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Juviler P, Wegman S, Yousefi-Nooraie R, Erlick MR, Schriefer J, Ellis K, Temple LK, Cupertino AP, Wakeman D. Implementation and Qualitative Analysis of Peer Support for New Pediatric Gastrostomy Tube Families. J Surg Res 2024; 302:92-99. [PMID: 39094261 DOI: 10.1016/j.jss.2024.06.032] [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: 03/08/2024] [Revised: 05/22/2024] [Accepted: 06/22/2024] [Indexed: 08/04/2024]
Abstract
INTRODUCTION Gastrostomy tube (G-tube) insertion in children has frequent complications, including dislodgment and return to the system, which are associated with emotional burden for caregivers. To address these issues, we developed a peer support program for caregivers of children with new G-tubes and aimed to explore program feasibility and acceptability. METHODS The G-tube Buddy Program is a peer support program that pairs an experienced G-tube caregiver with new G-tube caregivers. Between April 2022 and December 2022, seven mentors and 21 mentees participated in the program. Five mentors and ten mentees participated in semi-structured focus groups and interviews. Transcripts were analyzed using both inductive and deductive qualitative methods. RESULTS We identified five prominent domains: peer support relationship dynamics; mentor and mentee-specific factors; determinants of program success; mentor and mentee perception of the program; and suggestions for program improvement. These domains encompassed main themes: support consisted primarily of assistance with daily life and social and emotional support; texting was usually the preferred communication method; mentee satisfaction is rooted in humanness, teaching, and generation of hope; mentors participated due to positive feelings regarding helping new caregivers with financial motivation being less important; and, participants perceived the program as a valuable source of support for new caregivers that complements and expands the reach of care they receive from clinical providers. CONCLUSIONS A peer support model for families with new G-tubes appears feasible and acceptable from participant perspectives. Responses validate the program's potential to add value to the postoperative care of children with G-tubes and will guide program optimization.
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Affiliation(s)
- Peter Juviler
- Department of Surgery, University of Rochester Medical Center, Rochester, New York.
| | - Sarah Wegman
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Reza Yousefi-Nooraie
- Department of Public Health Sciences, University of Rochester, Rochester, New York
| | - Mariah R Erlick
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Jan Schriefer
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, New York
| | - Krystle Ellis
- Golisano Children's Hospital, University of Rochester Medical Center, Rochester, New York
| | - Larissa K Temple
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Ana Paula Cupertino
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Derek Wakeman
- Division of Pediatric Surgery, Department of Surgery, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, New York
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Margol ML, Dantes G, Dutreuil VL, Jahan A, Santore MT, Linden AF. The Association of Social Determinants of Health With Short Term Pediatric Gastrostomy Tube Outcomes. J Surg Res 2024; 296:352-359. [PMID: 38306941 DOI: 10.1016/j.jss.2023.12.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 12/07/2023] [Accepted: 12/29/2023] [Indexed: 02/04/2024]
Abstract
INTRODUCTION Social determinants of health (SDH) have been found to be important contributors to postoperative outcomes, especially those related to procedures that require significant postoperative resources. The association between short-term gastrostomy tube (GT) outcomes and SDH in the pediatric population is unknown. METHODS A retrospective review was performed of all patients less than 18 y old who received a GT between January 2018 and December 2020 at a single institution. Data including demographics, area deprivation index (ADI), and perioperative information were collected. Patient characteristics were compared in those that did and did not have an unexpected emergency department (ED) visit within 6 wk of discharge from GT placement. Statistical analysis was performed using Wilcoxon sum-rank, Chi-squared test, and Fisher's exact test where applicable, and univariable and multivariable logistic regression. RESULTS Of the 541 children who underwent GT placement, 112 (20.7%) returned to the ED within 6 wk postdischarge. In univariable analysis, Black children had 1.64 the odds of an unexpected ED visit compared to White children (95% confidence interval [CI] 1.04-2.60, P = 0.03). When controlling for ethnicity, primary language, insurance, ADI and comorbidities, Black children had 1.80 the odds of an unexpected ED visit compared to White children (95% CI 1.10-2.97, P = 0.02). Final model fit which added a race by ADI interaction term revealed Black children had 2.52 the odds of an unexpected ED visit compared to White children in the low (1-6) ADI group (95% CI 1.41-4.60, P = 0.002). Within advantaged neighborhoods (ADI 1-6), the probability of unplanned ED visits for White children was 17.3% (95%CI 8.9% - 31.1%), which was significantly lower than that for Black children (34.6%, 95% CI 18.8% - 54.7%; P value = 0.006). CONCLUSIONS Race and neighborhood disadvantage can be associated with unexpected ED visits within 6 wk of discharge from GT placement in the pediatric population. For procedures that require significant postdischarge resources it is important to study the effect of SDH on return to the healthcare system as they can be an important driver of disparities in outcomes.
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Affiliation(s)
- Matthew L Margol
- Emory University School of Medicine, Atlanta, Georgia; Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Goeto Dantes
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Valerie L Dutreuil
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Afrin Jahan
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Matthew T Santore
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Allison F Linden
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
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Iantorno SE, Scaife JH, Bryce JR, Yang M, McCrum ML, Bucher BT. Emergency Department Utilization for Pediatric Gastrostomy Tubes Across the United States. J Surg Res 2024; 295:820-826. [PMID: 38160493 DOI: 10.1016/j.jss.2023.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 09/30/2023] [Accepted: 11/12/2023] [Indexed: 01/03/2024]
Abstract
INTRODUCTION Emergency Department (ED) visits for gastrostomy tube complications in children represent a substantial health-care burden, and many ED visits are potentially preventable. The number and nature of ED visits to community hospitals for pediatric gastrostomy tube complications is unknown. METHODS Using the 2019 Nationwide Emergency Department Sample, we performed a retrospective cross-sectional analysis of pediatric patients (<18 y) with a primary diagnosis of gastrostomy tube complication. Our primary outcome was a potentially preventable ED visit, defined as an encounter that did not result in any imaging, procedures, or an inpatient admission. Univariate and multivariable logistic regression analyses were used to determine the associations between patient factors and our primary outcome. RESULTS We observed 32,036 ED visits at 535 hospitals and 15,165 (47.3%) were potentially preventable. The median (interquartile range) age was 2 (1, 6) years and 17,707 (55%) were male. Compared to White patients, patients with higher odds of potentially preventable visits were Black (adjusted odds ratio (aOR) [95% confidence interval {CI}]: 1.07 [1.05-1.11], P < 0.001) and Hispanic (aOR [95% CI]: 1.05 [1.02-1.08], P = 0.004). Patients with residential zip codes in the first (aOR [95% CI]: 1.08 [1.04, 1.12], P < 0.001), second (aOR [95% CI]: 1.07 [1.03, 1.11], P < 0.001), and third (aOR [95% CI]: 1.09 [1.05, 1.13], P < 0.001) median household income quartiles had higher odds of potentially preventable visits compared to the highest. CONCLUSIONS In a nationally representative sample of EDs, 47.3% of visits for pediatric gastrostomy tubes were potentially preventable. Efforts to improve outpatient management are warranted to reduce health-care utilization for these patients.
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Affiliation(s)
- Stephanie E Iantorno
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah.
| | - Jack H Scaife
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jacoby R Bryce
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Meng Yang
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Marta L McCrum
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Brian T Bucher
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
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Borinsky SA, Cameron BA, Xue Z, LaFata S, Kiran A, Ocampo AA, McCallen J, Lee CJ, Redd WD, Cotton CC, Eluri S, Reed CC, Dellon ES. Feeding Tube Placement, Complications, and Treatment Responses in a Large Eosinophilic Esophagitis Patient Population. J Pediatr Gastroenterol Nutr 2023; 77:753-759. [PMID: 37697476 PMCID: PMC11213236 DOI: 10.1097/mpg.0000000000003941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
OBJECTIVES Feeding tubes can provide a temporary or long-term solution for nutritional therapy. Little is known regarding the use of feeding tubes in patients with eosinophilic esophagitis (EoE). We sought to describe the characteristics and outcomes in EoE patients requiring tube feeding. METHODS This was a retrospective cohort study of EoE patients at a large tertiary care health system. Demographics, clinical characteristics, and endoscopic findings were extracted from medical records, and patients who had a feeding tube were identified. Patients with and without a feeding tube were compared. Details about the tube, complications, and treatment were extracted. Growth, global symptomatic, endoscopic, and histopathologic (<15 eos/hpf) responses were compared before and after the initiation of feeding tube therapy. RESULTS We identified 39 of 1216 EoE patients who had a feeding tube (3%). Feeding tube patients were younger (mean age 6.3 years), reported more vomiting, and had a lower total endoscopic reference score than non-feeding tube patients ( P < 0.01 for all). Tubes were used for therapy for an average of 6.8 years, with most patients (95%) receiving both pharmacologic and formula treatment for EoE. An emergency department visit for a tube complication was required in 26%. Tube feeding improved body mass index z score ( P < 0.01), symptomatic response (42%), endoscopic response (53%), and histologic response (71%). CONCLUSIONS Among EoE patients, only a small subset required a feeding tube and predominantly were young children with failure to thrive. Feeding tubes significantly improved growth and, when used in combination with other treatments, led to reduced esophageal eosinophilic inflammation.
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Affiliation(s)
- Stephanie A. Borinsky
- Pediatric Gastroenterology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Brenderia A. Cameron
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Zeyun Xue
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Sean LaFata
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Akshatha Kiran
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Adolfo A. Ocampo
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Justin McCallen
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Christopher J. Lee
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Walker D. Redd
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Cary C. Cotton
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Swathi Eluri
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Craig C. Reed
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
- Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine; University of North Carolina School of Medicine, Chapel Hill, NC
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Stevens J, Reppucci ML, Mironuck T, Nolan MM, Choi YM, Moulton SL. A precision-designed gastrostomy button securement device. J Pediatr Surg 2023; 58:76-81. [PMID: 36283851 DOI: 10.1016/j.jpedsurg.2022.09.025] [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: 09/05/2022] [Accepted: 09/16/2022] [Indexed: 01/12/2023]
Abstract
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.
