 2021 using International Classification of Disease-10 and Office of Population Censuses and Survey's Classification-4. England Office for National Statistics data were used for population census. MEDLINE and EMBASE were systematically searched for epidemiology of cerebral palsy. Results There were 23 079 gastrostomies inserted in children <15 years in England (2000-2021) leading to a frequency of 12.4 insertions per 100 000 children per year and 1383 gastrostomy insertions in 15-18 years age group (6 per 100 000). The overall gastrostomy insertion rate in children <15 years has increased from 3.7 procedures per 100 000 in 2000 to 18.3 per 100 000 in 2017. Prevalence of cerebral palsy remained stable (1.5-3.3 per 1000 birth) since 1985. Conclusions There was a significant increase in the rate of gastrostomy insertion in children in England during most of the last 20 years not explained by a stable prevalence of cerebral palsy.
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Affiliation(s)
- Mara Popescu
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Mohamed Mutalib
- Faculty of Life Sciences and Medicine, King's College London, London, UK
- Evelina London Children's Hospital, London, UK
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Tazi K, Kotilea K, Dassonville M, Bontems P. Complications of Percutaneous and Surgical Gastrostomy Placements in Children: a Single-Centre Series. JPGN REPORTS 2023; 4:e316. [PMID: 37200716 PMCID: PMC10187850 DOI: 10.1097/pg9.0000000000000316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 03/22/2023] [Indexed: 05/20/2023]
Abstract
Gastrostomy placement is a standard procedure for children requiring enteral feeding for more than 3-6 weeks. Various techniques have been described (percutaneous endoscopic, laparoscopy, and laparotomy), and many complications have been reported. In our center, gastrostomy placement is performed either percutaneously by pediatric gastroenterologists, by laparoscopy/laparotomy by the visceral surgery team, or jointly, that is laparoscopic-assisted percutaneous endoscopic gastrostomy. This study aims to report all complications and identify risk factors and ways to prevent them. Methods This is a monocentric retrospective study including children younger than 18 years who underwent gastrostomy placement (percutaneous or surgical) between January 2012 and December 2020. Complications that occurred up to 1 year after placement were collected and classified according to their time of onset, degree of severity, and management. A univariate analysis was conducted to compare the groups and the occurrence of complications. Results We established a cohort of 124 children. Sixty-three (50.8%) presented a concomitant neurological disease. Fifty-nine patients (47.6%) underwent endoscopic placement, 59 (47.6%) surgical placement, and 6 (4.8%) laparoscopic-assisted percutaneous endoscopic gastrostomy. Two hundred and two complications were described, including 29 (14.4%) major and 173 (85.6%) minor. Abdominal wall abscess and cellulitis were reported 13 times. Patients who underwent surgical placement presented more complications (major and minor combined) with a statistically significant difference compared with the endoscopic technique. Patients with a concomitant neurological disease had significantly more early complications in the percutaneous group. Patients with malnutrition had significantly more major complications requiring endoscopic or surgical management. Conclusion This study highlights a significant number of major complications or complications requiring additional management under general anesthesia. Children with a concomitant neurological disease or malnutrition are at greater risk of severe and early complications. Infections remain a frequent complication, and prevention strategies should be reviewed.
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Affiliation(s)
- Kaoutar Tazi
- From the Paediatric Gastroenterology Department, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Kallirroi Kotilea
- From the Paediatric Gastroenterology Department, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Martine Dassonville
- Paediatric Surgery Department, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Patrick Bontems
- From the Paediatric Gastroenterology Department, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
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Mårtensson U, Nilsson S, Nolbris MJ, Wijk H, Mellgren K. Pain and discomfort in children with gastrostomy tubes - In the context of hematopoietic stem cell transplantation. J Pediatr Nurs 2023; 70:79-89. [PMID: 36848740 DOI: 10.1016/j.pedn.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 01/05/2023] [Accepted: 02/11/2023] [Indexed: 02/27/2023]
Abstract
BACKGROUND In children with malignant and severe non-malignant disorders undergoing hematopoietic stem cell transplantation (HSCT), treatment related pain and discomfort are common. Food consumption may become troublesome, making the use of a gastrostomy tube (G-tube) necessary and resulting in complications, why the purpose was to explore pain and discomfort during the transplantation and post-transplantation time. METHODS This was a mixed methods study where data were collected along the child's total health-care process between 2018 and 2021. Questions with fixed answer options were used, simultaneously, semi-structured interviews were performed. In total, sixteen families participated. Descriptive statistics and content analysis were used to describe analysed data. FINDINGS Intense pain was common during the post-surgery phase, especially in conjunction with G-tube care, which is why the children needed support to manage the situation. After the post-surgery phase when the skin has healed, most of the children experienced minor to no pain or bodily discomfort, why the G-tube became a well-functioning and supportive tool in daily life. CONCLUSIONS This study describes variations in and experiences of pain and bodily discomfort in conjunction with G-tube insertion in a unique sample of children who had undergone HSCT. In conclusion, the children's comfort in daily life after the post-surgery phase seemed to be only marginally affected by G-tube insertion. Children with severe non-malignant disorders seemed to experience a higher frequency and intensity of pain and bodily discomfort due to the G-tube than children with malignant disorders. PRACTICE IMPLICATIONS The paediatric care team need competence in assessing G-tube related pain and awareness that experiences may differ depending on the child's disorder.
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Affiliation(s)
- Ulrika Mårtensson
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, SE- 405 30 Gothenburg, Sweden.
| | - Stefan Nilsson
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, SE- 405 30 Gothenburg, Sweden; Department of Pediatrics, The Queen Silvia Children's Hospital, Gothenburg, Sweden.
| | - Margaretha Jenholt Nolbris
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, SE- 405 30 Gothenburg, Sweden; Department of Pediatrics, The Queen Silvia Children's Hospital, Gothenburg, Sweden.
| | - Helle Wijk
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, SE- 405 30 Gothenburg, Sweden; Chalmers Technology University, Centre for Health Care Architecture, SE- 405 30 Gothenburg, Sweden.
| | - Karin Mellgren
- Department of Paediatrics, Institute for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SE- 416 85 Gothenburg, Sweden.
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12
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Cone-beam computed tomography-assisted percutaneous gastrostomy tube insertion in children with challenging anatomy. Pediatr Radiol 2023; 53:963-970. [PMID: 36720724 DOI: 10.1007/s00247-023-05593-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/11/2022] [Accepted: 01/10/2023] [Indexed: 02/02/2023]
Abstract
BACKGROUND Percutaneous radiological gastrostomy tube insertion is a common procedure in children. An approach using ultrasound and fluoroscopy may not be feasible in patients with challenging anatomy; therefore, advanced techniques or other imaging modalities may be required. OBJECTIVE To describe our experience using cone-beam computed tomography (CT)-assisted percutaneous gastrostomy insertion in pediatric patients with challenging anatomy. MATERIALS AND METHODS A retrospective review was performed in children who underwent cone-beam CT-assisted percutaneous radiologic gastrostomy between January 2015 and July 2019. Indications, technique, outcomes, complications, and radiation dose (reference-point air kerma, air kerma area product) were assessed through chart and imaging review. Descriptive statistics only were used. RESULTS Twenty-seven procedures were attempted in 26 patients. Reasons for utilizing cone-beam CT guidance were high-positioned stomach (n = 10), interposing bowel loops and liver (n = 19), omphalocele (n = 1), severe scoliosis (n = 1), and ventriculoperitoneal shunt (n = 1). Technical success was 85% (23/27). Mean procedure time was 96 min (range 50-131 min). No safe access route into the stomach was encountered in four patients; three were referred for surgical gastrostomy and one had a successful re-attempt. Radiation dose data was obtained from 19 procedures (17 successful) with a total dose in successful procedures ranging from 8.1 to 63.6 mGy (average 26.2 mGy, median 24.9 mGy). The number of cone-beam CT acquisitions per procedure ranged from 1 to 4. Major complication frequency was 11% (3/27) (bleeding, peritonitis, and aspiration pneumonia); minor complication frequency was 3.7% (1/27). CONCLUSION This study shows that cone-beam CT guidance can be useful for assisting percutaneous radiologic gastrostomy in children with challenging anatomy.
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13
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Percutaneous endoscopic gastrostomy tube placement via the introducer technique is safe and effective in children when compared to the laparoscopic technique. Pediatr Surg Int 2022; 38:2005-2011. [PMID: 36161356 DOI: 10.1007/s00383-022-05247-3] [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] [Accepted: 09/15/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE We compare our experience of percutaneous endoscopic gastrostomy, introducer technique (PEG) and laparoscopic technique (LapGT) at a tertiary care pediatric hospital. METHODS Isolated PEGs and LapGTs placements were reviewed at our institution from August 2016 through January 2018. Demographics, procedure time, operative charges, and 30-day complications were reviewed. Means of quantitative values were compared using the student's t test. Categorical values were compared using the X2 test. RESULTS Ninety-three isolated gastrostomy tubes were placed in children aged 2 weeks to 19 years. There were 56 PEGs (60%) and 37 LapGTs (40%), based on surgeon preference. There was no significant difference in demographics between the two groups. Mean operative time for PEG was 59% shorter (14 vs. 33 min, p < 0.001). Operating room charges averaged $4500 less in the PEG group ($11,400 vs. $15,900, p < 0.001). Neither group had complications that required a return to the operating room within 30 days postoperatively. There was no difference in the rate of fundoplication after gastrostomy tube placement. In two cases PEGs were converted to LapGTs after safety criteria for PEG were not met. CONCLUSION The PEG introducer technique, when used with clearly defined safety criteria, decreased operative time and cost without compromising safety. LEVEL OF EVIDENCE III.
