Complications of laparoscopy-aided gastrostomies in pediatric practice

A precision-designed gastrostomy button securement device

BACKGROUND

Gastrostomy buttons (g-buttons) are commonly placed in children to facilitate weight gain, correct nutritional deficiencies, and provide hydration and/or medication delivery. At our institution, parents are taught to place a gauze sponge under their child's g-button and secure it with strips of tape; however, the g-button still moves in the tract, which delays wound healing and leads to a variety of tract-related complications. We viewed this universal problem as a challenge and a prime opportunity for innovation.

METHODS

In 2016, a pediatric surgeon and a team of graduate engineering students outlined the problem, created a list of design requirements, and began to iterate on a variety of device designs.

RESULTS

Over 400 design ideas were iterated upon to various degrees. The first prototype was studied in a small clinical trial, in which 80% of caregivers reported satisfaction with the design, but 90% noted difficulty connecting the extension feeding tube. A second-generation prototype was developed, which included a reusable lid and disposable base layer. Third- generation prototypes added "edge-grippers" to facilitate attaching the extension tubing, plus pre-cut absorbent, sterile gauze pads to fit around the stem of the g-button. Finally, in 2020, the design was finalized with the addition of a childproof hinge between the lid and base layer.

CONCLUSIONS

An intuitive g-button securement device was created to simplify daily gauze replacement, reduce tract-related complications, and lower the cost of care. A randomized controlled trial comparing the securement device to the "tic-tac-toe" dressing will begin in early 2022 with results available later this year.

Systematic review of gastrostomy complications and outcomes in pediatric cancer and bone marrow transplant

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.

The Effect of Gastrostomy Placement on Gastric Function in Children: a Prospective Cohort Study

BACKGROUND

A gastrostomy placement is frequently performed in pediatric patients who require long-term enteral tube feeding. Unfortunately, postoperative complications such as leakage, feeding intolerance, and gastroesophageal reflux frequently occur. These complications may be due to postoperative gastric dysmotility. Our aim was to evaluate the effect of gastrostomy placement on gastric emptying in children.

METHODS

A prospective study was performed including 50 children undergoing laparoscopic gastrostomy. Before and 3 months after gastrostomy, assessment was performed using the 13C-octanoic acid breath test, 24-h pH monitoring, and reflux symptom questionnaires.

RESULTS

Gastric half-emptying time significantly increased from the 57th to the 79th percentile (p < 0.001) after gastrostomy (p < 0.001). Fifty percent of patients with normal preoperative gastric emptying develop delayed gastric emptying (DGE, P > 95) after gastrostomy (p = 0.01). Most patients (≥75%) with leakage and/or feeding intolerance after gastrostomy had DGE after operation. A decrease in gastric emptying was associated with an increase in esophageal acid exposure time (r = 0.375, p < 0.001).

CONCLUSION

Gastrostomy placement in children causes a significant delay in gastric emptying. Postoperative DGE was associated with gastroesophageal reflux and was found in most patients with postoperative leakage and feeding intolerance. These negative physiologic effects should be taken into account when considering gastrostomy placement in children.

Long-term outcomes of children undergoing video-assisted gastrostomy

PURPOSE

The aims of this study were to assess the short- and long-term complication rates after video-assisted gastrostomy (VAG), the effects of age and gender on long-term complications and the effect of duration of gastrostomy tube retention on the need for gastroraphy when the gastrostomy device was removed.

METHODS

This was a retrospective study of children undergoing VAG at a single institution. Children who died or moved from the area were excluded. The rates of short- and long-term complications developing at 3-6 months or 2 or more years, respectively, were compared.

RESULTS

A total of 170 children were studied, out of a cohort of 303 children. The median age at surgery was 2 years. The median duration of postoperative long-term follow-up was 5 years (2-9 years). The complications at the respective short and long-term follow-ups were as follows: granulation tissue, leakage, infection and vomiting. There were no differences in the short- versus long-term complication rates for gender and age. Children needing gastroraphy had used a gastrostomy device significantly longer compared with children with spontaneous closure.