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Affiliation(s)
- Jenny Stevens
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Marina L Reppucci
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Margo M Nolan
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Young Mee Choi
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Steven L Moulton
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; EZaLife, LLC, Littleton, CO, USA
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6
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Tran NN, Mahdi EM, Ourshalimian S, Sanborn S, Alquiros MT, Kingston P, Lascano D, Herrington C, Votava-Smith JK, Kelley-Quon LI. Factors Associated With Gastrostomy Tube Complications in Infants With Congenital Heart Disease. J Surg Res 2022; 280:273-279. [PMID: 36030602 PMCID: PMC10231870 DOI: 10.1016/j.jss.2022.07.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 07/08/2022] [Accepted: 07/28/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Children with congenital heart disease (CHD) often experience feeding intolerance due to aspiration, inability to tolerate feed volume, or reflux within the first few months of life, requiring a surgically placed gastrostomy tube (GT) for durable enteral access. However, complications such as GT dislodgement, cellulitis, and leakage related to GT use are common. GT-related complications can lead to unscheduled pediatric surgery clinic or emergency room (ER) visits, which can be time consuming for the family and increase overall healthcare costs. We sought to identify factors associated with GT complications within 2 wk after GT surgery and 1-y after discharge home following GT placement in infants with CHD. METHODS We performed a retrospective cohort study using the Society of Thoracic Surgeons database and electronic medical records from a tertiary children's hospital. We identified infants <1 y old underwent CHD surgery followed by GT surgery between September 2013-August 2018. Demographics, pre-operative feeding regimen, comorbidities, and GT-related utilization were measured. Postoperative GT complications (e.g., GT cellulitis, leakage, dislodgement, obstruction, and granulation tissue) within 2 wk after the GT surgery and an unplanned pediatric surgery clinic or ER visit within 1-y after discharge home were captured. Bivariate comparisons and multivariable logistic regression evaluated factors associated with GT complications and unplanned clinic or ER visits. A Kaplan-Meier failure curve examined the timing of ER/clinic visits. RESULTS Of 152 infants who underwent CHD then GT surgeries, 66% (N = 101) had postoperative GT complications. Overall, 83 unscheduled clinic visits were identified after discharge, with 37% (N = 31) due to concerns about granulation tissue. Of 137 ER visits, 48% (N = 66) were due to accidental GT dislodgement. Infants who were hospitalized for ≥2 wk after GT surgery had more complications than those discharged home within 2 wk of the GT surgery (40.6% versus 15.7%, P = 0.002). Infants receiving oral nutrition before CHD surgery (38.6% versus 60%, P=<0.001) or with single ventricle defects (19.8% versus 37.3%, P = 0.02) had fewer GT complications. After adjusting for type of cardiac anomaly, infants receiving oral nutrition prior to CHD surgery had a decreased likelihood of GT complications (odds ratio OR 0.46; 95% confidence intervals CI:0.23-0.93). A Kaplan-Meier failure curve demonstrated that 50% of the cohort experienced a complication leading to an unscheduled ER/clinic visit within 6 mo after discharge. CONCLUSIONS Unplanned visits to the ER or pediatric surgery clinic occur frequently for infants with CHD requiring a surgically placed GT. Oral feedings before cardiac surgery associated with fewer GT complications. Prolonged hospitalization associated with more GT complications. Optimizing outpatient care and family education regarding GT maintenance may reduce unscheduled visits for this high-risk, device-dependent infant population.
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Affiliation(s)
- Nhu N Tran
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, California.
| | - Elaa M Mahdi
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Stephanie Sanborn
- Clinical Nutrition and Lactation Services, Children's Hospital Los Angeles, Los Angeles, California
| | - Maria Theresa Alquiros
- Division of Cardiothoracic Surgery, Children's Hospital Los Angeles, Los Angeles, CA Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Paige Kingston
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Danny Lascano
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Cynthia Herrington
- Division of Cardiothoracic Surgery, Children's Hospital Los Angeles, Los Angeles, CA Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jodie K Votava-Smith
- Division of Cardiology, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California
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Nicholson GT, Goldstein BH, Petit CJ, Qureshi AM, Glatz AC, McCracken CE, Kelleman MS, Meadows JJ, Zampi JD, Shahanavaz S, Mascio CE, Chai PJ, Romano JC, Healan SJ, Pettus JA, Batlivala SP, Raulston JEB, Hock KM, Maskatia SA, Beshish A, Law MA. Impact of Management Strategy on Feeding and Somatic Growth in Neonates with Symptomatic Tetralogy of Fallot: Results from the Congenital Cardiac Research Collaborative. J Pediatr 2022; 250:22-28.e4. [PMID: 35772511 DOI: 10.1016/j.jpeds.2022.06.024] [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: 03/16/2022] [Revised: 06/10/2022] [Accepted: 06/22/2022] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To evaluate early growth following primary or staged repair of neonatal symptomatic tetralogy of Fallot (sTOF). STUDY DESIGN We performed a retrospective, multicenter cohort study of consecutive infants with sTOF who underwent initial intervention at age ≤30 days, from 2005 to 2017. Management strategies were either primary repair or staged repair (ie, initial palliation followed by complete repair). The primary outcome was change in weight-for-age z-score (ΔWAZ) from the initial intervention to age 6 ± 2 months. Secondary outcomes included method and mode of feeding, feeding-related medications, and feeding-related readmissions. Propensity score adjustment was used to account for baseline differences between groups. A secondary analysis was performed comparing patients stratified by the presence of adequate growth (6-month ΔWAZ > -0.5) or inadequate growth (6-month ΔWAZ ≤ -0.5), independent of treatment strategy. RESULTS The study cohort included 143 primary repair subjects and 240 staged repair subjects. Prematurity was more common in the staged repair group. After adjustment, median ΔWAZ did not differ between treatment groups over the first 6 months of life (primary: -0.43 [IQR, -1.17 to 0.50]; staged: -0.31 [IQR, -1.31 to 0.71]; P = .55). For the entire cohort, ΔWAZ was negative (-0.36; IQR, -1.21 to 0.63). There were no between-group differences in the secondary outcomes. Secondary analysis revealed that the subjects with adequate growth were more likely to be orally fed at initial hospital discharge (P = .04). CONCLUSIONS In neonates with sTOF, growth trajectory over the first 6 months of life was substandard, irrespective of treatment strategy. Those patients with adequate growth were more likely to be discharged from the index procedure on oral feeds.
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Affiliation(s)
- George T Nicholson
- Division of Cardiology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN.
| | - Bryan H Goldstein
- The Heart Institute, Cincinnati Children's Hospital Medical Center and Division of Pediatric Cardiology, University of Cincinnati College of Medicine, Cincinnati, OH; Heart Institute, UPMC Children's Hospital of Pittsburgh, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Christopher J Petit
- Children's Heart Center Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA; Morgan Stanley Children's Hospital, Columbia University Vagelos College of Physicians & Surgeons, New York, NY
| | - Athar M Qureshi
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Andrew C Glatz
- The Cardiac Center, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Courtney E McCracken
- Children's Heart Center Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Michael S Kelleman
- Children's Heart Center Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Jeffery J Meadows
- Division of Cardiology, Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, CA
| | - Jeffrey D Zampi
- Division of Cardiology, Department of Pediatrics, CS Mott Children's Hospital, University of Michigan School of Medicine, Ann Arbor, MI
| | - Shabana Shahanavaz
- The Heart Institute, Cincinnati Children's Hospital Medical Center and Division of Pediatric Cardiology, University of Cincinnati College of Medicine, Cincinnati, OH; Section of Pediatric Cardiology, Department of Pediatrics, Washington University School of Medicine, St Louis, MO
| | - Christopher E Mascio
- The Cardiac Center, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Division of Pediatric Cardiothoracic Surgery, Department of Cardiovascular and Thoracic Surgery, West Virginia University School of Medicine, Morgantown, WV
| | - Paul J Chai
- Children's Heart Center Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Jennifer C Romano
- Section of Pediatric Cardiothoracic Surgery, Department of Cardiac Surgery, CS Mott Children's Hospital, University of Michigan School of Medicine, Ann Arbor, MI
| | - Steven J Healan
- Division of Cardiology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Joelle A Pettus
- Children's Heart Center Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Sarosh P Batlivala
- The Heart Institute, Cincinnati Children's Hospital Medical Center and Division of Pediatric Cardiology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - James E B Raulston
- Division of Pediatric Cardiology, Department of Pediatrics, Children's of Alabama, University of Alabama Birmingham School of Medicine, Birmingham, AL
| | - Kristal M Hock
- Division of Pediatric Cardiology, Department of Pediatrics, Children's of Alabama, University of Alabama Birmingham School of Medicine, Birmingham, AL
| | - Shiraz A Maskatia
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Asaad Beshish
- Children's Heart Center Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Mark A Law
- Division of Pediatric Cardiology, Department of Pediatrics, Children's of Alabama, University of Alabama Birmingham School of Medicine, Birmingham, AL
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Frank C, Williams RF, Boulden T, Kink R, Paton EA. Ultrasound is safe and highly specific for confirmation of proper gastrostomy tube replacement in pediatric patients. J Pediatr Surg 2022; 57:390-395. [PMID: 35216797 DOI: 10.1016/j.jpedsurg.2022.01.024] [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: 09/22/2021] [Revised: 01/12/2022] [Accepted: 01/21/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Gastrostomy tube (GT) dislodgement is a common cause of Pediatric Emergency Department (PED) visits. Postoperative patients and those who require stoma dilation are more likely to have complications during emergent replacement. Although incorrect replacement can cause significant morbidity overall, the occurrence is infrequent. Contrast injection of the GT is considered the standard for confirming proper placement. Case reports in both pediatric and adult patients suggest that ultrasound can be used to confirm proper replacement. The objective of the present study was to assess the utility of ultrasound to confirm GT placement in pediatric patients most at risk for complications from incorrect replacement. METHODS This is a non-randomized cohort pilot trial to determine the sensitivity and specificity of ultrasound to confirm proper replacement of a GT in a Pediatric Emergency Department. RESULTS We enrolled 55 pediatric subjects, of which 50 had ultrasound imaging after GT replacement in the PED prior to contrast injection. Ultrasound was found to have 96% sensitivity and 100% specificity for confirming GT placement. CONCLUSIONS Ultrasound is a safe and reliable confirmatory study to confirm GT placement in pediatric patients, especially those at highest risk of complications from incorrect placement. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Cailin Frank
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Le Bonheur Children's Hospital, 848 Adams Ave, Memphis, TN 38103, United States; University of Tennessee Health Science Center, 800 Madison Ave, Memphis, TN 38103, United States.
| | - Regan F Williams
- University of Tennessee Health Science Center, 800 Madison Ave, Memphis, TN 38103, United States; Division of Pediatric Surgery, Le Bonheur Children's Hospital, 848 Adams Ave, Memphis, TN 38103, United States
| | - Thomas Boulden
- University of Tennessee Health Science Center, 800 Madison Ave, Memphis, TN 38103, United States; Department of Radiology, Le Bonheur Children's Hospital, 848 Adams Ave, Memphis, TN 38103, United States
| | - Rudy Kink
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Le Bonheur Children's Hospital, 848 Adams Ave, Memphis, TN 38103, United States; University of Tennessee Health Science Center, 800 Madison Ave, Memphis, TN 38103, United States
| | - Elizabeth A Paton
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, 848 Adams Ave, Memphis, TN 38103, United States; College of Nursing, University of Tennessee Health Science Center, 874 Union Ave, Memphis, TN 38103, United States
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9
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A Study of Postoperative Complications Occurring at Home With Pediatric Gastrostomy Feeding Tubes. J Pediatr Gastroenterol Nutr 2022; 75:30-35. [PMID: 35759538 DOI: 10.1097/mpg.0000000000003474] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Gastrostomy tubes (G-tubes) provide long-term feeding assistance to children with severe feeding dysfunction. Although there are a host of complications that occur at home with current pediatric G-tube feeding, their prevalences and outcomes remain relatively unstudied. This study aims to identify and describe such complications. METHODS A dual-round survey was administered to 98 participants through the Feeding Tube Awareness Foundation, a 501(c)(3) organization that supports parents and caretakers of G-tube-fed children. Information was collected broadly regarding G-tube complications, causes, and attitudes toward such complications. RESULTS Infection (56%), itching/irritation/redness (52%), and leakage (51%) were the leading G-tube related complications. The average time that G-tubes were replaced was 3.4 ± 1.2 months as compared to the typical recommended period of up to 6 months. Of the caretakers who had not experienced G-tube displacement, 7.9% wanted to see a change in current G-tubes to address the issue, compared with 75% of those who had experienced displacement. This 67.1% differential in caretakers' attitudes toward G-tubes based on their prior experience with a particular complication was the largest gap among all other listed complications. CONCLUSIONS G-tube complications are prevalent and varied. A sizable portion of G-tube users experience complications severe enough to require intervention. Of these, G-tube displacement is particularly critical and frequently precedes other prevalent complications, namely gastric leakage, infection, and tissue granulation.