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14
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Outcomes of Gastrostomy Tubes in Newborns With Congenital Heart Disease and Comparison of Techniques. J Surg Res 2022; 280:475-485. [PMID: 36063624 DOI: 10.1016/j.jss.2022.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 06/09/2022] [Accepted: 07/27/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Gastrostomy tube (GT) placement for enteral access is one of the most common procedures for infants with numerous conditions such as congenital heart disease (CHD). Discrepancies in the literature exist regarding outcomes of newborns with CHD undergoing GT placement. This study sought to characterize postoperative outcomes and readmission complications in this patient population. METHODS The Nationwide Readmission Database was queried from 2010 to 2014 for all newborns who underwent GT placement during their index hospitalization. Newborns with or without CHD other than an isolated atrial or ventricular septal defect were compared using standard statistical tests. A propensity score-matched analysis was performed among newborns with or without CHD using > 100 covariates. RESULTS Seven thousand seven hundred thirty six patients underwent GT placement. Newborns with CHD (27%) more frequently underwent open GT (59% versus 55%) and less frequently underwent laparoscopic (17% versus 19%) or percutaneous (24% versus 26%) GT placement compared to those without CHD, P = 0.043. GT-related complications on index admission were similar between groups (7% versus 7%, P = 0.770). Newborns with CHD had higher overall readmission rates (39% versus 31%), more GT-related readmission complications (7% versus 3%), and higher readmission costs ($35,787 versus $20,073) compared to newborns without CHD, all P < 0.001. Laparoscopic GT was associated with the lowest rate of GT-related complications (0%) and overall readmission rates (27%) compared to open or percutaneous endoscopic gastrostomy (all P < 0.001). CONCLUSIONS Compared to newborns without CHD, newborns with CHD had higher rates of overall readmissions, readmission costs, and GT-related complications on readmission. The laparoscopic GT approach was underused despite fewer complications and readmissions.
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Mughal AZ, Subramanian T, Jones R, James D, Ogboli M, Soccorso G. Evaluating the use of laparoscopic-assisted gastrostomy tube feeding in children with epidermolysis bullosa: A single-center retrospective study. J Pediatr Surg 2022; 57:39-44. [PMID: 34876295 DOI: 10.1016/j.jpedsurg.2021.10.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 09/21/2021] [Accepted: 10/31/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Nutritional management of children with epidermolysis bullosa (EB) presents multiple challenges including reduced oral intake compounded by mucosal fragility. Gastrostomy tube feeding is effective in improving nutritional status however there is limited data on the safety and tolerance of this technique in EB children. We aim to review the effectiveness and morbidity of our minimally invasive two-port laparoscopic-assisted gastrostomy (LAG) approach using Seldinger techniques with serial dilatations in children with EB. METHODS A retrospective, observational cohort study was conducted on all consecutive EB patients who underwent LAG tube insertion between 2009 and 2019. Patient demographics, admission details and 12-month clinical outcomes were reported. RESULTS 32 EB patients underwent LAG placement. Median age at insertion was 7.3 (IQR ± 6.3) years, with 8 (25.0%) and 3 (9.4%) of patients also undergoing oesophageal dilatation and fundoplication, respectively. Minor complications arose in 58.1% of patients including: peri-stomal overgranulation (25.8%), gastrostomy infection (22.6%), pain (22.6%), mild gastrostomy leakage (16.1%), blockage (9.7%) and device failure (3.2%). 2 patients (6.5%) developed major complications with extensive gastrostomy site leakage. Improvements in growth were reflected in mean height Z-scores (-1.99 to -1.71). Mean weight Z-scores improved in patients aged 0-10 years (-2.30 to -1.61) and mean BMI Z-scores increased in patients more than 10 years (-2.71 to -1.46). No cases of gastrostomy-related mortality were reported. CONCLUSION LAG is well-tolerated in EB patients with improvements in growth and minimal morbidity 12-months post-gastrostomy insertion. An extended follow-up period is required to ascertain the long-term implications of gastrostomy feeding.
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Affiliation(s)
- Aishah Z Mughal
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom.
| | - Thejasvi Subramanian
- Department of Paediatric Surgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham B4 6NH, United Kingdom
| | - Rosie Jones
- Department of Dietetics, Birmingham Children's Hospital, Steelhouse Lane, Birmingham B4 6NH, United Kingdom
| | - Dawn James
- Department of Dermatology, Birmingham Children's Hospital, Steelhouse Lane, Birmingham B4 6NH, United Kingdom
| | - Malobi Ogboli
- Department of Dermatology, Birmingham Children's Hospital, Steelhouse Lane, Birmingham B4 6NH, United Kingdom
| | - Giampiero Soccorso
- Department of Paediatric Surgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham B4 6NH, United Kingdom
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16
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France DJ, Schremp E, Rhodes EB, Slagle J, Moroz S, Grubb PH, Hatch LD, Shotwell M, Lorinc A, Robinson J, Crankshaw M, Newman T, Weinger MB, Blakely ML. A pilot study to determine the incidence, type, and severity of non-routine events in neonates undergoing gastrostomy tube placement. J Pediatr Surg 2022; 57:1342-1348. [PMID: 34839947 PMCID: PMC9050962 DOI: 10.1016/j.jpedsurg.2021.10.019] [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: 04/30/2021] [Revised: 10/13/2021] [Accepted: 10/20/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Non-routine events (NRE) are defined as any suboptimal occurrences in a process being measured in the opinion of the reporter and comes from the field of human factors engineering. These typically occur well up-stream of an adverse event and NRE measurement has not been applied to the complex context of neonatal surgery. We sought to apply this novel safety event measurement methodology to neonates in the NICU undergoing gastrostomy tube placement. METHODS A prospective pilot study was conducted between November 2016 and August 2020 in the Level IV NICU and the pediatric operating rooms of an urban academic children's hospital to determine the incidence, severity, impact, and contributory factors of clinician-reported non-routine events (NREs, i.e., deviations from optimal care) and 30-day NSQIP occurrences in neonates receiving a G-tube. RESULTS Clinicians reported at least one NRE in 32 of 36 (89%) G-tube cases, averaging 3.0 (Standard deviation: 2.5) NRE reports per case. NSQIP-P review identified 7 cases (19%) with NSQIP-P occurrences and each of these cases had multiple reported NREs. One case in which NREs were not reported was without NSQIP-P occurrences. The odds ratio of having a NSQIP-P occurrence with the presence of an NRE was 0.695 (95% CI 0.06-17.04). CONCLUSION Despite being considered a "simple" operation, >80% of neonatal G-tube placement operations had at least one reported NRE by an operative team member. In this pilot study, NRE occurrence was not significantly associated with the subsequent reporting of an NSQIP-P occurrence. Understanding contributory factors of NREs that occur in neonatal surgery may promote surgical safety efforts and should be evaluated in larger and more diverse populations. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Daniel J. France
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA,Center for Research and Innovation in Systems Safety, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Emma Schremp
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA,Center for Research and Innovation in Systems Safety, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Evan B. Rhodes
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA,Center for Research and Innovation in Systems Safety, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jason Slagle
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA,Center for Research and Innovation in Systems Safety, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sarah Moroz
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA,Center for Research and Innovation in Systems Safety, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Peter H. Grubb
- Department of Pediatrics, Division of Neonatology, University of Utah, Salt Lake City,UT,USA
| | - Leon D. Hatch
- Department of Pediatrics, Division of Neonatology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amanda Lorinc
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA,Center for Research and Innovation in Systems Safety, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jamie Robinson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA,Department of Pediatric Surgery, Monroe Carell Jr. Children’s Hospital at Vanderbilt, TN, USA
| | - Marlee Crankshaw
- Neonatal Intensive Care Unit, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN, USA
| | - Timothy Newman
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA,Center for Research and Innovation in Systems Safety, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew B. Weinger
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA,Center for Research and Innovation in Systems Safety, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Martin L. Blakely
- Department of Pediatric Surgery, Monroe Carell Jr. Children’s Hospital at Vanderbilt, TN, USA
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Dougherty D, Rubalcava NS, Janke OG, Speck KE, Johnson KN, Jarboe MD. Ultrasound-Guided Gastrostomy Tube Placement: An Evaluation of Postoperative Complications in the Pediatric Population. J Laparoendosc Adv Surg Tech A 2022; 32:902-906. [PMID: 35671516 DOI: 10.1089/lap.2021.0752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Using ultrasound guidance has been demonstrated as a feasible alternative method for gastrostomy tube placement in the pediatric population. The aim of this study is to evaluate short- and long-term postoperative complications after ultrasound-guided gastrostomy tube placement (USGTP) and to compare them with complications after laparoscopic gastrostomy tube placement (LGTP). Methods: A retrospective chart review evaluated patients who underwent USGTP (n = 41) and LGTP (n = 120) at the same institution. Comparisons were made between the two groups in the context of demographics as well as 30-day and 6-month postoperative complications. A phone survey (n = 26) further identified USGTP complications potentially not captured in the electronic medical records. Results: There were no significant differences in age, gender, and indication for procedure between the two groups. Chart review revealed that USGTP and LGTP had statistically comparable rates of emergency department (ED) visits for postoperative complications. Among USGTP patients, 8% had a recorded ED visit within 30 days of the operation and 13% presented to the ED within 6 months, compared with 6% and 11%, respectively, in the LGTP group (P = .65, P = .69). The USGTP phone survey reported total complications over an average postoperative follow-up time of 34.6 months (range 8-87) and revealed a total ED visit rate of 35%, which is comparable with rates reported in the literature for minimally invasive feeding tube placement. Conclusion: USGTP is a safe and feasible alternative option for gastrostomy tube placement in the pediatric population and it has postoperative complication rates that are comparable with LGTP.
