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Muto M, Onishi S, Murakami M, Kedoin C, Yano K, Harumatsu T, Yamada K, Yamada W, Kaji T, Ieiri S. Useful traction technique for laparoscopic fundoplication without removing proceeding gastrostomy in a neurologically impaired patient with a body deformity. Asian J Endosc Surg 2022; 15:697-699. [PMID: 35066994 DOI: 10.1111/ases.13028] [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: 08/04/2021] [Revised: 12/27/2021] [Accepted: 01/06/2022] [Indexed: 11/27/2022]
Abstract
Severely neurologically impaired patients often require the creation of a gastrostomy when they develop difficulty with oral intake followed by antireflux surgery. We use a traction technique for laparoscopic fundoplication without removing the gastrostomy in such cases. Right lateral traction of the round ligament of the liver and left lateral traction of the stomach body are performed using a needle device. The left liver lobe is elevated with a liver retractor inserted via the epigastrium. This traction technique allows a sufficient surgical field for manipulating forceps to be created in cases with a gastrostomy, enabling fundoplication to be performed safely without removing the gastrostomy.
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Affiliation(s)
- Mitsuru Muto
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Shun Onishi
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Masakazu Murakami
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Chihiro Kedoin
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Keisuke Yano
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Toshio Harumatsu
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Koji Yamada
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Waka Yamada
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.,Clinical Training Center, Kagoshima University Hospital, Kagoshima, Japan
| | - Tatsuru Kaji
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.,Clinical Training Center, Kagoshima University Hospital, Kagoshima, Japan
| | - Satoshi Ieiri
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
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2
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Dreznik Y, Baazov A, Dvir N, Seguier-Lipszyc E, Zevit N, Nica A, Samuk I, Shamir R, Dlugi E, Freud E, Kravarusic D. Is fundoplication mandatory in children with neurological impairment undergoing gastrostomy? J Paediatr Child Health 2022; 58:588-592. [PMID: 34632661 DOI: 10.1111/jpc.15767] [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: 06/26/2021] [Revised: 09/10/2021] [Accepted: 09/12/2021] [Indexed: 11/29/2022]
Abstract
AIM Percutaneous endoscopic gastrostomy (PEG) and surgical gastrostomy (SG) are common procedures in children with neurological impairment (NI) with swallowing difficulties. Pulmonary aspirations are a major concern and performing concomitant or delayed fundoplication is still controversial, especially among these patients. The aim of our study was to review our experience with fundoplication performed concomitantly with gastrostomy or later and to evaluate patient outcomes. METHODS This is a retrospective, cohort study including all paediatric patients who underwent SG or PEG with or without Nissen fundoplication at Schneider Children's Medical Center of Israel between the years 2007 and 2018. Patients' clinical and surgical data were recorded and analysed. RESULTS Between 2007 and 2018, 345 patients underwent SG or PEG. Of these, 89 patients underwent fundoplication. Of the patients who underwent PEG/SG, 158 (45.8%) were neurologically impaired. Most of the patients who underwent fundoplication (n = 69, 77.5%) were NI patients (P = 0.0001). NI patients with refractory seizures showed almost no improvement in terms of relief of gastro-oesophageal reflux disease symptoms following fundoplication (P = 0.0001) compared to NI patients without refractory seizures. CONCLUSION Our findings suggest that in NI patients a concomitant fundoplication is not mandatory and is not efficacious in preventing gastro-oesophageal reflux disease in patients with refractory seizures.
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Affiliation(s)
- Yael Dreznik
- Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Israel, Petah-Tiqva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Artur Baazov
- Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Israel, Petah-Tiqva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nadav Dvir
- Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Israel, Petah-Tiqva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Emmanuelle Seguier-Lipszyc
- Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Israel, Petah-Tiqva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Noam Zevit
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,The Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petah-Tiqva, Israel
| | - Adrianna Nica
- Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Israel, Petah-Tiqva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Inbal Samuk
- Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Israel, Petah-Tiqva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Raanan Shamir
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,The Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petah-Tiqva, Israel
| | - Elena Dlugi
- Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Israel, Petah-Tiqva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Enrique Freud
- Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Israel, Petah-Tiqva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dragan Kravarusic
- Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Israel, Petah-Tiqva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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3
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Ulman H, Dokumcu Z, Elekberova V, Celtik U, Divarci E, Ozcan C, Erdener A. Long-term outcome and efficiency of symptom-selective approach to assess gastroesophageal reflux prior to gastrostomy in neurologically impaired children. Pediatr Surg Int 2021; 37:903-909. [PMID: 33783634 DOI: 10.1007/s00383-021-04891-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2021] [Indexed: 01/05/2023]
Abstract
PURPOSE To evaluate the necessity of preoperative screening for gastroesophageal reflux (GER) prior to gastrostomy in neurologically impaired children. METHODS Medical records of neurologically impaired children, who have undergone laparoscopic gastrostomy between January, 2004 and June, 2018, were retrospectively reviewed. Before the year of 2014, all patients who required gastrostomy had been routinely screened for GER pre-operatively, but after the year of 2014, only the ones with GER-related symptoms were tested. The characteristics and outcomes of Routine Screening (RS) and Selective Screening (SS) periods were compared. RESULTS There were 55 and 54 patients in the RS and SS periods, respectively. Demographics, primary pathologies, and mean follow-up durations (> 2 years) were similar. The rate of GER screening was significantly lower in the SS period (29.6% vs. 63.6%). The rate of Laparoscopic Nissen Fundoplication (LNF) combined with gastrostomy was significantly lower in the SS period (14.8% vs. 38.2%). During follow-up, the rates of new-onset GER symptoms (13% vs. 11.7%) and LNF requirement later on (6.5% vs. 8.8%) were statistically similar between the two periods. CONCLUSION Routine screening for GER is not necessary prior to gastrostomy in neurologically impaired children. Symptom-selective screening algorithm is safe and efficient in the long term.
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Affiliation(s)
- Hilmican Ulman
- Department of Pediatric Surgery, Ege University Faculty of Medicine, 35100, Bornova, Izmir, Turkey
| | - Zafer Dokumcu
- Department of Pediatric Surgery, Ege University Faculty of Medicine, 35100, Bornova, Izmir, Turkey.
| | - Vusale Elekberova
- Department of Pediatric Surgery, Ege University Faculty of Medicine, 35100, Bornova, Izmir, Turkey
| | - Ulgen Celtik
- Department of Pediatric Surgery, Ege University Faculty of Medicine, 35100, Bornova, Izmir, Turkey
| | - Emre Divarci
- Department of Pediatric Surgery, Ege University Faculty of Medicine, 35100, Bornova, Izmir, Turkey
| | - Coskun Ozcan
- Department of Pediatric Surgery, Ege University Faculty of Medicine, 35100, Bornova, Izmir, Turkey
| | - Ata Erdener
- Department of Pediatric Surgery, Ege University Faculty of Medicine, 35100, Bornova, Izmir, Turkey
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4
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Gulla KM, Sahoo T, Sachdev A. Technology-dependent children. Int J Pediatr Adolesc Med 2020; 7:64-69. [PMID: 32642538 PMCID: PMC7335821 DOI: 10.1016/j.ijpam.2019.07.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 07/09/2019] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Krishna Mohan Gulla
- Division of Pediatrics, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - Tanushree Sahoo
- Division of Neonatology, All India Institute of Medical Sciences, New Delhi, India
| | - Anil Sachdev
- Division of Pediatrics, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
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5
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Affiliation(s)
- James D Tutor
- Program in Pediatric Pulmonary Medicine, University of Tennessee Health Science Center, LeBonheur Children's Hospital, and St. Jude Children's Research Hospital, Memphis, TN
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6
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Poola AS, Sujka JA, Rentea RM, Fraser JD, St Peter SD. Success of Bolus Gastric Feeding After Fundoplication Among Children Who Require Preoperative Jejunal Feeding. J Laparoendosc Adv Surg Tech A 2018; 28:1117-1120. [PMID: 30207923 DOI: 10.1089/lap.2018.0117] [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
PURPOSE Management of complicated reflux in infants and children is controversial. Jejunal feedings are used when reflux complications occur with gastric feeds. We sought to determine how successful fundoplication is to allow for return of physiologic gastric feeds in patients requiring jejunal feeds preoperatively. METHODS A retrospective review of patients requiring jejunal feeds before fundoplication between 2010 and 2015 was conducted. RESULTS Two hundred thirteen children underwent fundoplication during the study period. One hundred fourteen (49%) children required preoperative jejunal feeds. Median preoperative jejunal feeding trial was 15 days (interquartile range [IQR] 8-36). After fundoplication, gastric feeds were attempted in all patients. Ninety-one (80%) patients tolerated feeds postoperatively without return of preoperative symptoms. Twenty-one (18%) children developed gastric feeding intolerance and were treated with jejunal feeds at a mean of 8 months postoperatively (range 3-17). Ten (9%) children eventually tolerated intragastric bolus feeds, requiring jejunal feeds for a median duration of 2.3 months (IQR 1-5). There were no differences seen in those who were able to tolerate gastric early after the operation and those who did not. Of the patients who were unable to tolerate bolus gastric feeds during the study, a higher proportion had neurologic impairment and were on jejunal feeds for a longer period of time before fundoplication. CONCLUSION In the majority of patients requiring continuous jejunal feeds to manage complications of reflux, fundoplication allows for transition to gastric bolus feeding.
