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One-Step Insertion of Low-Profile Gastrostomy in Pediatric Patients vs Pull Percutaneous Endoscopic Gastrostomy
Abstract
Background: Standard care for initiation of enteral feeding in children has been pull percutaneous endoscopic gastrostomy (pull-PEG). As an alternative to pull-PEG, a 1-step endoscopic procedure for inserting a low-profile gastrostomy tube "button" has been developed that allows initial placement of a balloon-retained device. This report presents outcomes of metrics used to compare button placement with pull-PEG in a pediatric population. Methods: Data were generated from procedural experiences of surgeons on pediatric patients (n = 374) with a variety of clinical indications for gastrostomy. Study population ages ranged from 6 days to 16 years, while weights were from 2-84 kg. Results: The button was successfully placed by the 1-step procedure in 98% of the respective study population, and median procedural times were 20 and 15 minutes for button and pull-PEG placements, respectively. Median times to first feeds were equivalent for the 1-step procedure and pull-PEG (6 hours), while times to first nutrition feeds were 12.5 and 10 hours, respectively. Stoma site complications within each study group were similar. Healthy stoma proportions were 65.2% and 73.2% in the 1-step procedure and pull-PEG groups, respectively, at first follow-up. Conclusions: Similar study outcomes between the 1-step procedure and pull-PEG groups suggest that the former is a feasible alternative to pull-PEG for initial tube placement in children. The 1-step method involves a single procedure and reduces patient exposure to anesthesia, operating room time, and the potential for complications compared with a pull-PEG requirement for multiple procedures.
© 2015 American Society for Parenteral and Enteral Nutrition.
... An external bumper is applied to secure the tube against the skin [2,4]. The initial PEG non balloon feeding tube cannot support long-term feeding and must be removed by endoscopy under a second general anesthesia to place a button [5]. Complication rates for PEG reported in the literature vary from 4% to almost 50%. ...
... This technique was immediately acceptable to children and their families. Only a few studies have reported postoperative complications of B-PEG in children, which seem to occur with a similar frequency to those of P-PEG [5,[12][13][14][15][16][17]. A previous study from our group comparing the frequency of complications in P-PEG and B-PEG found an associated marked reduction of stomal infection (29.0% and 10.6%, respectively) [12]. ...
... The present study highlights that B-PEG is a safe method: major complications are rare (< 2% of the study population). The present results are consistent with those of 2 previous studies reporting major complications in 1% and 7% of their study population [5,14]. Notably, these rates are lower than those reported for P-PEG reaching 10-15% [6,9]. ...
To assess the complications of one-step button percutaneous endoscopic gastrostomy (B-PEG) and determine risk factors for developing stomal infections or gastropexy complications. A retrospective study of 679 children who underwent a B-PEG procedure in a single tertiary care center over a 10-year period to December 2020 was conducted. Patient characteristics, early complications (occurring ≤ 7 days after the procedure), late complications (> 7 days after the procedure), and outcomes were collected from medical records. A list of potential risk factors, including age at procedure, prematurity, underlying neurological disease, and undernutrition, was determined a priori. At least 1 year of follow-up was available for 513 patients. Median follow-up duration was 2.8 years (interquartile range 1.0–4.9 years). Major complications were rare (< 2%), and no death was related to B-PEG. Early complications affected 15.9% of the study population, and 78.0% of children presented late complications. Development of granulation tissue was the most common complication followed in frequency by tube dislodgment and T-fastener complications. Only 24 patients (3.5%) presented stomal infections. Young age at the time of PEG placement (odds ratio (OR) 2.34 [1.03–5.30], p = .042) was a risk factor for developing peristomal infection. T-fastener migration occurred in 17.3% of children, and we found underlying neurological disease was a protective factor (OR 0.59 [0.37–0.92], p = .019).
Conclusion: B-PEG is a safe method and associated with a low rate of local infection. However, T-fasteners are associated with significant morbidity and require particular attention in young and premature infants. What is Known:
• Percutaneous endoscopic gastrostomy (PEG) is the preferred method to provide long-term enteral nutrition in children to prevent malnutrition. The Pull-PEG method is still the most commonly used with complications , such as stomal infection. Since its description, only a few studies have reported postoperative complications of one-step button PEG (B-PEG).
What is New:
• T-fastener complications were not rare, and underlying neurologic disease was a protective factor. A very low rate of stomal infection was described, and young age at the time of PEG placement was a risk factor. The B-PEG is a safe method with fewer major complications than P-PEG in children.
... This technique was immediately acceptable to children and their families. Only a few studies have reported postoperative complications of B-PEG in children, which seem to occur with a similar frequency to those of P-PEG (9)(10)(11)(12)(13)(14)(15). A previous study from our group comparing the frequency of complications in P-PEG and B-PEG found an associated marked reduction of stomal infection (29.0% and 10.6%, respectively) (9). ...