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Affiliation(s)
- Danielle Dougherty
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Nathan S Rubalcava
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Olivia G Janke
- College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, USA
| | - K Elizabeth Speck
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Kevin N Johnson
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Marcus D Jarboe
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA.,Department of Radiology, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
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18
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Stewart S, Briggs KB, Fraser JA, Dekonenko C, Svetanoff WJ, Rentea RM, Aguayo P, Juang D, Hendrickson RJ, Snyder CL, Peter SDS, Oyetunji TA, Fraser JD. Laparoscopic Gastrostomy in Infants During an Open Abdominal Procedure: A Novel Approach. J Laparoendosc Adv Surg Tech A 2022; 32:1005-1009. [PMID: 35666589 DOI: 10.1089/lap.2022.0117] [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: 11/12/2022] Open
Abstract
Introduction: Infants with intra-abdominal pathology necessitating open abdominal surgery may also require placement of a gastrostomy tube (GT). Use of laparoscopy provides better visualization for gastrostomy placement and lowers the risk of complications compared with an open approach. We describe a series of patients who underwent laparoscopic GT placement at the time of an open abdominal procedure. Methods: All patients who underwent an open abdominal procedure with concurrent laparoscopic gastrostomy from January 2010 to June 2020 were reviewed. Descriptive statistics were performed with categorical variables reported as proportions and continuous variables reported as medians with interquartile range [IQR]. Results: Twelve patients were included; 8 (67.5%) were male. The median age at time of surgery was 10 weeks [IQR 6, 14], with a median weight of 4.1 kg [IQR 3.4, 4.8]. Ten patients had the laparoscope placed through the open incision, whereas 2 had the laparoscope placed through a separate incision. Median operative time was 106 minutes [IQR 80, 125]. There were no intraoperative complications. Postoperative complications included surgical site infection in 5 (41.7%), leaking around the GT in 3 (25%), and malfunction of the tube in 1 (8.3%). One patient required reoperation 28 days postoperatively due to malfunction. Conclusion: Laparoscopic GT can be safely performed at the time of an open abdominal procedure, and frequently through the same incision, harnessing the benefits of a laparoscopic approach even when an open incision is needed.
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Affiliation(s)
- Shai Stewart
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Kayla B Briggs
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - James A Fraser
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Charlene Dekonenko
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Wendy Jo Svetanoff
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Rebecca M Rentea
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Pablo Aguayo
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - David Juang
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | | | - Charles L Snyder
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Tolulope A Oyetunji
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA.,Department of Surgery, Quality Improvement and Surgical Equity Research (QISER) Center, Kansas City, Missouri, USA
| | - Jason D Fraser
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA
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Berman L, Baird R, Sant'Anna A, Rosen R, Petrini M, Cellucci M, Fuchs L, Costa J, Lester J, Stevens J, Morrow M, Jaszczyszyn D, Amaral J, Goldin A. Gastrostomy Tube Use in Pediatrics: A Systematic Review. Pediatrics 2022; 149:186999. [PMID: 35514122 DOI: 10.1542/peds.2021-055213] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/28/2022] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Despite frequency of gastrostomy placement procedures in children, there remains considerable variability in preoperative work-up and procedural technique of gastrostomy placement and a paucity of literature regarding patient-centric outcomes. OBJECTIVES This review summarizes existing literature and provides consensus-driven guidelines for patients throughout the enteral access decision-making process. DATA SOURCES PubMed, Google Scholar, Medline, and Scopus. STUDY SELECTION Included studies were identified through a combination of the search terms "gastrostomy," "g-tube," and "tube feeding" in children. DATA EXTRACTION Relevant data, level of evidence, and risk of bias were extracted from included articles to guide formulation of consensus summaries of the evidence. Meta-analysis was conducted when data afforded a quantitative analysis. EVIDENCE REVIEW Four themes were explored: preoperative nasogastric feeding tube trials, decision-making surrounding enteral access, the role of preoperative imaging, and gastrostomy insertion techniques. Guidelines were generated after evidence review with multidisciplinary stakeholder involvement adhering to GRADE methodology. RESULTS Nearly 900 publications were reviewed, with 58 influencing final recommendations. In total, 17 recommendations are provided, including: (1) tTrial of home nasogastric feeding is safe and should be strongly considered before gastrostomy placement, especially for patients who are likely to learn to eat by mouth; (2) rRoutine contrast studies are not indicated before gastrostomy placement; and (3) lLaparoscopic placement is associated with the best safety profile. LIMITATIONS Recommendations were generated almost exclusively from observational studies and expert opinion, with few studies describing direct comparisons between GT placement and prolonged nasogastric feeding tube trial. CONCLUSIONS Additional patient- and family-centric evidence is needed to understand critical aspects of decision-making surrounding surgically placed enteral access devices for children.
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Affiliation(s)
- Loren Berman
- Departments of Surgery.,Sidney Kimmel Medical School at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Robert Baird
- Department of Pediatric General and Thoracic Surgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ana Sant'Anna
- Department of Pediatrics, Division of Gastroenterology and Nutrition, McGill University Health Center, Montreal, Quebec, Canada
| | - Rachel Rosen
- Aerodigestive Center, Division of Gastroenterology, Boston Children's Hospital, Boston, Massachusetts
| | - Maria Petrini
- Pediatrics.,Sidney Kimmel Medical School at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Michael Cellucci
- Pediatrics.,Sidney Kimmel Medical School at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Lynn Fuchs
- Neonatology.,Sidney Kimmel Medical School at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Joanna Costa
- Neonatology.,Sidney Kimmel Medical School at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jennifer Lester
- Nutrition.,Sidney Kimmel Medical School at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jenny Stevens
- Department of Surgery, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Michele Morrow
- Therapy Services, Nemours Children's Health, Wilmington, Delaware.,Sidney Kimmel Medical School at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Joao Amaral
- Department of Diagnostic Imaging, Division of Interventional Radiology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Adam Goldin
- Department of Surgery, Seattle Children's Hospital, University of Washington, Seattle, Washington
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20
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Lapkus M, DeMare AM, England AL, Akay B, Brahmamdam P. Pediatric Laparoscopic Gastrostomy With T-Fasteners: A Technique to Decrease Surgical Site Infection. Am Surg 2022:31348221101589. [PMID: 35576173 DOI: 10.1177/00031348221101589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Morta Lapkus
- Department of Surgery, 7005Beaumont Health, Royal Oak, MI, USA
| | | | - Angela L England
- Section of Pediatric Surgery, 7005Beaumont Health, Royal Oak, MI, USA
| | - Begum Akay
- Section of Pediatric Surgery, 7005Beaumont Health, Royal Oak, MI, USA.,Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Pavan Brahmamdam
- Section of Pediatric Surgery, 7005Beaumont Health, Royal Oak, MI, USA.,Oakland University William Beaumont School of Medicine, Rochester, MI, USA
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21
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Naji H, Gheewale A, Safi E, Tuma F. Assessing clinical outcomes of modified laparoscopic gastrostomy in children: a case control study. BMC Surg 2022; 22:61. [PMID: 35193601 PMCID: PMC8862243 DOI: 10.1186/s12893-022-01515-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 02/10/2022] [Indexed: 11/10/2022] Open
Abstract
Background With gastrostomy becoming a common surgical procedure within the pediatric population surgeons continued to introduce modifications on the procedure to overcome some of the challenges and minimize complications. Modified U-stitches laparoscopic gastrostomy is gaining favor in some centers including the center of this study. Hence, this study was conducted to evaluate and compare its outcomes. Methods Eighty-nine gastrostomy procedures performed between 2013 and 2020 were reviewed to evaluate the surgical outcomes of a novel modified U-stitches laparoscopic gastrostomy (MLG) to the standard laparoscopic gastrostomy (LG) in children. The main outcome measured is the rate of postoperative complications encompassing dislodgement of gastrostomy button, leak around button, local infection, and development of granulation tissue post-surgery which is compared between the two population groups. Results The rate of leak around the button was found to be significantly less in the MLG (4%) compared to (15%) in the traditional LG approach with a p-value of 0.03. However, the overall complication rate for MGL is 63%; while it is 73% for LG. Conclusions The modified U-stitches laparoscopic gastrostomy has a lower rate of complications in comparison to the standard laparoscopic gastrostomy making it a preferred technique for gastrostomy placement in children.
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Affiliation(s)
- Hussein Naji
- Mediclinic Parkview Hospital, Dubai, UAE.,Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE
| | - Aafia Gheewale
- Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE.
| | - Ebtesam Safi
- Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE
| | - Faiz Tuma
- Central Michigan University College of Medicine, Mount Pleasant, MI, USA.,Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
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22
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Craven MD. Repurposing medical devices as "button" esophagostomy tubes for extended nutritional support. J Vet Intern Med 2021; 36:196-203. [PMID: 34786762 PMCID: PMC8783322 DOI: 10.1111/jvim.16313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 10/29/2021] [Accepted: 11/03/2021] [Indexed: 11/28/2022] Open
Abstract
Background Esophagostomy tubes (E‐tubes) are widely utilized for extended nutritional support in dogs and cats. Problems associated with their use include the unwieldy excess (10‐20 cm) of external tubing, constant need for neck wraps and necessity for skin sutures, suture tract infection, and tube loss if sutures fail. Objectives To evaluate 2 different, low profile (LP) “button” products intended for use in people as enteral (jejunostomy [J] and gastrojejunostomy [G‐J]) feeding tubes for suitability as LP E‐tubes in dogs and cats. Animals A young giant breed dog that required extended (>6 months) nutritional and fluid support during recovery from severe neurological illness with protracted adipsia, anorexia, and dysphagia. Methods Prospective evaluation of 2 commercially available LP feeding devices after placement of a standard E‐tube. An LP J‐tube and an LP G‐J tube were assessed in consecutive 4‐week trials, for tube retention, patient comfort, stoma health, and functionality. Results Both products performed extremely and equally well as LP E‐tubes in this clinical patient, enhancing patient freedom and comfort by eliminating external tubing, skin sutures, and bandaging. The dual port G‐J tube allows medication delivery (eg, sucralfate) to the entire esophagus, but for safety alone (ie, to avoid aspiration), the single port J‐tube appears the best device for client‐owned patients. Conclusions and Clinical Importance The LP enteral feeding tubes from the human medical field can be successfully used as LP E‐tubes in dogs and cats, offering superior patient comfort, with no obvious detriment to the patient and main drawback of higher cost.