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10
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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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11
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Skertich NJ, Lee TK, Grunvald MW, Sivakumar A, Tiglao RM, Madonna MB, Pillai S, Shah AN. The effect of standardized discharge instructions after gastrostomy tube placement on postoperative hospital utilization. J Pediatr Surg 2022; 57:418-423. [PMID: 33867152 DOI: 10.1016/j.jpedsurg.2021.03.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/02/2021] [Accepted: 03/15/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND/PURPOSE Gastrostomy tube (GT) placement is a common pediatric procedure with high postoperative resource utilization. We aimed to determine if standardized discharge instructions (SDI) reduced healthcare utilization rates. METHODS We performed a retrospective cohort study comparing postoperative hospital utilization of patients who underwent initial GT placement pre- and post-SDI protocol implementation from 2014-2019. Statistical analyses included Chi-square tests, multivariable adjusted logistic regression, adjusted Cox proportion hazard regression, and adjusted Poisson regression models when appropriate. RESULTS 197 patients were included, 102 (51.8%) before and 95 (48.2%) after protocol implementation. On primary analysis, SDI patients did not have significantly different total postoperative hospital utilization events at 30-days (48.0% vs. 38.9%, p = 0.25). On secondary analysis, SDI patients had lower rates of ED (8.4% vs. 19.6%, p = 0.026) and office visits (11.6% vs. 25.5%, p = 0.017) at 30-days. Non-SDIs patients had greater odds of ED visits (OR2.7, 95%CI 1.3-5.9, p = 0.01), office visits (OR3.7, 95%CI 1.7-8.1, p = 0.001) and phone calls (OR2.6, 95%CI 1.2-5.7, p = 0.016) at 1-year. The adjusted hazard ratio was 2.0 (95%CI 1.4-3.0, p < 0.001). Incident rate ratio were 1.8 (95%CI 1.2-2.5, p = 0.002) at 30-days and 1.9 (95%CI 1.5-2.4, p < 0.001) at 1-year post-discharge. CONCLUSIONS SDIs post-GT placement may reduce multiple aspects of postoperative hospital utilization.
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Affiliation(s)
- Nicholas J Skertich
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL, 60612, USA
| | | | - Miles W Grunvald
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL, 60612, USA
| | | | - Rona M Tiglao
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL, 60612, USA
| | - Mary Beth Madonna
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL, 60612, USA
| | - Srikumar Pillai
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL, 60612, USA
| | - Ami N Shah
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL, 60612, USA.
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12
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Singh H, Morrison M, McIltrot K. Education Following Pediatric Gastrostomy Tube Placement: An Integrative Review. J Pediatr Nurs 2021; 61:387-393. [PMID: 34601247 DOI: 10.1016/j.pedn.2021.09.015] [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: 01/22/2021] [Revised: 09/10/2021] [Accepted: 09/15/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is a gap in knowledge regarding the necessary components for pediatric gastrostomy tube education. This integrative review addresses the question "What are the educational components following pediatric gastrostomy placement?" METHODS A literature search was conducted using PubMed, CINAHL, and Cochrane Library electronic databases, along with a hand search. Articles for review included those in the pediatric population, English language, and publication dates between 2010 and 2020. RESULTS Ultimately, 7 articles met the inclusion criteria for review. Articles were all pediatric focused (0-18 years), and were a mix of quantitative and qualitative designs, along with one non-research paper. Three major themes were identified from the literature including that gastrostomy tube education should be a multidisciplinary effort, that education should take a standardized approach, and that it should include psychosocial elements that enhance caregiver knowledge and empowerment. DISCUSSION This review demonstrates that while there is no consensus on a superior mode or means of education, pediatric gastrostomy discharge education must be standardized and high quality to promote the best patient and caregiver outcomes. Further research should aim to address which forms of education, if any, lead to the best outcomes, and how education can best be delivered to promote caregiver knowledge and ease.
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13
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Durgin JM, Slatnick B, Yang A, Crum R, Wynne N, Neumeyer C, Kim HB, Demehri FR. The Paired T-Fastener Technique: A Bolster-Free Gastropexy for Laparoscopic Gastrostomy Tube Placement. J Laparoendosc Adv Surg Tech A 2021; 31:1431-1435. [PMID: 34677092 DOI: 10.1089/lap.2021.0336] [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: 11/13/2022] Open
Abstract
Purpose: Gastropexy during laparoscopic gastrostomy tube (GT) insertion can be technically challenging. T-fasteners are an effective method of gastropexy. However, the use of external bolsters requires an additional procedure for removal and may cause skin complications due to pressure necrosis. We describe our experience utilizing T-fasteners in a novel way that eliminates external bolsters during laparoscopic GT placement. Methods: Pediatric patients requiring enteral access who underwent gastrostomy at a single institution using the paired T-fastener technique were reviewed. Gastropexy was achieved by passing pairs of T-fasteners, under laparoscopic and/or endoscopic guidance, through single stab incisions into the stomach in a square configuration, allowing the suture from one T-fastener to be tied subcutaneously to its paired suture. This eliminates the need for external bolsters. Operative time and 30-day postoperative complications, including local wound infection, granulation tissue formation, bleeding, and tube replacement, are reported. Results: Thirty patients underwent gastrostomy placement using the paired T-fastener technique. Mean age was 9.2 years (standard deviation [SD] 6.9) and mean weight 29.9 kg (SD 21.0). Mean tube length was 2.2 cm (SD 0.71). Eight patients underwent an additional procedure at the time of gastrostomy. Mean operative time was 74.4 minutes (SD 39.7). Five patients developed a local wound infection requiring antibiotics. Five developed granulation tissue. Seven patients underwent tube replacement within 30 days for dislodgment or stem upsize. Conclusion: The paired T-fastener technique is a safe and efficient method for primary button gastrostomy placement. This method eliminates the need for additional trocars or external bolsters and may be helpful in patients with thick abdominal walls.
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Affiliation(s)
- Jonathan M Durgin
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Brianna Slatnick
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Robert Crum
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Nicole Wynne
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Corinne Neumeyer
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Heung Bae Kim
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Farokh R Demehri
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
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14
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Jeziorczak PM, Frenette RS, Lee J, Coe SC, Aprahamian CJ. Size Matters: Early Gastrostomy Tube Dislodgment in Children. J Laparoendosc Adv Surg Tech A 2021; 31:1372-1375. [PMID: 34492202 DOI: 10.1089/lap.2021.0352] [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
Background: Gastrostomy tube (g-tube) complications are typically minor and site related with major complications related to dislodgment before tract establishment. With the recent adoption of 12F g-tubes; size of tube has not been evaluated. There is limited research on the efficacy and dislodgment rates of 12 and 14F g-tubes within the early dislodgment window (<42 days postsurgery). Materials and Methods: A retrospective study from June 1, 2013 to May 25, 2020 was performed. A total of 888 patient encounters were identified, with a final data set of 835 being used for analysis. A subset of 21 patients was evaluated based on early dislodgment status. Fisher's exact test and Welch's two-sample test analyses were used to test for significance between groups (P < .05). Results: The early dislodgment rate is low at 2.5% (21/835). There was a significant impact of g-tube size on dislodgment rates. When evaluated by g-tube size, 12F g-tubes are nearly four times more likely to dislodge before 6 weeks than 14F g-tubes. In addition, the average age of 12F patients who dislodged early was significantly lower than that of the population for 14F patients. Conclusions: There is a significant difference in early dislodgment rate and age between the 12F g-tube compared with a 14F. These data suggest a trade-off of the smaller balloon in 12F g-tubes and potential for more limited use in our smallest children.
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Affiliation(s)
- Paul M Jeziorczak
- Department of Pediatric Surgery, OSF Healthcare- Children's Hospital of Illinois, Peoria, Illinois, USA.,University of Illinois College of Medicine Peoria, Peoria, Illinois, USA
| | - Riley S Frenette
- Department of Pediatric Surgery, OSF Healthcare- Children's Hospital of Illinois, Peoria, Illinois, USA.,Kirksville College of Osteopathic Medicine, AT Still University, Kirksville, Missouri, USA
| | - Joan Lee
- University of Illinois College of Medicine Peoria, Peoria, Illinois, USA
| | - Sarah C Coe
- University of Illinois College of Medicine Peoria, Peoria, Illinois, USA
| | - Charles J Aprahamian
- Department of Pediatric Surgery, OSF Healthcare- Children's Hospital of Illinois, Peoria, Illinois, USA.,University of Illinois College of Medicine Peoria, Peoria, Illinois, USA
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15
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Kvello M, Knatten CK, Bjørnland K. Laparoscopic Gastrostomy Placement in Children Has Few Major, but Many Minor Early Complications. Eur J Pediatr Surg 2020; 30:548-553. [PMID: 31891947 DOI: 10.1055/s-0039-3401988] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Laparoscopic gastrostomy (LAPG) is an increasingly popular alternative to more traditional gastrostomy techniques. This study evaluates early postoperative complications following LAPG and investigates risk factors for gastrostomy complications. MATERIALS AND METHODS Retrospective study of patients <16 years undergoing LAPG from 2005 to 2018. Early postoperative complications (<30 days) were grouped as gastrostomy-related or general and graded according to the Clavien-Dindo classification for surgical complications. RESULTS A total of 104 patients, of which 54 (52%) had neurological impairment (NI), were included. Median age and weight were 1.2 years (1 day-15.2 years) and 8.9 kg (3.4-36), respectively. Operating time was median 37 minutes (19-86) and shorter in the second half of the patients (46 vs. 35 minutes, p = 0.04). A total of 40 (38%) patients experienced 53 gastrostomy-related complications. Of these, seven complications needed surgical treatment; severe leakage (2), too short gastrostomy button (1), feeding difficulties (1), gastric outlet obstruction (1), omentum trapped in umbilical port sutures (1), and suspected fascial defect (1). Stoma infection and granulation tissue were reported in 13 and 12%, respectively. Tube dislodgement occurred in six patients and was managed with bedside reinsertion in all. Gastrostomy-related complications were less frequent in NI patients (46 vs 22%, p = 0.01). CONCLUSION LAPG is a safe procedure with few major complications, but a high rate of minor complications. Operating time declined during the study period, and NI patients had fewer gastrostomy-related complications.