CONCLUSION

Complications after VAG decrease over time. A longer duration of gastrostomy device retention leads to increased need for gastroraphy.

Enteral tube feeding for individuals with cystic fibrosis: Cystic Fibrosis Foundation evidence-informed guidelines

Nutrition is integral to the care of individuals with cystic fibrosis (CF). Better nutritional status is associated with improved pulmonary function. In some individuals with CF, enteral tube feeding can be useful in achieving optimal nutritional status. Current nutrition guidelines do not include detailed recommendations for enteral tube feeding. The Cystic Fibrosis Foundation convened an expert panel to develop enteral tube feeding recommendations based on a systematic review of the evidence and expert opinion. These guidelines address when to consider enteral tube feeding, assessment of confounding causes of poor nutrition in CF, preparation of the patient for placement of the enteral feeding tube, management of the tube after placement and education about enteral feeding. These recommendations are intended to guide the CF care team, individuals with CF, and their families through the enteral tube feeding process.

A Core Outcome Set for Children With Feeding Tubes and Neurologic Impairment: A Systematic Review

CONTEXT

Uncertainty exists about the impacts of feeding tubes on neurologically impaired children. Core outcome sets (COS) standardize outcome selection, definition, measurement, and reporting.

OBJECTIVE

To synthesize an evidence base of qualitative data on all outcomes selected and/or reported for neurologically impaired children 0 to 18 years living with gastrostomy/gastrojejunostomy tubes.

DATA SOURCES

Medline, Embase, and Cochrane Register databases searched from inception to March 2014.

STUDY SELECTION

Articles examining health outcomes of neurologically impaired children living with feeding tubes.

DATA EXTRACTION

Outcomes were extracted and assigned to modified Outcome Measures in Rheumatology 2.0 Filter core areas; death, life impact, resource use, pathophysiological manifestations, growth and development.

RESULTS

We identified 120 unique outcomes with substantial heterogeneity in definition, measurement, and frequency of selection and/or reporting: "pathophysiological manifestation" outcomes (n = 83) in 79% of articles; "growth and development" outcomes (n = 13) in 55% of articles; "death" outcomes (n = 3) and "life impact" outcomes (n = 17) in 39% and 37% of articles, respectively; "resource use" outcomes (n = 4) in 14%. Weight (50%), gastroesophageal reflux (35%), and site infection (25%) were the most frequently reported outcomes.

LIMITATIONS

We were unable to investigate effect size of outcomes because quantitative data were not collected.

CONCLUSIONS

The paucity of outcomes assessed for life impact, resource use and death hinders meaningful evidence synthesis. A COS could help overcome the current wide heterogeneity in selection and definition. These results will form the basis of a consensus process to produce a final COS.

Guided Transabdominal U-Stitches Gastropexy: A Simplified Technique for Secure Laparoscopic Gastrostomy Tube Insertion

Introduction: Insecure gastropexy, gastric mucosa overgrowth, granulation tissue formation, and a nonhealing gastrostomy are unwanted consequences encountered in the current minimally invasive gastrostomy tube (GT) placement techniques. Aiming to overcome these problems we have developed a simplified laparoscopic-assisted GT insertion (LAG) procedure using guided transabdominal U-stitches (GTU) gastropexy. Materials and Methods: We retrospectively reviewed all LAG cases performed in our institute using the GTU technique. In brief, a curved clamp is inserted intragastrically through the laparoscopic port and guides a needle across the abdominal and gastric walls to exit, then re-enter back, through the port in an out-in-out fashion creating multiple spaced transabdominal U-stitches that are tied over pledgets. Results: Between March 2008 and January 2015, 31 cases had LAG attempted using GTU. Two cases were converted to open procedures for non-LAG-related reasons. The median age of the remaining 29 cases was 37 (range, 0.3-154.9) months. Of those patients, 20 had fundoplication (LAG-Fundo), whereas the remaining 9 had LAG-only. The mean operative times for LAG-Fundo and LAG-only were 148 ± 57.5 minutes and 41 ± 12.4 minutes, respectively. During a median follow-up of 21 (range, 4-81) months we did not encounter any procedure-related mortality, intraabdominal leaks, or bowel injuries. One patient required redo gastropexy due to unplanned early U-stitch removal, and 7 cases had transient external GT leak, granuloma formation, and/or skin infection. Conclusions: GTU can achieve a simple and secure LAG, avoiding the catastrophic complications of intraabdominal leak without the need of special instruments or enlarging the port's wound. Using a smaller wound and intraabdominally placed mucosa helps in minimizing the risk of wound infection and external leak. Transient complications are expected during the earlier phase of the learning curve.