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Affiliation(s)
- Melanie D Craven
- Western College of Veterinary Medicine, 52 Campus Dr., Saskatoon, Saskatchewan, S7N 5B4, Canada
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Saberi RA, Gilna GP, Slavin BV, Ribieras AJ, Cioci AC, Urrechaga EM, Parreco JP, Perez EA, Sola JE, Thorson CM. Pediatric Gastrostomy Tube Placement: Less Complications Associated with Laparoscopic Approach. J Laparoendosc Adv Surg Tech A 2021; 31:1376-1383. [PMID: 34748427 DOI: 10.1089/lap.2021.0347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: There are few nationwide studies comparing outcomes of open, laparoscopic (LAP), and percutaneous endoscopic (PEG) gastrostomy tube (GT) placement in the pediatric population. Materials and Methods: The Nationwide Readmissions Database from 2010 to 2014 was used to identify patients ≤18 years (excluding newborns) who underwent GT placement. Demographics, hospital characteristics, and outcomes were compared by the GT approach. Results: There were 3278 patients (41% female, age 3 ± 5 years) identified who underwent GT placement (40% open versus 32% PEG versus 28% LAP). Following an open approach, there were higher rates of GT-related complications (10% versus 4% LAP versus 3% PEG) and postoperative gastrointestinal issues (24% versus 12% LAP versus 9% PEG) on index hospitalization, both P < .001. Readmission within 30 days and 1 year were 18% and 43%, respectively. Overall readmission rates were not affected by the GT approach (44% open versus 44% LAP versus 43% PEG, P = .773). However, readmission for GT-related complications was the lowest following the LAP approach (<0.3% versus 2% open versus 2% PEG, P < .001). When those who also underwent fundoplication were excluded, conversion to gastrojejunostomy or jejunostomy (GJ/J) on readmission was higher following open and PEG approaches (4% open versus 2% PEG versus 0% LAP, P = .039). Conclusions: Compared with PEG gastrostomy and open gastrostomy, LAP GT placement appears to have lower index complications and reoperation rates, and at least comparable readmission outcomes. Despite these advantages, LAP GT placement remains underutilized.
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Affiliation(s)
- Rebecca A Saberi
- Division of Pediatric Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Gareth P Gilna
- Division of Pediatric Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Blaire V Slavin
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Antoine J Ribieras
- Division of Pediatric Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Alessia C Cioci
- Division of Pediatric Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Eva M Urrechaga
- Division of Pediatric Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Joshua P Parreco
- Division of Trauma and Surgical Critical Care, Memorial Regional Hospital, Hollywood, Florida, USA
| | - Eduardo A Perez
- Division of Pediatric Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Juan E Sola
- Division of Pediatric Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Chad M Thorson
- Division of Pediatric Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
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McSweeney ME, Mitchell PD, Smithers CJ, Doherty A, Perkins J, Rosen R. A Retrospective Review of Primary Percutaneous Endoscopic Gastrostomy and Laparoscopic Gastrostomy Tube Placement. J Pediatr Gastroenterol Nutr 2021; 73:586-591. [PMID: 34259651 DOI: 10.1097/mpg.0000000000003236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The laparoscopic-assisted gastrostomy tube placement (LAP) has increasingly become the preferred method for placing gastrostomy tubes in infants and children. The goal of this retrospective review was to examine our institutional experiences with our transition from the percutaneous endoscopic gastrostomy (PEG) procedure to LAP technique. METHODS All patients undergoing primary PEG or LAP gastrostomy at Boston Children's Hospital between January 2010 and June 2015 were identified. The primary aim was to compare complication rates within the first 6 months after tube placement; differences in total hospital procedural costs, hospital resource utilization, and postoperative gastroesophageal reflux disease were examined. RESULTS Nine hundred and eighty-seven patients (442 PEG and 545 LAP gastrostomy tubes) were included. No differences in total complications within 6 months were seen. Patients undergoing PEG placement had more gastrostomy-related complications (PEG 30 [6.7%] vs LAP 13 [2.4%], P = 0.0007) and cellulitis (PEG 23 [5.1%] vs LAP 2 [0.4%], P = 0.03) within the first week of placement. Patients undergoing LAP procedures had more granulation tissue episodes (PEG 19 [4.4%] vs LAP 107 [19.8%], P = 0.005). No differences in emergency room visits, hospital readmissions, or postoperative gastroesophageal reflux disease were seen, although transition to a gastrojejunal tube was higher in patients undergoing LAP procedure (PEG 20 patients [4.6%] vs LAP 51 patients [9.5%], P = 0.0008). CONCLUSIONS Total complications were similar between patients undergoing PEG versus LAP gastrostomy tube placement. Patients with the PEG procedure had more complications within the first week of placement versus patients with the LAP procedure had more granulation skin complications.
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Affiliation(s)
| | - Paul D Mitchell
- Clinical Research Center, Boston Children's Hospital, Boston, MA
| | - C Jason Smithers
- Department of General Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Ashley Doherty
- Information Services, Boston Children's Hospital, Boston, MA
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25
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Demirel BD, Yagiz B, Hancioglu S, Caltepe G. Comparing Different Techniques in Children With or Without a Simultaneous Fundoplication: Does the Gastrostomy Technique Matter? J Laparoendosc Adv Surg Tech A 2021; 31:1067-1072. [PMID: 34525317 DOI: 10.1089/lap.2021.0049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose: To evaluate the results of different gastrostomy techniques and the impact of simultaneous fundoplication. Materials and Methods: The patients who underwent a gastrostomy procedure between 2009 and 2019 in a single tertiary center were evaluated retrospectively. The patients are divided into groups depending on the gastrostomy techniques as open gastrostomy (OG), laparoscopic gastrostomy (LG), percutaneous endoscopic gastrostomy (PEG), and laparoscopy-assisted PEG (LAPEG). Preoperative characteristics and postoperative outcomes are compared among the groups. Results: Two hundred forty-four patients (75, 60, 91, and 18 patients in OG, LG, PEG, and LAPEG groups, respectively) are enrolled in the study. Although rates of minor or major complications did not demonstrate a significant difference among the groups, no major complications were encountered in the LAPEG group, while the lowest minor complications were observed in the PEG group (P > .05). Length of postoperative initiation of enteral feeding and length of hospital stay (LOS) were highest in the OG group (P = .000). Performing a concurrent fundoplication procedure significantly delayed the initiation of enteral feeding and increased the LOS in all of the groups (P < .005). Conclusions: Although PEG is a safe and reproducible technique of gastrostomy in selected patients, LAPEG may expand the boundaries of PEG by reducing the major complication rates. Although simultaneous fundoplication may complicate the perioperative period, it does not have significance on outcomes.
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Affiliation(s)
- Berat Dilek Demirel
- Department of Pediatric Surgery, Ondokuz Mayıs University Medical School, Samsun, Turkey
| | - Beytullah Yagiz
- Department of Pediatric Surgery, Ondokuz Mayıs University Medical School, Samsun, Turkey
| | - Sertac Hancioglu
- Department of Pediatric Surgery, Ondokuz Mayıs University Medical School, Samsun, Turkey
| | - Gonul Caltepe
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Ondokuz Mayıs University Medical School, Samsun, Turkey
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Endoscopic vs laparoscopic paediatric gastrostomies: Time to change our practice? J Pediatr Surg 2021; 56:1317-1321. [PMID: 33933266 DOI: 10.1016/j.jpedsurg.2021.03.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 03/13/2021] [Accepted: 03/25/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Gastrostomy insertion is a common procedure for paediatric surgeons, with the percutaneous endoscopic gastrostomy (PEG) technique long favoured for its simplicity and speed. However, there is growing evidence to suggest that primary laparoscopic balloon gastrostomy (LBG) insertions may have lower complication rates. This study aimed to determine the relative safety and healthcare resource burden of PEG and LBG. METHODS A retrospective review of all primary gastrostomy insertions (2011-2019). Primary outcome measures included return to theatre for emergency laparotomy and healthcare burden (total gastrostomy-related admissions, length of stay and total theatre utilisation). RESULTS 338 PEGs and 277 LBGs were inserted with a minimum follow-up period of six months. Following PEG insertion 12/338(3.6%) children required an emergency laparotomy for gastrostomy-related complications. This compared to 2/277(0.7%) following LBG insertion (ARR2.8% (95%CI0.6-5.0), p < 0.0267). When considering all gastrostomy related admissions, there was no significant difference in total theatre utilisation (PEG = 85 [IQR58-117] minutes, LBG = 86 [IQR75-105] minutes, p = 0.12). However, PEGs were found to have an overall longer length of stay 4 [IQR3-7] vs 3 [IQR2-4] days. CONCLUSIONS LBGs carry a significantly lower rate of major complications and are not associated with an increased healthcare burden. LBG should be considered as the first line method of gastrostomy insertion in children.
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27
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Optimal management of gastrojejunal tube in the ENFit era - Interventions that changed practice. J Pediatr Surg 2021; 56:1430-1435. [PMID: 32921428 DOI: 10.1016/j.jpedsurg.2020.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/07/2020] [Accepted: 08/02/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND We experienced a high incidence of jejunal tube (JEJ) displacement in children who underwent percutaneous endoscopic transgastric jejunostomy (PEGJ), ever since the introduction of ENFit connector (2017). METHODS Two interventions were introduced in 2018 - fixative suture to PEGJ ENFit connector, and conversion to balloon transgastric-jejunal feeding device (Balloon GJ) whenever possible. Children receiving PEGJ and Balloon GJ in 2.8 years were categorized into 3 eras: 2016 (pre-ENFit), 2017 (ENFit) and 2018 (interventional), for comparison of complications and sequelae. Kaplan-Meier survival curves with log-rank test (P < 0.05) were applied. RESULTS 100 children underwent 323 JEJ insertions - PEGJ (n = 237), Balloon GJ (n = 86). Complications occurred in 188 JEJs (58%), more frequently with PEGJ than Balloon GJ (69% vs. 29%, P < 0.0005). PEGJ had higher complication/1000-tube-days (6 vs. 0, P < 0.0005). In 2018, complication rate reduced from 76% to 30% (P < 0.0005) owing to effectiveness of PEGJ connector suture application (P = 0.019), and increased utilization of Balloon GJ (16% to 44%, P = 0.005). Balloon GJ showed better JEJ survival (P = 0.019), less morbidity (emergency attendance, X-ray) and greater cost-effectiveness than PEGJ. CONCLUSIONS Balloon GJ had better overall outcomes than PEGJ. Suture application to connector successfully reduced JEJ internal displacement in PEGJ; however, conversion to Balloon GJ should be strongly considered. LEVEL OF EVIDENCE II.
