Fluoroscopically guided percutaneous gastrostomy in children

Antibiotic prophylaxis for percutaneous endoscopic gastrostomy in pediatric patients: a meta-analysis

PURPOSE

To investigate if Antibiotic Prophylaxis (AP) can prevent wound and/or systemic infection in pediatric patients who underwent Percutaneous Endoscopic Gastrostomy (PEG).

METHODS

PubMed, Embase, and Cochrane databases were searched for Randomized Controlled Trials (RCT) and Observational Studies that compared AP vs. no Intervention (NI) in children submitted to PEG. Odds ratios (OR) with 95% confidence intervals (CI) were pooled with random-effect models. Quality assessment and risk of bias were performed as outlined by Cochrane recommendations.

RESULTS

Four studies, including one RCT, with a total of 568 patients were included, in which 230 (40.5%) individuals received AP. The use of AP during PEG reduced the incidence of systemic infection (OR 0.46; 95% CI 0.24-0.90; p = 0.02; I² = 0). However, no statistical difference was found for wound infection (OR 0.85; 95% CI 0.43-1.69; p = 0.64; I² = 12%) and for the composite outcome of any kind of infection (OR 0.74; 95% CI 0.13-4.06; p = 0.73; I² = 67%).

CONCLUSION

In this pooled analysis of 568 infants who underwent PEG, the use of AP reduced the incidence of systemic infection. Our results were compatible with findings obtained in the adult population. No differences were found regarding wound infection or the composite outcome of any kind of infection.

Double-blind randomized clinical trial of percutaneous endoscopic gastrostomy versus radiologically inserted gastrostomy in children

Background

The aim of this RCT was to determine whether radiologically inserted gastrostomy (RIG) in children is associated with more complications than percutaneous endoscopic gastrostomy (PEG).

Methods

Children at a single tertiary children's hospital requiring a primary gastrostomy were randomized to PEG or RIG. Patients were followed by assessors blinded to the insertion method. Complications were recorded, assigned a severity score, and analysed by zero-inflated Poisson regression analysis on an intention-to-treat basis, adjusting for length of follow-up.

Results

Over a 3-year period, 214 children were randomized (PEG, 107; RIG, 107), of whom 100 received PEG and 96 RIG. There was no significant difference in the number of complications between PEG and RIG groups (P = 0·875), or in the complication score: patients undergoing RIG had a 1·04 (95 per cent c.i. 0·89 to 1·21) times higher complication score than those who underwent PEG (P = 0·597). Only age had an independent significant effect on complication score, with older patients having a 0·97 (0·95 to 1·00) times lower complication score per year.

Conclusion

PEG and RIG are both safe methods of gastrostomy insertion with a low rate of major complications. Registration number: NCT01920438 (http://www.clinicaltrials.gov).

Gastrostomy insertion in children: percutaneous endoscopic or percutaneous image-guided?

BACKGROUND/PURPOSE

Gastrostomy insertion in children can be performed in many ways, but which is the best technique remains uncertain. This study evaluates the outcome of percutaneous endoscopic gastrostomy (PEG) and image-guided gastrostomy (IG).

METHODS

We reviewed children who had either PEG (n = 136) inserted by pediatric surgeons or IG (n = 195) inserted by interventional radiologists in our hospital between May 2004 and July 2008. Gastrostomy-related complications were given scores ranging from 20 for major complications (eg, peritonitis, gastrointestinal bleed, and visceral injury) to 1 for minor (eg, site infection and tube migration), and total score per month of follow-up was calculated per patient.

RESULTS

Conversion to laparoscopic or open gastrostomy was more frequent in PEG versus IG (P = .001). Fewer PEG patients (28%) had complications than did IG (47%) (P = .001). One PEG patient developed a gastrocolic fistula. In the IG group, 2 patients had transverse colon puncture, 1 had intraperitoneal tube detachment, and 1 had upper gastrointestinal bleeding. When scored and adjusted by length of follow-up, PEG had lower scores compared with IG, indicating a better outcome (P = .03). These findings were supported by zero-inflated Poisson regression analysis.