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Affiliation(s)
- Ashwini S Poola
- Department of Pediatric Surgery, Children's Mercy Hospital , Kansas City, Missouri
| | - Joseph A Sujka
- Department of Pediatric Surgery, Children's Mercy Hospital , Kansas City, Missouri
| | - Rebecca M Rentea
- Department of Pediatric Surgery, Children's Mercy Hospital , Kansas City, Missouri
| | - Jason D Fraser
- Department of Pediatric Surgery, Children's Mercy Hospital , Kansas City, Missouri
| | - Shawn D St Peter
- Department of Pediatric Surgery, Children's Mercy Hospital , Kansas City, Missouri
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7
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Aumar M, Lalanne A, Guimber D, Coopman S, Turck D, Michaud L, Gottrand F. Influence of Percutaneous Endoscopic Gastrostomy on Gastroesophageal Reflux Disease in Children. J Pediatr 2018; 197:116-120. [PMID: 29655862 DOI: 10.1016/j.jpeds.2018.02.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 01/12/2018] [Accepted: 02/01/2018] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To determine if gastroesophageal reflux disease (GERD) is present at long-term follow-up after percutaneous endoscopic gastrostomy (PEG), and to identify factors associated with the occurrence or aggravation of GERD after PEG placement. STUDY DESIGN This prospective, observational study was conducted in our single tertiary center over a 13-year period (gastrostomy performed from 1990 to 2003 and follow-up to 2015). Every child who underwent PEG in our center (N = 368) from 1990 to 2003 was eligible. GERD was defined by clinical manifestations requiring antisecretory or prokinetic treatment, occurrence of a GERD-related complication, or the need for antireflux surgery. Outcomes among patients without antireflux surgery were also assessed. Multivariate analysis was used to identify factors aggravating GERD after PEG placement. RESULTS A total 326 patients (89%; 56% with a neurologic impairment) were studied with a median follow-up after 3.5 years (range, 2.0-13.5 years). After PEG placement, GERD appeared in 11% of patients and was aggravated in 25% of patients with preexisting GERD. Factors associated with GERD worsening after PEG placement were neurologic impairment and preexisting GERD. Only 53 patients (16%) required antireflux surgery, among whom 22 required surgery in the year after PEG. Neurologic impairment was the only factor significantly associated with the need for antireflux surgery. CONCLUSIONS GERD predominantly remains clinically controlled after PEG placement. Routine antireflux surgery at the time of PEG placement is not justified.
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Affiliation(s)
- Madeleine Aumar
- CHU Lille, University of Lille, Reference Center for Congenital and Malformative Esophageal Diseases (CRACMO), Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Jeanne de Flandre, Lille University Children's Hospital, Lille, France.
| | - Arnaud Lalanne
- CHU Lille, University of Lille, Reference Center for Congenital and Malformative Esophageal Diseases (CRACMO), Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Jeanne de Flandre, Lille University Children's Hospital, Lille, France
| | - Dominique Guimber
- CHU Lille, University of Lille, Reference Center for Congenital and Malformative Esophageal Diseases (CRACMO), Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Jeanne de Flandre, Lille University Children's Hospital, Lille, France
| | - Stéphanie Coopman
- CHU Lille, University of Lille, Reference Center for Congenital and Malformative Esophageal Diseases (CRACMO), Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Jeanne de Flandre, Lille University Children's Hospital, Lille, France
| | - Dominique Turck
- CHU Lille, University of Lille, Reference Center for Congenital and Malformative Esophageal Diseases (CRACMO), Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Jeanne de Flandre, Lille University Children's Hospital, Lille, France
| | - Laurent Michaud
- CHU Lille, University of Lille, Reference Center for Congenital and Malformative Esophageal Diseases (CRACMO), Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Jeanne de Flandre, Lille University Children's Hospital, Lille, France
| | - Frédéric Gottrand
- CHU Lille, University of Lille, Reference Center for Congenital and Malformative Esophageal Diseases (CRACMO), Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Jeanne de Flandre, Lille University Children's Hospital, Lille, France
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8
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Hospital variation in rates of concurrent fundoplication during gastrostomy enteral access procedures. Surg Endosc 2018; 32:2201-2211. [DOI: 10.1007/s00464-017-5518-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 03/14/2017] [Indexed: 10/18/2022]
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9
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Yap BKY, Nah SA, Chen Y, Low Y. Fundoplication with gastrostomy vs gastrostomy alone: a systematic review and meta-analysis of outcomes and complications. Pediatr Surg Int 2017; 33:217-228. [PMID: 27889821 DOI: 10.1007/s00383-016-4028-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/25/2016] [Indexed: 01/16/2023]
Abstract
PURPOSE We compare the outcomes of fundoplication with gastrostomy vs gastrostomy alone and review the need for subsequent fundoplication after the initial gastrostomy alone. METHODS We searched studies published from 1969 to 2016 for comparative outcomes of concomitant fundoplication with gastrostomy (FGT) vs gastrostomy insertion alone (GT) in children. Gastrostomy methods included open, laparoscopic, and endoscopic procedures. Primary aims were minor and major complications. Secondary aims included post-operative reflux-related complications, fundoplication specific complications, and need for subsequent fundoplication after GT. RESULTS We reviewed 447 studies; 6 observational studies were included for meta-analysis, encompassing 2730 children undergoing GT (n = 1745) or FGT (n = 985). FGT was associated with more minor complications [19.9 vs 11.4%, OR 2.02, 95% confidence interval (CI) 1.43-2.87, p ≤ 0.0001, I 2 = 0%], minor complications requiring revision (6.8 vs 3.0%, OR 2.27, 95% CI 1.28-4.05, p = 0.005, I 2 = 0%), and more overall complications (21.3 vs 12.0%, OR 1.99, 95% CI 1.43-2.78, p < 0.0001, I 2 = 0%). Incidence of major complications (1.8 vs 2.0%, OR 1.39, 95% CI 0.62-3.11, p = 0.42, I 2 = 5%) and reflux-related complications (8.8 vs 10.3%, OR 0.75, 95% CI 0.35-1.68, p = 0.46, I 2 = 0%) in both groups was similar. Incidence of subsequent fundoplication in GT patients was 8.6% (mean). CONCLUSIONS Gastrostomy alone is associated with fewer minor and overall complications. Concomitant fundoplication does not significantly reduce reflux-related complications. As few patients require fundoplication after gastrostomy, current evidence does not support concomitant fundoplication.
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Affiliation(s)
- Brendan K Y Yap
- Department of Pediatric Surgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Shireen Anne Nah
- Department of Pediatric Surgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Yong Chen
- Department of Pediatric Surgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Yee Low
- Department of Pediatric Surgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.
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10
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Abstract
Occupational therapists in pediatric practice are often required to evaluate and treat children with eating problems. The lack of a standardized eating assessment has hindered therapists' ability to define normal oral-motor development, identify unequivocally those children who will benefit from intervention, refine treatment procedures using information gained through accurate assessment, and monitor progress in clinical and research settings. The purposes of this review are to (a) outline the scope of eating problems in children with oral-motor impairments, (b) establish the need for a quantitative eating assessment, (c) review the assessments currently available, and (d) suggest directions for future development.
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11
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Kakade M, Coyle D, McDowell DT, Gillick J. Percutaneous endoscopic gastrostomy (PEG) does not worsen vomiting in children. Pediatr Surg Int 2015; 31:557-62. [PMID: 25895072 DOI: 10.1007/s00383-015-3707-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/07/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE We aimed to evaluate the rate and examine potential predictors of subsequent anti-reflux procedures in a population undergoing percutaneous endoscopic gastrostomy (PEG) insertion. MATERIALS We retrospectively reviewed the pre- and post-operative clinical course of patients undergoing PEG insertion over a 10-year period with respect to indication, underlying co-morbidity, and GER investigation and management. RESULTS We reviewed data on 170 patients. Neurological disability (e.g., cerebral palsy) was the most common underlying condition in those undergoing PEG insertion (n = 104) followed by cystic fibrosis (n = 29). Oropharyngeal dysphagia and failure to thrive were the commonest indications for PEG. Eight patients (4.7%) reported increased frequency of vomiting after PEG, 6 (75%) of whom had a pre-operative diagnosis of GER. Two (25%) patients from this sub-group subsequently required anti-reflux surgery. Patient's with neurological disease were not at increased risk of new-onset GER or increased vomiting following PEG insertion compared to those with non-neurological conditions (p = 0.259). In total, 8 (4.7%) and 7 (4.1%) patients underwent fundoplication and gastrojejunal tube insertion, respectively. CONCLUSIONS PEG insertion does not appear to induce symptomatic gastro-oesophageal reflux in the majority of children, suggesting that in the majority of cases, a concurrent anti-reflux procedure is unnecessary. Parents should be counseled accordingly.