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28
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Evans J, Gardiner B, Green D, Gibson F, O'Connor G, Lanigan J. Systematic review of gastrostomy complications and outcomes in pediatric cancer and bone marrow transplant. Nutr Clin Pract 2021; 36:1185-1197. [PMID: 34245471 DOI: 10.1002/ncp.10724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Nutrition support is essential in children with cancer, including those undergoing bone marrow transplant (BMT), to reduce the risk of malnutrition and associated deleterious outcomes. Enteral nutrition is more commonly provided via nasogastric than gastrostomy tubes because of safety concerns with the latter in immunocompromised children. This systematic review investigated the incidence and type of complications and outcomes in pediatric cancer patients fed by gastrostomy. METHODS Databases were searched for randomized and observational studies investigating the use of any gastrostomy device in children aged <18 years with any cancer diagnosis, including those undergoing BMT. Five cohort and 11 case series studies were included. Owing to clinical heterogeneity, meta-analyses were not performed. RESULTS Quality of evidence varied, with five studies judged at serious risk of bias and poor quality; however, the remaining 11 were considered to range from moderate to good quality. Across studies, 54.6% of children developed one or more complications, of which 76.6% were classified as minor, 23.4% major. The most frequent complications included inflammation (52% of episodes), infection (42.1%), leakage (22.3%), and granuloma (21%). Evidence regarding infection rates in cancer/BMT patients compared with other disease states was inconclusive. Gastrostomy feeding was associated with improvement or stabilization of nutrition status in 77%-92.7% of children. CONCLUSION Gastrostomy feeding in this population is relatively safe and effective in stabilizing or improving nutrition status throughout treatment. Complications are frequent but mostly minor. Placement requires careful consideration of the complications, benefits, nutrition risk and status at diagnosis, and quality of life.
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Affiliation(s)
- James Evans
- Dietetics Department, Great Ormond Street Hospital for Children, London, UK.,University College London Great Ormond Street Institute of Child Health, London, UK
| | - Breeana Gardiner
- Dietetics Department, Great Ormond Street Hospital for Children, London, UK
| | - Dan Green
- Section of Public Health, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Faith Gibson
- School of Health Sciences, University of Surrey, Guildford, Surrey, UK.,Centre for Outcomes and Experience Research in Children's Health, Illness and Disability (ORCHID), Great Ormond Street Hospital for Children, London, UK
| | - Graeme O'Connor
- Dietetics Department, Great Ormond Street Hospital for Children, London, UK.,University College London Great Ormond Street Institute of Child Health, London, UK
| | - Julie Lanigan
- University College London Great Ormond Street Institute of Child Health, London, UK
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29
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Open Primary Button Versus Laparoscopic Percutaneous Endoscopic Gastrostomy: Results From a Case-control Study. J Pediatr Gastroenterol Nutr 2021; 72:e4-e9. [PMID: 32740516 DOI: 10.1097/mpg.0000000000002877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Open primary balloon gastrostomy (PBG) presents a potential alternative to percutaneous endoscopic gastrostomy (PEG) in children as it obviates the need for change under general anaesthetic; however, the complication profile of PBG compared to PEG is not well defined. Previous series comparing the two have been hampered by the groups not being equivalent. Our paediatric surgical centre has offered PBG as an alternative PEG since 2014. We used a matched case-control study to compare outcomes for PBG and PEG. METHODS Patients undergoing PBG were used as "cases" and matched 1:3 by age and diagnosis to patients undergoing PEG, demographics, and clinical data as "controls." Primary outcome was rate of complications classified according to Clavien-Dindo (I-V). Secondary outcomes included time to feed and length of stay. Non-parametric, categorical and multivariate logistic regression analyses were performed. Data here presented as median with interquartile range (IQR). RESULTS We included 140 patients (35 PBG:105 PEG). The 2 groups were comparable for sex, weight at surgery, and follow-up duration. Median operative time was longer for PBG (43 min [IQR 36.5-61.5] vs 27.5 min [18.25-47.75], P < 0.001). Multivariate analysis demonstrated a statistically significant, higher incidence of symptomatic granulation tissue in PBG (10 [29%] vs 6 [6%], P = 0.0008), this remained significant on multivariate analysis (OR 7.56 [2.33-23.5], P = 0.001), no other complication remained significant. The overall complication rate was not statistically different. CONCLUSIONS PBG and PEG have similar overall complication rates; however, PBG appears to have a higher incidence of granulation tissue. This observation must be weighed against the need for further general anaesthetic which is not insignificant in medically complex children.
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30
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Khirallah MG, Bustangi N. Laparoscopic management of persistent gastrocutaneous fistula after feeding gastrostomy appliance removal in children. ANNALS OF PEDIATRIC SURGERY 2020. [DOI: 10.1186/s43159-020-00057-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Feeding gastrostomy is widely used in children that have troubles of swallowing and need to stablish enteral feeding. There are several methods for creation of that stoma. After the children gain their normal ability of swallowing, this tube or appliance is removed. Failure of spontaneous closure of gastrostomy opening after removal of the tube was reported with an incidence of 0.5 to 3.9%. The purpose of authors was to study laparoscopic management of persistent gastrocutaneous fistula after failure of conservative measures.
Results
There were 19 patients, 12 males. Main cause for feeding gastrostomy was neurological. Most feeding gastrostomy tubes were inserted endoscopically. The mean operative time was 57 ± 10.2 min. The mean time of full oral intake was 24 ± 3.5 h. No wound infection had developed. There was no recurrence of fistula after management.
Conclusion
Laparoscopic management of persistent gastrocutaneous fistula is safe, feasible, and associated with no recurrence of fistula.
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31
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Gourishankar A. Indolent complication after percutaneous endoscopic gastrostomy: a case report of gastric fistula. WORLD JOURNAL OF PEDIATRIC SURGERY 2020; 3:e000202. [DOI: 10.1136/wjps-2020-000202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/07/2020] [Accepted: 10/09/2020] [Indexed: 11/03/2022] Open
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Button Gastrostomy Tubes for Pediatric Patients: A Tertiary Care Center Experience. Int J Pediatr 2020; 2020:5286283. [PMID: 33133200 PMCID: PMC7568778 DOI: 10.1155/2020/5286283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/12/2020] [Indexed: 11/25/2022] Open
Abstract
Results Out of 34 patients who underwent gastrostomy tube insertion, 30 patients had their long tube replaced by a button gastrostomy. Majority were males (N = 18, 60%). Prolonged nasogastric tube feeding was the main indication of referral (N = 17, 56%) followed by feed intolerance (N = 6, 17%) and gastroesophageal reflux disease (N = 5, 16%). The main underlying diseases at referral were neurological impairment (N = 19, 63%) and metabolic disorders (N = 4, 13%). There was no significant difference between patients with neurological disorders and other diseases in terms of gender, nationality, or age. Laparotomy with gastrostomy is the main approach used (N = 18, 60%). No reported complications of button tubes in 50% of the patients (N = 15). Conclusions Prolonged nasogastric tube feeding is the main indication of referral for gastrostomy tube insertion. Neurological disorders are the main diagnosis for the cases operated upon. Laparotomy with gastrostomy is the procedure of choice at our center. Majority of patients had no reported complications of button tube replacement. These children are likely to benefit from the button tube with fewer complications.
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33
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Suh CR, Kim W, Eun BL, Shim JO. Percutaneous Endoscopic Gastrostomy and Nutritional Interventions by the Pediatric Nutritional Support Team Improve the Nutritional Status of Neurologically Impaired Children. J Clin Med 2020; 9:jcm9103295. [PMID: 33066538 PMCID: PMC7602143 DOI: 10.3390/jcm9103295] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 10/08/2020] [Accepted: 10/10/2020] [Indexed: 11/18/2022] Open
Abstract
Aim: To evaluate the long-term effects of nutritional improvement following percutaneous endoscopic gastrostomy (PEG) tube feeding stratified by previous feeding method and to assess the impact of underlying muscle tone on the outcomes of the nutritional intervention. Methods: Neurologically impaired children who underwent PEG tube insertion and nutritional intervention provided by a pediatric nutritional support team were enrolled. We measured anthropometric variables, laboratory parameters, and nutritional intake at baseline, 6 months after PEG insertion, and the last visit. We evaluated the percent ideal body weight (PIBW), body mass index (BMI)-for-age z-score, and percentiles and calculated the ratios of calorie intake compared to required requirement (CIR) and protein intake compared to recommended requirement (PIR). Results: The PIBW and BMI-for-age z-score improved during the first 6 months (p = 0.003 and p = 0.005, respectively). The CIR (p = 0.015) and PIR (p = 0.004) increased during the study period. The baseline BMI and PIBW of the previous nasogastric tube feeding group were better than those of the oral feeding group (p = 0.02 and p = 0.03, respectively). The BMI-for-age z-score, PIBW, CIR, and PIR improved in the hypertonic group (p = 0.03, 0.02, 0.03, and 0.01, respectively). Conclusion: PEG tube feeding and active nutritional intervention improved the nutritional status of neurologically impaired children immediately after PEG insertion. The nutritional requirements might vary by the muscle tonicity.
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Affiliation(s)
- Chae-ri Suh
- Department of Pediatrics, Korea University College of Medicine, Korea University Guro Hospital 1, Seoul 08308, Korea; (C.-r.S.); (B.-L.E.)
- Pediatric Nutritional Support Team, Korea University Guro Hospital, Seoul 08308, Korea;
| | - Wonkyung Kim
- Pediatric Nutritional Support Team, Korea University Guro Hospital, Seoul 08308, Korea;
| | - Baik-Lin Eun
- Department of Pediatrics, Korea University College of Medicine, Korea University Guro Hospital 1, Seoul 08308, Korea; (C.-r.S.); (B.-L.E.)
| | - Jung Ok Shim
- Department of Pediatrics, Korea University College of Medicine, Korea University Guro Hospital 1, Seoul 08308, Korea; (C.-r.S.); (B.-L.E.)
