Safety of percutaneous endoscopic gastrostomy in medically complicated infants

Advances and challenges of gastrostomy insertion in children

When oral feeding cannot provide adequate nutritional support to children, enteral tube feeding becomes a necessity. The overall aim is to ultimately promote appropriate growth, improve the patient's quality of life and increase carer satisfaction. Nasogastric tube feeding is considered appropriate on a short-term basis. Alternatively, gastrostomy feeding offers a more convenient and safer feeding option especially as it does not require frequent replacements, and carries a lower risk of complications. Gastrostomy tube feeding should be considered when nasogastric tube feeding is required for more than 2-3 wk as per the ESPEN guidelines on artificial enteral nutrition. Several techniques can be used to insert gastrostomies in children including endoscopic, image guided and surgical gastrostomy insertion whether open or laparoscopic. Each technique has its own advantages and disadvantages. The timing of gastrostomy insertion, device choice and method of insertion is dependent on the local expertise, patient requirements and family preference, and should be individualized with a multidisciplinary team approach. We aim to review gastrostomy insertion in children including indications, contraindications, history of gastrostomy, insertion techniques and complications.

Comparison of general endotracheal anesthesia versus sedation without endotracheal intubation during initial percutaneous endoscopic gastrostomy insertion for infants: A retrospective cohort study

BACKGROUND

Critical airway incidents are a major cause of morbidity and mortality during anesthesia. Delayed management of airway obstruction quickly leads to severe complications due to the reduced apnea tolerance in infants and neonates. The decision of whether to intubate the trachea during anesthesia is therefore of great importance, particularly as an increasing number of procedures are performed outside of the operating room.

AIM

In this retrospective cohort study, we evaluated airway management for infants below 6 months of age undergoing percutaneous endoscopic gastrostomy insertion. We compared demographic, procedural, and health outcome-related data for infants undergoing percutaneous endoscopic gastrostomy insertion under general endotracheal anesthesia (n = 105) to those receiving monitored anesthesia care (n = 44) without endotracheal intubation.

METHODS

A retrospective chart review was completed for all infants <6 months of age who underwent percutaneous endoscopic gastrostomy insertion in our institution's endoscopy suite between January 2002 and January 2017. Descriptive statistics summarized numeric variables using medians and corresponding ranges (minimum-maximum), and categorical variables using frequencies and percentages. Differences in study outcomes between patients undergoing general anesthesia or monitored anesthesia care were evaluated with univariate quantile or Firth logistic regression for numerical and categorical outcomes, respectively. Results are presented as β [95% confidence interval] or odds ratio [95% confidence interval] along with corresponding p-values.

RESULTS

Both groups were similar in distribution of age, race, and gender. However, patients selected for general anesthesia had lower median body weights (3.9 kg [range: 2.0-6.7] vs. 4.4 kg [range: 2.6-6.9]), higher percentages of cardiac (95.2% vs. 84.1%), and/or neurologic comorbidities (74.3% vs. 56.8%) and were more frequently given American Society of Anesthesiologists level IV classifications (41.9% vs. 29.6%) indicating that these infants may have had more severe disease than patients selected for monitored anesthesia care. Three monitored-anesthesia-care patients required intraoperative conversion to general anesthesia. General anesthesia patients experienced greater odds of intraoperative hypoxemia (45.2% vs. 29.0%; odds ratio: 2.0 [0.9-4.3], p-value: .09) and required postoperative airway intervention more frequently than monitored-anesthesia-care patients (13.03% vs. 2.3%; odds ratio: 4.6 [0.8-25.6], p-value: .08). Procedure times were identical in both groups (6 min), but general anesthesia resulted in longer median anesthesia times (44 min [range: 22-292] vs. 12 min [range:19-136]; β:13 [95% 6.9-19.1], p-value: < .001).

CONCLUSION

Study results suggest that providers selected general anesthesia over monitored anesthesia care for infants and neonates with low body weights, cardiac comorbidities, and neurologic comorbidities. Increased rates of airway intervention, and increased length of stay may be at least partially related to more severe patient comorbidity, as indicated by higher American Society of Anesthesiologists classifications. However, due to the exploratory nature of these analyses, further confirmatory studies are needed to evaluate the impact of airway selection during PEG on postoperative patient outcomes.

Percutaneous endoscopic gastrostomy in children: A tertiary center experience

INTRODUCTION

Percutaneous endoscopic gastrostomy (PEG) is a common procedure in children. The outcomes of PEG could be affected by the associated disease. We aimed to evaluate the outcomes and safety of PEG tube placement in a tertiary care center with special attention to patients with cardiac disease, ventriculoperitoneal (VP) shunt, or peritoneal dialysis (PD) catheter.

METHODS

This retrospective study included 113 pediatric patients who had PEG tube insertion from 2011 to 2021. Eighteen patients (15.93%) had cardiac disease, five patients (4.42%) had PD catheters, and three patients (2.65%) had VP shunt.

RESULTS

The median age was 3 years (interquartile range: 1-6), and females represented 55% of our patients. The weight ranged from 2.57 to 60 kg, and the most common indication for insertion was neurological disease (n = 56; 49.56%). The median operative time was 30 (20-45) minutes. Pneumonia and vomiting were the most frequent complications (n = 20, 17.7%). Thirty-day mortality occurred in four patients (3.54%) and 1-year mortality in 10 patients (8.85%). Nine patients (7.96%) required fundoplication, and four patients (3.53%) had tube removal and reinsertion. There was no association between weight and postoperative complications (odds ratio: 0.97; P = .48). There were no differences in postoperative complications among patients with cardiac diseases, PD catheters, and VP shunts. No complications were reported in patients with VP shunt. One patient with cardiac disease and one patient with PD catheter required fundoplication. Removal and reinsertion were needed in one patient with a PD catheter.