... The present study highlights that B-PEG is a safe method: major complications are rare (<2% of the study population). The present results are consistent with those of 2 previous studies reporting major complications in 1% and 7% of their study population (11,12). Notably, these rates are lower than those reported for P-PEG reaching 10%-15% (5,7). ...
... Development of stomal granulation tissue is a common complication in B-PEG with variable rates from 4% to 50% (11,12,14,16), which seems to be more frequent than in P-PEG and could be explained by the deeper abdominal incision required for B-PEG than P-PEG (11). ...
Purpose
To assess the complications of one-step button percutaneous endoscopic gastrostomy (B-PEG) and determine risk factors for developing stomal infections or gastropexy complications.
Methods
A retrospective study of 679 children who underwent a B-PEG procedure in a single tertiary care center over a 10-year period to December 2020 was conducted. Patient characteristics, early complications (occurring ≤7 days after the procedure), late complications (> 7 days after the procedure), and outcomes were collected from medical records. A list of potential risk factors, including age at procedure, prematurity, underlying neurological disease, and undernutrition, was determined a priori.
Results
At least 1 year of follow-up was available for 513 patients. Median follow-up duration was 2.8 years (interquartile range 1.0–4.9 years). Major complications were rare (< 2%), and no death was related to B-PEG. Early complications affected 15.9% of the study population, and 78.0% of children presented late complications. Development of granulation tissue was the most common complication followed in frequency by tube dislodgment and T-fastener complications. Only 24 patients (3.5%) presented stomal infections. Young age at the time of PEG placement (odds ratio (OR) 2.34 [1.03–5.30], p = .042) was a risk factor for developing peristomal infection. T-fastener migration occurred in 17.3% of children, and we found underlying neurological disease was a protective factor (OR 0.59 [0.37–0.92], p = .019).
Conclusion
B-PEG is a safe method and associated with a low rate of local infection. However, T-fasteners are associated with significant morbidity and require particular attention in young and premature infants.
... Concern over inadvertent intestinal perforation and/or enteric fistulae associated with the PEG technique [3] has led to an expansion in the number of methods 1 3 for safe placement of gastrostomy tubes, with combinations of open, laparoscopic, and fluoroscopic techniques [4]. A further concern in children associated with the PEG technique is the need for repeated general anaesthetics (GA) to exchange the tube either with a new tube or a button device The percutaneous endoscopic primary button gastrostomy (PEG-B) approach attempts to address this [5][6][7]. ...
... The PEG-T was carried out using a push-pull technique as originally described by Gauderer [2] (Fig. 1). The PEG-B was carried out as per manufacturer's instructions (MIC-KEY Introducer Kit (Kimberly-Clark Corp, Roswell, Georgia) and as previously described by Göthberg and Björnsson [5] (Fig. 2). ...
... Despite this policy, we found a significant difference between tube and button groups with the latter having significantly fewer anaesthetics. This is supported in similar studies [5][6][7]. It is also important to consider the laparoscopic approach to placing a primary button, which, of course, also only requires one anaesthetic [3]. ...
PurposeTo compare the clinical outcomes and financial implications of the percutaneous endoscopic primary button gastrostomy (PEG-B) insertion using T-fastener technique with the percutaneous endoscopic gastrostomy tube insertion (PEG-T) using a push–pull technique.Methods
Data were prospectively gathered on 122 patients undergoing gastrostomy insertion over a 3-year period (2016–2019). Our primary outcome measure was the number of second general anaesthetics (GA) required in relation to the gastrostomy tube. Secondary outcome measures included complications and cost.ResultsFollowing exclusion criteria of lap assisted, concomitant procedure or insufficient data, 105 patients were analysed. Sixty-two (61%) PEG-B were inserted using a T-fastener technique. Forty-three (39%) PEG-T were inserted using a push–pull technique. Two (3.2%) patients with a PEG-B required a GA change or reinsertion of device compared with 31 (72%) of the PEG-T group who underwent a tube change under GA to either a button or a new tube in the study period (p < 0.01). The requirement for GA changes in the PEG-T group results in a considerably higher cost for this approach than the PEG-B approach. There was no difference between the number of peri-operative and post-operative complications between the two groups; however, the PEG-T group appeared to have higher rate of major operative complications (n = 3 bowel injuries). Whereas in the PEG-B group: complications were minor technical issues and displacement requiring replacement under fluoroscopy. In the follow-up period, rates of granulation tissue requiring intervention and stoma site infections were equivalent between groups.Conclusion
The PEG-B technique of placing a gastrostomy avoids the need for a replacement of gastrostomy tube under GA and its associated risk of repeat GA and financial cost. Furthermore, the technique is potentially associated with fewer major complications. We conclude, therefore, that the PEG-B approach reduces the interventional and financial burden on the patient, their family, and the healthcare provider, and could be considered as a safe alternative for paediatric gastrostomy insertion.
... Another postulated benefit of the push technique is decreased risk for peristomal infections because the tube is not exposed to the oral bacterial flora during insertion. Although the push technique is associated with a lower peristomal infection rate than PEG-P in adults [5], a similar advantage has not been shown in pediatric patients [6,7]. ...