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Affiliation(s)
- Madhavi Kakade
- Department of Pediatric Surgery, Temple Street Children's University Hospital, Dublin 1, Ireland,
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12
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Kawahara H, Tazuke Y, Soh H, Yoneda A, Fukuzawa M. Does laparoscopy-aided gastrostomy placement improve or worsen gastroesophageal reflux in patients with neurological impairment? J Pediatr Surg 2014; 49:1742-5. [PMID: 25487474 DOI: 10.1016/j.jpedsurg.2014.09.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 09/05/2014] [Indexed: 01/10/2023]
Abstract
BACKGROUND/PURPOSE The purpose of this study was to retrospectively investigate whether laparoscopy-aided gastrostomy placement (LGP) improved or worsened gastroesophageal reflux (GER) in neurological impairment (NI) patients. METHODS Subjects included 26 NI patients nourished via nasogastric tubes (age, 1-17years; median, 6years). They were divided into groups based on the percentage of time with an esophageal pH <4.0 (reflux index: RI) before LGP: Group 1 (GI, n=13), RI <5.0%; Group II (GH, n=13), RI ≥5.0%. Acid/nonacid reflux episodes (RE) were evaluated using combined pH-multichannel intraluminal impedance (pH-MII) monitoring, and gastric emptying was measured with the C breath test before and after LGP. RESULTS RI and number of RE evaluated with pH analyses and number of total/acid distal and proximal bolus RE with pH-MH increased significantly in GI. RI and acid clearance time with pH analyses and number of total bolus RE with pH-MII decreased significantly in GH. Gastric emptying parameters did not change significantly in GI, whereas the half-gastric emptying time and gastric emptying coefficient improved significantly in GH. CONCLUSION LGP reduces GER in NI patients with pathological GER by improving gastric emptying, although it has a paradoxical influence on those without pathological GER.
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Affiliation(s)
- Hisayoshi Kawahara
- Department of Pediatric Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan.
| | - Yuko Tazuke
- Department of Pediatric Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Osaka, Japan
| | - Hideki Soh
- Department of Pediatric Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Osaka, Japan
| | - Akihiro Yoneda
- Department of Pediatric Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Osaka, Japan
| | - Masahiro Fukuzawa
- Department of Pediatric Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Osaka, Japan
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13
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Abstract
The decision to initiate enteral feedings is multifaceted, involving medical, financial, cultural, and emotional considerations. Children who have developmental or acquired disabilities are at risk for having primary and secondary conditions that affect growth and nutritional well-being. This clinical report provides (1) an overview of clinical issues in children who have developmental or acquired disabilities that may prompt a need to consider nonoral feedings, (2) a systematic way to support the child and family in clinical decisions related to initiating nonoral feeding, (3) information on surgical options that the family may need to consider in that decision-making process, and (4) pediatric guidance for ongoing care after initiation of nonoral feeding intervention, including care of the gastrostomy tube and skin site. Ongoing medical and psychosocial support is needed after initiation of nonoral feedings and is best provided through the collaborative efforts of the family and a team of professionals that may include the pediatrician, dietitian, social worker, and/or therapists.
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14
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Diagnosis of gastroesophageal reflux and anti-reflux procedures among Polish children with gastrostomies: a 10-year nationwide analysis. Eur J Clin Nutr 2013; 67:1169-74. [PMID: 24065062 PMCID: PMC3898100 DOI: 10.1038/ejcn.2013.164] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 07/06/2013] [Accepted: 07/29/2013] [Indexed: 01/09/2023]
Abstract
BACKGROUND/OBJECTIVES To analyse the approach to diagnose gastroesophageal reflux (GER) and the qualification criteria for anti-reflux (AR) procedures in Polish children fed via gastrostomy between 2000 and 2010. SUBJECTS/METHODS An electronic questionnaire containing questions on the demographic and clinical data of patients with gastrostomies was distributed to six Polish centres of nutritional therapy. The portion pertaining to GER included data on clinical exponents, diagnostic procedures (pH-metry, pH-impedance, scintigraphy and upper gastrointestinal (GI) series) and AR. RESULTS In total, 348 children (M199/F149; age at gastrostomy 5.78±5.49 years) were included. Data on the diagnosis of GER and the AR criteria were available for 343 and 336 subjects, respectively. Percutaneous endoscopic gastrostomy was performed in 258/348 patients (74.1%), while surgery was performed in 80/348 patients (23%). The data from 10/348 (2.9%) cases were unavailable. At least one of the tests for GER was conducted in 177/343 (51.6%) of patients: pH-metry in 74/343 (21.6%), pH-impedance in 17/343 (5.0%), scintigraphy in 60/343 (17.5%) and upper GI series in 102/343 (29.7%). GER was reported in 114/343 cases (33.2%), and fundoplication was performed in 87 children (76.3% of patients with GER). The highest congruence between a positive test result and the decision to perform fundoplication was documented in cases of scintigraphy and upper GI series (P=0.00000 and P=0.00191, respectively). A significant increase in the prevalence of simultaneous gastrostomy and AR was observed over the decade analysed (r=0.8, P=0.009). This study revealed a centre-specific attitude towards the diagnosis of GER and the assessment of qualifications for fundoplication in Polish gastrostomy-fed children. CONCLUSIONS The unified diagnostic algorithm of GER and the universal qualification criteria for AR procedures need to be defined for gastrostomy-fed children.
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Ponsky TA, Gasior AC, Parry J, Sharp SW, Boulanger S, Parry R, Ostlie DJ, St Peter SD. Need for subsequent fundoplication after gastrostomy based on patient characteristics. J Surg Res 2013; 179:1-4. [PMID: 23110973 DOI: 10.1016/j.jss.2012.03.064] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Revised: 03/13/2012] [Accepted: 03/28/2012] [Indexed: 11/17/2022]
Affiliation(s)
- Todd A Ponsky
- Department of Surgery, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
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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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Noble LJ, Dalzell AM, El-Matary W. The relationship between percutaneous endoscopic gastrostomy and gastro-oesophageal reflux disease in children: a systematic review. Surg Endosc 2012; 26:2504-12. [PMID: 22437953 DOI: 10.1007/s00464-012-2221-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2011] [Accepted: 11/14/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND The relationship between percutaneous endoscopic gastrostomy (PEG) insertion and gastro-oesophageal reflux disease (GERD) is widely disputed in the current literature. The aim of this systematic review is to examine the available evidence documenting the association between PEG and GERD. METHODS The following databases were searched: MEDLINE (1950 to week 2, January 2011), PubMed, ISI Web of Knowledge (1898 to week 2, January, 2011), EMBASE (1980 to week 2, January 2011) and The Cochrane Central Register of Controlled Trials (CENTRAL) using the terms "gastroesophageal reflux", "gastroesophageal disease", "GERD", "GERD", "GER", "GER" and "percutaneous endoscopic gastrostomy", "PEG", "gastrostomy". In addition, the reference lists of all included studies were reviewed for relevant citations. Studies examining children pre and post insertion of PEG for GERD and written in English language were included. Data extraction was performed by two authors, and the methodology and statistical analysis of each study were assessed. RESULTS Eight studies were included in this systematic review. Two reported increased incidence of GERD after PEG. However, neither was of high methodological quality. The remaining six reported no change or decreased GERD. Nonetheless, few demonstrated rigorous methodology. CONCLUSIONS The current evidence examining the effect of PEG insertion on GERD has been inconsistent and is not of high quality and therefore is unconvincing, preventing a definitive conclusion. Overall, the available literature on this topic does not demonstrate a causal effect of PEG insertion on GERD.
