A guide to the management of common gastrostomy and gastrojejunostomy tube problems

Gastrostomy Tubes: Indications, Types, and Care

Gastrostomy tube insertion has become a more common practice in pediatric patients. An increasing number of children both in health-care facilities and at home are relying on temporary or long-term enteral feeding. Gastrostomy tube placement can be accomplished by various methods and by a variety of specialists. Despite the overall safety of these procedures, both early and late complications can occur. It is important for pediatricians and pediatric subspecialists to be familiar with and aware of the indications, safety, and management of gastrostomies. This paper provides a comprehensive overview of the topic.

The Impact of Proactive Gastrostomy Tube Placement on Treatment-related Outcomes in Young Children With High-grade Central Nervous System Tumors

Young children undergoing treatment with intensive chemotherapy for high-grade central nervous system (CNS) tumors are at risk for malnutrition, yet no guidelines exist for the placement of enteral tubes. Prior studies evaluated the impact of proactive gastrostomy tube (GT) placement with a narrow scope of outcomes, such as weight. To examine the impact of proactive GT on comprehensive treatment outcomes, we performed a single-center, retrospective study of children younger than 60 months of age with high-grade CNS tumors treated per CCG99703 or ACNS0334 between 2015 and 2022. Of 26 patients included, 9 (35%) underwent proactive GT, 8 (30%) had rescue GT, and 9 (35%) had a nasogastric tube (NGT). Clinically significant weight loss occurred in 47% of patients with NGT during induction compared with 22% with proactive GT ( P = 0.274); however, between cohorts, there was no significant difference in antibiotic or parenteral nutrition utilization, weight loss at therapy completion, and duration of hospitalization. Therefore, proactive GT placement was modestly effective at preventing significant weight loss during induction, however, there was no clear benefit for hospitalization duration, antibiotic, or parental nutrition requirements compared with NGT. We recommend an individualized approach to GT placement for young children with CNS malignancies undergoing intensive chemotherapy.

Changes in Medical Charges Following Intensive Multidisciplinary Intervention for Pediatric Gastrostomy Tube Dependence

OBJECTIVE

Intensive multidisciplinary intervention (IMI) is the most evidence-based approach to treat pediatric feeding disorders. The goal of this exploratory study was to assess changes in health care charges for patients with gastrostomy tube dependence following participation in IMI compared to a waitlist control.

METHODS

Medical charges were assessed for 9 families who participated in IMI compared to 6 control families on a multi-year waitlist for IMI. The IMI and control groups were compared on raw charges submitted as well as individual year-over-year changes in medical charges.

RESULTS

The IMI group decreased health care charges by 71% on average in the year following IMI compared to the control group increasing charges by 22% over the same period.

CONCLUSIONS

IMI also holds potential cost-savings in the year following treatment compared to children who do not receive treatment and adds to previous research focusing on long-term cost effectiveness of IMI.

A Study of Postoperative Complications Occurring at Home With Pediatric Gastrostomy Feeding Tubes

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.

Mealtime Support: A Pilot Case Series study of an Effective, Cost-saving Outpatient Hunger-Based Feeding Program for Tube Dependency

Tube feeding is essential for children who cannot meet nutritional requirements orally. Over time, this can lead to tube dependency with negative impacts on the quality of life of children and families.

Objective

We aimed to examine the efficacy of a multidisciplinary child-led, hunger-based approach called "Mealtime Support" at the Stollery Children's Hospital in Edmonton. Nutritional outcomes, parental satisfaction, and cost implications were evaluated over 9 months postprogram completion per child.

Methods

The ambulatory meal program was delivered 2-3 times a day, for 2 weeks, by an occupational therapist and dietitian, under medical supervision. Hunger was promoted by reducing tube fed calories by 80% before commencement. Caregivers completed 12-question subjective surveys pre- and postintervention. Microcosting methods compared costs between the program and ongoing tube feeding.