- Pediatric Nutritional Support Team, Korea University Guro Hospital, Seoul 08308, Korea;
- Correspondence: ; Tel.: +82-2-2626-3157
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34
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Backman E, Sjögreen L. Gastrostomy tube insertion in children with developmental or acquired disorders: a register-based study. Dev Med Child Neurol 2020; 62:1191-1197. [PMID: 32697341 DOI: 10.1111/dmcn.14634] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/09/2020] [Indexed: 01/10/2023]
Abstract
AIM To describe trends in gastrostomy tube insertion in children with developmental or acquired disorders in Sweden and assess their demographic characteristics. METHOD Children aged 0 to 18 years with gastrostomy tube insertions recorded between 1998 and 2014 were identified in the Swedish National Patient Register. Associations between disorder type and year of surgery, as well as age at surgery, were analysed using linear regression analyses. The association between disorder type and mortality 2 years from gastrostomy tube insertion was also analysed using logistic regression analysis. RESULTS The data for 4112 children (2182 males, 1930 females), with a median age of 2 years (interquartile range=1-8y), were analysed. Children who presented with developmental disorders were the largest group (n=3501, 85%). The most common diagnosis in children with developmental disorders was cerebral palsy (n=165, 4%). In children with acquired disorders, acute lymphoblastic leukaemia (n=117, 3%) was the most common diagnosis. Gastrostomy tube insertions increased from 1998 to 2014, with the greatest increase in children with developmental disorders, who were younger than children with acquired disorders when the gastrostomy tube was first inserted. Age at tube insertion decreased in both groups during the study period. Mortality was higher in children with acquired disorders, suggesting that gastrostomy tube insertion should be part of a palliative care approach. INTERPRETATION Child characteristics differed depending on whether the underlying disorder was developmental or acquired, suggesting a need for clinical health care guidelines related to the specific goals of gastrostomy tube insertion. WHAT THIS PAPER ADDS Gastrostomy tube insertions increased by 140% from 1998 to 2014 in Sweden. The age of children with developmental disorders decreased by 1 month per year during the study period. Children presenting with developmental disorders were younger than children with acquired disorders when the gastrostomy tube was first inserted. Mortality was higher in children with acquired disorders.
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Affiliation(s)
- Ellen Backman
- School of Health and Welfare, Halmstad University, Halmstad, Sweden.,Regional Habilitation Center, Region Halland, Kungsbacka, Sweden
| | - Lotta Sjögreen
- Orofacial Resource Centre for Rare Diseases, Public Dental Service, Mun-H-Center, Gothenburg, Sweden.,Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
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35
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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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Variability in the Method of Gastrostomy Placement in Children. CHILDREN-BASEL 2020; 7:children7060053. [PMID: 32492791 PMCID: PMC7346129 DOI: 10.3390/children7060053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 04/17/2020] [Accepted: 05/28/2020] [Indexed: 11/24/2022]
Abstract
Although gastrostomy placement is one of the most common procedures performed in children, the optimal technique remains unclear. The purpose of this study was to evaluate variability in the method of gastrostomy tube placement in children in the United States. Patients <18 years old undergoing percutaneous endoscopic gastrostomy (PEG) or surgical gastrostomy (SG) (including open or laparoscopic) from 1997 to 2012 were identified using the Kids’ Inpatient Database. Method of gastrostomy placement was evaluated using a multivariable mixed-effects logistic regression model with a random intercept term and a patient-age random-effect term. A total of 67,811 gastrostomy placements were performed during the study period. PEG was used in 36.6% of entries overall and was generally consistent over time. PEG placement was less commonly performed in infants (adjusted odds ratio [aOR] 0.30, 95%CI 0.26–0.33), children at urban hospitals (aOR: 0.38, 95%CI 0.18–0.82), and children cared for at children’s hospitals (aOR 0.57, 95%CI 0.48–0.69) and was more commonly performed in children with private insurance (aOR 1.17, 95%CI 1.09–1.25). Dramatic variability in PEG use was identified between centers, ranging from 0% to 100%. The random intercept and slope terms significantly improved the model, confirming significant center-level variability and increased variability among patients <1 year old. These findings emphasize the need to further evaluate the safest method of gastrostomy placement in children, in particular among the youngest patients in whom practice varies the most.
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37
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Leveraging the Incidence, Burden, and Fiscal Implications of Unplanned Hospital Revisits for the Prioritization of Prevention Efforts in Pediatric Surgery. Ann Surg 2020; 271:191-199. [PMID: 29927779 DOI: 10.1097/sla.0000000000002885] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To characterize procedure-level burden of revisit-associated resource utilization in pediatric surgery with the goal of establishing a prioritization framework for prevention efforts. SUMMARY OF BACKGROUND DATA Unplanned hospital revisits are costly to the health care system and associated with lost productivity on behalf of patients and their families. Limited objective data exist to guide the prioritization of prevention efforts within pediatric surgery. METHODS Using the Pediatric Health Information System (PHIS) database, 30-day unplanned revisits for the 30 most commonly performed pediatric surgical procedures were reviewed from 47 children's hospitals between January 1, 2012 and March 31, 2015. The relative contribution of each procedure to the cumulative burden of revisit-associated length of stay and cost from all procedures was calculated as an estimate of public health relevance if prevention efforts were successfully applied (higher relative contribution = greater potential public health relevance). RESULTS 159,675 index encounters were analyzed with an aggregate 30-day revisit rate of 10.8%. Four procedures contributed more than half of the revisit-associated length of stay burden from all procedures, with the highest relative contributions attributable to complicated appendicitis (18.4%), gastrostomy (13.4%), uncomplicated appendicitis (13.0%), and fundoplication (9.4%). Four procedures contributed more than half of the revisit-associated cost burden from all procedures, with the highest relative contributions attributable to complicated appendicitis (18.8%), gastrostomy (14.6%), fundoplication (10.4%), and uncomplicated appendicitis (10.2%). CONCLUSIONS AND RELEVANCE A small number of procedures account for a disproportionate burden of revisit-associated resource utilization in pediatric surgery. Gastrostomy, fundoplication, and appendectomy should be considered high-priority targets for prevention efforts within pediatric surgery.
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Abstract
BACKGROUND/AIM Percutaneous endoscopic gastrostomy tube (PEG) has replaced the standard open surgical gastrostomy for enteral nutrition. However, several complications were reported, especially in children less than 10 kg. Our objective was to report the outcomes of percutaneous endoscopic gastrostomy in children according to their weight. PATIENTS AND METHODS 163 children had PEG tube insertion in our tertiary referral hospital from January 2007 to March 2019. Patients were divided into two groups according to the weight; group I (less than 10 kg; n = 112) and group II (more than 10 kg; n = 51). Comparisons were made between the two groups for incidence of postoperative complications, the need for reintervention, 30-day, and 1-year mortality. RESULTS There were 51 males (45.5%) in group I and 27 in group II (52.9%) (P = 0.38). The mean weight at the time of endoscopy was 5.9 ± 1.53 and 17.3 ± 8.23 kg and the mean American Society of Anesthesiologists (ASA) score was 2.6 ± 0.67 and 2.43 ± 0.57 in group I and II, respectively (P = 0.101). The most common associated condition was cerebral palsy (50 (44.6%) and 24 (47.1%) in group I and II, respectively; P = 0.77). The mean operative time was 30.28 ± 11.57 min in group I and 33.62 ± 23.36 min in group II (P = 0.221). Skin complications were the most commonly encountered complications of PEG, and 49% (n = 48) required the removal and replacement of the tube under general anesthesia in group I and 41% (n = 21) in group II (P = 0.84). There was no significant difference in the complication between groups. CONCLUSION : PEG is a safe technique in children less than 10 kg, and the complications rate is comparable with older children. The use of positive transillumination and small needle for measuring the distance between the skin and the stomach enhances the safety of the procedure. PEG should be considered in children less than 10 kg who need supportive or continuous enteral nutrition for different reasons.
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Affiliation(s)
- Osama A. Bawazir
- Department of Surgery, Faculty of Medicine in Umm Al-Qura University at Makkah, Makkah, Saudi Arabia,Address for correspondence: Dr. Osama A. Bawazir, Department of Surgery, Faculty of Medicine, Umm Al.Qura University, P.O. Box 715, Makkah 21955, Saudi Arabia. King Faisal Specialist Hospital and Research Centre, Dept. of Surgery, Jeddah, KSA. E-mail: ;
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A simple technique for the management of refractory gastrostomy site complications a technical innovation in gastrostomy tube site revision. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2020. [DOI: 10.1016/j.epsc.2019.101335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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A Case of Laparoscopic-Assisted Percutaneous Endoscopic Gastrostomy (LAPEG) for Gastric Volvulus. Case Rep Med 2019; 2019:3468084. [PMID: 31871462 PMCID: PMC6913307 DOI: 10.1155/2019/3468084] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 08/24/2019] [Accepted: 11/20/2019] [Indexed: 11/18/2022] Open
Abstract
Background Percutaneous endoscopic gastrostomy (PEG) is the standard modality for long-term enteral nutrition for patients with dysphagia. Compared with open gastrostomy, though PEG is an extremely safe procedure with fewer complications, there are severe cases due to anatomical features. For these cases, laparoscopic-assisted percutaneous endoscopic gastrostomy (LAPEG) is the optimal method. Case Presentation A 52-year-old man had a disturbance in swallowing because of cerebral infarction. We attempted PEG under gastrointestinal fiberscope (GIF) and colon fiberscope inspection; however, the procedure was unsuccessful because it was impossible to move the transverse colon downward. We therefore attempted LAPEG to observe the stomach and other organs. Under laparoscopic observation, we diagnosed gastric volvulus, classified as the organo-axial type. For this reason, inserting the tube through the skin was very difficult. We easily corrected the gastric volvulus by using laparoscopic forceps and were finally able to place the PEG tube safely. Discussion Gastric volvulus is rare in clinical practice. The treatment of gastric volvulus depends on whether mucosal ischemia is present. Endoscopic reduction of gastric volvulus is effective for many patients. Surgical treatment should be considered for patients with gastric volvulus that frequently recurs. In our patient, completely inserting the GIF was impossible; therefore, we could not correctly diagnose gastric volvulus. Laparoscopy-assisted PEG is a useful and safe technique for placing a gastrostomy tube in patients presenting with anatomical difficulties. Moreover, in our patient, gastropexy was performed with PEG. Therefore, LAPEG may be used to prevent the recurrence of gastric volvulus. Gastropexy is a useful option in LAPEG. Conclusions Laparoscopy has the advantage of allowing a direct inspection of the stomach while gastrostomy is performed and may reveal complications to PEG insertion. Furthermore, in our patient, gastropexy was performed with PEG.