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Affiliation(s)
- Louise J Noble
- Division of Paediatric Gastroenterology, Hepatology and Nutrition, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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Kawahara H, Mitani Y, Nose K, Nakai H, Yoneda A, Kubota A, Fukuzawa M. Should fundoplication be added at the time of gastrostomy placement in patients who are neurologically impaired? J Pediatr Surg 2010; 45:2373-6. [PMID: 21129548 DOI: 10.1016/j.jpedsurg.2010.08.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2010] [Accepted: 08/12/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND/PURPOSE Patients who have advanced neurologic impairment (NI) and require gastrostomy placement (GP) frequently have symptomatic gastroesophageal reflux. We investigated the outcomes of GP without fundoplication in patients who had NI. METHODS This was a retrospective review of 54 patients with NI (median, 7 years; range, 1-18 years) undergoing GP alone. The operative criteria included medically controllable or no reflux symptoms. The patients were divided into 2 groups based on the percentage of total esophageal time with a pH less than 4.0 (reflux index, or RI): group I (GI, n = 33), RI less than 5.0% (median age, 6 years; range, 2-15 years); group II (GII, n = 21), RI 5.0% or greater (median age, 10 years; range, 1-18 years). Data are expressed as medians and ranges. RESULTS Nutritional management was successfully conducted after GP with or without the administration of lansoprazole, famotidine, or rikkunshito in all but 2 patients. One GI patient with alpha-thalassemia required fundoplication, and one GII patient with Cockayne syndrome required gastrojejunal tube feeding. The RI increased significantly in GI patients (2.1% [0%-4.8%] vs 4.5% [0.2%-11.4%], P = .004), whereas it decreased significantly in GII patients (11.2% [5.9%-41.6%] vs 9.8% [1.05-26.6%], P = .04). CONCLUSION Gastroesophageal reflux and related symptoms rarely deteriorate to require additional treatment after GP in patients with NI. Gastrostomy placement is a less invasive and effective procedure for improving the quality of life in those patients.
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Affiliation(s)
- Hisayoshi Kawahara
- Department of Pediatric Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, 840 Murodo-cho Izumi, Osaka 594-1101, Japan.
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Saadah OI. Gastro-oesophageal reflux in children with cerebral palsy after percutaneous endoscopic gastrostomy: Any predictors? Arab J Gastroenterol 2009. [DOI: 10.1016/j.ajg.2009.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Novotny NM, Jester AL, Ladd AP. Preoperative prediction of need for fundoplication before gastrostomy tube placement in children. J Pediatr Surg 2009; 44:173-6; discussion 176-7. [PMID: 19159739 DOI: 10.1016/j.jpedsurg.2008.10.030] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Accepted: 10/07/2008] [Indexed: 10/21/2022]
Abstract
PURPOSE Percutaneous endoscopic gastrostomy (PEG) tube placement is a common procedure performed for children with oral aspiration and failure to thrive. The concurrent presence of gastroesophageal reflux (GER) may be difficult to diagnose in these children and may dictate the need for an antireflux procedure. The purpose of this study was to review our preoperative evaluation of children undergoing PEG placement to better elucidate preoperative factors that may require eventual fundoplication. METHODS A retrospective review at a tertiary care, children's hospital between May 2002 and August 2007 was performed of patients undergoing PEG placement. Patients were identified through database search by operative procedure codes. Patient groups were defined as those undergoing PEG alone (group 1) and those requiring fundoplication after prior PEG (group 2). Comparison of patient demographics and radiologic qualitative results of GER was analyzed using chi(2) analysis, with significance determined at P < .05. RESULTS A total of 863 patients underwent PEG placement over this 64-month period. A sampled cohort of patients undergoing PEG over a year comprised group 1. Forty-four patients (5.1%) underwent Nissen fundoplication after prior PEG placement (group 2). Patient demographics were similar between the groups. Comparison of comorbid conditions and qualitative indicators of GER between the groups showed only cerebral palsy had a significantly higher associated risk of GER that required antireflux surgery. Preoperative clinical assessment had a 95% positive predictive value in identifying children who required only PEG. CONCLUSIONS Despite the high predictive value of individualized clinical assessment in the ultimate decision for gastrostomy without need of fundoplication, further studies are needed to determine whether children with conditions such as cerebral palsy may require a concurrent antireflux surgery at the time of gastrostomy.
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Affiliation(s)
- Nathan M Novotny
- Department of Surgery, Indiana University School of Medicine, Indianapolis, 46202, USA
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21
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Sullivan PB. Gastrointestinal disorders in children with neurodevelopmental disabilities. ACTA ACUST UNITED AC 2008; 14:128-36. [DOI: 10.1002/ddrr.18] [Citation(s) in RCA: 134] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Ngerncham M, Barnhart DC, Haricharan RN, Roseman JM, Georgeson KE, Harmon CM. Risk factors for recurrent gastroesophageal reflux disease after fundoplication in pediatric patients: a case-control study. J Pediatr Surg 2007; 42:1478-85. [PMID: 17848234 DOI: 10.1016/j.jpedsurg.2007.04.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND/PURPOSE Recurrent gastroesophageal reflux disease (rGERD) is a common problem after fundoplication. Previous studies attempting to identify risk factors for rGERD have failed to control for confounding variables. The purpose of this study was to identify significant risk factors for rGERD after controlling for potential confounding variables. METHODS A retrospective, matched case-control study was conducted at a tertiary children's hospital. Cases (n = 116) met 1 of these criteria: reoperation for rGERD, symptomatic rGERD (confirmed by upper gastrointestinal series, esophagogastroduodenoscopy, or pH monitoring), or postoperative reinstitution of antireflux medication for more than 8 weeks. Controls (n = 209) were matched for surgeon, approach (laparoscopic/open), technique (partial/complete), and approximate operative date. Univariate and multivariable associations were analyzed by conditional logistic regression. RESULTS Significant risk factors for rGERD were age of less than 6 years (odds ratio [OR], 3.6; 95% confidence interval [CI], 1.7-7.5), preoperative hiatal hernia (OR, 3.2; 95% CI, 1.4-7.3), postoperative retching (OR, 5.1; 95% CI, 2.6-10.0), and postoperative esophageal dilatation (OR, 10.8; 95% CI, 1.8-65.4). Interestingly, significant association was not found between neurologic impairment and rGERD after controlling for potential confounding variables. CONCLUSION Age of less than 6 years, preoperative hiatal hernia, postoperative retching, and postoperative esophageal dilatation are independently associated with increased risk of rGERD. Neurologic impairment alone does not increase the risk of developing rGERD.
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Affiliation(s)
- Monawat Ngerncham
- Department of Epidemiology and International Health, University of Alabama at Birmingham, Birmingham, AL 35294, USA
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Abstract
PURPOSE Children with cystic fibrosis (CF) have a high prevalence of gastroesophageal reflux disease (GERD). As GERD is associated with chronic respiratory symptoms and feeding problems, fundoplication is often performed in children with CF. Although the outcomes of fundoplication have been described across diverse pediatric groups, there is no published experience with CF. METHODS The records of 25 children with CF who underwent fundoplication in our center were reviewed. Data on symptoms and diagnostic testing results as well as on complications related to fundoplication were collected. Nutritional parameters and pulmonary function were compared before and after fundoplication. RESULTS There was no mortality associated with fundoplication, but 12% had complications that required a subsequent surgical procedure. Whereas 28% were able to discontinue their antireflux medications, 48% developed symptoms of recurrent GERD. Overall, there was no change in body mass index, body mass index percentile, or the slope of forced expiratory volume in 1 second (FEV1) after fundoplication. Children who had an FEV1 of less than 60% predicted at the time of fundoplication exhibited an improvement in FEV1 slope compared to those with FEV1 of 60% or more (+5.3% vs -8.6% per year, P = .004). CONCLUSION The complication rate of fundoplication is similar to what has been reported in large series in children without CF. There is a high rate of recurrent GERD and little apparent benefit for either nutritional or pulmonary outcomes. The observed difference on FEV1 slope, in those with moderate-severe vs mild lung disease, highlights the need to thoroughly evaluate the role of fundoplication in children with CF.
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Affiliation(s)
- R Paul Boesch
- Division of Pediatric Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.
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Rothenberg SS. Laparoscopic redo Nissen fundoplication in infants and children. Surg Endosc 2006; 20:1518-20. [PMID: 16902749 DOI: 10.1007/s00464-005-0123-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2005] [Accepted: 10/02/2005] [Indexed: 11/30/2022]
Abstract
From January 1994 to December 2004, 118 patients with recurrent gastroesophageal reflux disease (GERD) after fundoplication underwent laparoscopic redo Nissen fundoplication. The patients ranged in age from 6 months to 19 years (mean, 7 years), and weighed from 6.4 to 85 kg. Of the 118 patients, 64 had previous open fundoplications, 53 had previous laparoscopic fundoplications, and 19 had more than one previous fundoplication. All the procedures had been successfully completed laparoscopically. The average operative time was 100 min. The intraoperative complication rate was 1.1%. The average time to full feeding was 1.8 days, and the average hospital stay was 2.2 days. The postoperative complication rate was 3.6%. The wrap failure rate during an average follow-up period of 48 months was 6%. Laparoscopic redo Nissen fundoplication for a failed antireflux procedure is a safe and effective procedure. It has the same benefits as a primary laparoscopic Nissen for GERD, with low morbidity and a quicker recovery. Early follow-up evaluation suggests that the long-term outcome is superior to that associated with open redo fundoplication.