CONCLUSION

PEG is feasible in low-weight infants with a low complication rate. The complication rate is low in patients with VP shunt, PD catheter, and cardiac patients.

Surgical Antimicrobial Prophylaxis in Abdominal Surgery for Neonates and Paediatrics: A RAND/UCLA Appropriateness Method Consensus Study

Surgical site infections (SSIs), i.e., surgery-related infections that occur within 30 days after surgery without an implant and within one year if an implant is placed, complicate surgical procedures in up to 10% of cases, but an underestimation of the data is possible since about 50% of SSIs occur after the hospital discharge. Gastrointestinal surgical procedures are among the surgical procedures with the highest risk of SSIs, especially when colon surgery is considered. Data that were collected from children seem to indicate that the risk of SSIs can be higher than in adults. This consensus document describes the use of preoperative antibiotic prophylaxis in neonates and children that are undergoing abdominal surgery and has the purpose of providing guidance to healthcare professionals who take care of children to avoid unnecessary and dangerous use of antibiotics in these patients. The following surgical procedures were analyzed: (1) gastrointestinal endoscopy; (2) abdominal surgery with a laparoscopic or laparotomy approach; (3) small bowel surgery; (4) appendectomy; (5) abdominal wall defect correction interventions; (6) ileo-colic perforation; (7) colorectal procedures; (8) biliary tract procedures; and (9) surgery on the liver or pancreas. Thanks to the multidisciplinary contribution of experts belonging to the most important Italian scientific societies that take care of neonates and children, this document presents an invaluable reference tool for perioperative antibiotic prophylaxis in the paediatric and neonatal populations.

Effectiveness and Complication Rate of Percutaneous Endoscopic Gastrostomy Placement in Pediatric Oncology Patients

PURPOSE

Malnutrition is a significant issue for pediatric patients with cancer. We sought to evaluate the effectiveness and complication rate of percutaneous endoscopic gastrostomy (PEG) placement in pediatric oncology patients.

METHODS

A retrospective chart review was performed on 49 pediatric oncology patients undergoing PEG placement at Johns Hopkins All Children's Hospital between 2000 and 2016. Demographic and clinical characteristics, complications, absolute neutrophil count at time of PEG placement and at time of complications, length of stay, and mortality were identified. Weight-for-age Z-scores were evaluated at time of- and six months post-PEG placement.

RESULTS

The overall mean weight-for-age Z-score improved by 0.73 (p<0.0001) from pre- (-1.11) to post- (-0.38) PEG placement. Improvement in Z-score was seen in patients who were malnourished at time of PEG placement (1.14, p<0.0001), but not in those who were not malnourished (0.32, p=0.197). Site infections were seen in 12 (24%), buried bumper syndrome in five (10%), and tube dislodgement in one (2%) patient. One patient (2%) with fever was treated for possible peritonitis. There were no cases of other major complications, including gastric perforation, gastrocolic fistula, clinically significant bleeding, or PEG-related death documented.

CONCLUSION

Consistent with previous studies, our data suggests a relationship between site complications (superficial wound infection, buried bumper syndrome) and neutropenia. Additionally, PEG placement appears to be an effective modality for improving nutritional status in malnourished pediatric oncology patients. However, larger prospective studies with appropriate controls and adjustment for potential confounders are warranted to confirm these findings.

Percutaneous endoscopic gastrostomy in small infants unable to swallow safely

BACKGROUND

Data about percutaneous endoscopic gastrostomy (PEG) insertions in small infants are limited, and most studies include older children. We aimed to evaluate the safety of PEG placement in infants weighing ≤5 kg together with their follow-up results.

METHODS

A retrospective evaluation was made of records between January 2005 and December 2019.

RESULTS

A total of 43 infants were ≤5 kg at the time of PEG insertion. The mean age was 5 ± 3 (19 days-16 months) months and the mean weight was 4.3 ± 0.6 (2.7-5.0) kg. The primary diagnoses were neurological disorders in 25, metabolic disorders in nine, cleft palates in four, muscular disorders in four, and a cardiac disorder in one. All procedures were completed successfully. A self-resolving pneumoperitoneum developed in one (2.3%). The tube was extruded in six (14%) patients postoperatively which required suture-approximation of the skin and subcuticular tissues. The tube was removed in four (9%) patients with achievement of oral feeds on the long-term. Eighteen (42%) died of primary diseases. The tubes were in situ for a median of 12.4 (17 days-73 months) months in these patients. A total of 20 (46.5%) patients are currently being followed up and their tubes are in situ for a median of 50.3 (4.7 month-9.8 years) months.

CONCLUSIONS

Percutaneous endoscopic gastrostomy placement is safe in small infants with associated morbidities. Complications related to the procedure are within acceptable limits. The accidental extrusion of the tube was a special consideration in this patient group. The overall mortality was high because of underlying primary diseases.