... Recently, PEG placement with the push technique and T-fastener gastropexy (PEG-T) has been introduced in pediatric patients [6], and this particular method has gained popularity. So far, there are only a few studies that have evaluated the PEG-T technique in pediatric patients [6 -8], therefore, we wanted to report our initial experience with the PEG-T with particular emphasis on peri-and postoperative complications. ...
... The MIC-KEY Introducer Kit (Kimberly-Clark Corp, Roswell, GA, United States) was used in all patients, and the gastrostomy was placed according to the manufacturer's procedure as previously described by Göthberg and Björnsson [6]. The standard tube was a 14 Fr bolus gastrostomy balloon tube. ...
Background and study aims Insertion of a percutaneous endoscopic gastrostomy (PEG) with push-through technique and T-fastener fixation (PEG-T) has recently been introduced in pediatric patients. The T-fasteners allow a primary insertion of a balloon gastrostomy. Due to limited data on the results of this technique in children, we have investigated peri- and postoperative outcomes after implementation of PEG-T in our department.
Patients and methods This retrospective chart review included all patients below 18 years who underwent PEG-T placement from 2010 to 2014. Main outcomes were 30-day postoperative complications and late gastrostomy-related complications.
Results In total, 87 patients were included, and median follow-up time was 2.4 years (1 month – 4.9 years). Median age and weight at PEG-T insertion were 1.9 years (9.4 months – 16.4 years) and 10.4 kg (5.4 – 33.0 kg), respectively. Median operation time was 28 minutes (10 – 65 minutes), and 6 surgeons and 3 endoscopists performed the procedures. During the first 30 days, 54 complications occurred in 41 patients (47 %). Most common were peristomal infections treated with either local antibiotics in 11 patients (13 %) or systemic antibiotics in 11 other patients (13 %). 9 patients (10 %) experienced tube dislodgment. Late gastrostomy-related complications occurred in 33 patients (38 %). The T-fasteners caused early and late complications in 9 (10 %) and 11 patients (13 %), respectively. Of these, 4 patients (5 %) had subcutaneously migrated T-fasteners which were removed under general anesthesia.
Conclusion We found a high rate of complications after PEG-T. In particular, problems with the T-fasteners and tube dislodgment occurred frequently after PEG-T insertion.
... [1][2][3] In recent years, many additional techniques for gastrostomy tube (G-tube) placement have emerged, including combinations of endoscopy, laparoscopy, fluoroscopy, and new methods for securing the stomach to the abdominal wall. [4][5][6][7][8][9][10][11][12][13] Each method carries its own complications, and comparative studies are limited and low powered. Thus, it remains unclear which techniques are safest. ...
... 5,13,15 Several other small series have evaluated newer alterations of technique, such as the use of T-fasteners or trocars in PEG, 9 different methods of securing the stomach in laparoscopic cases, 6 or comparing pull-style PEG tubes to push-style buttons. 10 An early study at our institution compared laparoscopic gastrostomy to PEG and found a significantly increased risk of complications, including dislodgement requiring return to odds ratio (OR), with PEG technique. However, this study did not evaluate other techniques for gastrostomy placement. ...
... However, investigators agree that the vast majority of complications are minor. [1][2][3][5][6][7][9][10][11][12][13][14][15][16] Dislodgement risk in particular can be difficult to capture, since parents and emergency department staff often replace tubes without notifying the surgical team. Thus, we chose only to track those dislodgements which required replacement in the operating room. ...
Background
Gastrostomy tube placement is a common procedure that can be accomplished with a variety of techniques, each with its attendant complications. In an effort to standardize practice at our institution, we retrospectively evaluated complications including early dislodgement requiring operative repair, leaks, and granulation tissue to determine the optimal technique.
Materials and methods
A retrospective cohort study (June 2008-July 2014) evaluating children (<18) receiving gastrostomy tubes was completed. We recorded demographic data, placement technique, and postoperative complications within 120 days. The seven techniques in use at our institution were categorized into three groups: standard pull-type techniques for percutaneous endoscopic gastrostomies (PEGs), “push” techniques using transabdominal sutures or T-fasteners for securement of the stomach, and “fascial” techniques using sutures directly from the stomach to the abdominal fascia at the stoma site. Descriptive statistics were analyzed using t test and Kruskal-Wallis tests as appropriate, and outcomes with P < 0.05 were considered significant.
Results
Of the 450 patients, 255 (56.7%) were male. Median age and weight at the time of operation were 19.3 months (interquartile range, 6.5-89.6 months) and 9.0 kg (interquartile range, 5.7-17.1 kg) respectively. By technique, 245 patients underwent fascial placement (54.4%), 112 underwent push (24.9 %), and 93 underwent PEG (20.7%). Push and fascial techniques were less likely become dislodged than PEG, with odds ratios (ORs) of 0.14 (confidence interval CI 0.02-0.66) and 0.31 (CI 0.11-0.83), respectively. Fascial techniques had more granulation tissue than either push or PEG pull methods, OR 2.39 (CI 1.20-3.36), and more leakage, OR 2.22 (CI 1.19-4.15).