Results

From 2016 to 2017, 6 children were enrolled and 5 completed the program. At 1-month postintervention, 4/5 of the children were 100% orally fed. Parents reported improvement in mealtime struggles (P = 0.005), reduction in worry about their child's eating (P = 0.005), and improvement in their child's appetite/variety foods eaten (P = 0.004). Over 2 years, the potential cost savings were estimated at $43,471.00. By 6 months, all feeding tubes were removed.

Conclusions

Mealtime support was safe and successful in reducing tube dependency and cost-effective compared to no intervention or hospital based programs, which suggests that there is a need to develop and fund Canadian outpatient feeding programs.

Early feeding after percutaneous endoscopic gastrostomy tube placement in trauma and surgical intensive care patients: A retrospective cohort study

BACKGROUND

Critically ill patients experience frequent interruptions in enteral nutrition(EN). For ventilated patients who undergo percutaneous endoscopic gastrostomy tube(PEG) placement, post-procedure fasting time varies from 1-24hrs, depending on the surgeon's preference. There is no evidence to support prolonged fasting after PEG placement. This study's purpose was to determine if there is an increased complication rate associated with reduced fasting time after PEG.

METHODS

150 adult ventilated trauma and surgical ICU patients at a level I trauma center underwent PEG placement March 2015-May 2018 by one of 6 surgical intensivists. Retrospective review revealed variable post-PEG fasting practices among them: 1 started EN at 1hr, 2 at 4hrs, 2 at 6hrs, and 1 at 24hrs. Time to initiation of EN and complication rates were assessed. Patients were divided into early feeding(<4hrs) and prolonged fasting(≥4hrs) groups.

RESULTS

Median post-procedure fasting time was 5.5hrs. Complications included bleeding(2), infection(1), tube leak(1), feeding intolerance(1) and aspiration(0). The overall complication rate was 3.3%, with feeding intolerance rate 0.7% and aspiration rate 0%. There was no difference in complication rate for early feeding(3.1%) as compared to delayed feeding(3.4%) (OR 0.92, 95%CI 0.10-8.52, p = 0.7).

CONCLUSION

Complication rates following PEG placement in ventilated trauma and surgical ICU patients are low and do not change with early feeding <4hr compared to prolonged fasting ≥4hr. Early feeding after PEG is probably safe. With this data, a randomized controlled trial is underway that will provide evidence to support a more consistent practice, thus mitigating a source of EN interruption in a population vulnerable to malnutrition. This article is protected by copyright. All rights reserved.

Technology-Dependent Children

There are a growing number of medically complex children with implanted devices. Emergency physicians with a basic knowledge of these devices can troubleshoot and fix many of the issues that may arise. Recognition of malfunction of these devices can reduce morbidity and mortality among this special population. In this article, we review common issues that may arise in children with gastrostomy tubes, central nervous system shunts, cochlear implants, and vagal nerve stimulators.

Imaging of acute gastric emergencies: a case-based review

The stomach is one of the most frequently imaged organs in the body with dedicated and incidental inclusion in chest imaging modalities. Gastric emergencies often present clinically with non-specific abdominal, nausea, and vomiting. As such, imaging plays a critical role in early identification and treatment of a myriad of gastric emergencies. The goal of this paper is to showcase gastric emergencies as they appear on multimodality imaging.

Fluoroscopy: An essential diagnostic modality in the age of high-resolution cross-sectional imaging