Percutaneous Endoscopic Gastrostomy and Nutritional Interventions by the Pediatric Nutritional Support Team Improve the Nutritional Status of Neurologically Impaired Children

Aim: To evaluate the long-term effects of nutritional improvement following percutaneous endoscopic gastrostomy (PEG) tube feeding stratified by previous feeding method and to assess the impact of underlying muscle tone on the outcomes of the nutritional intervention. Methods: Neurologically impaired children who underwent PEG tube insertion and nutritional intervention provided by a pediatric nutritional support team were enrolled. We measured anthropometric variables, laboratory parameters, and nutritional intake at baseline, 6 months after PEG insertion, and the last visit. We evaluated the percent ideal body weight (PIBW), body mass index (BMI)-for-age z-score, and percentiles and calculated the ratios of calorie intake compared to required requirement (CIR) and protein intake compared to recommended requirement (PIR). Results: The PIBW and BMI-for-age z-score improved during the first 6 months (p = 0.003 and p = 0.005, respectively). The CIR (p = 0.015) and PIR (p = 0.004) increased during the study period. The baseline BMI and PIBW of the previous nasogastric tube feeding group were better than those of the oral feeding group (p = 0.02 and p = 0.03, respectively). The BMI-for-age z-score, PIBW, CIR, and PIR improved in the hypertonic group (p = 0.03, 0.02, 0.03, and 0.01, respectively). Conclusion: PEG tube feeding and active nutritional intervention improved the nutritional status of neurologically impaired children immediately after PEG insertion. The nutritional requirements might vary by the muscle tonicity.

Variability in the Method of Gastrostomy Placement in Children

Although gastrostomy placement is one of the most common procedures performed in children, the optimal technique remains unclear. The purpose of this study was to evaluate variability in the method of gastrostomy tube placement in children in the United States. Patients <18 years old undergoing percutaneous endoscopic gastrostomy (PEG) or surgical gastrostomy (SG) (including open or laparoscopic) from 1997 to 2012 were identified using the Kids’ Inpatient Database. Method of gastrostomy placement was evaluated using a multivariable mixed-effects logistic regression model with a random intercept term and a patient-age random-effect term. A total of 67,811 gastrostomy placements were performed during the study period. PEG was used in 36.6% of entries overall and was generally consistent over time. PEG placement was less commonly performed in infants (adjusted odds ratio [aOR] 0.30, 95%CI 0.26–0.33), children at urban hospitals (aOR: 0.38, 95%CI 0.18–0.82), and children cared for at children’s hospitals (aOR 0.57, 95%CI 0.48–0.69) and was more commonly performed in children with private insurance (aOR 1.17, 95%CI 1.09–1.25). Dramatic variability in PEG use was identified between centers, ranging from 0% to 100%. The random intercept and slope terms significantly improved the model, confirming significant center-level variability and increased variability among patients <1 year old. These findings emphasize the need to further evaluate the safest method of gastrostomy placement in children, in particular among the youngest patients in whom practice varies the most.

Percutaneous endoscopic gastrostomy in children less than 10 kilograms: A comparative study

BACKGROUND/AIM

Percutaneous endoscopic gastrostomy tube (PEG) has replaced the standard open surgical gastrostomy for enteral nutrition. However, several complications were reported, especially in children less than 10 kg. Our objective was to report the outcomes of percutaneous endoscopic gastrostomy in children according to their weight.

PATIENTS AND METHODS

163 children had PEG tube insertion in our tertiary referral hospital from January 2007 to March 2019. Patients were divided into two groups according to the weight; group I (less than 10 kg; n = 112) and group II (more than 10 kg; n = 51). Comparisons were made between the two groups for incidence of postoperative complications, the need for reintervention, 30-day, and 1-year mortality.

RESULTS

There were 51 males (45.5%) in group I and 27 in group II (52.9%) (P = 0.38). The mean weight at the time of endoscopy was 5.9 ± 1.53 and 17.3 ± 8.23 kg and the mean American Society of Anesthesiologists (ASA) score was 2.6 ± 0.67 and 2.43 ± 0.57 in group I and II, respectively (P = 0.101). The most common associated condition was cerebral palsy (50 (44.6%) and 24 (47.1%) in group I and II, respectively; P = 0.77). The mean operative time was 30.28 ± 11.57 min in group I and 33.62 ± 23.36 min in group II (P = 0.221). Skin complications were the most commonly encountered complications of PEG, and 49% (n = 48) required the removal and replacement of the tube under general anesthesia in group I and 41% (n = 21) in group II (P = 0.84). There was no significant difference in the complication between groups.

CONCLUSION

: PEG is a safe technique in children less than 10 kg, and the complications rate is comparable with older children. The use of positive transillumination and small needle for measuring the distance between the skin and the stomach enhances the safety of the procedure. PEG should be considered in children less than 10 kg who need supportive or continuous enteral nutrition for different reasons.

Impact of Gastrostomy Tube Placement on Short-Term Weight Gain in Hospitalized Premature Infants

BACKGROUND

Gastrostomy tube (G-tube) placement is a long-term alternative to oral or nasogastric feeding for premature infants who cannot safely feed orally or need supplemental nutrition for adequate growth.

METHODS

We compared daily weight changes for G-tube infants 14 and 30 days preplacement and postplacement, excluding the first 7 days post-G-tube insertion. Infants <37 weeks of gestation without major congenital anomalies and discharged from 327 United States neonatal intensive care units (2004-2013) were included. Incidence of in-hospital outcomes including hypoxic ischemic encephalopathy, intraventricular hemorrhage grade 3 or 4, necrotizing enterocolitis, and patent ductus arteriosus ligation was examined. Additionally, we estimated a treatment effect model in which infants with a G-tube were matched 1:1 to untreated controls based on propensity scores; main outcome was the average treatment effect (weight gain) for treated infants during the 7, 14, or 30 days immediately prior to discharge.