Feeding gastrostomy in children with complex heart disease: when is a fundoplication indicated?

PURPOSE

Malnutrition is common among children with complex heart disease (CHD). Feeding gastrostomies are often used to improve the nutritional status of such patients. Our purpose was to evaluate a cohort of children with CHD following open Stamm gastrostomy without fundoplication.

METHODS

We reviewed all CHD patients who underwent feeding gastrostomy placement from 1/1/2004 to 4/7/2015. Demographic data, cardiac diagnoses, operative details, post-operative complications, and the need for GJ feeding and fundoplication were examined.

RESULTS

Open Stamm gastrostomy was performed in 111 patients. Median age at surgery was 37 weeks (3 weeks-13.7 years); average weight was 5.3 ± 4.9 kg. Thirty-four patients (30 %) experienced a total of 37 minor complications, including tube dislodgement after stoma maturation (20), superficial surgical site infection (13), mechanical failure (3), and bleeding (1). Three patients experienced a major complication (need for return to the OR or peri-operative death <30 days). Three patients required a subsequent fundoplication. Fifty-six surviving patients (62 %) continue gastrostomy feeds, of which 7 (13 %) patients require GJ feeds.

CONCLUSION

Children with CHD tolerate an open Stamm gastrostomy well with minimal major complications. These results support very selective use of fundoplication in infants and children with CHD who require a feeding gastrostomy.

Pre- and postoperative vomiting in children undergoing video-assisted gastrostomy tube placement

Background. The aim of this study was to determine the incidence of pre- and postoperative vomiting in children undergoing a Video-Assisted Gastrostomy (VAG) operation. Patients and Methods. 180 children underwent a VAG operation and were subdivided into groups based on their underlying diagnosis. An anamnesis with respect to vomiting was taken from each of the children's parents before the operation. After the VAG operation, all patients were followed prospectively at one and six months after surgery. All complications including vomiting were documented according to a standardized protocol. Results. Vomiting occurred preoperatively in 51 children (28%). One month after surgery the incidence was 43 (24%) in the same group of children and six months after it was found in 40 (22%). There was a difference in vomiting frequency both pre- and postoperatively between the children in the groups with different diagnoses included in the study. No difference was noted in pre- and postoperative vomiting frequency within each specific diagnosis group. Conclusion. The preoperative vomiting symptoms persisted after the VAG operation. Neurologically impaired children had a higher incidence of vomiting than patients with other diagnoses, a well-known fact, probably due to their underlying diagnosis and not the VAG operation. This information is useful in preoperative counselling.

Preemptive gastrostomy tube placement after Norwood operation

OBJECTIVE

Because infants undergoing a Norwood operation have poor interstage weight gain, we hypothesized that preemptive gastrostomy tube (GT) placement would result in earlier discharge, improved growth, and higher survival to stage 2.

STUDY DESIGN

Records of 74 neonates who underwent a Norwood operation were reviewed until stage 2 palliation. The patients were divided into conventional (n = 43) and preemptive GT groups (n = 31). Data included demographics, cardiac surgery, feeding strategy, length of hospitalization, and mortality.

RESULTS

Transplant-free survival to stage 2 was significantly higher in the preemptive group, but there were no significant differences in survival to discharge after stage 1, length of hospitalization, and weight-for-age z-score at discharge and at stage 2 palliation. In the conventional group, 27 of 43 underwent GT placement, all via laparotomy, 23 with Nissen fundoplication. In the preemptive group, all underwent GT placement (21 laparoscopic, 10 laparotomy), 7 with Nissen fundoplication. A second gastric intervention was performed in 11 of 21 with laparoscopic GT (7 conversion to gastrojejunostomy tube, 4 Nissen fundoplication).