The importance of fluoroscopy as an imaging modality has been minimized relative to other cross-sectional modalities, including high-resolution computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound. Fluoroscopy examinations have decreased in clinical practice due to reduced appreciation of its usefulness, insufficient training of residents, fewer staff with adequate expertise, and poor reimbursements relative to other modalities. We revisit and build upon the prior literature and history of this decreased utilization. We then seek to prove continued value, through categorized examples and within multiple subspecialties, wherein fluoroscopy plays an integral part toward clinical diagnoses as well as optimizing patient outcomes. This is particularly true for motility and esophageal disorders, where structure and function with real-time evaluation is essential.  We additionally show several post-operative cases where the synergy of fluoroscopy with CT and endoscopy is apparent.  The fluoroscopic radiologist also has the unique ability to vary patient positioning, as opposed to traditional CT or MRI, where orthogonal views are employed without positional or temporal changes. We turn attention to the modern era, with synergistic and novel cases demonstrating that fluoroscopy remains instrumental toward achieving a diagnosis alongside other modalities. Our cases stress the need to maintain expertise in fluoroscopy skill, and underline its continued importance in residency training programs.  We conclude that fluoroscopy is a relatively inexpensive modality that is often under-appreciated in diagnostic radiology. We suggest that competency in fluoroscopy is crucial for future generations of radiologists to both work with their peers, as well as to aid clinicians in the optimal treatment of patients.

Profile of hospital admissions for adults with cerebral palsy: a retrospective cohort study

AIM

To retrospectively profile acute hospital admissions for a defined cohort of adults with cerebral palsy (CP).

METHOD

Five years of health service data were interrogated to identify acute health service use by adults with CP. Admission types were described, admission reasons categorized using International Classification of Diseases, 10th Revision codes, and length of stay (LOS) calculated. Any differences between paediatric and adult subsets were explored.

RESULTS

Individuals with CP constituted 2922 admissions. Of these, 850 (29%) were adult admissions. There were significant differences between admission reasons for paediatric and adult cohorts, with adults predominantly seeking hospital admission for emergency rather than planned care (emergency reason: adults 62.1%, paediatrics 25.2%; p<0.001). The median adult admission LOS was longer than that of children (p<0.001). The primary diagnosis admission reason in the adult data set was respiratory illness (20%) followed closely by gastrostomy dysfunction (19%).

INTERPRETATION

Adults with CP predominantly access acute hospital services for emergency health care. A high frequency of admissions is associated with respiratory illness and gastrostomy dysfunction in adults with CP. What this paper adds Adults with cerebral palsy (CP) access acute inpatient services for emergency health care. Hospital admissions are predominantly because of respiratory illness and gastrostomy dysfunction. Admission length of stay is longer for adults than children. Many adults with CP require hospitalization more than once a year.

Technology-dependent children

In recent past, revolution in medical technology resulted in improved survival rates and outcomes of critically ill children. Unfortunately, its impact relating to morbidity is not well documented. Although survival rates of these critically ill children who are medically fragile and technology-dependent have improved, we as health professionals are still in the learning curve to improve the quality of life of these children at home. Factors such as support from society, infrastructure, and funding play an important role in technology-dependent child care at home. In this review, commonly prescribed home-based medical technologies such as home ventilation, enteral nutrition, renal replacement therapy, and peripherally inserted central catheter, which are useful for quick revision, are described.

Adapted Crusting Technique in Children with Peristomal Lesions: A Case Series

OBJECTIVE

To describe the care of pediatric patients who had a gastrostomy and developed peristomal lesions and received a systematic single adapted crusting technique in a pediatric ICU in a tertiary Brazilian hospital.

METHODS

An analysis of six cases presenting traumatic, noninfectious peristomal lesions with ostium enlargement resulting in gastric residual leaks. All six patients received the same treatment over 7 to 15 days.

RESULTS

Lesion improvement was observed in all patients after 48 hours and considered attributable to the standard treatment recommended by ostomy professionals.

CONCLUSIONS

The adapted crusting technique was effective in the treatment of children with peristomal lesions. This technique may be beneficial to other patient and organizational outcomes such as improving safety of care, decreasing pain and discomfort, reducing nursing workload and hospital costs, and improving quality of life.