Conclusions
Dislodgement is most likely with PEG techniques. Granulation and leakage are most likely with fascial suture techniques. Push techniques are associated with the lowest complication rate.
... Besides the fact that the procedure has been utilized for ages (Jacob, et al. 2015), the advancements in the procedure are still constant (Peters, Balduyck, Nour, 2010). The process can be further optimized and utilized if the risk of in fection becomes less (Segal, et al. 2001 Often patients, who went through gastrostomy have to deal with some minor to major infection (Göthberg, Björnsson, 2016;Jacob, et al. 2015). Recently a newer technique One Step (OS), (MIC-KEY INTRODUCER KIT) which was developed by Kimberly-Clark Corporation in 2008(Gothb erg, Bjornsson, 2016 and was used in di fferent centers as replacement method for PEG (Gothberg, Bjornsson, 2016). ...
... They can be removed most of the time without sedation , in spite of the fact that many gastroenterologist may pick to utilize sedation and endoscopy at times (Brewster, Weil, Ladd, 2012;Peters, Balduyck, Nour, 2010). Both procedures (PT & OS) were compared in previous studies for t iming of procedure and period to establish feeds (Göthberg, Björnsson, 2016;Jacob, et al. 2015), ...
ARTICLE INFO ABSTRACT B ackground: The process of gas trosto my has been used for long time for health purposes while the pro cedu res been evolving according to the requirement s and adv ancement s of ti mes. Thi s research st udy is based on the comparison between P ercutaneous Endoscopi c Gastrostomy and On e-Step Gastrostomy regarding the in fectious rate in hospit alized Children at a Tertiary Care Hospit al in Jedd ah, Saudi Arabia. Methodology: Ou r retrospectiv e study of 132 P ati ents, at king Abdul-Aziz un iversity hospital KAUH from 1 st Janu ary 2002 to 31st December 2019 was approved by the Ins titutional ethical commit tee, Fil e nu mbers were review ed from Log Sheets in the endoscopy unit & ho spital record archives. The inclusion criteria for the study were below 14 years of age, regardless of th eir di agnosis who had gastrostomy tube pl acement. And th e exclusion crit eria P ati ents who had do ne surgical gast rosto my. Res ults : According to th e research study, the rate of in fection was considerably low for th e participants with the one-step Gast rosto my. The difference was around 10 .62%. Co nclusio n: The research conclud es that the On e step Technique is better th an th e pull-th rough technique regarding infecti on rate, but furt her larg e study needed for solid conclusion. Copyright © 2020, Bakr Alhussaini and Nawaf Al-Dajani. This is an open acc ess article distributed under the Creative Commons Attribution Lice nse, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
... Gothburg et al. retrospectively analysed 374 patients who had either one step button gastrotomy placement (206) with pull PEG insertion (168) in a paediatric population between January 2005 and December 2015. The first feed was given 6 h after the procedure [20]. Since 2015 the authors have altered their practice to reflect this and now feed at 6 h. ...
... Risk factors include under/over-distension of the stomach and significant kyphoscoliosis [19]. The risk of colonic injuries are reduced by ensuring that the endoscope light is clearly visible transcutaneously and that the needle is continually aspirated making sure that as it is inserted through the abdominal wall into the stomach it is under direct vision [20]. ...
PurposeGastrostomy buttons are normally inserted in two stages. For children, both stages are performed under general anaesthetic (GA) in the UK. We report our 20 years experience of the SPRING technique. (Single stage, Percutaneous, Rapid INsertion of a Gastrostomy button).Method
This paper retrospectively analysed case notes of all children who underwent a SPRING procedure between 1994 and 2014 in our institute. Patient details, success of placement, recovery process and early post-operative complications were recorded. A gastroscope is passed, and two Cope Gastrointestinal Anchor Sutures positioned. A dilator and splittable sheath are passed over a guide wire, the dilator is removed and a button inserted.Results300 patients underwent a GA for SPRING procedure.190 had a neurological diagnosis, 39 had Cystic Fibrosis, 16 had renal failure, and 55 had miscellaneous diagnoses. The age range was 3–238 months and their weights ranged from 3.0 to 128 kg. Of 300 attempts, 287 (95.6%) were successfully inserted. 12 required a 2.5 cm mini-laparotomy to identify the stomach and in one case the procedure was abandoned. Fourteen (4.9%) had a major complication requiring a 2nd GA and seventeen (5.9%) had minor surgical complications not requiring GA. The overall complication rate was 10.8%.ConclusionSPRING technique is a simple method for single stage gastrostomy button insertion with an acceptable complication rate.
... Göthberg (28). Some blame the sutures being cut too late (3-5 weeks postoperative) and recommend doing so within 2-3 weeks (25,27,29). ...