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Affiliation(s)
- S S Rothenberg
- The Mother and Child Hospital at Presbyterian/St Lukes, Denver, CO, USA
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Rothenberg SS. The first decade's experience with laparoscopic Nissen fundoplication in infants and children. J Pediatr Surg 2005; 40:142-6; discussion 147. [PMID: 15868575 DOI: 10.1016/j.jpedsurg.2004.09.031] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND/PURPOSE Fundoplication for gastroesophageal reflux disease is a common procedure performed in infants and children. This report describes over a 10-year experience with more than 1000 consecutive laparoscopic Nissen fundoplications. METHODS Ages ranged from 5 days to 18 years and weight from 1.2 to 120 kg. The procedures were performed using a 5 trocar technique and with 5- or 3-mm instruments depending on the size of the patient. Of 1050 fundoplications, 1048 were completed successfully through laparoscopy. RESULTS Average operative time dropped dramatically from 109 minutes for the first 30 cases compared with 38 minutes for the last 30. Intraoperative and postoperative complications were 0.26% and 4.0%, respectively. Average time to discharge post fundoplication was 1.1 days. The wrap failure rate is 4.0%. CONCLUSIONS This study shows in a large operative experience for 10 years that laparoscopic fundoplication is safe and effective in the pediatric population. Clinical results are comparable to the traditional open fundoplication but with a significant decrease in morbidity and hospitalization.
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Affiliation(s)
- Steven S Rothenberg
- The Mother and Child Hospital at Presbyterian/St Luke's Medical Center, Denver, CO 80218, USA.
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Tuğtepe H, Iskit HS, Bozkurt S, Kiyan G, Yeğen BC, Dağli TE. Effects of Stamm Gastrostomy on Gastric Emptying Rate in Rats. Eur Surg Res 2004; 36:362-6. [PMID: 15591745 DOI: 10.1159/000081645] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2004] [Accepted: 07/27/2004] [Indexed: 11/19/2022]
Abstract
AIM Although frequency of gastroesophageal reflux (GER) increases after gastrostomy, the role of gastric emptying in GER has not been evaluated. In this study, we examined the effects of Stamm gastrostomy on gastric emptying rate in rats and whether Stamm gastrostomy induces GER or not. METHODS Sprague-Dawley rats were divided into three groups. Stamm gastrostomy was done in the first group (SG). Sham operation was carried out in group 2 and the 3rd group served as control. Gastric emptying was assessed using both liquid and solid meals in each group at postoperative 14th day. For solid meal emptying, after fasting of 16 h, the rats were fed for 3 h and gastric emptying rate was measured at the fifth hour. Methylcellulose was used for emptying of liquids and it was given after the animals were fasted for 16 h and gastric emptying rate was measured 30 min later. Histological evaluation for GER was performed in all groups. RESULTS GER was observed pathophysiologically in 5 of the 7 rats in SG group. Gastric emptying rates of liquid and solid meals were found to be similar in control, SG or sham groups. CONCLUSION Surgical gastrostomy does not affect the gastric emptying of solid and liquid meals in rats. Other mechanisms should be considered in the development of GER observed following gastrostomy.
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Affiliation(s)
- H Tuğtepe
- Department of Pediatric Surgery, Marmara University School of Medicine, Istanbul, Turkey.
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Abstract
BACKGROUND/PURPOSE Although quite reliable, gastrostomy may require revision. However, there are no reports in the literature specifically delineating identifiable risk factors or circumstances that lead to gastrostomy revision in children with gastrostomy. The purpose of this report was to determine the rate of revision and correlate any factors that may lead to revision. METHODS A retrospective chart review was performed on 1,042 children who underwent gastrostomy at The Children's Hospital, Denver, Colorado, between 1992 and 2002. Charts of children who underwent gastrostomy were reviewed for pertinent clinical factors and compared with those who required gastrostomy revision. RESULTS Of the 1,042 children, who had gastrostomies, 67 revisions were required in 61 children (6%). Of the many possible factors that could have had an influence on the revision rate, only fundoplication, percutaneous endoscopic gastrostomy (PEG), migration of the gastrostomy site, and time correlated with the need for gastrostomy revision. CONCLUSIONS Parents should be made aware that there is a 6% chance that their child's gastrostomy may need revision and that the need for revision may increase with PEG, initial construction before 18 months of age, and the advancing age of the gastrostomy. Surgeons should avoid placing the gastrostomy near the costal margin, making a large gastrostomy exit tract through the abdominal wall and inserting a gastrostomy into the nutritionally depleted pulmonary stressed neurologically challenged child without first attempting to improve the child's nutritional status.
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Affiliation(s)
- Sarah J Conlon
- University of Vermont School of Medicine, Burlington, VT, USA
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Harrington JW, Brand DA, Edwards KS. Seizure disorder as a risk factor for gastroesophageal reflux in children with neurodevelopmental disabilities. Clin Pediatr (Phila) 2004; 43:557-62. [PMID: 15248009 DOI: 10.1177/000992280404300608] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The proportion of children with severe neurodevelopmental disabilities, in whom symptoms of gastroesophageal reflux develop after gastrostomy placement, has not been well studied. The medical records of children who received a gastrostomy tube (with or without a simultaneous antireflux procedure) at our institution between 1987 and 1997 were reviewed to identify neurologically related diagnoses at the time of the gastrostomy, diagnostic tests ordered to detect reflux, and dates and reasons for re-admissions within 2 years of discharge. Of 102 patients studied, 37 received a gastrostomy tube alone. Complete follow-up data were available for 30 of these patients, 7 of whom (23%) required subsequent antireflux surgery within 2 years. Patients with a seizure disorder had greater than a 4-fold risk of re-admission for this operation compared with other patients (57% [4/7] vs. 13% [3/23]; P=0.03). In a child with severe neurodevelopmental disability, the existence of a seizure disorder at the time of a gastrostomy operation increases the risk of subsequently requiring an antireflux procedure by a factor of 4.
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Affiliation(s)
- John W Harrington
- Department of Pediatrics, New York Medical College and Westchester Medical Center, 312 Munger Pavilion, Valhalla, NY 10595, USA
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George DE, Dokler M. Percutaneous endocopic gastrostomy in children. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2002. [DOI: 10.1053/tgie.2002.37439] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Jesus LED. Refluxo gastroesofágico no paciente encefalopata. Rev Col Bras Cir 2002. [DOI: 10.1590/s0100-69912002000400008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Gottrand F, Michaud L. Percutaneous endoscopic gastrostomy and gastro-esophageal reflux: are we correctly addressing the question? J Pediatr Gastroenterol Nutr 2002; 35:22-4. [PMID: 12142804 DOI: 10.1097/00005176-200207000-00005] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Razeghi S, Lang T, Behrens R. Influence of percutaneous endoscopic gastrostomy on gastroesophageal reflux: a prospective study in 68 children. J Pediatr Gastroenterol Nutr 2002; 35:27-30. [PMID: 12142806 DOI: 10.1097/00005176-200207000-00007] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Among other complications, the development of or an increase of gastroesophageal reflux (GER) is considered to be associated with percutaneous endoscopic gastrostomy (PEG). However, the few studies performed to date show controversial results. METHODS Continuous 24-hour pH monitoring was performed prospectively in 68 patients before and at least 3 days after percutaneous endoscopic gastrostomy placement. None of the patients had been treated for gastroesophageal reflux. RESULTS The percentage of patients with abnormal test results did not differ significantly before and after PEG insertion (22.1% versus 25%). Nor did the median reflux index change significantly before and after gastrostomy for the whole group of patients (2.6% versus 3.4%). The median reflux index increased significantly (from 1.8 to 5.4) only in patients who underwent PEG implantation in the antrum (n = 9). Clinical signs of GER correlated poorly with the results of pH monitoring. CONCLUSIONS Data in this study strongly suggest that, in general, percutaneous endoscopic gastrostomy does not provoke gastroesophageal reflux. Results also indicate that placement in the antrum may be unfavorable.
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Affiliation(s)
- Stefan Razeghi
- Department of Pediatrics and Adolescent Medicine, Friedrich Alexander University of Erlangen, Germany.