CONCLUSION

Major complications were rare and observed more frequently after IG. Minor complications were observed in both procedures but were significantly less common in PEG.

Complications associated with image-guided gastrostomy and gastrojejunostomy tubes in children

OBJECTIVE

To evaluate the complications associated with the image-guided insertion of gastrostomy (G) and gastrojejunostomy (GJ) tubes in children, performed by the retrograde percutaneous route.

METHODS

A convenience sample of 208 charts of 840 patients recorded as having G and/or GJ tubes placed by the interventional radiology service in a 4-year period (1995-1999) at the Hospital for Sick Children in Toronto, Canada, were selected for review. Complications were categorized as major (including subcutaneous abscess, peritonitis, septicemia, gastrointestinal bleeding, and death) or minor.

RESULTS

In total, 253 tubes (208 G tubes, 41 GJ tubes, 4 G and GJ tubes) were placed in the 208 patients reviewed. The median age at the time of insertion was 15 months (range: 7 days-18 years). The most common diagnostic category was neurologic disease (47%). The main indications for tube insertion were recorded as failure to thrive (57%) and risk of aspiration (47%). Major complications were seen in 5% of patients. Peritonitis was noted in 3%, and there was 1 death related to tube insertion (0.4%). Minor complications were found in 73% of patients, including tube dislodgement (37%), tube leakage (25%), and G-tube site skin infection (25%). GJ tubes had a higher rate than G tubes of obstruction, migration, dislodgement, leakage, and intussusception. Site infection, gastroesophageal reflux, and bleeding from the site were seen less frequently in patients with GJ tubes compared with G tubes.

CONCLUSION

G and GJ tubes placed by the image-guided retrograde percutaneous method are associated with a wide range of complications. The majority of these are minor and are predominantly related to tube maintenance, but major complications, including death, do occur.

Imaging and intervention in the gastrointestinal tract in children

Vascular and interventional techniques have become an integral component of modern pediatric healthcare. Minimally invasive procedures of the gastrointestinal tract now comprise a large part of any active pediatric interventional practice. Magnetic resonance cholangiopancreatography offers a reliable, non-invasive means to evaluate patients with possible pancreatic or biliary pathology. This article reviews treatment of esophageal strictures and placement of gastronomy and gastrojejunostomy tubes and discusses new developments. Placement of percutaneous cecostomy tubes is a relatively new procedure that creatively uses the techniques developed for placement of percutaneous gastronomy tubes. This procedure offers significant benefits and lasting positive lifestyle changes for patients suffering from fecal incontinence. Liver biopsy in high-risk patients can be performed safely using measures designed to significantly decrease the risk of post-biopsy hemorrhage, such as track embolization or the transjugular approach.

Future directions in interventional pediatric radiology

In conclusion, the explosion of interventional radiology and its impact on the pediatric patient have resulted in a completely new approach to the subspecialty of interventional pediatric radiology. The interventional radiologist has become an integral part of the management of patients and has become directly involved in the day-to-day care of patients. The use of interventional MR imaging recently has been described in clinical trial. Open-configuration magnets that allow full access to the patient and are equipped with instrument tracking systems provide an interactive environment in which biopsies, endoscopic procedures, and minimally invasive interventions or surgeries are performed. In addition, thermal ablation and image-based control of energy deposition also can be performed. Among these procedures, noninvasive MR-guided focused ultrasound ablation has the most promising future and may replace some conventional surgery. The merging of new and exciting technologies including MR, ultrasound, CT, and fluoroscopy into an environment in which both surgical and interventional radiologic procedures can be performed with image guidance is the basis of the operating room of the future. The role of the interventional radiologist as both the imager and interventionalist is central to this procedural environment; however, the interventional radiologist must accept all the responsibilities of imaging, therapy, patient care, and associated complications.

