Replacing gastrostomy tubes with collapsible bumpers in pediatric patients: Is it safe to "cut" the tube and allow the bumper to pass enterally?

The "cut and push" method of removing percutaneous endoscopic gastrostomy tube is not safe in paediatric patients

PURPOSE

A "cut and push" (CP) approach has been described in the literature for removal of percutaneous endoscopic gastrostomy (PEG) tubes. The aim of this study is to investigate the safety profile of this method in children.

METHOD

Our study included all children who underwent CP procedure for either removal or replacement of Freka PEG tube at our centre between January 2016 and August 2021. Parents contacted to establish if the internal component had been seen in the stools post-procedure. If not seen, a plain film of chest, abdomen and pelvis was arranged followed by computerised tomography (CT) scan. The presence of the internal component as a retained foreign body on imaging was evaluated along with any complication.

RESULTS

Of the 27 patients included, six (22.2%) patients had the internal component seen in the stool. Five (18.5%) patients in total had a retained internal component with three (11.1%) patients had major complications requiring complex surgical interventions, and two (7.4%) patients required endoscopic retrieval.

CONCLUSION

Our study reports more severe complications that required complex surgical interventions compared to the previous studies. We believe that this method of removal is not safe in children and should be abandoned. Also, patients with Down syndrome might be at higher risk of retention and complications.

‘Cut and push’ as an alternative to endoscopic retrieval of PEG type gastrostomy tubes

PURPOSE

Percutaneous Endoscopically placed Gastrostomy (PEG) tubes are frequently used in children. The traditional endoscopic method to remove/change the PEG device requires general anaesthesia in children. A minimally invasive alternative is the 'Cut and Push' method (C&P): avoiding the risks/wait times of general anaesthesia and reducing resource burden. Data regarding the safety/effectiveness of C&P in children are lacking with concerns raised about the possibility of gastrointestinal obstruction.

METHODS

We retrospectively reviewed all cases of PEG removal / change to button in children (< 18 years) between December 2020 and January 2022. Cases were identified from a prospectively maintained database and all cases of C&P included. Parents/carers were asked if the child had suffered any complications following C&P and if flange was visualised in stools.

RESULTS

During the time period, 27 PEGs were either removed or changed to button via C&P. The average waiting time for C&P was 14.29 days, significantly shorter than the minimum 6-month waiting time for elective endoscopy. Our evaluation revealed no complications of C&P at median 70 days (range 25-301). In three cases the flange was visualised in the stool, at 2 days, 3 days and 5 weeks following C&P respectively.

DISCUSSION

These data support the available literature suggesting C&P is an effective means to facilitate minimally invasive and prompt PEG removal/change to button in children. We recommend minimum weight and age parameters for this procedure and further evaluation of the safety and resource implications of this technique.

Percutaneous endoscopic gastrostomy tube replacement after head and neck surgery: A case report

INTRODUCTION

Percutaneous endoscopic gastrostomy (PEG) has been available since the 1980s. Routine replacement is conducted at bedside with relatively few complications. Two replacement methods have come into practice: the percutaneous method and the endoscopic method. The laparoscopic method has recently become favorable in the pediatric population.

PRESENTATION OF CASE

Herein, we describe a situation in which a gastrostomy tube was replaced at bedside on a patient with previous head and neck surgery for lingual cancer. The percutaneous traction method was used, and gastrostomy tube replacement into the gastric lumen could not be confirmed on subsequent imaging. The patient was ultimately taken to surgery for an open procedure where it was discovered that initial PEG placement had traversed the small bowel mesentery en route to the gastric lumen.

DISCUSSION

The PEG tube is not a permanent device and routine exchange every 6-12 months is recommended. The percutaneous method and endoscopic method for gastrostomy tube replacement have both been used routinely, each with their set of complications. A third technique, laparoscopic placement, is the preferred modality in the pediatric population. Advantages are twofold: direct visualization of the stomach, thus eliminating inadvertent hollow viscus injury, and applicability in infants too small to undergo endoscopy necessary for PEG tube placement.

CONCLUSION

Consideration for laparoscopic placement or replacement in the head and neck cancer patient population, in which interval endoscopy is impossible, is thus advocated.

Gastrostomy Tube Use in Pediatrics: A Systematic Review

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.

Percutaneous Endoscopic Gastrostomy in Children: An Update to the ESPGHAN Position Paper

BACKGROUND

The European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) position paper from 2015 on percutaneous endoscopic gastrostomy (PEG) required updating in the light of recent clinical knowledge and data published in medical journals since 2014.