Unlabelled:
Gastrostomy placement is a standard procedure for children requiring enteral feeding for more than 3-6 weeks. Various techniques have been described (percutaneous endoscopic, laparoscopy, and laparotomy), and many complications have been reported. In our center, gastrostomy placement is performed either percutaneously by pediatric gastroenterologists, by laparoscopy/laparotomy by the visceral surgery team, or jointly, that is laparoscopic-assisted percutaneous endoscopic gastrostomy. This study aims to report all complications and identify risk factors and ways to prevent them.
Methods:
This is a monocentric retrospective study including children younger than 18 years who underwent gastrostomy placement (percutaneous or surgical) between January 2012 and December 2020. Complications that occurred up to 1 year after placement were collected and classified according to their time of onset, degree of severity, and management. A univariate analysis was conducted to compare the groups and the occurrence of complications.
Results:
We established a cohort of 124 children. Sixty-three (50.8%) presented a concomitant neurological disease. Fifty-nine patients (47.6%) underwent endoscopic placement, 59 (47.6%) surgical placement, and 6 (4.8%) laparoscopic-assisted percutaneous endoscopic gastrostomy. Two hundred and two complications were described, including 29 (14.4%) major and 173 (85.6%) minor. Abdominal wall abscess and cellulitis were reported 13 times. Patients who underwent surgical placement presented more complications (major and minor combined) with a statistically significant difference compared with the endoscopic technique. Patients with a concomitant neurological disease had significantly more early complications in the percutaneous group. Patients with malnutrition had significantly more major complications requiring endoscopic or surgical management.
Conclusion:
This study highlights a significant number of major complications or complications requiring additional management under general anesthesia. Children with a concomitant neurological disease or malnutrition are at greater risk of severe and early complications. Infections remain a frequent complication, and prevention strategies should be reviewed.
... Indeed, the "Société française d'Anesthésie et de Réanimation" (SfAR) and the "Société Francophone de Nutrition Clinique et Métabolisme" recommend perioperative nutritional management in order to reduce the operative risks linked to undernutrition [4]. In Madagascar, techniques are still conventional with a surgical approach due to inadequate endoscopic equipment. ...
Ostomy feeding remains a reference approach for enteral nutritional assistance. In Madagascar, the techniques are still conventional surgical procedures due to the lack of adequate endoscopic equipment. This study aims to evaluate the benefits and risks of enteral nutrition with a two-week follow-up. Included patients who had benefited from enteral nutrition by tube feeding using nasogastric, gastrostomy, and jejunostomy tubes over six months in Joseph Ravoahangy Andrianavalona Hospital. Prevalence, age and gender, current body mass index (BMI), weight, nutritional grade, initial pathology, psychological status, comorbidities, type of feeding stoma, and the surgical technique (gastrostomy or jejunostomy) were studied. After 15 days, the effectiveness of enteral nutrition was assessed using BMI, serum albumin, C-Reactive Protein (CRP) level, as well as postoperative complications and quality of life. The patient's outcome on the 15th day has been determined. The Chi-square test analyzed the associations and Mann Whitney test compared the effects of enteral nutrition by ostomy and gastric tube use. Forty-two patients were included, aged 47(17-78). The sex ratio was 0.5. Initially, the body mass index was 17(12-23) kg/m², the serum albumin value 3.4 (2.5-4.7) gr/dl with a median CRP level of 16 (2-74.2) mg/l. Nutritional assistance resulted in a weight variation between baseline and 15th day. Comparing enteral nutrition by ostomy and gastric tube, only variation of C Reactive Protein on the 15th day has a significative difference. Mortality was 33% (gastrostomy), 31% (jejunostomy), 24% (nasogastric tube). Nutritional support and the choice of ostomy or gastric tube for enteral nutrition were not associated with mortality. The effectiveness of nutritional assistance is still questionable in this study if the results are more promising in the literature. The death rate linked to the initial pathology and the general state of the patients is still considerable, hence the interest in decision-making in multidisciplinary consultation meetings.
... Push one-step PEG insertion has grown in popularity in recent years [5]. The advantage of this technique over a standard PEG tube implant is that it enables the primary insertion of a balloon and avoids the need for a second general anesthesia for tube removal and substitution with a low-level device [9]. Because the large bumper is prevented from passing down the esophagus, the one-step device is preferred in patients with a significant anesthetic risk and a history of cardiac or esophageal surgery. ...
Tube feeding is a therapeutic intervention that is aimed at providing nutritional support and is important in the nutritional and gastrointestinal management of children with neurological disability (ND) worldwide. Since the publication of the first European Society of Gastroenterology, Hepatology, and Nutrition (ESPGHAN) consensus paper in 2017, some aspects of tube-feeding modalities have attracted the interest of the scientific community more than others, including the type of enteral formulas, enteral access, and the challenging practice of tube weaning. The purpose of this review was to report on the most recent hot topics and new directions in tube-feeding strategies for children with ND.