RESULTS

Of 329,254 infants, 1393 (0.4%) received a G-tube, increasing from 0.2% in 2004 to 0.6% in 2013. Daily weight gain was significantly less during days 8-14 postplacement compared with 14 days preplacement but was similar between 30 days preplacement and 8-30 days postplacement. After matching, G-tube infant weight gain during the 7 days predischarge was less than among controls, but there was no difference in weight gain between treated and control patients for 14 days and 30 days predischarge.

CONCLUSIONS

The prevalence of G-tube placement has increased. G-tube use in infants was not associated with improved short-term daily weight gain.

Comparison of Tolerance and Complication Rates Between Early and Delayed Feeding After Percutaneous Endoscopic Gastrostomy Placement in Children

BACKGROUND

Enteral nutrition is commonly initiated 24 hours after percutaneous endoscopic gastrostomy (PEG) in children. Adult studies report safe refeeding within 1 to 6 hours of PEG, and these findings have been cautiously applied to children. Comparative studies assessing early versus next-day refeeding in children are currently lacking. This study evaluates feeding tolerance and complications following early versus next-day refeeding in children.

METHODS

This is a single-center, pre-post study. In June 2015 our clinical practice changed to begin refeeding within 6 hours of PEG. Children receiving early refeeding from December 2015 to August 2017 were included. A retrospective cohort from February 2013 to April 2015 was used for comparison.

RESULTS

Forty-six children received early refeeding after PEG and 37 received next-day refeeding. Gender distribution was similar in the 2 groups. Early refeeding patients were slightly older (3.5 vs 2.2 years) and heavier (15.5 vs 11.5 kg) at PEG placement compared to next-day refeeding patients. Early refeeding patients experienced greater postprocedural nausea and/or vomiting (19% vs 8%, P < 0.001) and leakage, irritation, and infection around the stoma (19% vs 0.0%, P < 0.001). Compared to early refeeders, next-day refeeding patients experienced higher occurrence of fever (35% vs 13%, P = 0.021), longer nutritional disruption (24.6 vs 3.7 hours, P < 0.001), and longer length of stay (51 vs 27 hours; P < 0.001). One next-day refeeding patient experienced peritonitis. One early refeeding patient experienced cellulitis requiring hospitalization and a second experienced gastrostomy tube migration into the peritoneal cavity requiring removal.

CONCLUSION

Early refeeders experienced higher rates of postprocedural nausea or vomiting and irritation, leakage, or infection around the stoma; but experienced lower rates of postoperative fever. Early refeeding resulted in reduced nutritional interruption and hospital length of stay.

Pediatric Endoscopy, Update 2020

Optimal management of pediatric endoscopy requires a multidisciplinary approach. In most hospitals, endoscopy in pediatric patients is performed by conventional gastroenterologists and only a few centers have specialized pediatric gastroenterologists. This is due to the fact that the number of pediatric gastroenterologists is limited and not all of them are experienced in endoscopic techniques. However, there are also some pediatric centers offering a high-quality and high-volume endoscopy service provided by very experienced pediatric gastroenterologists. Up to now, the literature on pediatric endoscopy is rather sparse. In this article, we describe current knowledge and practice of endoscopic procedures in pediatric patients, which should be relevant for both the adult and pediatric gastroenterologists.

Complications in children with percutaneous endoscopic gastrostomy (PEG) placement

INTRODUCTION

The aim of this study was to analyze the complication rates and mortality in association with different operative techniques of percutaneous endoscopic gastrostomy (PEG), age, underlying diseases and other risk factors. Moreover, analysis of the indications of PEG insertion and the underlying comorbidities was also performed.

METHODS

This study performs a literature analysis of PEG-related complications in children. Literature was searched on PubMed^® (1994-2017) using terms "percutaneous endoscopic gastrostomy", "complications", "mortality" and "children".

RESULTS

Eighteen articles with 4631 patients were analyzed. The mean age was 3 years (0-26 years). Operative techniques were: pull technique in 3507 (75.7%), 1 stage PEG insertion in 449 (9.7%), introducer technique in 435 (9.4%), image-guided technique in 195 (4.2%) and laparoscopic-assisted PEG in 45 (1.6%). Most frequent indications for PEG insertion were dysphagia (n = 859, 32.6%), failure to thrive (n = 723, 27.5%) and feeding difficulties (n = 459,17.4%). Minor complications developed in n1518 patients (33%), including granulation  (n = 478, 10.3%), local infection (n = 384, 8.3%) and leakage (n = 279, 6%). In 464 (10%) patients, major complications occurred; the most common were systemic infection (n = 163, 3.5%) and cellulitis (n = 47, 1%). Severe complication like perforation occurred in less than 0.3%. Patients with lethal outcomes (n = 7, 0.15%) had severe comorbidities; and the cause of mortality was sepsis in all cases. Prematurity or young age did not affect complication rate. Patients with ventriculoperitoneal (VP) shunt had higher risk of major complications. In high-risk patients, laparoscopic-assisted PEG insertion had less major and severe complication than traditional pull technique.

CONCLUSIONS

PEG is a safe operative technique; although minor complications are relatively common and occur in up to 1/3 of patients, there is a fairly low rate of severe complications. Two-thirds of PEG patients have at least one comorbidity. Patients with VP shunt have higher risk of major complications. In high-risk patients, laparoscopic-assisted PEG is recommended.

