Gastrocutaneous fistulae in children - A systematic review and meta-analysis of epidemiology and treatment options

Gastroenterologist's Guide to Gastrostomies

Gastroenterologists are frequently consulted for evaluation feeding tube placement, or for management of complications in an existing feeding tube. Though a frequent topic of consultation for GI Fellows, there are few comprehensive resources for feeding tube placement and troubleshooting available. In this review, we discuss different types of feeding tubes, when each should be considered, and various methods and techniques for placement. Considerations for when one type, method, technique, or specialty may be preferred over the other will be discussed. Additionally, we discuss management of the many complications of indwelling feeding tubes. Our goal is to create a comprehensive review for gastroenterologists to cover clinically relevant questions related to feeding tube placement and management.

Percutaneous endoscopic gastrostomy in children: A tertiary center experience

INTRODUCTION

Percutaneous endoscopic gastrostomy (PEG) is a common procedure in children. The outcomes of PEG could be affected by the associated disease. We aimed to evaluate the outcomes and safety of PEG tube placement in a tertiary care center with special attention to patients with cardiac disease, ventriculoperitoneal (VP) shunt, or peritoneal dialysis (PD) catheter.

METHODS

This retrospective study included 113 pediatric patients who had PEG tube insertion from 2011 to 2021. Eighteen patients (15.93%) had cardiac disease, five patients (4.42%) had PD catheters, and three patients (2.65%) had VP shunt.

RESULTS

The median age was 3 years (interquartile range: 1-6), and females represented 55% of our patients. The weight ranged from 2.57 to 60 kg, and the most common indication for insertion was neurological disease (n = 56; 49.56%). The median operative time was 30 (20-45) minutes. Pneumonia and vomiting were the most frequent complications (n = 20, 17.7%). Thirty-day mortality occurred in four patients (3.54%) and 1-year mortality in 10 patients (8.85%). Nine patients (7.96%) required fundoplication, and four patients (3.53%) had tube removal and reinsertion. There was no association between weight and postoperative complications (odds ratio: 0.97; P = .48). There were no differences in postoperative complications among patients with cardiac diseases, PD catheters, and VP shunts. No complications were reported in patients with VP shunt. One patient with cardiac disease and one patient with PD catheter required fundoplication. Removal and reinsertion were needed in one patient with a PD catheter.

CONCLUSION

PEG is feasible in low-weight infants with a low complication rate. The complication rate is low in patients with VP shunt, PD catheter, and cardiac patients.

An Evaluation of Pediatric Gastrocutaneous Fistula Closure Through the Punch Excision of Epithelized Tract Procedure

BACKGROUND

Persistent gastrocutaneous fistulae frequently complicate gastrostomy tube placement. A minimally invasive technique for tract closure employing balloon catheter retraction and punch excision of the epithelized tract (PEET) was recently reported. We hypothesized the PEET technique of closure would lead to decreased complications without an increased incidence of recurrence.

METHODS

We conducted a single-center retrospective cohort study evaluating children who underwent gastrocutaneous fistula (GCF) closure 1/1/2018-12/31/2021, comparing patients who underwent the PEET procedure to those repaired with layered closure. Procedure duration and outcomes were additionally compared to the 2018-2019 National Surgical Quality Improvement Program (NSQIP) Participant Use File (PUF) database.

RESULTS

Sixty-two children underwent operative GCF closure, including 25 with PEET and 37 traditional layered closure. Procedural time was significantly decreased employing PEET (14 vs 26 minutes, P < .0001), less than half the national median by the NSQIP PUF database of 292 GCF closures (14 vs 34.5 minutes, P < .0001). Those repaired with the PEET method experienced no episodes of recurrence, surgical site infection, readmission, reoperation, or mortality within 30 days of the procedure. Conversely, in traditional closure, there was a 24.3% complication rate, including 7 surgical site infections, 1 readmission, and 2 unplanned reoperations. National procedural complication rate by NSQIP PUF was 5.5%, with a 4.8% rate of surgical site infection, .3% reoperation incidence, and .3% mortality.

DISCUSSION

Our study suggests GCF closure employing the PEET procedure is a safe, more efficient method of tract closure than the traditional layered closure technique.

The PEET procedure: Punch Excision of Epithelialized Tracts for gastrocutaneous fistula closure

BACKGROUND

Persistent Gastrocutaneous Fistula (GCF) is common problem encountered in the pediatric population. Several management options for intervening on pediatric persistent GCF have been described and range from open surgical management to medical management. Here we describe a novel adaptation on a previously described technique that utilizes a punch biopsy to excise the GCF we have coined as Punch Excision of Epithelialized Tracts (PEET).

METHODS

The steps to this procedure include passing a punch biopsy tool over a Foley catheter. The catheter is inserted into the GCF tract, the balloon is inflated, the catheter is retracted against the abdominal wall, and the punch biopsy instrument is pushed through the skin and subcutaneous tissue circumferentially excising the tract.