... The process can be further optimized and utilized if the risk of in fection becomes less (Segal, et al. 2001 Often patients, who went through gastrostomy have to deal with some minor to major infection (Göthberg, Björnsson, 2016;Jacob, et al. 2015). Recently a newer technique One Step (OS), (MIC-KEY INTRODUCER KIT) which was developed by Kimberly-Clark Corporation in 2008(Gothb erg, Bjornsson, 2016 and was used in di fferent centers as replacement method for PEG (Gothberg, Bjornsson, 2016). Tube site infection is the most common minor complication following PEG placement. ...
... In the "push" technique, the MIC-KEY Introducer Kit (Kimberly-Clark Corp, Roswell, GA, United States) was used according to the manufacturer's procedure as previously described by Göthberg and Björnsson [21]. The stomach was first punctured under endoscopic control with 3 T-fasteners with resorbable sutures. ...
Background
Laparoscopic Nissen fundoplication (LNF) and gastrostomy tube (GT) placement may be performed concomitantly in children with gastro-esophageal reflux disease (GERD) and failure to thrive. We aimed to evaluate the rate and risk factors for LNF failure in children undergoing concomitant LNF/GT.MethodsA retrospective multi-institutional cohort study was conducted, reviewing patients that underwent LNF (2005–2014). Data collected included patient demographics, comorbidities, and type of GT (laparoscopy- or endoscopy-assisted). The primary outcome measure was LNF failure. Data was compared using contingency tables or Mann–Whitney tests, when appropriate. An exploratory analysis by Kaplan–Meier survival and Cox proportional hazards analysis was performed to determine predictors of time to LNF failure after LNF/GT.ResultsOf 189 children that underwent LNF, 99 (52%) had a concomitant GT (55% laparoscopy-, 45% endoscopy-assisted). LNF failed in 15% after LNF/GT and in 17% after LNF alone (p = 0.84), at a median age of 23 months (IQR 8–41). Using univariate analysis, we found that a younger age at the time of surgery (p = 0.05), prematurity (p = 0.0018), esophageal atresia (p = 0.01), and endoscopy-assisted GT (p = 0.02) were potential predictors of LNF failure after LNF/GT. After multivariate regression analysis, prematurity (p = 0.007) remained significantly associated with LNF failure after LNF/GT. No predictive factors for LNF failure after LNF alone were identified.Conclusions
Concomitant GT insertion and LNF is a common practice, as half of the children that undergo LNF also received GT insertion. Children born preterm or with esophageal atresia comprise a fragile population at high-risk of LNF failure after LNF/GT. Prospective, multicentric studies are needed to evaluate the best GT technique to use in children undergoing LNF.
... Many previous studies, including those referenced here, have been unable to control for patient variables when assessing complication rates in retrospective studies of different gastrostomy devices and tube insertion techniques (14,19,(23)(24)(25)(26)(27) . By using a matched case-control study methodology we have been able to control for some of this variability and create comparable Copyright © ESPGHAN and NASPGHAN. ...
Objectives:
Open primary balloon gastrostomy (PBG) presents an potential alternative to percutaneous endoscopic gastrostomy (PEG) in children as it obviates the need for change under general anaesthetic (GA), however the complication profile of PBG compared to PEG is not well defined. Previous series comparing the two have been hampered by the two groups not being equivalent. Our paediatric surgical centre has offered PBG as an alternative PEG since 2014. We used a matched case-control study to compare outcomes for PBG and PEG.
Methods:
Patients undergoing PBG were used as "cases" and matched 1:3 by age and diagnosis to patients undergoing PEG, demographics and clinical data as "controls". Primary outcome was rate of complications classified according to Clavien-Dindo(I-V). Secondary outcomes included time to feed and length of stay. Non-parametric, categorical analyses and multivariate logistic regression were performed. Data here presented as median [IQR].
Results:
We included 140 patients (35 PBG:105 PEG). The two groups were comparable for gender, weight at surgery and follow-up duration. Median operative time was longer for PBG (43 min [IQR 36.5-61.5] vs. 27.5 min [18.25-47.75], p < 0.001). Multivariate analysis demonstrated a statistically significant, higher incidence of symptomatic granulation tissue was more common in PBG (10(29%) vs 6(6%), p = 0.0008), this remained significant on multivariate analysis (OR 7.56[2.33-23.5], p = 0.001), nil other complication remained significant nor was overall complication rate statistically different.
Conclusions:
PBG and PEG have similar overall complication rates, however PBG appears to have a higher incidence of granulation tissue. This observation must be weighed against the need for further GA which is not insignificant in medically complex children.
... One study of 221 pediatric patients revealed that over Any further distribution of this work must maintain attribution to the author(s) and the title of the work, journal citation and DOI. 70% experienced minor complications, with the most frequently encountered complications directly related to stoma formation, including hypergranulation, bacterial infection, skin breakdown, and device dislodgment [3,6]. PG tube design improvements, including the replacement of external catheters with a skin-level button [7], have reduced the rate of complications over the years. ...