Safety and Efficacy of Bedside Percutaneous Endoscopic Gastrostomy Placement in the Neonatal Intensive Care Unit

OBJECTIVE

The aim of the study is to describe the safety and efficacy of bedside percutaneous endoscopic gastrostomy (PEG) placement in a level 3 neonatal intensive care unit (NICU).

METHODS

A retrospective chart review was performed on 106 infants with a birthweight ≤6 kg receiving bedside PEG placement at Johns Hopkins All Children's Hospital between 2007 and 2013. Preprocedure, postprocedure, and demographic data were collected. The main safety outcome was postprocedure complication rate and the main efficacy outcome was time to initiate feeds and time on respiratory support.

RESULTS

The mean birth weight and mean gestational age of our population at the time of procedure were 2.2 kg and 33 weeks, respectively. There were 9 total complications (8.5%) with major complications being only 2 (1.8%). There were no instances of blood stream infections. The mean length of time to initiate feeds was 1.2 days (standard deviation [SD] = 1.2). Ninety-three percent of patients were extubated within 24 hours.

CONCLUSIONS

Bedside PEG placement is safe with minimal complications. It is associated with little need for ventilator support and allows for early re-initiation of feeds and early success at reaching goal feedings.

Infant Percutaneous Endoscopic Gastrostomy: Risks or Benefits?

BACKGROUND/AIMS

To present a single center's experience with percutaneous endoscopic gastrostomy (PEG) tube placement in infants.

METHODS

Clinical records of infants who underwent PEG tube placement between January 2010 and December 2015 were reviewed. All patients underwent an upper gastrointestinal contrast study and an abdominal ultrasonography before the procedure. PEGs were performed with a 6-mm endoscope using the standard pull-through technique. Data regarding gestational age, birth weight, age and weight, days to feeding start, days to full diet, and complications were reviewed.

RESULTS

Twenty-three patients were included. The most common indication was dysphagia related to hypoxic-ischemic encephalopathy. Median gestational age was 37 weeks (range, 24-41) and median birth weight was 2,605 grams (560-4,460). Patients underwent PEG procedures at a median age of 114 days (48-350); mean weight was 5.1 kg (3.2-8.8). In all patients but one, a 12-Fr tube was positioned. Median feeding start was 3 days (1-5) and on average full diet was achieved 5 days after the procedure (2-11). Six minor complications were recorded and effectively treated in the outpatient clinic; no major complications were recorded.

CONCLUSIONS

PEG is safe and feasible in infants when performed by highly experienced physicians.

Evaluating complication rates and outcomes among infants less than 5kg undergoing traditional percutaneous endoscopic gastrostomy insertion: A retrospective chart review

PURPOSE

Percutaneous endoscopic gastrostomy (PEG) enables enteral nutrition for patients with inadequate oral intake. Laparoscopic guidance of PEG insertion is used for high-risk populations, including in infants less than 5kg at insertion. This study aimed to assess complication rates with traditional PEG tube insertion in infants less than 5kg at a single tertiary care center.

METHODS

A retrospective review of patients less than 5kg who underwent PEG insertion was conducted. PEG insertion-related complications, up to four years following insertion, were collected. Outcomes were reported as counts and percentages, or median with minimum and maximum values.

RESULTS

480 pediatric gastrostomy procedures between January 1, 2009 and February 1, 2017, were screened, with 129 included for analysis. Median weight at PEG insertion was 3800g. Superficial surgical site infection (SSI) occurred in 6 (4.7%) patients, and 1 (0.8%) required readmission for intravenous antibiotics. One (0.8%) required endoscopic management for retained foreign body, 1 (0.8%) required operative management for gastrocolic fistula, and 1 (0.8%) for persistent gastrocutaneous fistula. No deep space SSI, procedure-related hemorrhage requiring readmission or transfusion, buried bumper syndrome, or procedure-related mortality occurred.

CONCLUSION

Traditional PEG tube insertion in infants less than 5kg results in complication rates comparable to pediatric literature standards.

LEVEL OF EVIDENCE

Level II, retrospective prognosis study.

Comparison of operative outcomes between surgical gastrostomy and percutaneous endoscopic gastrostomy in infants

PURPOSE

Safety profile of different gastrostomy procedures in small children has not been well studied. This study was conducted to investigate whether complication and mortality rates differ between surgical gastrostomy (G-tube) and percutaneous endoscopic gastrostomy (PEG) in infants and neonates.

METHODS

In this retrospective study utilizing the Kids' Inpatient Database, all infants who underwent either G-tube or PEG as a sole procedure were identified. Variables included age, gender, race, presence of neurological impairment, prematurity, complex chronic condition, and severity of illness/risk of mortality subclasses. Postoperative complication, reoperation, and mortality rates were compared between G-tube and PEG. A subgroup of neonates was also analyzed.

RESULTS

A total of 1456 infants were identified (G-tube n=874, PEG n=582). In univariate analysis, the rates of adverse outcomes were not significantly different (G-tube vs PEG complication rate was 7.3% and 6.7%, p=0.65; mortality rate 1.3% and 0.7%, p=0.29, respectively). Adjusted odds ratios (ORs) for complication were 1.07 (G-tube vs PEG, 95% confidence interval [CI] 0.700-1.620) for overall infants and 1.19 (95% CI 0.601-2.350) for the neonatal subgroup. Similarly, adjusted ORs for mortality did not differ significantly both in infants (OR 1.749, 95% CI 0.532-5.755) and in the neonatal subgroup (OR 2.153, 95% CI 0.566-8.165).