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Mathus-Vliegen EM, Koning H, Taminiau JA, Moorman-Voestermans CG. Percutaneous endoscopic gastrostomy and gastrojejunostomy in psychomotor retarded subjects: a follow-up covering 106 patient years. J Pediatr Gastroenterol Nutr 2001; 33:488-94. [PMID: 11698769 DOI: 10.1097/00005176-200110000-00014] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Whether psychomotor retarded persons should be treated by percutaneous endoscopic gastrostomy (PEG) or by surgical gastrostomy combined with an antireflux procedure is controversial. Therefore, the authors investigated the feasibility of a PEG and enteral feeding in these patients. METHODS Patients referred from specialized institutions for a PEG placement were assessed extensively by a multidisciplinary team. When considered eligible, age and general condition determined the choice of treatment under general anesthesia (group 1) or conscious sedation (group 2). Patients were followed up after 1 and 7 days, 4 and 12 weeks, and thereafter every 6 to 12 weeks. Data were collected prospectively over a period of 5 years until gastrostomy removal, death, or arrival at the censory date, 6 months after PEG placement. The endpoints were 1) to evaluate the procedure and its complications; 2) to discover barriers that impeded adequate nutrition; and 3) to explore the appropriateness of the choice of PEG or percutaneous endoscopic gastrojejunostomy (PEJ). RESULTS The procedure was successful in 95% of patients, in every patient in group 1 (35/35; median age, 4.1 years) and in 20 of 23 patients (87%) in group 2 (median age, 22.0 years). There were no procedure-related deaths and no 30-day mortality. Major complications changed from procedure-related problems in the short term (5.4%) to tube-related problems in the long-term (24.1%). Nausea and vomiting interfered with adequate feeding mainly in young children, but dietary adjustments alleviated the symptoms and ensured an adequate intake. The choice of a PEG was incorrect in four patients: surgery was needed twice and two PEGs had to be converted into a PEJ. All seven primarily indicated PEJs seemed justified and of temporary need in five. CONCLUSIONS In severely disabled patients, a PEG and adequate enteral nutrition is feasible in the setting of a multidisciplinary approach and protocol-wise follow-up. Yet, anatomic deformities and restricted pulmonary function rendered the procedure more difficult. In cases with obvious aspiration or gastroesophageal reflux, a PEJ combined with acid suppression and prokinetic drugs may be tried before surgery.
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Affiliation(s)
- E M Mathus-Vliegen
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
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Abstract
Improvements in the provision of oxygen, mechanical ventilation, tracheostomy care, enteral and parenteral nutrition, and dialysis have expanded the population of technology-dependent children. This article attempts to review pertinent points regarding these services, including common complications. Primary care and subspecialty physicians must smooth the transition of these children to the home environment, but a comprehensive team approach is necessary for the recognition of medical complications and provision of appropriate family teaching and psychosocial supports.
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Affiliation(s)
- J C Haffner
- Division of Critical Care Medicine, University of South Florida College of Medicine and All Children's Hospital, St. Petersburg, Florida, USA
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35
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Fonkalsrud EW, Bustorff-Silva J, Perez CA, Quintero R, Martin L, Atkinson JB. Antireflux surgery in children under 3 months of age. J Pediatr Surg 1999; 34:527-31. [PMID: 10235314 DOI: 10.1016/s0022-3468(99)90065-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE The aim of this study was to analyze the indications and results of fundoplication in 110 infants under 3 months of age. METHODS A retrospective review was conducted on the charts of all infants operated on for gastroesophageal reflux disease (GERD) at the UCLA Medical Center from January 1980 to December 1997. There were 59 boys and 51 girls. Recurrent emesis was the indication for operation in 62 of 110 infants, and respiratory symptoms in 85 of 110, with 54 of 110 having both. Neurological impairment was present in 32%. Prematurity was present in 21%; 35% had associated anomalies. Overall, 81 of 110 infants (73.6%) had one or more associated major malformations or disorders. Reflux was confirmed by upper gastrointestinal series findings in 63 of 78, esophageal pH monitoring in 60 of 62, and endoscopy in five of seven. RESULTS Mean age at operation was 1.8+/-0.1 months and mean weight was 3,686+/-90.2 g. A Nissen fundoplication was performed on 104 children, and six underwent a Thal procedure. Thirty-one had a gastric emptying procedure for delayed gastric emptying. Complications occurred in 7 infants. Emesis was controlled in 57 of 62 patients, aspiration in 38 of 48, and apneic spells in 54 of 57. Follow-up greater than 6 months was available for 73 patients. There were nine late deaths, all related to severe associated malformations. Seven patients required a redo fundoplication for recurrent reflux. CONCLUSIONS Nissen fundoplication can be performed safely in symptomatic infants under 3 months of age with low mortality and morbidity rates and with resolution of the presenting symptoms in 79% of infants.
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Affiliation(s)
- E W Fonkalsrud
- Division of Pediatric Surgery, UCLA School of Medicine, Los Angeles, CA 90095-1749, USA
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36
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Kutiyanawala MA, Hussain A, Johnstone JM, Everson NW, Nour S. Gastrostomy complications in infants and children. Ann R Coll Surg Engl 1998; 80:240-3. [PMID: 9771219 PMCID: PMC2503076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
Abstract
Thirty children have had percutaneous endoscopic gastrostomy (PEG) inserted for feeding purposes. During a follow-up period of 5-45 months (mean 24 months), complications were recorded in 13 patients. Some patients had more than one complication. Complications included colocutaneous fistula, gastro-oesophageal reflux, wound infection, granulation tissue formation, tube leakage, tube blockage and bleeding. The authors present a retrospective review of the results and discuss the management of these complications.
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37
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Abstract
Gastroesophageal reflux (GER) is a common disorder in infants and children with a high rate of spontaneous resolution. Some children, however, will continue to have problems and progress from functional GER to pathogenic GER. In children with functional GER, diagnostic testing and pharmacologic treatment is unnecessary. In more involved cases, there are a number of tests available that help to quantify and qualify the extent of disease. Treatment begins with conservative measures and progresses to acid neutralization/supression and medications to enhance motility. Should medical management fail to control the consequences of reflux disease, surgical intervention is warranted.
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Affiliation(s)
- V M Tsou
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Eastern Virginia Medical School, Children's Hospital of The King's Daughters, Norfolk, Virginia, USA
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38
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Sulaeman E, Udall JN, Brown RF, Mannick EE, Loe WA, Hill CB, Schmidt-Sommerfeld E. Gastroesophageal reflux and Nissen fundoplication following percutaneous endoscopic gastrostomy in children. J Pediatr Gastroenterol Nutr 1998; 26:269-73. [PMID: 9523860 DOI: 10.1097/00005176-199803000-00006] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Abnormal gastroesophageal reflux after percutaneous endoscopic gastrostomy is a serious problem in neurologically impaired children. Protective fundoplication has been advocated. Whether esophageal pH monitoring before percutaneous endoscopic gastrostomy will predict later problems with gastroesophageal reflux is unclear. METHODS Eighty-five mostly neurologically impaired pediatric patients who underwent percutaneous endoscopic gastrostomy were studied retrospectively regarding complications, success of nutritional rehabilitation, and the incidence of pathologic gastroesophageal reflux. Follow-up period was 1 to 4 years. Twenty-four-hour esophageal pH monitoring was performed in 46 patients before percutaneous endoscopic gastrostomy. RESULTS There were no deaths. Two major complications occurred that required surgical intervention, and 14 minor complications occurred related to the procedure. Z-scores for weight increased significantly after percutaneous endoscopic gastrostomy. pH probe results were normal in 22 patients (group 1). Five required medical treatment for gastroesophageal reflux after percutaneous endoscopic gastrostomy, but only 1 (5%) later required Nissen fundoplication. pH probe results were abnormal in 24 patients (group 2). Nineteen required medical therapy for gastroesophageal reflux, and 7 (29%) later needed fundoplication (p < 0.05, incidence of fundoplication group 1 vs. group 2). Improvement in Z-scores was similar in patients requiring and not requiring fundoplication. CONCLUSIONS Percutaneous endoscopic gastrostomy is a safe and effective technique for long-term nutritional support in children. Abnormal gastroesophageal reflux is common. Normal findings in an esophageal pH study before percutaneous endoscopic gastrostomy may be predictive of a favorable outcome with respect to gastroesophageal reflux. This is in contrast to patients with abnormal results in pH studies before percutaneous endoscopic gastrostomy of whom a relatively large percentage may later require fundoplication. Improved nutritional status after percutaneous endoscopic gastrostomy does not appear to have an impact on the severity of gastroesophageal reflux.
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Affiliation(s)
- E Sulaeman
- Louisiana State University Medical Center, Department of Pediatrics, New Orleans 70112-2822, USA
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39
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Abstract
BACKGROUND/PURPOSE Fundoplication for gastroesophageal reflux disease is a common procedure performed in infants and children. This report describes a 4-year experience with 220 consecutive laparoscopic Nissen fundoplications. METHODS Ages ranged from 5 days to 18 years and weight from 1.4 to 100 kg. The procedures were performed using a five-trocar technique and with 5- or 3.4-mm instruments depending on the size of the patient. RESULTS Two hundred eighteen fundoplications were completed successfully. Average operative time dropped dramatically from 109 to 55 minutes for the first 30 cases compared with the last 30. Intraoperative and postoperative complication rates were 2.6% and 7.3%, respectively. Average time to discharge postfundoplication was 1.6 days. The wrap failure rate is 3.4%. CONCLUSIONS This study shows that although the learning curve for laparoscopic fundoplication may be steep, the procedure is safe and effective in the pediatric population. The clinical results are comparable to the traditional open fundoplication but with a significant decrease in morbidity and hospitalization.