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Guanà R, Garofalo S, Lonati L, Teruzzi E, Cisarò F, Gennari F. Laparoscopic Repair of a Gastrocolocutaneous Fistula: Percutaneous Endoscopic Gastrostomy Placement Complications in Children. J Laparoendosc Adv Surg Tech A 2019; 30:216-220. [PMID: 31742485 DOI: 10.1089/lap.2019.0517] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Gastrostomy tube placement (G-Tube) is a frequently offered procedure in children with feeding difficulties. Various procedures exist for G-Tube, with the pull technique more commonly used for a percutaneous endoscopic gastrostomy (PEG) in children, considered by many to be the safer approach. Major complications requiring reoperation range from 3% to 5%, depending on the study. In our center, PEG placement is performed by gastrointestinal endoscopists through the pull technique. In the last 5 years, there were 150 procedures, with 15 minor and 3 major complications. We will describe the last 3 cases, plus a fourth PEG placement at another center. Patients and Methods: Patients ranged from 2 to 10 years (median age: 4.5 years). Median weight was 10.7 kg (range: 7-18 kg). Patients were neurologically impaired children, except one with severe nephropathy. Results: Laparoscopic repair with a 3-trocar technique was effective, when the patient's general condition allowed for it. After fistula repair, a new gastrostomy was placed; this step can be performed endoscopically under laparoscopic control (or can be performed completely laparoscopically). Conclusions: In 4 patients, we faced unusual PEG placement complications, due to colon interposition during blind gastric puncture. In those with anatomical deformities or previous surgery, or dealing with toddlers (under 10 kg), we suggest laparoscopic-assisted PEG, or a full laparoscopic gastrostomy to avoid the risk of a major complication.
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Affiliation(s)
- Riccardo Guanà
- Department of Pediatric General Surgery, Regina Margherita Children's Hospital, University Hospital of Health and Science, Turin, Italy
| | - Salvatore Garofalo
- Department of Pediatric General Surgery, Regina Margherita Children's Hospital, University Hospital of Health and Science, Turin, Italy
| | - Luca Lonati
- Department of Pediatric General Surgery, Regina Margherita Children's Hospital, University Hospital of Health and Science, Turin, Italy
| | - Elisabetta Teruzzi
- Department of Pediatric General Surgery, Regina Margherita Children's Hospital, University Hospital of Health and Science, Turin, Italy
| | - Fabio Cisarò
- Department of Pediatric General Surgery, Regina Margherita Children's Hospital, University Hospital of Health and Science, Turin, Italy
| | - Fabrizio Gennari
- Department of Pediatric General Surgery, Regina Margherita Children's Hospital, University Hospital of Health and Science, Turin, Italy
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Hirose R, Shirai T, Yamada T, Nakamura M, Kai H, Inatomi K, Yanagi Y, Iwanaka T, Ishii M, Iwasaki A. Laparoscopic-assisted Stamm-gastrostomy: technical modifications to ease suturing inside the minimal trocar site. Surg Today 2019; 50:783-786. [PMID: 31720827 DOI: 10.1007/s00595-019-01914-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 10/26/2019] [Indexed: 10/25/2022]
Abstract
Laparoscopic gastrostomy tube placement has been increasingly adopted by pediatric surgeons. We herein report our experience with the performance of a laparoscopic-assisted Stamm-operation inside the minimal trocar site without the extension of the trocar site incision or mini-laparotomy. We present some technical modifications that facilitate suturing inside the minimal trocar site. METHODS A retrospective chart review was conducted of cases involving patients who underwent laparoscopic-assisted gastrostomy, using a simple extracorporeal method inside the trocar site from April 1998 to March 2018. RESULTS One hundred five gastrostomy tubes were placed in a laparoscopic-assisted operation. All but two of the cases involved patients with neurological impairment. The mean age was 12.5 years; 28 cases were > 16 years of age. Seventy-five cases underwent gastrostomy during laparoscopic fundoplication. All gastrostomy procedures were completed without intraoperative difficulties; however, 8 cases, which involved a thick abdominal wall, required extension of the trocar site. No cases required conversion to open gastrostomy. No major complications were observed. Two patients developed continuous peristomal cellulitis after surgery, due to the mismatch of the site position and an unsuitable button device size. CONCLUSION We demonstrated that laparoscopic gastrostomy with fully extracorporeal suturing within the trocar site is feasible and beneficial, especially for the most neurologically impaired pediatric cases. Technical modification, changing the order of the process, and suturing technique in the minimal space, made it easier to perform the procedures inside the minimal trocar hole.
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Affiliation(s)
- Ryuichiro Hirose
- Department of General Thoracic, Breast, Pediatric Surgery, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan.
| | - Takeshi Shirai
- Department of General Thoracic, Breast, Pediatric Surgery, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan
| | - Takaharu Yamada
- Department of Pediatrics, Faculty of Medicine, Saga University, 5-1-1 Nabeshima Saga-shi, Saga, 840-8502, Japan
| | - Masatoshi Nakamura
- Pediatric Surgery, Aso Iizuka Hospital, 3-83, Yoshio, Iizuka-shi, Fukuoka, 820-8505, Japan
| | - Hiroki Kai
- Pediatric Surgery, National Hospital Organization Kyushu Medical Center Hospital, 1-8-1 Jigyo-hama, Chuo-ku, Fukuoka, 810-8563, Japan
| | - Kaori Inatomi
- Department of General Thoracic, Breast, Pediatric Surgery, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan
| | - Yusuke Yanagi
- Department of General Thoracic, Breast, Pediatric Surgery, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan
| | - Tsuyoshi Iwanaka
- Department of General Thoracic, Breast, Pediatric Surgery, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan
| | - Minori Ishii
- Department of General Thoracic, Breast, Pediatric Surgery, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan
| | - Akinori Iwasaki
- Department of General Thoracic, Breast, Pediatric Surgery, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan
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Thaker S, Misra MV. A comparison of laparoscopic gastrostomy tubes and percutaneous endoscopic gastrostomy in infants: results from a single institution. J Pediatr Surg 2019; 54:2453-2456. [PMID: 31493884 DOI: 10.1016/j.jpedsurg.2019.06.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 06/21/2019] [Accepted: 06/30/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND/PURPOSE Laparoscopic gastrostomy (LG) and percutaneous endoscopic gastrostomy (PEG) are two common methods for gastrostomy feeding tube placement in children. There have been limited studies evaluating these surgical interventions in infants under 12 months of age. METHODS This study is a retrospective review of 186 patients who underwent either LG or PEG placement over a 5-year period at a single institution. The primary outcome for this study was the complication rate between the two groups. RESULTS Of 186 patients who underwent gastrostomy tube placements, n = 130 patients comprised the PEG cohort, and n = 56 made up the LG cohort. The demographics of the two cohorts were comparable in weight, age, and co-morbidities. The overall complication rate was 29.6% The breakdown of 31.5% complications in the PEG group vs. 25% in the laparoscopic group was not statistically different. However, the PEG group did have significantly more patients who required general anesthetic for additional procedures related to G tube placement. CONCLUSION Laparoscopy and endoscopy are both acceptable options for gastrostomy tube placements in infants. However, this study identifies that PEG placements are associated with significantly increased risk for the need of additional procedures requiring general anesthesia in this patient population.
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Affiliation(s)
- Shefali Thaker
- Department of Pediatric Surgery, Connecticut Children's Medical Center, Hartford, CT, USA.
| | - Meghna V Misra
- Department of Pediatric Surgery, Connecticut Children's Medical Center, Hartford, CT, USA.
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Osei H, Munoz-Abraham AS, Kim JS, Kazmi S, Myint J, Chatoorgoon K, Greenspon J, Fitzpatrick C, Villalona GA. Perioperative Antibiotics Are Independent Predictors for Major Complications in Pediatric Patients Undergoing Gastrostomy Placement. J Laparoendosc Adv Surg Tech A 2019; 29:1259-1263. [DOI: 10.1089/lap.2019.0316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Hector Osei
- Department of Pediatric Surgery, SSM Health Cardinal Glennon Children's Hospital, St. Louis, Missouri
| | | | - Jin Sun Kim
- Department of Surgery, Division of Pediatric Surgery, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Sakina Kazmi
- Department of Surgery, Division of Pediatric Surgery, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Janine Myint
- Department of Surgery, Division of Pediatric Surgery, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Kaveer Chatoorgoon
- Department of Pediatric Surgery, SSM Health Cardinal Glennon Children's Hospital, St. Louis, Missouri
- Department of Surgery, Division of Pediatric Surgery, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Jose Greenspon
- Department of Pediatric Surgery, SSM Health Cardinal Glennon Children's Hospital, St. Louis, Missouri
- Department of Surgery, Division of Pediatric Surgery, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Colleen Fitzpatrick
- Department of Pediatric Surgery, SSM Health Cardinal Glennon Children's Hospital, St. Louis, Missouri
- Department of Surgery, Division of Pediatric Surgery, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Gustavo A. Villalona
- Department of Pediatric Surgery, SSM Health Cardinal Glennon Children's Hospital, St. Louis, Missouri
- Department of Surgery, Division of Pediatric Surgery, Saint Louis University School of Medicine, St. Louis, Missouri
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Kumar AS, Bani Yaghoub M, Rekab K, Hall M, Attard TM. Pediatric multicenter cohort comparison of percutaneous endoscopic and non-endoscopic gastrostomy technique outcomes. J Investig Med 2019; 68:413-418. [PMID: 31562228 DOI: 10.1136/jim-2019-001028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2019] [Indexed: 11/03/2022]
Abstract
Enteral access is one of the mainstays of nutritional support. Several different modalities for gastrostomy placement are established. In pediatrics, however, there is a limited evidence base supporting the choice of 1 modality over the others. We retrospectively compared elective percutaneous endoscopically placed gastrostomy (PEG) with surgical and interventional radiology-placed gastrostomy outcomes using the Pediatric Hospital Inpatient Sample multicenter administrative database (Pediatric Health Information System). Pediatric patients (<18 years) undergoing planned elective gastrostomy (2010-2015) were included. Coded gastrostomy procedure subtype, patient demographic characteristics, chronic comorbidities and subsequent related outcomes, mortality, readmission, length of stay and total cost of admission were analyzed. Univariate analysis differentiated among gastrostomy techniques. The effect of gastrostomy on mortality and 30-day readmission were determined using a forward, stepwise, binary logistic regression. Generalized linear models were used to estimate the effect of gastrostomy type on length of stay and total cost. During the study period, 11,712 children underwent gastrostomy, including PEG (27%). Patients with chronic comorbidities were more, or as likely to undergo non-PEG procedures. Postoperatively, PEG patients were less likely to require mechanical ventilation and total parenteral nutrition (TPN). Gastrostomy type was not predictive of mortality; predictors included non-White race and need for mechanically assisted ventilation. Readmission following gastrostomy was common (29.5%), and more likely in PEG patients (OR 1.31). Predictors of readmission included earlier TPN (OR 1.39), cardiovascular (OR 1.17) and oncology (OR 4.17) comorbidities. Our study suggests that PEG placement entails similar length of stay and cost as in non-PEG gastrostomy. Patients undergoing PEG were less likely to require mechanical ventilation and TPN postoperatively. Mortality is similar in both groups although more likely with specific comorbidities. Racial background appeared to be associated with choice of gastrostomy, length of stay and mortality.