Hypergranulation, bacterial infection, and device dislodgment are common complications associated with percutaneous gastronomy (PG) tube placement for enteral feeding largely attributable to delayed stoma tract maturation around the device. Stoma tract maturation is a wound-healing process that requires collective and complete migration of an advancing epithelial layer. While it is widely accepted that micropatterned surfaces enhance cell migration when cells are cultured directly on the substrate, few studies have investigated the influence of apical contact guidance from micropatterned surfaces on cell migration, as occurs during stoma tract formation. Here, we developed 2D and 3D in vitro epithelial cell migration assays to test the effect of various Sharklet micropatterns on apically-guided cell migration. The 2D modified scratch wound assay identified a Sharklet micropattern (+10SK50×50) that enhanced apical cell migration by 4-fold ( p = 0.0105) compared to smooth controls over the course of seven days. The best-performing micropattern was then applied to cylindrical prototypes with the same outer diameter as a pediatric PG tube. These prototypes were evaluated in the novel 3D migration assay where magnetic levitation aggregated cells around prototypes to create an artificial stoma. Results indicated a 50% increase ( p < 0.0001) in cell migration after seven days along Sharklet-micropatterned prototypes compared to smooth controls. The Sharklet micropattern enhanced apically-guided epithelial cell migration in both 2D and 3D in vitro assays. These data suggest that the incorporation of a Sharklet micropattern onto the surface of a PG tube may accelerate cell migration via apical contact, improve stoma tract maturation, and reduce skin-associated complications.
... Some described that children and adults should continue oral urea assumption lifelong; for this reason, they may benefit from chronic administration through a low-profile gastrostomy-button or G-button, which could ensure correct and adequate drug intake [48,49]. ...
Nephrogenic syndrome of inappropriate antidiuresis (NSIAD), first described in 2005, is a rare genetic X-linked disease, presenting with hyponatremia, hyposmolarity, euvolemia, inappropriately concentrated urine, increased natriuresis, and undetectable or very low arginine-vasopressine (AVP) circulating levels. It can occur in neonates, infants, or later in life. NSIAD must be early recognized and treated to prevent severe hyponatremia, which can show a dangerous impact on neonatal outcome. In fact, it potentially leads to death or, in case of survival, neurologic sequelae. This review is an update of NSIAD 12 years after the first description, focusing on reported cases of neonatal and infantile onset. The different molecular patterns affecting the AVP receptor 2 (V2R) and determining its gain of function are reported in detail; moreover, we also provide a comparison between the different triggers involved in the development of hyponatremia, the evolution of the symptoms, and modality and efficacy of the different treatments available.
... Göthberg e Björnsson, em 2016, publicaram um estudo retrospectivo que comparou a colocação de um button primário de GEP, pela técnica de introdução, com a GEP pela técnica de tração (sonda de 15 Fr), em crianças (GÖTHBERG & BJÖRNSSON, 2016). Na técnica de tração foram incluídos 168 pacientes (100% de taxa de sucesso), 23% deles oncológicos, enquanto que na de introdução foram incluídos 206 pacientes (98% de taxa de sucesso), sendo 10% oncológicos. ...
MELLO, Gustavo Francisco de Souza e. Gastrostomia Endoscópica Percutânea Ambulatorial, Pelos Métodos de Tração (Gauderer-Ponsky) e Introdução (Russell), em Pacientes com Câncer de Cabeça e Pescoço: Ensaio Clínico Randomizado. Tese (Doutorado em Oncologia) – Programa de Pós-Graduação em Oncologia, Instituto Nacional de Câncer, Rio de Janeiro, 2016.