CONCLUSIONS

When G-tube and PEG were performed as the only procedure throughout a hospitalization in infants and neonates, the two techniques had comparable risks of postoperative complications and mortalities.

LEVEL OF EVIDENCE

Retrospective comparative study, Level III.

Infant gastrostomy outcomes: The cost of complications

PURPOSE

Comparative outcomes of enhanced percutaneous endoscopic gastrostomy (PEG) and laparoscopic gastrostomy (LG) have not been elucidated in infants. We describe the outcomes and procedural episodic expenditures of PEG versus LG in this high-risk population.

METHODS

One hundred eighty-three gastrostomies in children under 1year were reviewed from our institution spanning 1/2011-6/2015. Pertinent demographics and 3-month complications (mortality, gastrocolic fistula, reoperation, cellulitis, granulation, pneumonia, and tube dislodgement <6weeks) were collected. Facility and professional administrative data was used to conduct a charge and cost analysis of PEG and LG procedures as well as their statistically significant complications.

RESULTS

Seventy-eight PEG and 105 LG infants were compared. LG infants were significantly younger, had higher ASA class, and increased frequency of cardiopulmonary disease. Significant major complications included a 3.8% incidence of gastrocolic fistula among PEGs (3.8% vs 0%, p=0.04) and 7.6% early tube dislodgements among LG infants (0 vs. 7.6%, p=0.01), resulting in $86,896 of additional charges with PEG complication. Incorporating complication frequency, average charges and variable cost per case were $8964 and $253 greater using PEG.

CONCLUSIONS

Despite a healthier cohort, infants undergoing enhanced PEG have more morbid and costly complications. LG may be the less burdensome approach to gastrostomy in infants.

LEVEL OF EVIDENCE

Case-Control Study/Retrospective Comparative Study - Level III.

Tracheostomy Among Infants With Hypoplastic Left Heart Syndrome Undergoing Cardiac Operations: A Multicenter Analysis

BACKGROUND

Less than 2.7% of infants undergoing congenital heart disease operations have difficulty weaning from invasive mechanical ventilation. In such instances, clinicians may choose to perform tracheostomy. Limited literature has examined tracheostomy placement specifically in infants with hypoplastic left heart syndrome (HLHS). This study evaluated the risk factors for tracheostomy placement in infants with HLHS and examined the outcomes of these infants before their first hospital discharge.

METHODS

This retrospective analysis of the Pediatric Heath Information System data set included infants with HLHS who underwent stage 1 Norwood operation, a hybrid procedure, or heart transplant from 2004 through 2013.

RESULTS

We identified 5721 infants with HLHS, and 126 underwent tracheostomy placement. Infants in the tracheostomy group had more morbidities and a higher mortality rate across the study period. Diagnosis of chromosomal abnormalities, anomalies of the trachea and esophagus, larynx, diaphragm and nervous system, bilateral vocal cord paralysis, and necrotizing enterocolitis, and procedures including extracorporeal membrane oxygenation support, cardiac catheterization, and gastrostomy tube were independently associated with tracheostomy placement in the study population. Despite an overall increase in rates of tracheostomy performed in infants with HLHS during the study period, the mortality rate did not improve among tracheostomy patients.

CONCLUSIONS

Several risk factors were identified in infants with HLHS in whom a tracheostomy was placed during their first hospitalization. Despite an overall increase in rates of tracheostomies during the study period, the mortality rate did not improve among these patients. Appropriate family counseling and thorough preoperative case selection is suggested when discussing possible tracheostomy placement in infants with HLHS.

Combined endoscopic gastrostomy ("Pull-Introducer Technique"): a new less traumatic technique for preterm and small for gestational age patients

INTRODUCTION

The most common endoscopic gastrostomy technique is the "Pull-Through" or Gauderer-Ponsky technique. This is a transoral technique in which the internal bumper of the tube goes in through the esophagus. However this has been shown to be traumatic and often impossible in newborns and small for gestational age (SGA) patients, therefore a transabdominal technique must be used in this cases. We have developed a new transabdominal technique which combines two classical methods. This technique avoids the inconvenience of passing the internal bumper through the esophagus.

PATIENTS AND METHODS

We have used this combined technique in five SGA patients. The technique consists of inserting a replacement tube using a Pull kit as installation device.

RESULTS

There were no complications during these five procedures and the patients were fed 2 hours later.

DISCUSSION

The main advantage of this technique is the use of kits that are already found in endoscopy units and endoscopists are familiar with. The disadvantage is the use of a balloon tube that can break or deflate.

A comparison of pediatric gastrostomy tube placement techniques

PURPOSE

This study aimed to compare different techniques for placement of gastrostomy tubes in a pediatric population.

STUDY DESIGN

A retrospective review was performed for patients less than 18 years of age who underwent gastrostomy tube placement at a single academic children's hospital between 2010 and 2012. Techniques for gastrostomy placement included Open Stamm, percutaneous endoscopic gastrostomy (PEG), fluoroscopy guided, laparoscopic, and laparoscopic assisted PEG. Pre-operative characteristics of patients and post-operative outcomes were compared between techniques.

RESULTS

Most patients underwent an Open Stamm (43 %) or PEG (39 %). There were significant differences between groups with respect to primary diagnoses, prior surgeries, and ASA classification. Major complications were rare, with less than 3 % requiring reoperation within 30 days; however, minor complications and returns to the emergency department were common. Unintentional tube dislodgements occurred in 22 % of all patients, with Open Stamm technique identified as an independent predictor of unintentional dislodgement (p < 0.0001).