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Affiliation(s)
- Ashwath S Kumar
- Pedaitics, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Majid Bani Yaghoub
- Mathematics and Statistics, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Kamel Rekab
- Mathematics and Statistics, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Thomas Mario Attard
- Gastroenterology, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
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Burman L, Diaz M, Viktorsdóttir MB, Sjövie H, Stenström P, Salö M, Arnbjörnsson EÓ. Wound Infection after Laparoscopic-Assisted Gastrostomy in Infants. Surg J (N Y) 2019; 5:e96-e102. [PMID: 31508490 PMCID: PMC6727022 DOI: 10.1055/s-0039-1696731] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 07/22/2019] [Indexed: 12/21/2022] Open
Abstract
Background
Gastrostomy placement in children is one of the most frequently performed pediatric surgical procedures and laparoscopic-assisted gastrostomy (LAG) is the preferred technique. Wound infection after LAG has become a significant concern due to the emergence of antibiotic resistance. The aim of this study was to describe the frequency of wound infection after LAG in children younger than 2 years of age and to identify the associated risk factors and the bacterial species involved.
Methods
Information about wound infection, results from bacterial cultures, and type of antibiotic treatment used within 30 postoperative days after LAG were compiled for infants who underwent LAG from 2010 to 2017. A retrospective chart review was performed. Data was compiled from charts and from an electronic database containing prospectively collected data. A multivariate logistic analysis was used to explore potential risk factors. Preoperative antibiotic prophylaxis and postoperative local wound care were conducted according to standard procedures.
Results
The 141 included infants underwent surgery at a median age of 10 months (range: 1–24). Thirty-eight (27%) patients had a clinically determined wound infection, bacteria were cultured from 26/38 (69%), and 30/38 (79%) received antibiotic treatment. The median interval from surgery to detection of a clinical wound infection was 14 days (range: 4–30). The most common microbes discovered were skin bacteria
Staphylococcus aureus
or
Streptococcus pyogenes
, but respiratory and intestinal bacteria were also found. Multivariate logistic regression analysis revealed no independent risk factors for infection such as age, gender, or underlying diagnosis.
Conclusion
Infants have a high rate of postoperative clinical wound infection after LAG despite the use of preoperative antibiotic prophylaxis and intense local wound care. Gender, age at operation, and previous diagnoses were not found to be independent risk factors for wound infection.
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Affiliation(s)
- Linnéa Burman
- Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, Pediatric Surgery, Lund, Sweden
| | - Maia Diaz
- Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, Pediatric Surgery, Lund, Sweden
| | - Margrét Brands Viktorsdóttir
- Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, Pediatric Surgery, Lund, Sweden
| | - Helen Sjövie
- Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, Pediatric Surgery, Lund, Sweden
| | - Pernilla Stenström
- Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, Pediatric Surgery, Lund, Sweden
| | - Martin Salö
- Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, Pediatric Surgery, Lund, Sweden
| | - Einar Ólafur Arnbjörnsson
- Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, Pediatric Surgery, Lund, Sweden
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McGrath KH, Hardikar W. Gastrostomy tube use in children with cancer. Pediatr Blood Cancer 2019; 66:e27702. [PMID: 30854790 DOI: 10.1002/pbc.27702] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 02/18/2019] [Accepted: 02/20/2019] [Indexed: 01/14/2023]
Abstract
Children with cancer are at risk of malnutrition, which can impair critical childhood processes of growth and development and contribute to poor health outcomes. Enteral nutrition can effectively ameliorate malnutrition or weight loss in children with cancer; however, published nutrition support algorithms contain minimal specific information on gastrostomy tube use, and current literature is limited. Decisions about gastrostomy tube insertion in children with cancer can be challenging. Consideration of gastrostomy tube insertion is only appropriate in children with long-term dependence on enteral nutrition, particularly when nasogastric tube insertion is predicted or proven to be problematic. Specific indications for patient selection are unclear, and referring clinicians may be unaware of important absolute and relative contraindications. Complications are predominantly minor in nature; however, reported rates are high. Morbidity must be weighed carefully against the need and anticipated duration of enteral nutrition support, and further research in this area is needed.
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Affiliation(s)
- Kathleen H McGrath
- Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital, Melbourne, Australia.,Intestinal Failure and Clinical Nutrition Group, Murdoch Children's Research Institute, Melbourne, Australia
| | - Winita Hardikar
- Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
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Trivić I, Hojsak I. Evaluation and Treatment of Malnutrition and Associated Gastrointestinal Complications in Children with Cerebral Palsy. Pediatr Gastroenterol Hepatol Nutr 2019; 22:122-131. [PMID: 30899688 PMCID: PMC6416384 DOI: 10.5223/pghn.2019.22.2.122] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 12/31/2018] [Indexed: 01/25/2023] Open
Abstract
The majority of children with cerebral palsy (CP) have feeding difficulties and are especially prone to malnutrition. The early involvement of a multidisciplinary team should aim to prevent malnutrition and provide adequate nutritional support. Thorough nutritional assessment, including body composition, should be a prerequisite for the nutritional intervention. As in typically-developed children nutritional support should start with dietary advice and the modification of oral feeding, if safe and acceptable. However, for prolonged feeding, in the presence of unsafe swallowing and inadequate oral intake, enteral nutrition should be promptly initiated and early gastrostomy placement should be evaluated and discussed with parents/caregivers. Gastrointestinal problems (oropharyngeal dysfunction, gastroesophageal disease, and constipation) in children with CP are frequent and should be actively detected and adequately treated as they can further worsen the feeding process and nutritional status.
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Affiliation(s)
- Ivana Trivić
- Referral Center for Pediatric Gastroenterology and Nutrition, Children's Hospital Zagreb, Zagreb, Croatia
| | - Iva Hojsak
- Referral Center for Pediatric Gastroenterology and Nutrition, Children's Hospital Zagreb, Zagreb, Croatia.,University of Zagreb, School of Medicine, Zagreb, Croatia.,Josip Juraj Strossmayer University of Osijek, School of Medicine, Osijek, Croatia
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Caldas ACS, Dias RS, Sousa SDMAD, Teixeira E. Creative and sensitive production of care-educational technology for families of children with gastrostomy. ESCOLA ANNA NERY 2019. [DOI: 10.1590/2177-9465-ean-2018-0144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract Objective: To describe the production process of a care-educational technology for families of children with gastrostomy based on the models of Hildegard Peplau and Paulo Freire. Method: Descriptive and qualitative research, carried out from October 2016 to February 2017 in three health units and a residential unit in São Luís, MA, Brazil. Thirteen family members participated. Were used from the creative method sensitive to dynamic body knowledge, semi-structured interview and observation. Thematic analysis. Results: From the problem situations that emerged from the corpus, the contents of the technology were constructed, and decoding in subtopics. The technology is of the printed type (booklet), titled The child and his gastrostomy: a guide for families and caregivers. Contains 24 pages and nine content topics, with texts and images. Conclusion: Social evidence that favored the production of a technology that is sensitive to reality, which, after being validated, will help families emerged. Implications for practice: The booklet can be used in the teaching and assistance activities of the families.
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Affiliation(s)
| | | | | | - Elizabeth Teixeira
- Universidade do Estado do Amazonas, Brasil; Centro Universitário Luterano de Manaus, Brasil
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Abstract
Systematic reviews (SRs) are a form of research methodology that addresses a specific research question by collecting, appraising and summarising all empirical evidence that fits pre-specified eligibility criteria. Systematic reviews have grown exponentially since their emergence in the late 1970 s as evidence-based medicine permeated medical culture. With several key advantages and limitations inherent to their design, all health care providers should be familiar with their basic structure, how to critically appraise them, and how to incorporate their findings into clinical practice. This review will contextualise systematic reviews within the broader framework of other review types, and outline the steps in conducting or appraising a systematic review. This includes the framing of an appropriate question, the search strategy, appraisal of included studies, as well as synthesis and analysis of the acquired data. A focus on SRs in the context of pediatric surgical practice will be emphasized. A concise primer on meta-analytic techniques is also provided, with resources highlighted for further reading.
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Affiliation(s)
- Robert Baird
- Department of Pediatric General Surgery, University of British Columbia, BCCH - Surgery - Ambulatory Care Bldg, K0-134, 4480 Oak Street, Vancouver, BC V6H 3V4, Canada.
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