METHODS

A systematic review of medical literature from 2014 to 2020 was carried out. Consensus on the content of the manuscript, including recommendations, was achieved by the authors through electronic and virtual means. The expert opinion of the authors is also expressed in the manuscript when there was a lack of good scientific evidence regarding PEGs in children in the literature.

RESULTS

The authors recommend that the indication for a PEG be individualized, and that the decision for PEG insertion is arrived at by a multidisciplinary team (MDT) having considered all appropriate circumstances. Well timed enteral nutrition is optimal to treat faltering growth to avoid complications of malnutrition and body composition. Timing, device choice and method of insertion is dependent on the local expertise and after due consideration with the MDT and family. Major complications such as inadvertent bowel perforation should be avoided by attention to good technique and by ensuring the appropriate experience of the operating team. Feeding can be initiated as early as 3 hours after tube placement in a stable child with iso-osmolar feeds of standard polymeric formula. Low-profile devices can be inserted initially using the single-stage procedure or after 2-3 months by replacing a standard PEG tube, in those requiring longer-term feeding. Having had a period of non-use and reliance upon oral intake for growth and weight gain-typically 8-12 weeks-a PEG may then safely be removed after due consultation. In the event of non-closure of the fistula the most successful method for closing it, to date, has been a surgical procedure, but the Over-The-Scope-Clip (OTSC) has recently been used with considerable success in this scenario.

CONCLUSIONS

A multidisciplinary approach is mandatory for the best possible treatment of children with PEGs. Morbidity and mortality are minimized through team decisions on indications for insertion, adequate planning and preparation before the procedure, subsequent monitoring of patients, timing of the change to low-profile devices, management of any complications, and optimal timing of removal of the PEG.

Open Primary Button Versus Laparoscopic Percutaneous Endoscopic Gastrostomy: Results From a Case-control Study

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.

Nutritional Outcome in Home Gastrostomy-Fed Children with Chronic Diseases

The aim of the study was to assess the anthropometric outcomes after gastrostomy tube (GT) placement in children with chronic diseases and the influence of primary diagnosis, age, and nutritional support. A longitudinal, multicenter, and prospective study was performed evaluating 65 children with GT feeding and chronic diseases (61.5% with neurological disease). Each child was evaluated three times (at baseline and at 6 and 12 months after GT placement) and the following data was collected: primary diagnosis, age at GT placement, anthropometry, and feeding regime. Repeated measures ANOVA were used to analyze the main effects (intra and intergroup) and the interactions effects on weight gain and linear growth at 6 and 12 months after GT placement. All patients significantly improved their body mass index (BMI)-for-age z-score (p < 0.001) and height-for-age z-score (p < 0.05) after 6 and 12-month of follow-up. BMI gain increased significantly the first 6 months, followed by a plateau, while height followed a linear trend. Children with GT placement before 18 months old experienced an accelerated growth rate during the first 6 months post-GT. This technique showed the effectiveness of GT placement improving nutritional status and growth catch up regardless of their primary diagnosis and the type of nutritional support.

Feeding tubes in children

PURPOSE OF REVIEW

A practical guide to different feeding tubes available for nutritional support in children, focused on indications, placement methods and complications.

RECENT FINDINGS

Enteral nutritional support refers to the delivery of nutrition into the gastrointestinal tract distal to the oesophagus. Different feeding tubes are available for exclusive or supplemental nutritional support in children who are unable to independently sustain their own growth, nutritional and hydration status. Gastric feeding is the first choice; however, jejunal feeding provides a good alternative route in the presence of contraindications or intolerance. Feeding tubes can be short or long term: nasogastric and nasojejunal tubes provide short-term nutrition support, gastrostomy and jejunostomy tubes, long-term enteral feeding. The latter are established surgically through the formation of a stoma, an artificial connection between gastric or jejunal lumen and the abdominal wall, performed either endoscopically (percutaneous endoscopic gastrostomy, percutaneous endoscopic gastrojejunostomy) or surgically (gastrostomy, direct jejunostomy). Awareness of different available options, technical considerations and potential risks will inform the decision-making process for an individual patient to ensure the correct balance between adequate enteral nutritional and unnecessary morbidity.

SUMMARY

Successful administration of nutrition support requires knowledge of the correct indication, route and specific functional details of the appropriate feeding tube.