CONCLUSIONS

Although conclusions from this retrospective analysis are limited due to heterogeneity between groups, open Stamm gastrostomy placement in children was associated with increased negative outcomes including unintentional tube dislodgements, returns to the emergency department, and need for reoperation within 30 days. Prospective analysis of the various techniques is needed to confirm that minimally invasive techniques for gastrostomy tube placement are associated with a less complicated post-operative course.

Complications of PEG are not related to age - The result of 10-year multicenter survey

PURPOSE

The aim of this study was to analyze whether the insertion of Percutaneous Endoscopic Gastrostomy (PEG) during infancy is related to higher morbidity. Moreover, we analyzed the structure of indications to PEG placement in various age groups of pediatric patients.

MATERIAL/METHODS

The study involved medical data of children after PEG insertion from six Polish endoscopic centers: infants (<12 months of age), toddlers (12-36 months), and preadolescents (>36 months).

RESULTS

The overall prevalence of early complications associated with PEG insertion was 5.14%; while they were noted in infants and preadolescents, none were recorded in toddlers. The analyzed age groups did not differ significantly in terms of the prevalence of late complications. Cerebral palsy (34.86%) and other chronic neurological conditions (34.29%) were the most frequent indications to PEG insertion in the whole group. Patients with congenital heart defects and multiple defect syndrome were inserted PEG at the youngest age; in contrast, the age at insertion was the highest in cystic fibrosis patients.

CONCLUSIONS

The early qualification to nutritional intervention via endoscopically formed gastrostomy can have important clinical implications with regards to improved therapeutic outcomes and reduced morbidity rates.

Laparoscopic versus percutaneous endoscopic gastrostomy placement in children: Results of a systematic review and meta-analysis

BACKGROUND:

Percutaneous endoscopic gastrostomy (PEG) and laparoscopic-assisted gastrostomy (LAG) are widely used in the paediatric population. The aim of this study was to determine which one of the two procedures is the most effective and safe method.

METHODS:

This systematic review was conducted according to the preferred reporting items for systematic reviews and meta-analyses statement. Primary outcomes were success rate, efficacy of feeding, quality of life, gastroesophageal reflux and post-operative complications.

RESULTS:

Five retrospective studies, comparing 550 PEG to 483 LAG placements in children, were identified after screening 2347 articles. The completion rate was similar for both procedures. PEG was associated with significantly more adjacent bowel injuries (P = 0.047), early tube dislodgements (P = 0.02) and complications that require reintervention under general anaesthesia (P < 0.001). Minor complications were equally frequent after both procedures.

CONCLUSIONS:

Because of the lack of well-designed studies, we have to be cautious in making definitive conclusions comparing PEG to LAG. To decide which type of gastrostomy placement is best practice in paediatric patients, randomised controlled trials comparing PEG to LAG are highly warranted.

Endoscopic button gastrostomy: Comparing a sutured endoscopic approach to the current techniques

PURPOSE

Button gastrostomy is the preferred feeding device in children and can be placed open or laparoscopically (LBG). Alternatively, a percutaneous endoscopic gastrostomy (PEG) can be placed initially and exchanged for a button. Endoscopic-assisted button gastrostomy (EBG) combines both techniques, using only one incision and suturing the stomach to the abdominal wall. The long-term outcomes and potential costs for EBG were compared to other techniques.

METHODS

Children undergoing EBG, LBG, and PEG (2010-2013) were compared. Patient demographics, procedure duration/complications, and clinic and emergency room (ER) visits for an eight-week follow-up period were compared.

RESULTS

Patient demographics were similar (32 patients/group). Mean procedure time (min) for EBG was 38 ± 9, compared to 58 ± 20 for LBG and 31 ± 10 for PEG (p<0.0001). The most common complications were granulation tissue and infection with a trend toward fewer infections in EBG group. Average number of ER visits was similar, but PEG group had fewer clinic visits. 97% of PEG patients had subsequent visits for exchange to button gastrostomy.

CONCLUSIONS

EBG is safe and comparable to LBG and PEG in terms of complications. It has a shorter procedure time than LBG and does not require laparoscopy, device exchange, or subsequent fluoroscopic confirmation, potentially reducing costs.

Percutaneous endoscopic gastrostomy (PEG) does not worsen vomiting in children

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.

ESPGHAN position paper on management of percutaneous endoscopic gastrostomy in children and adolescents

OBJECTIVES

This European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) position statement provides a comprehensive guide for health care providers to manage percutaneous endoscopic gastrostomy tubes in a safe, effective, and appropriate way.

METHODS

Relevant literature from searches of PubMed, CINAHL, and recent guidelines was reviewed. In the absence of evidence, recommendations reflect the expert opinion of the authors. Final consensus was obtained by multiple e-mail exchange and during 3 face-to-face meetings of the gastroenterology committee of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

RESULTS

Endoscopically placed gastrostomy devices are essential in the management of children with feeding and nutritional problems. The article focuses on practical issues such as indications and contraindications.

CONCLUSIONS

The decision to place an endoscopic gastrostomy has to be made by an appropriate multidisciplinary team, which then provides active follow-up and care for the child and the device.

Long-term outcomes of infants and children undergoing percutaneous endoscopy gastrostomy tube placement

OBJECTIVES

Little is known about long-term outcomes of patients undergoing percutaneous endoscopic gastrostomy (PEG) placement. The purpose of this study was to examine tube-related major complications in pediatric patients undergoing PEG placement during a 10-year follow-up period.