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Affiliation(s)
- S S Rothenberg
- Columbia Presbyterian/St Lukes Medical Center, Denver, Colorado, USA
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40
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Khattak IU, Kimber C, Kiely EM, Spitz L. Percutaneous endoscopic gastrostomy in paediatric practice: complications and outcome. J Pediatr Surg 1998; 33:67-72. [PMID: 9473103 DOI: 10.1016/s0022-3468(98)90364-5] [Citation(s) in RCA: 139] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE The aim of this study was to establish the morbidity and mortality of percutaneous endoscopic gastrostomy (PEG) in a tertiary referral paediatric practice and to identify risk factors for developing complications after a PEG. METHODS The medical records of all patients who had a percutaneous endoscopic gastrostomy attempted over a 5-year period (1990 to 1995) were reviewed. RESULTS One hundred thirty percutaneous gastrostomies were placed in 120 paediatric patients. Indications for insertion were inability to swallow (n = 74, of which, 52 were neurologically impaired), inadequate calorie intake (n = 30), special feeding requirements (n = 12), continuous enteral feeding in short gut (n = 2), and malabsorption (n = 2). All the children had complex medical problems, and 80% of the patients were rated as "high risk" for general anaesthesia (> or = ASA grade 3). Major complications developed in 21 children (17.5%) and minor complications in 27 (22.5%). Of the 17 children in whom gastroesophageal reflux (GOR) became symptomatic, 10 required a Nissen fundoplication. Nine of these 10 children were neurologically impaired (19% of the neurologically impaired children). One postrenal transplant patient on immunosuppression died 54 days after the procedure of intraabdominal sepsis. Thirty-one patients required secondary surgical procedures. CONCLUSIONS PEG is associated with significant morbidity. Neurologically impaired children are at risk of acquiring symptomatic GOR, but the risk does not warrant routine fundoplication. Major complications are common and need urgent surgical consultation with many requiring secondary surgical procedures. PEG in paediatric patients should be considered a major surgical undertaking.
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Affiliation(s)
- I U Khattak
- Great Ormond Street Hospital for Children, London, England
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41
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Tawfik R, Dickson A, Clarke M, Thomas AG. Caregivers' perceptions following gastrostomy in severely disabled children with feeding problems. Dev Med Child Neurol 1997; 39:746-51. [PMID: 9393888 DOI: 10.1111/j.1469-8749.1997.tb07376.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Feeding difficulties are common in neurologically impaired children, often leading to great distress and frustration in the child and family. A gastrostomy may be advocated if oral intake is inadequate causing poor weight gain or when there is significant aspiration during feeding, or if feeding is very distressing. To find out if caregivers were happy with the outcome of gastrostomy (with fundoplication, when indicated), a 35-item questionnaire was developed and sent to 38 of them. Twenty-nine replies were received and appeared to be representative of the whole group. Coughing, choking, and vomiting improved in most cases. Weight gain improved in all in whom it had been a problem. In the majority, it became easier to give the children their medications although control of epilepsy was unchanged overall. Time spent feeding the child was reduced and many caregivers had more time to devote to other children and themselves. Only one parent regretted the operation. In children with severe disability and feeding problems, a gastrostomy (with fundoplication if there is significant reflux) can reduce symptoms of vomiting, coughing, and choking, help growth and improve quality of life in the child, when patients are properly selected.
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Affiliation(s)
- R Tawfik
- Paediatric Gastroenterology, Booth Hall Children's Hospital, Manchester, UK
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Strauss D, Kastner T, Ashwal S, White J. Tubefeeding and mortality in children with severe disabilities and mental retardation. Pediatrics 1997; 99:358-62. [PMID: 9041288 DOI: 10.1542/peds.99.3.358] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To study the contribution of tubefeeding to mortality for children with severe disabilities and mental retardation. Previous research has suggested an association between tubefeeding and mortality. However, risk has never been determined using population-based data or defined in regard to patient variables. METHODS Retrospective analysis of a comprehensive statewide data set comprised of 4921 children with severe disabilities and mental retardation living in community and congregate care settings. The outcome measure was mortality; primary study variables included the presence of a feeding tube, measures of functional independence, type of residence, and medical comorbidity. RESULTS There were four findings. First, the use of a feeding tube was associated with virtually every disability. Second, when no study variables were controlled, statistically significant differences in mortality rates were noted between children who were tubefed and those who were not. The relative risk of mortality associated with use of a feeding tube was 2.1. Third, the use of a feeding tube was associated with a reduction in relative risk of mortality in children with tracheostomy (relative risk of mortality: .55). However, this association did not achieve statistical significance. Fourth, when study variables were controlled in a multivariate analysis, feeding tube use was associated with no identifiable increase in mortality among children with very severe disabilities, but was associated with an approximated doubled mortality rate among those with less severe disabilities. CONCLUSIONS We hypothesize that the increased mortality associated with tubefeeding may be attributable to a differential increase in pulmonary disease secondary to overly vigorous nutritional maintenance and subsequent aspiration after tube placement. For children with tracheostomy this risk may be reduced. If tracheostomy proves to be associated with a relatively more favorable outcome for tubefeeding, we hypothesize that it would reflect the benefits of tracheostomy in allowing access to the airway for suctioning and ventilation. Given the observed higher mortality rates among the less severely disabled children who are tubefed and the substantial costs associated with tubefeeding, a prospective, controlled study may be clinically indicated, ethically justifiable, and economically warranted.
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Affiliation(s)
- D Strauss
- Department of Statistics, University of California, Riverside 92521, USA
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Isch JA, Rescorla FJ, Scherer LR, West KW, Grosfeld JL. The development of gastroesophageal reflux after percutaneous endoscopic gastrostomy. J Pediatr Surg 1997; 32:321-2; discussion 322-3. [PMID: 9044145 DOI: 10.1016/s0022-3468(97)90202-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The relationship between percutaneous endoscopic gastrostomy (PEG) and subsequent development of gastroesophageal reflux (GER) is complex and not well understood. The authors retrospectively reviewed 82 children over a 5-year period who underwent PEG tube (n = 64) or PEG button (n = 18) placement. Children were evaluated preoperatively for clinical evidence of GER (C-GER) or radiographic GER (R-GER) with upper gastrointestinal contrast study or Tc99m gastric scinitiscan. Seventy-five patients were evaluated for clinical evidence of postoperative GER by direct family contact. Eleven of 39 (28%) patients with no GER preoperatively developed GER postoperatively, eight (20%) of whom required Nissen fundoplication (NF) or gastrojejunostomy (GJ) tube. Ten of 19 (53%) with preoperative C-GER but no R-GER continued to have GER after PEG, but only three required NF or GJ. Only one of nine children who had R-GER only developed clinical GER after PEG placement. Of the eight children with both C-GER and R-GER, only two (25%) required NF or GJ and two (25%) had no postoperative GER. The authors conclude that PEG tubes are useful in infants and children and are associated with a relatively low incidence of postoperative GER. If C-GER is absent, a PEG is a reasonable procedure to consider even in the presence of R-GER.
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Affiliation(s)
- J A Isch
- Department of Surgery, Indiana University, JW Riley Hospital for Children, Indianapolis 46202, USA
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44
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Borowitz SM, Sutphen JL, Hutcheson RL. Percutaneous endoscopic gastrostomy without an antireflux procedure in neurologically disabled children. Clin Pediatr (Phila) 1997; 36:25-9. [PMID: 9007344 DOI: 10.1177/000992289703600104] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
In children with major neurologic impairment, gastrostomies are often used to alleviate malnutrition and feeding difficulties. There has been a trend toward performing "protective" antireflux surgery in these children. Nineteen children with major neurologic impairment and feeding failure were prospectively evaluated and followed up after placement of a percutaneous endoscopic gastrostomy (PEG) without any antireflux procedure. Mean age at PEG placement was 34 months with mean follow-up of 20.7 months. All parents would recommend PEG to families with disabled children, and if given the chance, 95% would elect PEG again for their child. No child developed choking, gagging, or retching postoperatively. At the time of follow-up, postoperative gastroesophageal reflux did not appear to be a major clinical problem.