A Literature Review of Percutaneous Endoscopic Gastrostomy: Dealing With Complications

Sufficient energy and essential nutrients are vital for normal growth and development in childhood. Ideally, nutrition should be provided orally. However, if the gastrointestinal system is functional, enteral tube feeding can be used when nutritional requirements cannot be provided orally, thus providing nutritional benefits and enabling positive disease management in pediatric patients. Postoperative care in children allows monitoring of the position and functionality of the tube; performing nutrition intolerance, growth, hydration, and nutritional assessments; and performing metabolic and complication follow-ups. Tube feeding in pediatric patients is beneficial and has positive effects in controlling and managing diseases and providing appropriate nutrition in children. However, in postoperative patients, it is important to prevent potential complications, which can be classified into 5 groups: mechanical, gastrointestinal, metabolic, infectious, and pulmonary complications. Important points for managing complications include having enteral nutrition practices based on evidence-based guidelines, sharing outcomes with nurses working in clinical settings, creating enteral feeding guides in clinical settings, providing patients/patients' family with training in line with these guides, and maintaining follow-ups at home. This literature review discusses complications and practices regarding the management of complications after percutaneous endoscopic gastrostomy.

Complications of percutaneous gastrostomy and gastrojejunostomy tubes in children

Percutaneous feeding tubes are generally considered a safe option for enteral feeding and are widely used in children who require long-term nutritional support. However, complications are not infrequent and can range from bothersome to life-threatening. Radiologists should be familiar with the imaging appearances of potential complications for optimal patient care. In this review, we discuss radiologic appearances of common complications and less frequent but serious complications related to percutaneous feeding tubes. Additionally, as fluoroscopic feeding tube evaluation is often requested as the initial imaging study, we also discuss the fluoroscopic appearances of some uncommon complications.

Duodenal perforation after gastrostomy tube replacement: Case report and literature review

Gastrostomy is commonly used to provide long-term enteral access for patients with feeding impairment. Routine replacement is a safe procedure, but it has various complications. We present a case of nasopharyngeal cancer, who visited the emergency department for gastrostomy tube dislodgement. Diffuse abdominal pain developed 3 days after replacement of the gastrostomy tube with a temporary silicone Foley tube. Emergency diagnostic laparoscopy was performed and found tip migration and causing duodenal perforation. Tip migration and compression necrosis of mucosa were the possible mechanisms. The condition was successfully treated by emergency laparoscopic duodenorrhaphy.

Paediatric emergency department presentations due to feeding tube complications in children with cerebral palsy

AIM

To describe the characteristics of emergency department (ED) presentations due to complications from gastrostomy or gastrojejunal feeding tubes among children with cerebral palsy (CP), the complexity of complications and the management approaches taken.

METHODS

The Victorian CP Register was linked to the ED databases of Victoria's two tertiary paediatric hospitals, and data on presentations due to feeding tube complications were identified based on discharge diagnosis codes. Additional data on presentations were extracted from medical records.

RESULTS

Over 5 years, there were 234 ED presentations due to feeding tube-related complaints among a CP cohort (n = 2183). ED notes were located for 183 of the 234 presentations. The majority of presentations (90%) involved children with severe gross motor impairment. A total of 46% of presentations (n = 84) was triaged as lower urgency, and 68% (n = 124) took place between 08:00 am and 06:00 pm. The most common presenting complaint was tube dislodgement (n = 105; 70%). No investigations were recorded in the majority of cases, and in almost 90% of cases, the feeding tube was successfully replaced in the ED, usually by an ED physician (n = 74) and less frequently by a surgeon (n = 9), gastroenterologist (n = 2) or nurse (n = 8); 9% (n = 17) resulted in a hospital admission.

CONCLUSIONS

Most ED presentations due to feeding tube complaints in children with CP are in children with severe gross motor impairment but are able to be managed in the ED. As such, it is likely that care givers and other health professionals could manage some of the complications experienced in primary health-care settings closer to home.

Comparison of the Laparoscopic and Open Methods of Gastrostomy at Neonates and Infants Up To Three Months of Age

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.