METHODS

A retrospective chart review of patients undergoing PEG placement from April 1999 through December 2000 at Boston Children's Hospital was performed. Cumulative incident rates of major complications (defined by additional hospitalization, surgical or interventional radiology procedures) as well as time between PEG placement and major complications were evaluated using Kaplan-Meier survival analysis. Time to elective tube removal and patient mortality was also assessed.

RESULTS

One hundred thirty-eight patients (59% [n = 82] boys [median age 22.5 months] [interquartile range, IQR 9-72.5], weight 9.2 kg [IQR 6.1-15.8]), underwent PEG placement during the study period and were followed at our hospital for a median of 4.98 years (IQR 1.5-8.7) years. Median time to elective tube removal was 10.2 years, with approximately half of the patients estimated to still have an indwelling enteral tube 10 years after placement. Fifteen patients (11%) had at least 1 major complication related to their gastrostomy tubes during the examined time period. The cumulative incidence of patients having a major complication was 15% (95% confidence interval 8.9-24.5) by 5.4 years.

CONCLUSIONS

Children undergoing PEG placement have a long-term high risk of morbidity related to enteral tubes. Major complications can occur many years after PEG placement. Larger prospective studies may be useful to assess risk factors for PEG-related complications in pediatrics.

Diagnosis of gastroesophageal reflux and anti-reflux procedures among Polish children with gastrostomies: a 10-year nationwide analysis

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.

A simple method for percutaneous endoscopic gastrostomy tube removal: "tie and retrograde pull"

BACKGROUND/PURPOSE

Various techniques have been presented to remove the percutaneous endoscopically placed gastrostomy tube in children, but tubes with semi-rigid internal retaining discs are difficult or impossible to remove by external traction. We describe a simple and effective endoscopic removal technique that should be applicable to any type of percutaneous endoscopic gastrostomy tube.

METHODS

Percutaneous endoscopic gastrostomy tube removal was performed with the "tie and retrograde pull" technique. After a polypropylene suture was placed and tied 1cm over the skin level, the percutaneous endoscopic gastrostomy tube was cut 0.5 cm over the knot. The suture was cut from the connection point between the needle and the suture. The distal end of the suture was pushed through the stoma into the stomach. Then a forceps was inserted through the gastroscope. The suture was caught, and the residual percutaneous endoscopic gastrostomy portion was retrieved via retrograde traction on the suture.

RESULTS

The causes of exchange were determined to be planned tube replacement in 9, buried bumper syndrome in 1, and tube occlusion in 3 patients. The mean tube dwell time was 10.8 ± 3.9 months. Esophageal mucosal tear developed in 1 patient with epidermolysis bullosa during removal. No other complications occurred during PEG tube exchanges.

CONCLUSION

This is a rapid and useful technique that does not require any complex endoscopic devices.

Tolerance and efficacy of preventive gastrostomy feeding in pediatric oncology

BACKGROUND

Malnutrition in pediatric oncology remains underestimated, although having a negative impact on outcome. Enteral nutrition (EN) using percutaneous endoscopic gastrostomy (PEG) may prevent or reverse malnutrition consequences. We aimed to evaluate both efficacy and safety of early EN during tumors treatment in children.

PROCEDURES

Medical records of pediatric patients having a PEG tube inserted between 1995 and 2009 were retrospectively reviewed. We compared type and incidence of complications in Group 1, including 74 patients suffering from cancer, and control Group 2, including 57 patients with neurological impairment. Efficacy of EN was evaluated through nutritional parameters [Z-scores weight for height (W/H) and height for age (H/A)], post-operative complications and relapse rates. Statistical significance was set for P < 0.05.

RESULTS

PEG tolerance was similar in both groups, as shown by comparable complication rates (62% vs. 76%, NS). EN allowed improvement or stabilization of Z-score W/H in 76% of oncologic patients. The final height loss was lower (-0.5 vs. -1.2 SD of Z-scores H/A) when EN was started at the beginning of the oncologic treatment. In bone tumors, EN prevented weight loss during chemotherapy, and tended to lessen surgical complications, relapses and deaths.

CONCLUSIONS

Early gastrostomy feeding represents a relatively safe way to prevent malnutrition in children with cancer, and might play a role in bone tumors oncological outcome. Further prospective studies are needed to confirm these results and assess the impact of EN and PEG on quality of life.

Feeding and nutritional challenges in infants with single ventricle physiology

PURPOSE OF REVIEW

Adequate enteral nutrition and growth are vital to recovery and survival of infants following palliation for univentricular hearts. This group of patients experiences frequent feeding complications that may impede adequate delivery of enteral nutrition. This review presents the most recent data related to feeding practices, growth patterns and outcomes. It also explores management strategies for delivering enteral nutrition safely and effectively to this high-risk group of infants.

RECENT FINDINGS

Infants following palliation for single ventricle physiology have persistent growth failure until at least 14 months of life. Greater daily caloric intake attenuates this growth failure. Persistent growth failure is associated with increased mortality following cardiac surgery. Management of enteral nutrition varies widely both pre and postoperatively. Data suggest that standardizing feeding practices improves delivery of enteral nutrition and decreases feeding complications. Evidence-based international feeding guidelines do not exist.

SUMMARY

Delivery of adequate nutrition in infants with single ventricle physiology is essential to improve outcomes but is often difficult to achieve. Evidence-based feeding guideline development is crucial to improve outcomes in this group of patients.