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Affiliation(s)
- Morten Kvello
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, Oslo, Norway
| | | | - Kristin Bjørnland
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, Oslo, Norway
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16
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Weszelits SM, Ridosh MM, O'Connor A. Displaced Gastrostomy Tube in the Pediatric Emergency Department: Implementing an Evidence-based Algorithm and Quality Improvement Project. J Emerg Nurs 2020; 47:113-122. [PMID: 33221035 DOI: 10.1016/j.jen.2020.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/10/2020] [Accepted: 09/21/2020] [Indexed: 11/28/2022]
Abstract
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.
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17
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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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18
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Alerhand S, Tay ET. Point-of-care ultrasound for confirmation of gastrostomy tube replacement in the pediatric emergency department. Intern Emerg Med 2020; 15:1075-1079. [PMID: 32133576 DOI: 10.1007/s11739-020-02294-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 02/13/2020] [Indexed: 01/01/2023]
Abstract
Gastrostomy tubes (G-tubes) are frequently used in children for feeding and nutrition. Complications related to G-tubes (and G-buttons) in children represent a common presentation to the emergency department (ED). G-tube replacement is usually performed by pediatric emergency medicine physicians. Misplacement may lead to tract disruption, perforation, fistula tract formation, or feeding into the peritoneum. Contrast-enhanced radiographs are traditionally used for confirmation. In addition to a longer length-of-stay, repeat ED visits result in repeated radiation exposure. The use of point-of-care ultrasound (POCUS) instead of radiography avoids this exposure to ionizing radiation. Here, we describe three patients who presented with G-tube complications in whom POCUS alone performed by pediatricians was used for confirmation of the tubes' replacement. Two children presented to the ED with G-tube dislodgement, and one child presented with a ruptured balloon. In all three cases, a new G-tube was replaced at the bedside using POCUS guidance without the need for further radiographic studies. There were no known ED or clinic returns for G-tube complaints over the next 30 days. This is the first report of pediatricians using POCUS to guide and confirm G-tube replacement in children. The success of these cases suggests the technique's feasibility. Future prospective studies are needed to evaluate the learning curves, diagnostic accuracy, ED length-of-stay, and use of confirmatory imaging.
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Affiliation(s)
- Stephen Alerhand
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ, 07103, USA.
| | - Ee Tein Tay
- Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, New York, NY, 10016, USA
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19
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Nicholson GT, Glatz AC, Qureshi AM, Petit CJ, Meadows JJ, McCracken C, Kelleman M, Bauser-Heaton H, Gartenberg AJ, Ligon RA, Aggarwal V, Kwakye DB, Goldstein BH. Impact of Palliation Strategy on Interstage Feeding and Somatic Growth for Infants With Ductal-Dependent Pulmonary Blood Flow: Results from the Congenital Catheterization Research Collaborative. J Am Heart Assoc 2019; 9:e013807. [PMID: 31852418 PMCID: PMC6988161 DOI: 10.1161/jaha.119.013807] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background In infants with ductal‐dependent pulmonary blood flow, the impact of palliation strategy on interstage growth and feeding regimen is unknown. Methods and Results This was a retrospective multicenter study of infants with ductal‐dependent pulmonary blood flow palliated with patent ductus arteriosus (PDA) stent or Blalock‐Taussig shunt (BTS) from 2008 to 2015. Subjects with a defined interstage, the time between initial palliation and subsequent palliation or repair, were included. Primary outcome was change in weight‐for‐age Z‐score. Secondary outcomes included % of patients on: all oral feeds, feeding‐related medications, higher calorie feeds, and feeding‐related readmission. Propensity score was used to account for baseline differences. Subgroup analysis was performed in 1‐ (1V) and 2‐ventricle (2V) groups. The cohort included 66 PDA stent (43.9% 1V) and 195 BTS (54.4% 1V) subjects. Prematurity was more common in the PDA stent group (P=0.051). After adjustment, change in weight‐for‐age Z‐score did not differ between groups over the entire interstage. However, change in weight‐for‐age Z‐score favored PDA stent during the inpatient interstage (P=0.005) and BTS during the outpatient interstage (P=0.032). At initial hospital discharge, PDA stent treatment was associated with all oral feeds (P<0.001) and absence of feeding‐related medications (P=0.002). Subgroup analysis revealed that 2V but not 1V patients demonstrated significant increase in weight‐for‐age Z‐score. In the 2V cohort, feeding‐related readmissions were more common in the BTS group (P=0.008). Conclusions In infants with ductal‐dependent pulmonary blood flow who underwent palliation with PDA stent or BTS, there was no difference in interstage growth. PDA stent was associated with a simpler feeding regimen and fewer feeding‐related readmissions.
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Affiliation(s)
- George T Nicholson
- Division of Cardiology Department of Pediatrics Vanderbilt University School of Medicine Nashville TN
| | - Andrew C Glatz
- Department of Pediatrics The Cardiac Center Children's Hospital of Philadelphia Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Athar M Qureshi
- Lillie Frank Abercrombie Section of Cardiology Department of Pediatrics Texas Children's Hospital Baylor College of Medicine Houston TX
| | - Christopher J Petit
- Sibley Heart Center Cardiology Department of Pediatrics Children's Healthcare of Atlanta Emory University School of Medicine Atlanta GA
| | - Jeffery J Meadows
- Division of Cardiology Department of Pediatrics University of California San Francisco School of Medicine San Francisco CA
| | - Courtney McCracken
- Sibley Heart Center Cardiology Department of Pediatrics Children's Healthcare of Atlanta Emory University School of Medicine Atlanta GA
| | - Michael Kelleman
- Sibley Heart Center Cardiology Department of Pediatrics Children's Healthcare of Atlanta Emory University School of Medicine Atlanta GA
| | - Holly Bauser-Heaton
- Sibley Heart Center Cardiology Department of Pediatrics Children's Healthcare of Atlanta Emory University School of Medicine Atlanta GA
| | - Ari J Gartenberg
- Department of Pediatrics The Cardiac Center Children's Hospital of Philadelphia Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - R Allen Ligon
- Sibley Heart Center Cardiology Department of Pediatrics Children's Healthcare of Atlanta Emory University School of Medicine Atlanta GA
| | - Varun Aggarwal
- Lillie Frank Abercrombie Section of Cardiology Department of Pediatrics Texas Children's Hospital Baylor College of Medicine Houston TX
| | - Derek B Kwakye
- The Heart Institute Cincinnati Children's Hospital Medical Center Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH
| | - Bryan H Goldstein
- The Heart Institute Cincinnati Children's Hospital Medical Center Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH
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20
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Pars H, Soyer T. Home Gastrostomy Feeding Education Program: Effects on the Caregiving Burden, Knowledge, and Anxiety Level of Mothers. JPEN J Parenter Enteral Nutr 2019; 44:1029-1037. [DOI: 10.1002/jpen.1747] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 10/30/2019] [Accepted: 11/01/2019] [Indexed: 01/14/2023]
Affiliation(s)
- Hatice Pars
- Faculty of Nursing, Pediatric Nursing DepartmentHacettepe University Ankara Turkey
| | - Tutku Soyer
- Faculty of MedicineDepartment of Pediatric SurgeryHacettepe University Ankara Turkey
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21
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Kozlov Y, Novozhilov V, Kovalkov K, Rasputin A, Baradieva P, Razumovsky A. Comparison of the Laparoscopic and Open Methods of Gastrostomy at Neonates and Infants Up To Three Months of Age. J Laparoendosc Adv Surg Tech A 2019; 29:958-964. [PMID: 31107138 DOI: 10.1089/lap.2018.0106] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: An open surgical intervention is a common approach for gastrostomy tube placement in neonates and infants. Also available, however less often used, is a laparoscopic technique for low-profile gastrostomy tube (button) placement. In this study we compare the pre-, intra-, and post-procedural outcomes of each technique. Methods: We retrospectively evaluated all open and laparoscopically inserted gastrostomies at our department from January 2002 to December 2016 and compared them in terms of operative parameters and outcomes. Results: In the study interval, 44 open and 90 laparoscopically placed low-profile (button) gastrostomies were performed. There were no significant differences in gender distribution, mean age (42.54 versus 34.16 days), and mean weight (3311 versus 3476 g). The frequency of concomitant Nissen fundoplication was higher in the laparoscopy group (18% versus 47%; P < .05). The duration of G-tube placement by laparotomy was significantly longer (mean difference 16 minutes), than by laparoscopy, as were time periods between G-tube insertion and the onset of first feeding (mean differences 8.4 and 19.6 hours, respectively). Children in the laparoscopy group spent nearly 15 fewer days in the hospital than those who received a G-tube by laparotomy (29.0 versus 13.9; P < .05). Major complications were observed in 3 (6.82%) patients in the laparotomy group in the form of gastric content leak into the abdominal cavity and resulting peritonitis; complications were lower in the laparoscopy group (68.18% versus 13.33%; P = .03). Conclusions: Compared with open gastrostomy, the laparoscopic approach appears to be advantageous with respect to procedural duration, initiation of feedings, hospitalization duration, and rate of complications. Another difference was the frequency of concomitant Nissen fundoplication. Further prospective studies may determine the role of these patient-specific factors regarding who benefits most from the laparoscopic technique.