CONCLUSION

Preemptive GT placement is associated with improved survival to stage 2 after a Norwood operation but not with shorter hospitalization or better growth. A thorough gastrointestinal evaluation must be performed before GT placement to avoid additional surgery.

Primary squamous cell carcinoma arising at a gastrostomy tube site

Gastrostomy tubes are commonly used in children with feeding impairment. Postoperative complications such as the formation of granulation tissue are common and represent a type of chronic nonhealing wound. We present a case of a 24-year-old man with no history of malignancy who developed a primary cutaneous squamous cell carcinoma at a long-term gastrostomy tube site.

Laparoscopic Gastrostomy in Children with Congenital Heart Disease

AIM

The aim of this study was to study the type and frequency of complications and change in weight after a laparoscopic gastrostomy procedure in 31 children with congenital heart disease, comparing patient groups of children with univentricular and biventricular circulation, and with completed and uncompleted cardiac surgery.

METHODS

The method used was that of a retrospective study of all 31 children with congenital heart disease who underwent a laparoscopic gastrostomy at our center from 1995 to 2004.

MAIN OUTCOME MEASURES

Postoperative complications and body weight changes during follow-up were the main outcome measures used in this study.

RESULTS

Minor stoma-related problems were common in both groups. Two severe complications requiring an operative intervention occurred in the univentricular circulation group. Weight was normal at birth, low at the time of the gastrostomy procedure, and did not catch up completely during the follow-up period of a mean of 20 months. There were no significant differences regarding mean weight gain between the groups.

CONCLUSIONS

The complication rate after the laparoscopic gastrostomy procedure was higher in our patient group, compared to previously studied children with various diseases. Comparisons regarding mean weight gain between the groups showed no significant differences. The mean weight gain was low, suggesting that the energy expenditure in this patient group of children with severe congenital heart disease may be even higher than previously assumed.

Complications of video-assisted gastrostomy in children with or without a ventriculoperitoneal shunt

The aim of the study was to test the hypothesis that the presence of a ventriculoperitoneal shunt (VPS) influences the frequency of postoperative complications after video-assisted gastrostomy (VAG) in children. When using a power of 80%, a critical value for significance of 5% and an assumed population-based standard deviation of 0.4, it will be required to have a sample size of at least 14 children to show that a difference of 0.6 is significant when using Student's t test for paired samples. Thus, 15 consecutive children with VPSs were included in the present study. All the children had nutritional problems and underwent a VAG operation at a tertiary care university hospital. After the operation, the children were prospectively followed up. Specially trained nurses documented all complications according to a protocol. For the purpose of comparison, we had a control group of neurologically disabled children without VPSs, matched for age and operated with VAG. The children did not present with any serious postoperative intra-abdominal complications or central nervous system infection. There was no significant difference in the frequency of minor complications between the studied group and the control group. This study did not reveal that children with VPSs who undergo a VAG button placement are at high risk for infection and subsequent shunt malfunction. They did not have more postoperative problems than a matched control group of neurologically disabled children.

U-Stitch Laparoscopic Gastrostomy Technique Has a Low Rate of Complications and Allows Primary Button Placement: Experience with 461 Pediatric Procedures

BACKGROUND

Gastrostomy tube placement is among the most common gastrointestinal procedures performed in children. The U-stitch laparoscopic technique allows primary button placement and the advantages of laparoscopy. The purpose of this study was to quantify the completion rate and the occurrence of complications in a large single-institution experience.

MATERIALS AND METHODS

All laparoscopic gastrostomy procedures between April 2000 and May 2005 were reviewed. Complications that required operative treatment or hospital readmission were classified as early (<90 days) or late (> or =90 days).