Complications and effectiveness of gastrostomy feedings in pediatric cancer patients

PURPOSE

The objective of this study was to assess the complications and efficacy of gastrostomy (GT) feedings in pediatric cancer patients.

PATIENTS AND METHODS

We reviewed the medical records of 33 pediatric cancer patients who received enteral nutrition via a GT.

RESULTS

Median age was 9.4 years (range, 1-19.8 years), and 28 of the 33 patients had solid tumors. Seventeen patients had a significant weight loss (median, 8.5%) and therapy-related weight loss was anticipated in 16 patients. The GT device was placed an average of 5.5 months after diagnosis. Twenty-five patients were fed via a tube and eight via a button device. The tube was placed surgically in 21 cases (including all eight button types) and endoscopically in 12. Nutritional support lasted a median of 9.5 months. One or more complications occurred in 30 patients and were categorized as (a) insertion site reactions (inflammation, 23; infection/colonization, 14; exuberant granulation tissue, 6); (b) mechanical problems (leaking, 3; obstruction, 2; breakage, 1; accidental dislodgement, 2); (c) insertion site bleeding, 8; and (d) feeding intolerance, 12. Only one insertion site cellulitis progressed to a systemic infection. All eight patients with a button GT experienced insertion site complications, with local infection occurring significantly more often in patients with the button than in those with the tube GT. There were no significant associations between insertion technique and type of complication. Twenty-seven patients (82%) achieved or maintained ideal body weight with this intervention.

CONCLUSIONS

GT feeding was associated with minor complications, but permitted effective nutritional support for pediatric cancer patients.

Percutaneous feeding tube placement in pediatric patients: immediate and 30-day results

PURPOSE

To evaluate fluoroscopically guided percutaneous feeding tube placement in pediatric patients.

MATERIALS AND METHODS

Sixty-one procedures were performed. Periprocedural care protocol was changed after patient nine. Forty-eight-hour and 30-day outcomes were assessed.

RESULTS

Almost 97% of procedures were successful. The 48-hour major and minor complication rates were 1.9% and 9.6%, respectively, after the initial nine procedures. Risk factors for early complications were the use of the initial care protocol (P < .01) and patient weight below the 50th percentile (P < .05). Major and minor 30-day complication rates were 8.3% and 12.0%, respectively. Risk factors for delayed complications were placement of a gastrojejunostomy tube rather than a gastrostomy tube (P < .05) and immunosuppression (P < .05).

CONCLUSION

Percutaneous feeding tubes can be placed in children with a high rate of technical success. Optimal results require attention to periprocedural care. Morbidity is common during the first month of tube use.

Gastrostomy button placement through percutaneous gastrostomy tracts created with fluoroscopic guidance: experience in 27 children

PURPOSE

The authors report their experience with skin level (button) gastrostomy placement through radiologically created gastrostomy tracts.

PATIENTS AND METHODS

Fifty-two gastrostomy buttons have been placed in 27 children (average age, 73 months; range, 9-235 months). All buttons were placed through tracts created during earlier fluoroscopically guided percutaneous gastrostomy. Fifteen Bard mushroom-type buttons and 12 MIC-Key balloon-type buttons were initially placed. Patients have been followed up for an average of 13.4 months.

RESULTS

Button placement was successful at the initial attempt in 25 of 27 patients (93%). Tract age at button placement averaged 18.5 weeks. The average tract length measured 3.5 cm (1.7-6.0 cm). Tract rupture and peritoneal leakage occurred in three patients; one patient had the button immediately repositioned without sequela, and the remaining two patients underwent replacement of the gastrostomy tube into the stomach and successful button placement approximately 1 week later. There were no major complications. Minor problems (leak, granulation tissue, valve malfunction, balloon breakage) occurred in 19 patients.

CONCLUSION

Button gastrostomy is a useful alternative to the traditional gastrostomy tube for the pediatric population. Conversion with use of existing radiologically created tracts is possible and safe. Attention to tract integrity and proper button position is required to avoid complications.