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Affiliation(s)
- Yury Kozlov
- 1 Department of Neonatal Surgery, Municipal Pediatric Hospital, Irkutsk, Russia.,2 Department of Pediatric Surgery, Irkutsk State Medical Academy of Continuing Education (IGMAPO), Irkutsk, Russia.,3 Department of Pediatric Surgery, State Medical University, Irkutsk, Russia
| | - Vladimir Novozhilov
- 1 Department of Neonatal Surgery, Municipal Pediatric Hospital, Irkutsk, Russia.,2 Department of Pediatric Surgery, Irkutsk State Medical Academy of Continuing Education (IGMAPO), Irkutsk, Russia.,3 Department of Pediatric Surgery, State Medical University, Irkutsk, Russia
| | - Konstantin Kovalkov
- 4 Department of Pediatric Surgery, Municipal Pediatric Clinical Hospital, Kemerovo, Russia
| | - Andrey Rasputin
- 1 Department of Neonatal Surgery, Municipal Pediatric Hospital, Irkutsk, Russia
| | - Polina Baradieva
- 1 Department of Neonatal Surgery, Municipal Pediatric Hospital, Irkutsk, Russia
| | - Alexander Razumovsky
- 5 Department of Pediatric Surgery, Russian National Scientific Medical University, Moscow, Russia
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Barry WE, Barin EN, Marshall LC, Doherty M, Nguyen E, Mclaughlin C, Kaplan L, Stein JE, Jensen AR. Preoperative Educational Intervention Decreases Unplanned Gastrostomy-Related Health Care Utilization. Am Surg 2018. [DOI: 10.1177/000313481808401003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Apprehension in taking independent care of children with medical devices may lead to unnecessary visits to the ED and/or acute clinic (AC). To address these concerns, our institution implemented a gastrostomy tube (GT) class in 2011 for caretakers. We hypothesized that inappropriate GT-related ED/AC visits would be lower in preoperatively educated caregivers. We performed a retrospective cohort study of all patients aged 0 to 18 who received GT (surgical or percutaneous) at our institution between 2006 and 2015 (n = 1340). Class attendance (trained vs untrained) and unscheduled GT-related ED/AC visits one year after GT placement were reviewed. Gastrostomy-related ED/AC visits were classified as appropriate (hospital-based intervention) or inappropriate (site care and education/reassurance). Occurrence of ED/AC visits was compared between trained and untrained cohorts. We found that 59 per cent of patients had an unscheduled GT-related ED/AC visit within one year of placement. The trained cohort had 27 per cent less unplanned ED/AC visits within one year (mean 1.21 (SD 1.82) vs untrained 1.65 (2.24), P < 0.001). On multivariate analysis, GT education independently decreased one-year GT-related health care utilization (Odds Ratio 0.75, 95% Confidence Interval 0.59–0.95). Formal education seems to decrease GT-related health care utilization within one year of placement and should be integrated into a comprehensive care plan to improve caregiver self-efficacy.
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Affiliation(s)
- Wesley E. Barry
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
- Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Erica N. Barin
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Lori C. Marshall
- Patient and Family Education and Resources, Children's Hospital Los Angeles, Los Angeles, California
| | - Majella Doherty
- Patient and Family Education and Resources, Children's Hospital Los Angeles, Los Angeles, California
| | - Eugene Nguyen
- Patient and Family Education and Resources, Children's Hospital Los Angeles, Los Angeles, California
| | - Cory Mclaughlin
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Lucas Kaplan
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - James E. Stein
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
- Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Aaron R. Jensen
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
- Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
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23
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León AH, Hebal F, Stake C, Baldwin K, Barsness KA. Prevention of hypergranulation tissue after gastrostomy tube placement: A randomised controlled trial of hydrocolloid dressings. Int Wound J 2018; 16:41-46. [PMID: 30160369 DOI: 10.1111/iwj.12978] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 03/16/2018] [Indexed: 11/26/2022] Open
Abstract
Hypergranulation tissue formation is a common complication after gastrostomy tube (G-tube) placement, occurring in 44%-68% of children. Hydrocolloid dressings are often used in the treatment of hypergranulation tissue but have not been studied for the prevention of postoperative hypergranulation tissue. An institutional review board (IRB)-approved, prospective, randomised study was performed in paediatric patients who underwent G-tube placement at a single, large children's hospital from January 2011 to November 2016. After placement, patients were randomly assigned to (1) standard postoperative G-tube care, (2) standard hydrocolloid G-tube dressing, or (3) silver-impregnated hydrocolloid G-tube dressing, and the incidences of postoperative hypergranulation tissue formation, tube dislodgement, infection, and emergency department use were compared. A total of 171 patients were enrolled; 128 patients (75%) had at least 4 months of follow up and were included in the analyses. Eighty-nine patients (69.5%) developed hypergranulation tissue during the postoperative period, with no significant differences in incidence among the three treatment arms. Of those who developed hypergranulation tissue, 46 (56%) visited the emergency department, compared with 6 of the 39 patients (19%) who did not develop hypergranulation tissue. Hydrocolloid dressings (standard or silver-impregnated) do not prevent the development of hypergranulation tissue or other complications after G-tube placement in paediatric patients.
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Affiliation(s)
- Astrid H León
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Ferdynand Hebal
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Christine Stake
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Kerry Baldwin
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Safety and Efficacy of Bedside Percutaneous Endoscopic Gastrostomy Placement in the Neonatal Intensive Care Unit. J Pediatr Gastroenterol Nutr 2018; 67:40-44. [PMID: 29401084 DOI: 10.1097/mpg.0000000000001906] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE The aim of the study is to describe the safety and efficacy of bedside percutaneous endoscopic gastrostomy (PEG) placement in a level 3 neonatal intensive care unit (NICU). METHODS A retrospective chart review was performed on 106 infants with a birthweight ≤6 kg receiving bedside PEG placement at Johns Hopkins All Children's Hospital between 2007 and 2013. Preprocedure, postprocedure, and demographic data were collected. The main safety outcome was postprocedure complication rate and the main efficacy outcome was time to initiate feeds and time on respiratory support. RESULTS The mean birth weight and mean gestational age of our population at the time of procedure were 2.2 kg and 33 weeks, respectively. There were 9 total complications (8.5%) with major complications being only 2 (1.8%). There were no instances of blood stream infections. The mean length of time to initiate feeds was 1.2 days (standard deviation [SD] = 1.2). Ninety-three percent of patients were extubated within 24 hours. CONCLUSIONS Bedside PEG placement is safe with minimal complications. It is associated with little need for ventilator support and allows for early re-initiation of feeds and early success at reaching goal feedings.
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25
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Use of Point-of-Care Ultrasound to Guide Pediatric Gastrostomy Tube Replacement in the Emergency Department. Pediatr Emerg Care 2018; 34:145-148. [PMID: 29346232 DOI: 10.1097/pec.0000000000001400] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The presentation of a pediatric patient to the emergency department for a malfunctioning or dislodged gastrostomy tube (G-tube) is not uncommon. As such, these tubes are often replaced at the bedside. Improper placement can result in a number of complications, including perforation, fistula tract formation, peritonitis, and sepsis. The current criterion standard method to confirm proper G-tube placement is contrast-enhanced radiography. However, point-of-care ultrasound may be an alternative method to guide and confirm pediatric G-tube replacement in the emergency department. We report a series of cases on this novel point-of-care ultrasound application.
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26
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Abstract
Parents often bring their children to the emergency department for adverse events with their child's gastrostomy tube or button. This review will discuss the possible complications and the methods to handle them.
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27
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Hamilton EC, Curtin T, Slack RS, Ge C, Slade A, Hayes-Jordan A, Lally KP, Austin MT. Surgical Feeding Tubes in Pediatric and Adolescent Cancer Patients: A Single-institution Retrospective Review. J Pediatr Hematol Oncol 2017; 39:e342-e348. [PMID: 28678086 PMCID: PMC5610072 DOI: 10.1097/mph.0000000000000902] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The purpose of our study was to evaluate surgical enteric access in pediatric cancer patients to determine factors associated with postoperative complications. We performed a single-institution retrospective review of all patients below 21 years old with a primary cancer diagnosis who underwent surgical procedures for enteral access between 2004 and 2014. Multivariate logistic regression was performed to determine independent predictors of postoperative complications. During the study period, 122 patients had surgically placed feeding tubes, of whom 58% developed ≥1 complication(s) and 16% experienced a major complication. No single factor was significantly associated with developing any complication or major complication. Several trends were noted including increased complications associated with jejunostomy tubes, percutaneous endoscopic gastrostomy tubes, and abdominal radiation. Surgically placed enteric access in pediatric and adolescent cancer patients is associated with an extremely high complication rate emphasizing the importance of careful evaluation of these patients before embarking on surgical feeding access. Future work should evaluate mechanisms to decrease complications and/or explore alternative methods to provide supplemental nutrition in children and adolescents with cancer.
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Affiliation(s)
- Emma C. Hamilton
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas
| | - Thomas Curtin
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Rebecca S. Slack
- Department of Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Christine Ge
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Austen Slade
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas
| | - Andrea Hayes-Jordan
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Kevin P. Lally
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Mary T. Austin
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
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28
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Comparison of Emergency Department Visits for Complications of Gastrostomy Versus Gastrojejunostomy Tubes in Children. Pediatr Emerg Care 2017; 33:e71-e74. [PMID: 28968311 DOI: 10.1097/pec.0000000000001267] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study aims to evaluate frequency, type, and cost of gastrostomy tube (GT) versus gastrojejunostomy tube (GJT) complications in children presenting to the emergency department (ED). METHODS Patients were selected by electronic health record search for International Classification of Diseases, Ninth Revision, and procedure codes for GTs and GJTs/jejunostomy tubes. All children aged less than 18 years with GTs or GJTs placed during a 5-year period (2007-2012) at the University of Minnesota Masonic Children's Hospital were identified for retrospective review. Comparisons were made on demographic data, number and type of complications, and interventions performed for ED visits, which were abstracted from the electronic health record. Cost data were abstracted from the financial data system. RESULTS A total of 161 GT and GJT patients were identified; 31 children had 43 ED visits for complications. Ages ranged from 1 month to 17 years; median, 12 months; mean, 5.4 years; 25 (58%) were male, and 18 female (42%). Complications occurred in 15 GT (48.4%) and 16 GJT (51.6%) patients. The most common ED presenting complication was dislodgement, which occurred in 14 GTs (67%) and 18 GJTs (82%), followed by clogging 6 GTs (29%) and 1 GJTs (4.5%). Those presenting to the ED with GJT complications had higher mean overall charge (US $1987.00 vs US $913.10, P = 0.05). CONCLUSIONS Although GTs and GJTs had similar rates of complications and ED visits, GJT complications were more likely to result in hospital admission and intervention by radiology, require specialist involvement, and have a higher cost charged to the patient.