RESULTS

Laparoscopic gastrostomies were created in 461 patients during the study period with primary buttons being placed in 444 (96%). No procedure-related deaths occurred. Early complications included: reoperation secondary to tube dislodgement in 7 patients (1.5%), herniation of omentum postoperatively in 3 patients (0.6%), and development of granulation tissue or everted gastric mucosa requiring excision in 13 patients (3.2%). Late complications occurred in 8 patients (1.7%), with three (0.7%) requiring revision of the gastrostomy due to local site problems. Five patients (1.1%) had intraperitoneal placement of tubes during attempted replacement after 90 days. Age, infancy, and neurological impairment were not associated with a higher rate of complications.

CONCLUSION

The U-stitch gastrostomy technique is safe and allows primary button placement in infants and children. Its complication rate compares favorably to other reported gastrostomy techniques.

No increase in gastroesophageal reflux after laparoscopic gastrostomy in children

The objective of the study was to assess the influence of a laparoscopic video-assisted gastrostomy on acid gastroesophageal reflux (GER). A prospective uncontrolled study included 23 neurologically disabled children, from 10 months to 15 years of age, all with severe nutritional problems and in need of a gastrostomy. They all had a history of clinical GER problems including vomiting, choking and chest infections. A 24-h pH monitoring was used for a quantitative assessment of GER the day before surgery and 12+/-3 months (7-22 months) postoperatively. The gastrostomy was placed on the anterior wall of the stomach near the lesser curvature. The main outcome measure was the comparison of the pre- and postoperative 24-h pH monitoring and the reflux index (RI), i.e. the percentage of time with pH below 4. The results showed a non-significant reduction of RI from 6.8+/-4.5 preoperatively to 3.7+/-2.0 postoperatively. We conclude that a gastrostomy using the video-assisted technique and placing the stoma on the anterior wall of the stomach close to the lesser curvature does not cause aggravation of acid reflux.

Complications of video-assisted gastrostomy in children with malignancies or neurological diseases

AIM

To test the hypothesis whether the administration of cytostatic drugs close to surgery in children with malignancies influences the rate of postoperative complications.

METHOD

Included in the study were 27 children with malignancies and a control group of 27 neurologically impaired children. All the children had nutritional problems and underwent a video-assisted gastrostomy (VAG) operation during the period 1997-2002. The children were postoperatively followed up. All complications were documented according to a protocol by a specially trained nurse and correlated to the time elapsed from completion of the last preoperative or the first postoperative cytostatic drug treatment. The complications in the two groups were compared.

RESULTS

The children with malignant diseases did not have more postoperative complications of the VAG than those having neurological defects. There was no correlation to complications regarding timing of the operation and administration of cytostatic drugs.

CONCLUSION

This study revealed no aggravated influence of cytostatic drug treatment on early postoperative problems of VAG. The timing of cytostatic drug administration in relation to the surgical intervention did not influence the frequency of postoperative complications.

Video-assisted gastrostomy in infants less than 1 year

The objectives of this study were to report our experience with the laparoscopic video-assisted gastrostomy technique in infants operated during their first year of life. A total of 53 infants (35 males, 18 females) aged 6 +/- 3 months, varying from 3 weeks to 11 months, underwent video-assisted gastrostomy. They were prospectively followed up. Included are infants with neurological dysfunction, chromosomal anomalies, metabolic disorders, cardiac anomalies or respiratory insufficiency. All the infants were operated under general and local anaesthesia. Gastrostomy tube feeding began within 4 h after the operation. The infants were followed with a scheduled control at 1 and 6 months postoperatively documenting complications and weight gain. The main outcome measure was the number and type of complications as well as weight gain using the age-adjusted Z-score of weight to normalize the data relative to a reference population. The weight before and 6 months after the video-assisted gastrostomy was 5.5 +/- 1.6 and 8.5 +/- 1.6 kg, respectively. The Z-score increased significantly (P < 0.001) from -2.7+/-1.5 to -1.7 +/- 1.0. This illustrates the postoperative weight gain and catch-up. Short and long-term complications included minor local wound infection, leakage around the gastrostomy tube and granuloma, but no severe complications. Our results encourage the use of video-assisted gastrostomy as a safe technique to provide a route for long-term nutritional support even in infants less than 1 year.