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Affiliation(s)
- S M Borowitz
- Department of Pediatrics, University of Virginia, Charlottesville 22908, USA
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45
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Héloury Y, Plattner V, Mirallié E, Gérard P, Lejus C. Laparoscopic nissen fundoplication with simultaneous percutaneous endoscopic gastrostomy in children. Surg Endosc 1996; 10:837-41. [PMID: 8694949 DOI: 10.1007/bf00189545] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The aim of the study was to evaluate the results of laparoscopic Nissen fundoplication (LNF) with simultaneous percutaneous endoscopic gastrostomy (PEG) in children with gastroesophageal reflux (GER) disease documented by upper gastrointestinal contrast and/or pH monitoring and/or esophageal endoscopy. METHODS Fifteen LNF + PEGs were performed in children with pathologic antecedents: ten neurologically impaired children, two ORL (otorhinolaryngeal) pathologies. Two cases of AIDS, and one neuroblastoma. In one case, disruption of the fundoplication occurred during insufflation of the stomach. The child was reoperated on the 3rd day using an open procedure, so she was excluded from the results of the LNF. RESULTS Two children had postoperative complications: one with cardiac insufficiency, one case of dehydration. Fourteen LNFs were controlled at 3 months by gastroesophageal X-ray and pH-metry. The 14 gastroesophageal X-rays were normal in 12 cases; gastroesophageal reflux was present in two cases. Twelve pH monitorings were analyzed (two technical failures), the median time pH <4 was 0.2% (0-20). Only one pH monitoring was pathologic (pH <4: 20%). This recurrent reflux to led to a second LNF with a good clinical result. CONCLUSIONS In conclusion, it is possible to perform LNF and PEG during the same operative procedure. Short-term results are satisfactory with 14% recurrent GER. Long-term results need to be evaluated.
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Affiliation(s)
- Y Héloury
- Department of Pediatric Surgery, Hopital Mère-Enfant, Quai Moncousu, 44000, Nantes, France
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46
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Abstract
Gastroesophageal reflux (GER) is one of the most frequent symptomatic clinical disorders affecting the gastrointestinal tract of infants and children. During the past 2 decades, GER has been recognized more frequently because of an increased awareness of the condition and also because of the more sophisticated diagnostic techniques that have been developed for both identifying and quantifying the disorder. Gastroesophageal fundoplication is currently one of the three most common major operations performed on infants and children by pediatric surgeons in the United States. Normal gastroesophageal function is a complex mechanism that depends on effective esophageal motility, timely relaxation and contractility of the lower esophageal sphincter, the mean intraluminal pressure in the stomach, the effectiveness of contractility in emptying of the stomach, and the ease of gastric outflow. More than one of these factors are often abnormal in the same child with symptomatic GER. In addition, in patients with GER disease, and particularly in those patients with neurologic disorders, there appears to be a high prevalence of autonomic neuropathy in which esophagogastric transit and gastric emptying are frequently delayed, producing a somewhat complex foregut motility disorder. GER has a different course and prognosis depending on the age of onset. The incompetent lower esophageal sphincter mechanism present in most newborn infants combined with the increased intraabdominal pressure from crying or straining commonly becomes much less frequent as a cause of vomiting after the age of 4 months. Chalasia and rumination of infancy are self-limited and should be carefully separated from symptomatic GER, which requires treatment. The most frequent complications of recurrent GER in childhood are failure to thrive as a result of caloric deprivation and recurrent bronchitis or pneumonia caused by repeated pulmonary aspiration of gastric fluid. Children with GER disease commonly have more refluxing episodes when in the supine position, particularly during sleep. The reflux of acid into the mid or upper esophagus may stimulate vagal reflexes and produce reflex laryngospasm, bronchospasm, or both, which may accentuate the symptoms of asthma. Reflux may also be a cause of obstructive apnea in infants and possibly a cause of recurrent stridor, acute hypoxia, and even the sudden infant death syndrome. Premature infants with respiratory distress syndrome have a high incidence of GER. Esophagitis and severe dental carries are common manifestations of GER in childhood. Barrett's columnar mucosal changes in the lower esophagus are not infrequent in adolescent children with chronic GER, particularly when Heliobacter pylori is present in the gastric mucosa. Associated disorders include esophageal dysmotility, which has been recognized in approximately one third of children with severe GER. Symptomatic GER is estimated to occur in 30% to 80% of infants who have undergone repair of esophageal atresia malformations. Neurologically impaired children are at high risk for having symptomatic GER, particularly if nasogastric or gastrostomy feedings are necessary. Delayed gastric emptying (DGE) has been documented with increasing frequency in infants and children who have symptoms of GER, particularly those with neurologic disorders. DGE may also be a cause of gas bloat, gagging, and breakdown or slippage of a well-constructed gastroesophageal fundoplication. The most helpful test for diagnosing and quantifying GER in childhood is the 24-hour esophageal pH monitoring study. Miniaturized probes that are small enough to use easily in the newborn infant are available. This study is 100% accurate in diagnosing reflux when the esophageal pH is less than 4.0 for more than 5% of the total monitored time.
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Short TP, Patel NR, Thomas E. Prevalence of gastroesophageal reflux in patients who develop pneumonia following percutaneous endoscopic gastrostomy: a 24-hour pH monitoring study. Dysphagia 1996; 11:87-9. [PMID: 8721064 DOI: 10.1007/bf00417895] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Percutaneous endoscopic placement of feeding gastrostomies (PEG) was pioneered by Gauderer et. al. in 1980 [1]. Since then, it has become the preferred method of providing enteral nutritional support in children and adults because of advantages in morbidity and cost [2,3]. Pneumonia is a known sequel of this procedure, occurring at different rates, depending on the length of follow-up. Some series have shown an incidence of 10% at 30 days and others 56% at 11 months [4,5]. It does not appear that PEG feeding offers an advantage over the more traditional naso-enteric tube feeding methods in this respect. To study the prevalence of gastroesophageal reflux (GER) in PEG-fed patients, we quantitated GER by 24-hour intraesophageal pH monitoring in a group of patients who developed post-PEG pneumonia and compared it with a control group. Our study demonstrates an increased prevalence of GER in the pneumonia group compared with the control group. However, the exact contribution of this observed increased GER to the development of pneumonia needs to be determined.
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Affiliation(s)
- T P Short
- Department of Internal Medicine, James H. Quillen College of Medicine, East Tennessee State University, Johnson City, USA
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48
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Heine RG, Reddihough DS, Catto-Smith AG. Gastro-oesophageal reflux and feeding problems after gastrostomy in children with severe neurological impairment. Dev Med Child Neurol 1995; 37:320-9. [PMID: 7698523 DOI: 10.1111/j.1469-8749.1995.tb12010.x] [Citation(s) in RCA: 89] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
This study evaluated the effect of percutaneous endoscopic gastrostomy (PEG) on the feeding problems and gastro-oesophageal reflux (GOR) of 30 consecutive children with severe neurological impairment who had PEG between October 1990 and March 1993. Evaluation was by questionnaire, clinical history, examination, 24-hour oesophageal pH monitoring and endoscopy. Gastrostomy placement significantly reduced feeding time, feed-related choking episodes and frequency of chest infections. Family stress was significantly reduced in two-thirds of cases. Significant weight-gain occurred. The clinical severity of GOR was significantly increased in eight patients and fundoplication was required in five. 24-hour oesophageal pH measurements before PEG did not reliably predict subsequently increased GOR. Seven patients died, but their deaths were apparently unrelated to GOR. PEG effectively provides nutrition, improves feed-related stresses, but may exacerbate GOR.
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Affiliation(s)
- R G Heine
- Department of Gastroenterology, Royal Children's Hospital, Parkville, Victoria, Australia
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49
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Launay V, Gottrand F, Turck D. La gastrostomie percutanée endoscopique chez l’enfant. ACTA ACUST UNITED AC 1994. [DOI: 10.1007/bf02970060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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50
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Naureckas SM, Christoffel KK. Nasogastric or gastrostomy feedings in children with neurologic disabilities. Clin Pediatr (Phila) 1994; 33:353-9. [PMID: 8200170 DOI: 10.1177/000992289403300608] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Although pediatricians are increasingly aware of the problem of undernutrition in children with neurologic disabilities, many of these children remain poorly nourished despite prolonged attempts at oral feedings. We studied the effects of tube feeding on such children, using either nasogastric (NG) or gastrostomy (GT) feedings. Twenty-six patients (16 male, mean age at first visit 40.7 months) were followed while receiving tube feedings for a mean of 23 months. Thirteen children in the NG group were tube fed by nasogastric tube. The GT group consisted of two groups of children: 10 who began with nasogastric feedings and then changed to gastrostomy because of intolerance or need for reflux surgery, and three who were always tube fed via gastrostomy. Mean percent ideal body weight for height age (%IBWH) for the whole group improved from 73.2% to 94.2% (P < .0001), for the NG group from 72.1% to 89.3% (P < .002), and for the GT group from 74.2% to 98.8% (P < .0001). One patient died of unrelated severe upper airway obstruction. No patients reported hospitalization due to tube-feeding complications. Seventeen of the parents perceived that their child's mood was improved and that they spent less time in child care after NG or GT feedings were begun. We conclude that (1) both nasogastric and gastrostomy feedings safely improved nutrition in these children and (2) this objective improvement was often accompanied by subjective improvement. We suggest aggressive use of tube feedings in selected patients.
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Affiliation(s)
- S M Naureckas
- Department of Pediatrics, Children's Memorial Hospital, Northwestern University, Chicago, Illinois
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