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29
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Franken J, Mauritz FA, Stellato RK, Van der Zee DC, Van Herwaarden-Lindeboom MYA. The Effect of Gastrostomy Placement on Gastric Function in Children: a Prospective Cohort Study. J Gastrointest Surg 2017; 21:1105-1111. [PMID: 28424983 PMCID: PMC5486691 DOI: 10.1007/s11605-017-3376-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Josephine Franken
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Room KE.04.140.5, PO Box 85090, 3508 AB, Utrecht, The Netherlands.
| | - Femke A Mauritz
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Room KE.04.140.5, PO Box 85090, 3508 AB, Utrecht, The Netherlands
- Department of Gastroenterology and Hepatology, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Rebecca K Stellato
- Department of Biostatistics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - David C Van der Zee
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Room KE.04.140.5, PO Box 85090, 3508 AB, Utrecht, The Netherlands
| | - Maud Y A Van Herwaarden-Lindeboom
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Room KE.04.140.5, PO Box 85090, 3508 AB, Utrecht, The Netherlands
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30
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Jadcherla S, Khot T, Moore R, Malkar M, Gulati I, Slaughter J. Feeding Methods at Discharge Predict Long-Term Feeding and Neurodevelopmental Outcomes in Preterm Infants Referred for Gastrostomy Evaluation. J Pediatr 2017; 181:125-130.e1. [PMID: 27939123 PMCID: PMC5724518 DOI: 10.1016/j.jpeds.2016.10.065] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 09/23/2016] [Accepted: 10/19/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To test the hypothesis that oral feeding at first neonatal intensive care unit discharge is associated with less neurodevelopmental impairment and better feeding milestones compared with discharge with a gastrostomy tube (G-tube). STUDY DESIGN We studied outcomes for a retrospective cohort of 194 neonates <37 weeks' gestation referred for evaluation and management of feeding difficulties between July 2006 and July 2012. Discharge milestones, length of hospitalization, and Bayley Scales of Infant Development-Third Edition scores at 18-24 months were examined. χ2, Mann-Whitney U, or t tests and multivariable logistic regression models were used. RESULTS A total of 60% (n = 117) of infants were discharged on oral feedings; of these, 96% remained oral-fed at 1 year. The remaining 40% (n = 77) were discharged on G-tube feedings; of these, 31 (40%) remained G-tube dependent, 17 (22%) became oral-fed, and 29 (38%) were on oral and G-tube feedings at 1 year. Infants discharged on a G-tube had lower cognitive (P <.01), communication (P = .03), and motor (P <.01) composite scores. The presence of a G-tube, younger gestation, bronchopulmonary dysplasia, or intraventricular hemorrhage was associated significantly with neurodevelopmental delay. CONCLUSIONS For infants referred for feeding concerns, G-tube evaluations, and feeding management, the majority did not require a G-tube. Full oral feeding at first neonatal intensive care unit discharge was associated with superior feeding milestones and less long-term neurodevelopmental impairment, relative to full or partial G-tube feeding. Evaluation and feeding management before and after G-tube placement may improve long-term feeding and neurodevelopmental outcomes.
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Affiliation(s)
- Sudarshan Jadcherla
- Innovative Feeding Disorders Research Program, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, USA,Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, USA,Division of Pediatric Cardiology, Saint Louis University School of Medicine, Saint Louis, MO
| | - Tanvi Khot
- Innovative Feeding Disorders Research Program, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Rebecca Moore
- Innovative Feeding Disorders Research Program, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Manish Malkar
- Innovative Feeding Disorders Research Program, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, USA,Division of Pediatric Cardiology, Saint Louis University School of Medicine, Saint Louis, MO
| | - Ish Gulati
- Innovative Feeding Disorders Research Program, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, USA,Division of Pediatric Cardiology, Saint Louis University School of Medicine, Saint Louis, MO
| | - Jonathan Slaughter
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, USA,Division of Pediatric Cardiology, Saint Louis University School of Medicine, Saint Louis, MO
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Abstract
Obtaining reliable enteral and vascular access constitutes a significant fraction of a pediatric surgeon׳s job. Multiple approaches are available. Given the complicated nature of this patient population multiple complications can also occur. This article discusses the various techniques and potential complications associated with short- and long-term enteral and vascular access.
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Affiliation(s)
- James S Farrelly
- Division of Pediatric General and Thoracic Surgery, Yale Children's Hospital, Yale University School of Medicine, PO Box 208062, New Haven, Connecticut 06520-8062
| | - David H Stitelman
- Division of Pediatric General and Thoracic Surgery, Yale Children's Hospital, Yale University School of Medicine, PO Box 208062, New Haven, Connecticut 06520-8062.
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Kvello M, Åvitsland TL, Knatten CK, Pripp AH, Aabakken L, Emblem R, Bjørnland K. Trends in the use of gastrostomies at a tertiary paediatric referral centre. Scand J Gastroenterol 2016; 51:625-32. [PMID: 26679498 DOI: 10.3109/00365521.2015.1123288] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The aims of this study were to describe the population of paediatric patients undergoing gastrostomy placement at a Norwegian tertiary referral centre and to investigate trends over time in patient characteristics and operative technique. MATERIALS AND METHODS Patients <15 years of age getting a primary gastrostomy from 1994 to 2012 were included in this retrospective observational study. Patient data were collected from medical records and the National Registry. RESULTS Six-hundred forty-nine patients with a median age of 1.2 years [gestational week 30-14.9 years] were included. Neurological disorders (ND) was the most common underlying group of diagnosis (n = 311, 48%), followed by cardiac disease 104 (16%), congenital anomalies 85 (13%), respiratory disease 43 (7%), malignancy 29 (5%), and others 77 (12%). At follow-up, 162 (25%) patients were dead. A percutaneous endoscopic technique (PEG) was used in 401 (62%) patients, open surgery (OPEN) in 201 (31%) and laparoscopy (LAP) in 47 (7%). The number of gastrostomies per year more than doubled during the period (p < 0.001). More patients with cardiac disease and congenital anomalies were given a gastrostomy during the last years (all p < 0.05), whereas the number of patients with ND remained stable. Furthermore, there has been a decrease in median age and an increase in the number of PEG and LAP (p < 0.05). CONCLUSION The number of gastrostomy insertions has increased from 1994 to 2012. NDs is the most common underlying diagnosis in patients receiving a gastrostomy, PEG is the most common technique and patient characteristics have changed during the study period.
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Affiliation(s)
- Morten Kvello
- a Institute of Clinical Medicine, University of Oslo , Oslo , Norway ;,b Department of Gastrointestinal and Paediatric Surgery , Oslo University Hospital, Rikshospitalet , Norway
| | - Tone Lise Åvitsland
- a Institute of Clinical Medicine, University of Oslo , Oslo , Norway ;,b Department of Gastrointestinal and Paediatric Surgery , Oslo University Hospital, Rikshospitalet , Norway
| | - Charlotte Kristensen Knatten
- a Institute of Clinical Medicine, University of Oslo , Oslo , Norway ;,b Department of Gastrointestinal and Paediatric Surgery , Oslo University Hospital, Rikshospitalet , Norway
| | - Are Hugo Pripp
- c Oslo Centre of Biostatistics and Epidemiology, Oslo University Hospital , Oslo , Norway
| | - Lars Aabakken
- a Institute of Clinical Medicine, University of Oslo , Oslo , Norway ;,d Department of Gastroenterology , Oslo University Hospital, Rikshospitalet , Norway
| | - Ragnhild Emblem
- a Institute of Clinical Medicine, University of Oslo , Oslo , Norway ;,b Department of Gastrointestinal and Paediatric Surgery , Oslo University Hospital, Rikshospitalet , Norway
| | - Kristin Bjørnland
- a Institute of Clinical Medicine, University of Oslo , Oslo , Norway ;,b Department of Gastrointestinal and Paediatric Surgery , Oslo University Hospital, Rikshospitalet , Norway
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Khalil ST, Uhing MR, Duesing L, Visotcky A, Tarima S, Nghiem-Rao TH. Outcomes of Infants With Home Tube Feeding: Comparing Nasogastric vs Gastrostomy Tubes. JPEN J Parenter Enteral Nutr 2016; 41:1380-1385. [PMID: 27647478 DOI: 10.1177/0148607116670621] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The aim of this study was to determine the tube-related complications and feeding outcomes of infants discharged home from the neonatal intensive care unit (NICU) with nasogastric (NG) tube feeding or gastrostomy (G-tube) feeding. MATERIALS AND METHODS We performed a chart review of 335 infants discharged from our NICU with home NG tube or G-tube feeding between January 2009 and December 2013. The primary outcome was the incidence of feeding tube-related complications requiring emergency department (ED) visits, hospitalizations, or deaths. Secondary outcome was feeding status at 6 months postdischarge. Univariate and multivariate analyses were conducted. RESULTS There were 322 infants discharged with home enteral tube feeding (NG tube, n = 84; G-tube, n = 238), with available outpatient data for the 6-month postdischarge period. A total of 115 ED visits, 28 hospitalizations, and 2 deaths were due to a tube-related complication. The incidence of tube-related complications requiring an ED visit was significantly higher in the G-tube group compared with the NG tube group (33.6% vs 9.5%, P < .001). Two patients died due to a G-tube-related complication. By 6 months postdischarge, full oral feeding was achieved in 71.4% of infants in the NG tube group compared with 19.3% in the G-tube group ( P < .001). Type of feeding tube and percentage of oral feeding at discharge were significantly associated with continued tube feeding at 6 months postdischarge. CONCLUSION Home NG tube feeding is associated with fewer ED visits for tube-related complications compared with home G-tube feeding. Some infants could benefit from a trial home NG tube feeding.
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Affiliation(s)
- Syed Tariq Khalil
- 1 Division of Neonatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Michael R Uhing
- 1 Division of Neonatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lori Duesing
- 2 Division of Pediatric Gastroenterology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Alexis Visotcky
- 3 Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sergey Tarima
- 3 Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - T Hang Nghiem-Rao
- 1 Division of Neonatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Fernandez-Pineda I, Sandoval JA, Jones RM, Boateng N, Wu J, Rao BN, Davidoff AM, Shochat SJ. Gastrostomy Complications in Pediatric Cancer Patients: A Retrospective Single-Institution Review. Pediatr Blood Cancer 2016; 63:1250-3. [PMID: 26960180 PMCID: PMC5704922 DOI: 10.1002/pbc.25968] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 02/16/2016] [Indexed: 01/14/2023]
Abstract
BACKGROUND Complications in pediatric cancer patients after a gastrostomy (GT) placement have not been widely investigated. We aimed to evaluate the complication rate and nature of complications in this specific population. PROCEDURE Medical records of pediatric cancer patients having a GT placed at our institution from 1998 to 2013 were retrospectively reviewed. Variables analyzed included gender, age, diagnosis, surgical procedure, GT device, duration of GT usage, absolute neutrophil count (ANC) level at surgery, and complications. RESULTS One hundred seventy-one patients (92 males, 79 females), median age of 6 years (range, 0.2-21), who underwent 181 procedures (110 open, 59 endoscopic, and 12 laparoscopic) were identified. Diagnosis included central nervous system tumor (n = 101), solid tumor (n = 45), and leukemia/lymphoma (n = 25). A GT tube was used in 139 procedures and a GT button in 42. Median ANC level at procedure was 3,300/mm(3) (range, 0-38,988). Median duration of GT usage was 8 months (range, 0.2-142). One hundred seventy-seven complications occurred in 106 patients (61.9%) and were categorized as perioperative (<1 month after surgery, 20.3%) and late (>1 month after surgery, 79.7%). Major complications included 42 (23.7%) GT site infections and four (2.2%) intrabdominal complications. The most common minor complication was granulation tissue (28.8%). Younger age at procedure was associated with complications (P = 0.048) and an open technique was associated with GT site infection (P = 0.003). No statistical significance was observed between complications and gender, diagnosis, GT device, duration of GT usage, and ANC at procedure. CONCLUSIONS Younger patients were more likely to have complications, and GT site infections were more common after open GT procedures.