Introducing novel advanced practice roles into the health workforce: Dietitians leading in gastrostomy management

AIM

The number of advanced practice roles in the Australian health-care system is growing alongside contemporary health-care reforms. The present study aimed to evaluate the impact of introducing novel advanced practice dietitian roles in gastrostomy tube (g-tube) management and develop a competency framework for progressing opportunities in dietetics practice and policy.

METHODS

A questionnaire was distributed to service lead dietitians at six participating health-care networks at the completion of a dedicated advanced practice funding grant, and at 12-month follow up. Service changes (e.g. number of dietitians credentialed, service and adverse events, change in patient waiting times and staff satisfaction), enablers and barriers for the implementation of the novel roles (including pre-, during, and post-implementation), and clinical costing estimates to measure the financial impact on the health system were investigated. Participant feedback was also used to synthesise the development of an advanced scope of practice pathway to competency.

RESULTS

Responses were received from all participating health-care networks. Five out of six sites successfully implemented an advanced practice role in g-tube management, with conservative health system savings estimated at $185 000. Ten dietitians were credentialed, with a further seven trainees in progress. Over 200 service events were recorded, including those diverted from other health professionals. Enabling factors for successful introduction included strong executive and stakeholder support, resources provided by grant funding, and established credentialing governance committees. Barriers included recruitment and governance processes.

CONCLUSIONS

Opportunities exist for further expansion of advanced and extended practice roles for dietitians to meet future health-care demands.

Decision-making around gastrostomy tube feeding in children with neurologic impairment: Engaging effectively with families

Children with neurologic impairment may not be able to feed safely or sufficiently by mouth to maintain an adequate nutritional state. Gastrostomy tube (G-tube) feeding is an important, often essential, intervention in such situations. However, many parents and families struggle with the decision to proceed with G-tube feeding. This practice point reviews common reasons for decisional conflict in parents and explores key aspects of life with G-tube feeding. A framework for shared decision-making and the International Classification of Functioning, Disability and Health (ICF) approach are highlighted. Practical recommendations for clinicians on engaging with families for decision-making around this life-changing intervention are provided.

Paediatric gastrostomy stoma complications and treatments: A rapid scoping review

AIMS AND OBJECTIVES

To provide a scoping review of the types of treatments used to address paediatric skin-related stoma complications specific to infection, hypergranulation and gastric leakage, and explore their effectiveness and indications for use.

BACKGROUND

Stoma-related complications can be a common occurrence for children with gastrostomy (G) and gastrojejunostomy (GJ) tubes. Nurses require guidance to inform decision-making of the broad spectrum of treatments used in clinical practice.

DESIGN

A scoping review using a rapid review approach.

METHODS

Working with a multidisciplinary health professional team, search terms were generated. A systematic search of CINAHL, MEDLINE and EMBASE databases was completed, coupled with an Internet search to identify relevant clinical practice guidelines and hand searching of citation lists. Eligible articles were peer-reviewed English publications, focused on paediatric populations aged 18 years and under, dating from 2002-2016 and described complications and treatment approaches related to G- and GJ-tube stomas. Pertinent information was extracted using a standardised template, and a narrative synthesis approach was used to analyse the data.

RESULTS

Twenty-five articles were included in this review. Study designs varied, and complication management was often a secondary focus. A broad spectrum of treatments was used to manage each complication type. There was a lack of consensus on lines of therapy; however, a stepwise approach was often used for complication management, particularly for infections.

CONCLUSIONS

The evidence on the comparative effectiveness of different treatment strategies of skin-related gastrostomy stoma complications in paediatric practice is sparse. Current evidence is generally limited to expert opinions. Future studies examining efficacy of treatments and their indications for use with children are warranted.

RELEVANCE TO CLINICAL PRACTICE

Effective management of skin-related stoma complications is important to maintain health and wellness among children who rely on G- and GJ-tubes for nutrition support.

Comparison of Emergency Department Visits for Complications of Gastrostomy Versus Gastrojejunostomy Tubes in Children

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.