Closure after gastrostomy button

A gastrostomy device is removed from the gastrostoma when no longer needed. The aim of the study was to test the hypothesis of whether it is possible for the surgeon to decide which stoma has to be closed with a gastroraphy and which to leave for a spontaneous closure within a reasonable period of time. Out of a cohort of 321 patients, who had been operated with a video-assisted gastrostomy, we included all the 48 patients having had their gastrostomy button removed. These patients were carefully followed and the closure of the gastrostoma was registered. According to the institutional routine we waited at least 3 months after the removal of the gastrostomy device before suggesting to the child's guardians an operative closure of the stoma. In 26 patients the stoma closed within 3 months, whereas in 22 patients a surgical gastroraphy was performed. We found no differences between the two groups regarding the patients' diagnoses, the duration of the gastrostoma use or patient's age at the time of removal of the gastrostomy device. This study rejected the hypothesis of predictability of the gastrostoma closure. Thus, we recommend a routine expectance after the removal of a gastrostomy device for at least 1 month. If no spontaneous closure occurs, then a gastroraphy should be performed.

Omentum Herniation at a 2-mm Trocar Site

An infant underwent laparoscopy using a 2-mm trocar for the video optic to achieve a gastrostomy. Two days postoperatively, a trocar-site herniation of the omentum was noted and measured. This suggests that the operating surgeon should consider a secure closure of the wound even after a 2-mm trocar is used in infants.

Gastrostomy revision: incidence and indications

BACKGROUND/PURPOSE

Although quite reliable, gastrostomy may require revision. However, there are no reports in the literature specifically delineating identifiable risk factors or circumstances that lead to gastrostomy revision in children with gastrostomy. The purpose of this report was to determine the rate of revision and correlate any factors that may lead to revision.

METHODS

A retrospective chart review was performed on 1,042 children who underwent gastrostomy at The Children's Hospital, Denver, Colorado, between 1992 and 2002. Charts of children who underwent gastrostomy were reviewed for pertinent clinical factors and compared with those who required gastrostomy revision.

RESULTS

Of the 1,042 children, who had gastrostomies, 67 revisions were required in 61 children (6%). Of the many possible factors that could have had an influence on the revision rate, only fundoplication, percutaneous endoscopic gastrostomy (PEG), migration of the gastrostomy site, and time correlated with the need for gastrostomy revision.

CONCLUSIONS

Parents should be made aware that there is a 6% chance that their child's gastrostomy may need revision and that the need for revision may increase with PEG, initial construction before 18 months of age, and the advancing age of the gastrostomy. Surgeons should avoid placing the gastrostomy near the costal margin, making a large gastrostomy exit tract through the abdominal wall and inserting a gastrostomy into the nutritionally depleted pulmonary stressed neurologically challenged child without first attempting to improve the child's nutritional status.

Analysis of factors affecting the spontaneous closure of a gastrocutaneous fistula

BACKGROUND/PURPOSE

Few reports have documented the rate of persistence of a gastrocutaneous fistula (GCF) after gastrostomy removal or the reason for the persistence of a GCF. The purpose of this report was to analyze a large group of pediatric patients with a persistent GCF to determine the rate of persistence and any factors that correlate with the persistence of a GCF.

METHODS

This was a retrospective review of 1,042 children from The Children's Hospital, Denver, Colorado who had a gastrostomy constructed between 1992 and 2002. The charts of all children with a persistent GCF after gastrostomy catheter removal were analyzed for correlation between 13 clinical parameters and the persistence of a GCF.

RESULTS

There were 150 children with a persistent GCF for an incidence of 34%. Time elapsed between the creation of the GCF and removal of the gastrostomy appliance (< or =8 months versus >8 months) was the only parameter that showed any correlation with persistence of a GCF (P <.05). None of the other parameters studied showed any conclusive correlation with persistence of a GCF.

CONCLUSIONS

Time was the only factor that determined whether a surgically created GCF would persist after removal of a gastrostomy appliance.