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Affiliation(s)
| | - John A. Sandoval
- Department of Surgery, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Reagan M. Jones
- Department of Surgery, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Nana Boateng
- Department of Biostatistics, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Jianrong Wu
- Department of Biostatistics, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Bhaskar N. Rao
- Department of Surgery, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Andrew M. Davidoff
- Department of Surgery, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Stephen J. Shochat
- Department of Surgery, St Jude Children’s Research Hospital, Memphis, Tennessee,Correspondence to: Stephen J. Shochat, Department of Surgery, St. Jude Children’s Research Hospital, Memphis, Tennessee 38105.
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Goldin AB, Heiss KF, Hall M, Rothstein DH, Minneci PC, Blakely ML, Browne M, Raval MV, Shah SS, Rangel SJ, Snyder CL, Vinocur CD, Berman L, Cooper JN, Arca MJ. Emergency Department Visits and Readmissions among Children after Gastrostomy Tube Placement. J Pediatr 2016; 174:139-145.e2. [PMID: 27079966 DOI: 10.1016/j.jpeds.2016.03.032] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 01/25/2016] [Accepted: 03/10/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To define the incidence of 30-day postdischarge emergency department (ED) visits and hospital readmissions following pediatric gastrostomy tube (GT) placement across all procedural services (Surgery, Interventional-Radiology, Gastroenterology) in 38 freestanding Children's Hospitals. STUDY DESIGN This retrospective cohort study evaluated patients <18 years of age discharged between 2010 and 2012 after GT placement. Factors significantly associated with ED revisits and hospital readmissions within 30 days of hospital discharge were identified using multivariable logistic regression. A subgroup analysis was performed comparing patients having the GT placed on the date of admission or later in the hospital course. RESULTS Of 15 642 identified patients, 8.6% had an ED visit within 30 days of hospital discharge, and 3.9% were readmitted through the ED with a GT-related issue. GT-related events associated with these visits included infection (27%), mechanical complication (22%), and replacement (19%). In multivariable analysis, Hispanic ethnicity, non-Hispanic black race, and the presence of ≥3 chronic conditions were independently associated with ED revisits; gastroesophageal reflux and not having a concomitant fundoplication at time of GT placement were independently associated with hospital readmission. Timing of GT placement (scheduled vs late) was not associated with either ED revisits or hospital readmission. CONCLUSIONS GT placement is associated with high rates of ED revisits and hospital readmissions in the first 30 days after hospital discharge. The association of nonmodifiable risk factors such as race/ethnicity and medical complexity is an initial step toward understanding this population so that interventions can be developed to decrease these potentially preventable occurrences given their importance among accountable care organizations.
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Affiliation(s)
- Adam B Goldin
- Department of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA.
| | - Kurt F Heiss
- Emory University, Children's Healthcare of Atlanta, Atlanta, GA
| | - Matt Hall
- Children's Hospital Association, Overland Park, KS
| | | | - Peter C Minneci
- The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | | | - Marybeth Browne
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Mehul V Raval
- Emory University, Children's Healthcare of Atlanta, Atlanta, GA
| | - Samir S Shah
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Shawn J Rangel
- Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | - Loren Berman
- Nemours-Alfred I. DuPont Hospital for Children, Wilmington, DE
| | - Jennifer N Cooper
- The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Marjorie J Arca
- Medical College of Wisconsin/Children's Hospital of Wisconsin, Milwaukee, WI
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Abstract
Placement of gastrostomy tubes in infants and children has become increasingly commonplace. A historical emphasis on use of open gastrostomy has been replaced by less invasive methods of placement, including percutaneous endoscopic gastrostomy and laparoscopically assisted gastrostomy procedures. Various complications, ranging from minor to the more severe, have been reported with all methods of placement. Many pediatric patients who undergo gastrostomy tube placement will require long-term enteral therapy. Given the prolonged time pediatric patients may remain enterally dependent, further quality improvement and education initiatives are needed to improve long-term care and outcomes of these patients.
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Affiliation(s)
- Maireade E McSweeney
- Division of Gastroenterology and Nutrition, Department of Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - C Jason Smithers
- Department of General Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
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Abstract
PURPOSE Laparoscopic gastrostomy (LAPG) has gained popularity in children. The aim of this study was to compare the outcome of LAPG versus open gastrostomy (OG) in children with focus on complications, operative times and postoperative length of stay. METHODS Retrospective study of children who had gastrostomies inserted at our tertiary Pediatric Surgery Center from 2000 until 2013. The indications for a gastrostomy were an anticipated need for enteral support for at least 6 months. Totally 243 children were included in the study, 83 with LAPG and 160 with OG. RESULTS We found a significant difference in postoperative length of stay, 3 days in the LAPG group versus 4 days in the OG group but no difference in a sub-group analysis from 2010 to 2013 when both techniques were used. There was no difference in median operative time or complications rates. Granuloma was the dominating complication in both groups. CONCLUSION These two feeding-access techniques are comparable regarding complications, operative times and postoperative length of stay. The choice of surgical method should be individualized based on the patient's characteristics and the experience of the surgeon. The favorable results with LAPG in adults are not necessarily transferable to children since there are physiological and anatomical differences.
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Berman L, Sharif I, Rothstein D, Hossain J, Vinocur C. Concomitant fundoplication increases morbidity of gastrostomy tube placement. J Pediatr Surg 2015; 50:1104-8. [PMID: 25783337 DOI: 10.1016/j.jpedsurg.2014.07.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 07/23/2014] [Accepted: 07/27/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND Fundoplication is often performed in conjunction with gastrostomy tube (GT) placement in children, but there is a great deal of variation in rates of and indications for this procedure. Little is known about the impact of fundoplication on peri-operative outcomes. This study examines a national cohort of pediatric patients to compare risk-adjusted surgical outcomes in patients undergoing GT placement with or without concomitant fundoplication. METHODS We identified all patients undergoing GT placement in the 2012 National Surgical Quality Improvement Program - Pediatric. We evaluated demographics, comorbidities, complications, and length of stay for GT with fundoplication versus GT alone. We defined composite morbidity as a dichotomous variable for the presence of any complication. Logistic regression was performed to identify predictors of morbidity after adjusting for covariates. RESULTS 1289 GT patients were identified, and 148 (11.5%) underwent concurrent fundoplication. The fundoplication patients were more likely to be younger, have cardiac risk factors, and be on respiratory support. They also had higher rates of surgical site infection (7.4% vs 3.7%, p=0.03) and composite morbidity (16.9% vs 8.7%, p=0.001), and longer LOS (median 5 vs 3 days, p=<0.0001) compared to GT only. After adjusting for covariates, fundoplication was a predictor of composite morbidity and increased LOS. CONCLUSION Concomitant fundoplication is an independent risk factor for 30-day post-operative morbidity in patients undergoing GT placement. These findings do not negate the value of fundoplication but underscore the importance of careful patient selection, and should be taken into consideration when discussing risks and benefits with families.
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Affiliation(s)
- Loren Berman
- Nemours-A.I. duPont Hospital for Children, Wilmington, DE.
| | - Iman Sharif
- Nemours-A.I. duPont Hospital for Children, Wilmington, DE
| | - David Rothstein
- Division of Pediatric Surgery, Women and Children's Hospital of Buffalo, Buffalo, NY
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Baker L, Beres AL, Baird R. A systematic review and meta-analysis of gastrostomy insertion techniques in children. J Pediatr Surg 2015; 50:718-25. [PMID: 25783383 DOI: 10.1016/j.jpedsurg.2015.02.021] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Accepted: 02/13/2015] [Indexed: 01/23/2023]
Abstract
BACKGROUND Gastrostomy tubes are inserted via multiple techniques to provide a route for enteral feeding in the pediatric population. This review compares the rate of major complications and resource utilization associated with the various insertion techniques. METHODS Major electronic databases were queried for comparative studies of two or more insertion techniques, including open, laparoscopic, percutaneous endoscopic, or fluoroscopic guided. Major complications were defined as reoperation within 1 year or death. Screening of eligible studies, data extraction, and assessment of methodological quality were conducted independently by two reviewers. Forest and funnel plots were generated for outcomes using Revman 5.1, with p<0.05 considered significant. RESULTS Twenty-two studies with a total of 5438 patients met inclusion criteria. No differences in major complications were noted in studies comparing open versus laparoscopic approaches or open versus PEG. Studies comparing laparoscopic gastrostomy and PEG revealed a significantly increased risk in major complications with PEG (n=10 studies, OR 0.29, 95% CI: 0.17-0.51, p<0.0001). The number needed to treat to reduce one major complication by abandoning PEG is 45. CONCLUSIONS PEG is associated with an increased risk of major complications when compared to the laparoscopic approach. Advantages in operative time appear outweighed by the increased safety profile of laparoscopic gastrostomy insertion.
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Affiliation(s)
| | - Alana L Beres
- Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, Montreal, Quebec, Canada; McGill University Health Centre, Montreal, Quebec, Canada
| | - Robert Baird
- Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, Montreal, Quebec, Canada; McGill University Health Centre, Montreal, Quebec, Canada.
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Kozlov IA, Novozhilov VA, Rasputin AA, Us GP, Kuznetsova NN. [Button gastrostomy in children]. Khirurgiia (Mosk) 2015:48-53. [PMID: 25909552 DOI: 10.17116/hirurgia2015148-53] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
For the period January 2002 to December 2013 it was performed 84 interventions for introduction of gastrostomy tube. The first group included 24 open operations and the second group had 60 laparoscopic operations by using of button devices MIC-KEY (Kimberly-Clark, Roswell, USA) in neonates and infants. Statistically significant difference was not observed during comparison of demographic data of patients. Differences in groups were found in statistical analysis of intra- and postoperative parameters (p<0.05). Mean duration of surgery in the first group was 37.29 min, in the second group - 23.97 min. Time to start of feeding and transition to complete enteral nutrition was less in patients who underwent laparoscopic surgery than after open intervention (10.5 and 19.13 hours, 23.79 and 35.88 hours respectively; p<0.05). It was revealed augmentation of hospital stay in the 1st group in comparison with the 2(nd) group (11.71 and 7.09 days respectively; p<0.05). Frequency of postoperative complications was 18.33% in the 2(nd) group and 24% - in the 1st group (p<0.05). The authors consider that button devices are simply and effective technique of gastrostomy establishment in children. It is associated with minimal surgery duration and allows to start early enteral nutrition in comparison with open techniques.