RESULTS

Four patients at our institution have undergone GCF excision using the PEET approach. Mean duration of the GCF in our four patients was 9 months. Mean follow-up after GCF excision using the PEET approach was 7.8 months. No patients in the cohort had any post-operative complications including surgical site wound infection, emergency department visits, or re-hospitalizations related to their surgical care.

CONCLUSION

Based on our preliminary findings in this small patient cohort, we believe the PEET approach for managing persistent pediatric GCF has short-term efficacy and has the potential upside of utilizing fewer hospital resources to perform the procedure in a time-efficient manner.

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.

Prevention and management of major complications in percutaneous endoscopic gastrostomy

Background

Percutaneous endoscopic gastrostomy is a commonly used endoscopic technique where a tube is placed through the abdominal wall mainly to administer fluids, drugs and/or enteral nutrition. Several placement techniques are described in the literature with the ‘pull’ technique (Ponsky-Gardener) as the most popular one. Independent of the method used, placement includes a ‘blind’ perforation of the stomach through a small acute surgical abdominal wound. It is a generally safe technique with only few major complications. Nevertheless these complications can be sometimes life-threatening or generate serious morbidity.

Method

A narrative review of the literature of major complications in percutaneous endoscopic gastrostomy.

Results

This review was written from a clinical viewpoint focusing on prevention and management of major complications and documented scientific evidence with real cases from more than 20 years of clinical practice.

Conclusions

Major complications are rare but prevention, early recognition and popper management are important.

Subcutaneous Perforation of Recurrent Gastric Fistula After Abdominoplasty with Scar Revision

This case represents an unusual, and previously unreported, complication of delayed leakage of gastric contents into the subcutaneous tissues 2 years after division of a gastrostomy tube tract during abdominoplasty. Our patient required urgent exploration for contamination control and closure of the fistula and recovered fully. Persistent gastrocutaneous fistula is uncommon in adults and even less common is recannulization of a fistula track after initial closure. A thorough review of operative history and comparison to previous imaging were crucial for appropriate diagnosis and operative planning. Formal closure of gastrostomy tube sites during scar revision and abdominoplasty may help prevent the complication of delayed gastrostomy tube tract rupture into the subcutaneous tissues.

Displaced Gastrostomy Tube in the Pediatric Emergency Department: Implementing an Evidence-based Algorithm and Quality Improvement Project

INTRODUCTION

ED visits for gastrostomy tube-related complications are common, and many are related to tube displacement. Evidence-based practices can provide standardized care.

METHODS

This study was an evidence-based project to develop and implement an algorithm for the care of patients with a displaced gastrostomy tube in the emergency department. Providers were educated on the algorithm, and clinical practice change was evaluated. Provider knowledge was assessed using pretest and posttest; analyses included paired t test. Descriptive statistics of electronic medical record data on confirmation method, documentation, and referral were reported.

RESULTS

Provider knowledge was improved after the education (n = 22; t₍₂₁₎ = -3.80; P = 0.001). After the education, procedure notes were used and completed in 95% of the cases. Appropriate use of the confirmation method was present in 95% of the cases, and all cases were referred to the gastrostomy/specialty clinic.

DISCUSSION

Educating providers regarding care for displaced gastrostomy tubes increased their knowledge. A standardized algorithm improved care by decreasing the use of contrast studies, improving documentation, and referring patients to the gastrostomy/specialty clinic. This evidence-based algorithm offered health care providers a protocol to ensure consistent care for children in the emergency department and support for families.

Feeding Outcomes in Neonates With Trisomy 21 and Duodenal Atresia

BACKGROUND

Duodenal atresia (DA), a common cause of congenital duodenal obstruction, is associated with trisomy 21. The postoperative feeding issues are not well described in this population. We hypothesize that the combination of DA and trisomy 21 is associated with the need for postoperative enteral feeding access.

METHODS

A retrospective cohort of patients between 2010 and 2017 with the diagnosis of DA or duodenal stenosis was identified. Relevant prenatal and postnatal clinical data were abstracted. Univariate analyses were performed.

RESULTS

Forty-three patients were identified. Nineteen patients (44%) were diagnosed with trisomy 21. Eight patients (25% with trisomy 21) had gastrostomy placed at the time of DA repair. In the remaining patients (n = 35), 40% ultimately had a gastrostomy button placed. The indications for placement included poor oral skills (n = 8), aspiration (n = 5), and failure to thrive (n = 1). All these patients had trisomy 21, resulting in 82.4% of trisomy 21 patients having a gastrostomy. There was a significant association between trisomy 21 and placement of a gastrostomy button both during index admission (P = 0.003) and lifetime (P < 0.001). All trisomy 21 patients with congenital heart disease (n = 9) had a gastrostomy placed versus only five of eight trisomy 21 patients (62.5%) without structural heart disease (P = 0.006).

CONCLUSIONS

Our data suggest that a correlation exists between trisomy 21, structural congenital heart anomalies, DA, and the eventual need for gastrostomy. These data should inform operative planning for this patient population.