Mitigation of stomach dehiscence risk during gastrostomy tube changes - a retrospective analysis of patient outcomes

INTRODUCTION

Stomach dehiscence from the abdominal wall is a serious and potentially life-threatening complication of gastrostomy tube changes. This retrospective study evaluates gastric aspiration as an inexpensive and safe alternative to endoscopic or radiographic confirmation.

METHODS

From August 1998 to June 2016, 682 patients (301 female, 381 male) underwent 1713 gastrostomy tube changes in the medical setting, with an average age of 7.59years and an average site age of 3.43years. The most common diagnoses were GERD (304), aspiration (168), and failure to thrive (143).

RESULTS

All newly inserted tubes were aspirated to visually inspect for gastric fluid. This procedure as a confirmatory test for intragastric placement was found to have a positive predictive value of 99.5% and negative predictive value of 77.8%, with a sensitivity of 99.8% and specificity of 63.6%. In cases with successful aspiration of gastric fluid, 75.5% of changes resulted in no complications, with intraperitoneal insertion or leak in only 0.48% of cases.

CONCLUSIONS

Positive gastric aspirate is a strong predictor of proper G-tube placement with high sensitivity, eliminating the requirement of specialized equipment and the cost associated with endoscopic or radiographic guidance, and has a comparable or superior risk profile.

LEVELS OF EVIDENCE

Study of diagnostic test level II.

Comparison of Two Laparoscopic Techniques for Gastropexy in Children

BACKGROUND

Laparoscopic gastrostomy is a widely used interventional procedure in pediatric surgery. We report comparative data for two endosurgical methods for the fixation of the stomach against the abdominal wall, using the U-stitches technique and the Saf-T-Pexy® (Halyard Health Inc., Alpharetta, GA) system.

MATERIALS AND METHODS

Within the period from January 2012 to June 2014 we performed 24 operations involving laparoscopic placement of a gastrostomy tube using U-stitches (Group I) and 24 operations using the Saf-T-Pexy system (Group II). The two groups of patients were compared in terms of demographics and intraoperative and postoperative results.

RESULTS

No statistical difference (P > .05) was found while comparing the patients' demographics and intra- and postoperative results. The mean duration of the surgical procedure in Group I was 23.75 minutes; in contrast, the mean duration of surgery in Group II was 22.71 minutes (P > .05). The time to first feeding (9.96 hours versus 10.63 hours) and time to full enteral feeding (23.13 hours versus 24.5 hours) were consistent for patients from both groups (P > .05). A similar postoperative duration of stay was recorded for the patients from the comparison groups (7.25 days versus 7.21 days; P > .05). Statistical analysis of the two groups demonstrated a significant difference in the parameters of minor postoperative complications (41.67% versus 8.33%; P < .05).

CONCLUSIONS

Use of the Saf-T-Pexy system is a simple and efficient method for gastropexy involving placement of gastrostomy tubes that significantly reduces the number of postoperative complications.

[Button gastrostomy in children]

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.

Educating parents on gastrostomy devices: necessary components to achieve success

Often parents leave the hospital without the education needed to care for their child's gastrostomy device. Lack of nurse knowledge and the use of various types of devices contribute to their confusion and inability to adequately educate parents. An enhanced methodology and process to standardize gastrostomy education were designed and implemented. Data results confirmed an improvement in the knowledge and competency of both staff nurses and parents. Empowering staff nurses with knowledge and the necessary resources and tools to confidently educate parents, along with a standardized process, has improved overall outcomes.

Shared decision-making about assistive technology for the child with severe neurologic impairment

Shared decision-making is a process that helps frame conversations about value-sensitive decisions, such as introduction of assistive technology for children with neurologic impairment. In the shared decision-making model, the health care provider elicits family values relevant to the decision, provides applicable evidence in the context of those values, and collaborates with the family to identify the preferred option. This article outlines clinical, quality of life, and ethical considerations for shared decision-making discussions with families of children with neurologic impairment about gastrostomy tube and tracheostomy tube placement.