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Affiliation(s)
- Iu A Kozlov
- Tsentr khirurgii i reanimatsii novorozhdennykh Gorodskoĭ Ivano-Matreninskoĭ detskoĭ klinicheskoĭ bol'nitsy, Irkutsk; Kafedra detskoĭ khirurgii Irkutskoĭ gosudarstvennoĭ meditsinskoĭ akademii poslediplomnogo obrazovaniia
| | - V A Novozhilov
- Tsentr khirurgii i reanimatsii novorozhdennykh Gorodskoĭ Ivano-Matreninskoĭ detskoĭ klinicheskoĭ bol'nitsy, Irkutsk; Kafedra detskoĭ khirurgii Irkutskogo gosudarstvennogo meditsinskogo universiteta; Kafedra detskoĭ khirurgii Irkutskoĭ gosudarstvennoĭ meditsinskoĭ akademii poslediplomnogo obrazovaniia
| | - A A Rasputin
- Tsentr khirurgii i reanimatsii novorozhdennykh Gorodskoĭ Ivano-Matreninskoĭ detskoĭ klinicheskoĭ bol'nitsy, Irkutsk
| | - G P Us
- Tsentr khirurgii i reanimatsii novorozhdennykh Gorodskoĭ Ivano-Matreninskoĭ detskoĭ klinicheskoĭ bol'nitsy, Irkutsk
| | - N N Kuznetsova
- Tsentr khirurgii i reanimatsii novorozhdennykh Gorodskoĭ Ivano-Matreninskoĭ detskoĭ klinicheskoĭ bol'nitsy, Irkutsk
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Correa JA, Fallon SC, Murphy KM, Victorian VA, Bisset GS, Vasudevan SA, Lopez ME, Brandt ML, Cass DL, Rodriguez JR, Wesson DE, Lee TC. Resource utilization after gastrostomy tube placement: defining areas of improvement for future quality improvement projects. J Pediatr Surg 2014; 49:1598-601. [PMID: 25475801 DOI: 10.1016/j.jpedsurg.2014.06.015] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Revised: 06/22/2014] [Accepted: 06/25/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Gastrostomy tube (GT) placement is a frequent procedure at a tertiary care children's hospital. Because of underlying patient illness and the nature of the device, patients often require multiple visits to the emergency room for GT-related concerns. We hypothesized that the majority of our patient visits to the ER related to gastrostomy tube concerns were not medically urgent. The purpose of this study was to characterize the incidence and indications for GT-related emergency room visits and readmission rates in order to develop family educational material that might allow for these nonurgent concerns to be addressed on an outpatient basis. METHODS We reviewed the medical records of all patients with GT placement in the operating room from January 2011 to September 2012. We evaluated our primary outcome of ER visits at less than 30 days after discharge and 30-365 days after discharge. The purpose of the ER visit was categorized as either mechanical (dislodgement, leaking) or wound-related (infection, granulation tissue). Additional outcomes assessed included readmission rates, reoperation rates, and the use of gastrostomy contrast studies. RESULTS During the study period, 247 patients had gastrostomy tubes placed at our institution at a median age of 15.3 months (range 0.03 months-22 years). Of the total patient population, 219 were discharged less than 30 days after their operation (89%). Of these, 42 (20%) returned to the emergency room a total of 44 times within 30 days of discharge for concerns related to their GT. Avoidable visits related to leaking, mild clogs, and granulation tissue were seen in 17/44 (39%). An additional 40 patients among the entire cohort of 247 (16%) presented to the ER a total of 71 times 31-365 days post-discharge; 59 (83%) of these visits were potentially avoidable. The readmission rate related to the GT was low (4%). CONCLUSIONS Few studies have attempted to quantify the amount of postoperative resources utilized post-GT placement in children. Our findings indicated this is not an insignificant quantity. In response to these findings, we have developed a series of educational materials and identified a dedicated nurse to perform inpatient gastrostomy education to these patients prior to discharge.
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Affiliation(s)
- Jesus A Correa
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Sara C Fallon
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Kathleen M Murphy
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Veronica A Victorian
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - George S Bisset
- Edward B. Singleton Department of Pediatric Radiology, Texas Children's Hospital, Houston, TX
| | - Sanjeev A Vasudevan
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Monica E Lopez
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Mary L Brandt
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Darrell L Cass
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - J Ruben Rodriguez
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - David E Wesson
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Timothy C Lee
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
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Schweitzer M, Aucoin J, Docherty SL, Rice HE, Thompson J, Sullivan DT. Evaluation of a discharge education protocol for pediatric patients with gastrostomy tubes. J Pediatr Health Care 2014; 28:420-8. [PMID: 24582896 DOI: 10.1016/j.pedhc.2014.01.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 01/18/2014] [Accepted: 01/20/2014] [Indexed: 11/24/2022]
Abstract
INTRODUCTION To evaluate the impact of a preprocedure education protocol for children who receive a gastrostomy tube (GT). METHODS A preintervention-postintervention design, using surveys and comparison between preprotocol and postprotocol cohorts, was used to evaluate the effect of implementation of a standardized GT education protocol with 26 subjects on caregiver, patient, and provider outcomes. RESULTS The use of a preprocedure education protocol resulted in improved patient outcomes and increased caregiver knowledge and confidence and was considered a positive change by the providers. DISCUSSION Often education is a forgotten part of a medical procedure, and the importance of education is typically only recognized after an adverse event occurs. Establishing a standardized evidence-based education protocol for GT care improves overall care and satisfaction. Use of a systematic and family-centered interdisciplinary approach markedly improves patient care.
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Rollins H, Nathwani N, Morrison D. Optimising wound care in a child with an infected gastrostomy exit site. ACTA ACUST UNITED AC 2013; 22:1275-9. [DOI: 10.12968/bjon.2013.22.22.1275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Baker L, Emil S, Baird R. A comparison of techniques for laparoscopic gastrostomy placement in children. J Surg Res 2013; 184:392-6. [DOI: 10.1016/j.jss.2013.05.067] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 04/26/2013] [Accepted: 05/15/2013] [Indexed: 01/08/2023]
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Ten-year experience using antegrade enemas in children. J Pediatr 2012; 161:700-4. [PMID: 22683036 DOI: 10.1016/j.jpeds.2012.04.042] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Revised: 03/09/2012] [Accepted: 04/23/2012] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To describe a single-center, 10-year experience with the use of antegrade enemas. STUDY DESIGN Retrospective analysis of 99 patients treated with antegrade enemas at Nationwide Children's Hospital. RESULTS Study subjects (median age 8 years) were followed for a mean time of 46 months (range 2-125 months) after cecostomy placement. Seventy-one patients had the cecostomy placed percutaneously and 28 by surgery. Thirty-five patients had functional constipation and 64 patients an organic disease (spinal abnormalities, cerebral palsy, imperforate anus, Hirschsprung's disease). While using antegrade enemas, 71% became symptom-free, in 20 subjects symptoms improved, in 2 subjects symptoms did not change, and in 7 subjects symptoms worsened. Poor outcome was associated with surgical placement of the cecostomy (P < .001), younger age (P = .02), shorter duration of symptoms (P = .01), history of Hirschsprung's disease (P = .05), cerebral palsy (P = .03), previous abdominal surgery (P = .001), and abnormal colonic manometry (P = .004). In 88%, successful irrigation solution included use of a stimulant laxative, and subjects who used a stimulant did significantly better (P < .001) than subjects who started without a stimulant. In 13 patients, the cecostomy was removed 49.7 months after placement without recurrence of symptoms. Major complications occurred in 12 patients and minor complications in 47. CONCLUSIONS Antegrade enemas represent a successful and relatively safe therapeutic option in children with severe defecatory disorders. Prognostic factors are identified.
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Tutor JD, Gosa MM. Dysphagia and aspiration in children. Pediatr Pulmonol 2012; 47:321-37. [PMID: 22009835 DOI: 10.1002/ppul.21576] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Accepted: 08/11/2011] [Indexed: 11/08/2022]
Abstract
Aspiration is a significant cause of respiratory morbidity and sometimes mortality in children. It occurs when airway protective reflexes fail, especially, when dysphagia is also present. Clinical symptoms and physical findings of aspiration can be nonspecific. Advances in technology can lead to early diagnosis of dysphagia and aspiration, and, new therapeutic advances can significantly improve outcome and prognosis. This report first reviews the anatomy and physiology involved in the normal process of swallowing. Next, the protective reflexes that help to prevent aspiration are discussed followed by the pathophysiologic events that occur after an aspiration event. Various disease processes that can result in dysphagia and aspiration in children are discussed. Finally, the various methods for diagnosis and treatment of dysphagia in children are reviewed.
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Affiliation(s)
- James D Tutor
- Program in Pediatric Pulmonary Medicine, University of Tennessee Health Science Center, LeBonheur Children's Hospital, St. Jude Children's Research Hospital, Memphis, Tennessee 38103, USA.
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Gastrostomy tube replacement in a pediatric ED: frequency of complications and impact of confirmatory imaging. Am J Emerg Med 2012; 30:1501-6. [PMID: 22306396 DOI: 10.1016/j.ajem.2011.12.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Revised: 12/10/2011] [Accepted: 12/11/2011] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Gastrostomy tube (g-tube) dislodgement is a common problem in special needs children. There are no studies on the frequency of complications after g-tube replacement for children in a pediatric emergency department (ED). OBJECTIVES The objective of this study is to determine the frequency of misplacement and subsequent complications for children undergoing g-tube replacement in a pediatric ED and the impact of contrast-enhanced confirmatory imaging on ED length of stay (LOS). METHODS This was a retrospective review of children presenting to a pediatric ED over 16 months. Subjects were included if they underwent g-tube replacement in the ED. Records were reviewed for historical and procedural data including patient age, g-tube age, ED LOS, documented difficulties replacing the tube, performance of confirmatory imaging (contrast-enhanced radiograph), and complications identified within 72 hours of ED visit. RESULTS A total of 237 children met inclusion criteria. Three (1.2%) had evidence of g-tube misplacement, all of whom underwent confirmatory imaging. One complication from misplacement was identified (gastric outlet obstruction from overfilled balloon). Tract disruption was not identified for any subject. Eighty-four subjects (35%) had confirmatory imaging performed after replacement. Mean ED LOS in the imaged group was 265 vs 142 minutes for the nonimaged group (P < .001). No subjects with documentation of clinical confirmation had subsequent evidence of misplacement. CONCLUSIONS For children undergoing g-tube replacement in a pediatric ED, misplacement and associated complications were rare. Confirmatory imaging was associated with a considerably longer LOS. In the presence of clinical confirmation, confirmatory imaging may be judiciously used.
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Oh PS, Gill KZ, Lynch LJ, Cowles RA. Primary squamous cell carcinoma arising at a gastrostomy tube site. J Pediatr Surg 2011; 46:756-758. [PMID: 21496550 DOI: 10.1016/j.jpedsurg.2011.01.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Revised: 01/10/2011] [Accepted: 01/12/2011] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- Pilyung S Oh
- Division of Pediatric Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons and Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY 10032, USA
| | - Kamraan Z Gill
- Department of Pathology, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
| | - Lori J Lynch
- Division of Pediatric Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons and Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY 10032, USA
| | - Robert A Cowles
- Division of Pediatric Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons and Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY 10032, USA.
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