Introdução: A comparação das diferentes técnicas de gastrostomia endoscópica percutânea (GEP) mostra que todas são equivalentes em termos de segurança e taxa de sucesso. Diversos autores sugerem, entretanto, que o método de introdução resulta em menores taxas de infecção do estoma e que, no caso de pacientes portadores de câncer de cabeça e pescoço (CCP), também reduz o risco de implante metastático no local de punção. Apesar destas considerações, os dados da literatura são conflitantes na comparação dos resultados obtidos. Objetivos: Comparar as técnicas de tração e de introdução para realização de GEP, em caráter ambulatorial, em pacientes com CCP, em relação às taxas de sucesso técnico, complicações e duração do procedimento. Materiais e Métodos: Ensaio clínico randomizado, com seguimento dos pacientes por 6 meses. Foram selecionados pacientes adultos, portadores de CCP, em boas condições clínicas, encaminhados para realização de GEP pelas técnicas de tração ou introdução, no Hospital do Cancer I do Instituto Nacional de Câncer (HC I / INCA). Os desfechos primários estudados foram taxa de sucesso técnico, tempo de procedimento e taxas de complicações gerais e de infecção periestomal. Os desfechos secundários foram taxa de óbito, de alta por retirada eletiva e de sonda em uso ao final do estudo. Em todos os pacientes foram utilizados kits de 20 Fr das técnicas de tração ou introdução. A análise estatística foi realizada utilizando os testes t de Student ou qui-quadrado, quando apropriados, sendo considerado estatisticamente significativo o valor de P<0,05. Resultados: Entre Maio de 2013 e Abril de 2015, um total de 60 pacientes (48 homens e 12 mulheres) foram submetidos a GEP, 30 pela técnica de tração e 30 pela de introdução, todos em caráter ambulatorial. A taxa de sucesso foi de 100% para ambas as técnicas. Não houve diferença significativa entre os grupos em relação a distribuição de gênero, idade, presença de comorbidades e condições associadas (uso de sonda enteral, trismo, cirurgia abdominal prévia), tipo e localização de tumor, estadiamento e tratamento. Não houve diferença significativa na frequência de complicações gerais do procedimento entre as técnicas de tração e introdução (70% x 76,7%, P=0,771). Em relação ao tempo de ocorrência, a técnica de tração apresentou menor frequência de complicações imediatas (0% x 23,3%, P=0,011), mas não houve diferença entre complicações precoces (10% x 6,7%, P=0,999) ou tardias (70% x 63,3%, P=0,785). Em relação a gravidade, não houve diferenças significativas entre as técnicas de tração e introdução para complicações maiores (3,3% para ambas, P=0,999) ou menores (70% x 76,7%, P=0,711). Não houve diferença significativa na mortalidade entre os grupos (36,7% x 43,3%, P=0,792). A duração média do procedimento pela técnica de tração foi de 17,60 minutos contra 32,13 minutos para a técnica de introdução (P<0,001). Conclusão: A comparação entre as duas técnicas não mostrou diferenças significativas na frequência e nos tipos de complicações, mas a técnica de introdução tem uma duração do tempo de procedimento significativamente maior. A realização da GEP, em caráter ambulatorial, é segura para ambas as técnicas.
Palavras-chave: Gastrostomia endoscópica percutânea. Técnicas. Câncer de cabeça e pescoço. Procedimento ambulatorial.
ABSTRACT:
Outpatient Percutaneous Endoscopic Gastrostomy, by Pull (Gauderer-Ponsky) and Introduction (Russell) Methods, in Head and Neck Cancer Patients: Randomized Clinical Trial.
Introduction: The comparison of different percutaneous endoscopic gastrostomy (PEG) techniques shows that all are equivalent in terms of safety and success rate. Several authors suggest that the method of introduction is associated with lower infection rate than the pull method, because there is no transoral passage of the tube. In the case of patients with head and neck cancer (HNC) it also reduces the risk of metastatic implantation to the puncture site. Despite these considerations, the literature is conflicting when comparing the results. There are only few studies about PEG as an ambulatory procedure in HNC outpatients. Objectives: To compare pull and introduction techniques of PEG in HNC patients on an outpatient basis, regarding success rate, overall complication rate, infection rate and total duration of procedure. Materials and Methods: Randomized clinical trial, with a follow-up period of 6 months. Among the adult HNC patients refered to PEG at Cancer Hospital I, of the Brazilian National Cancer Institute (HC I / INCA), subjects in good clinical condition were selected to outpatient PEG tube placement by pull or introduction techniques. Primary endpoints were success rate, complications rate and total PEG procedure time. Secondary endpoints were mortality, elective tube removal and PEG tube in use rates at the end of the study. All patients received 20Fr PEG tubes. Statistical analysis was performed using the Student t test and the Chi-squared test, when appropriate. P values were considered significant when <0.05. Results: From May 2013 to April 2015, a total of 60 HNC outpatients (48 men and 12 women) underwent ambulatory PEG by pull or introducer technique (30 on each arm). The success rate was 100% for both techniques. There was no significant difference between the groups in relation to gender distribution, age, comorbidities and associated conditions (previous use of enteral tubes, trismus, previous abdominal surgery), type and tumor localization, staging and treatment. There was no significant difference in the procedure complication rate between the pull and introduction techniques (70% x 76.7%, P=0.771). Regarding the time of occurrence, the traction technique showed a lower rate of immediate complications (0% x 23.3%, P=0.011), but no difference between early (10% x 6.7%, P=0.999) or late complications (70% x 63.3%, P=0.785). Regarding the severity, there were no significant differences between pull and introduction techniques to major (3.3% for both, P=0.999) or minor complications (70% x 76.7%, P=0.711). There was no significant difference in mortality between groups (36.7% vs 43.3%, P=0.792). The average duration of the procedure by pull technique was 17.60 minutes versus 32.13 minutes for the introduction technique (P<0.001). Conclusion: The comparison between the two techniques showed no significant difference in the rate and type of complications, but the introduction technique had a longer duration of procedure time. The placement of a PEG tube by the two techniques is a safe and viable procedure on an outpatient basis.
Keywords: Percutaneous endoscopic gastrostomy. Techniques. Head and neck cancer. Outpatient procedure.
Introduction The T-fasteners gastrostomy (T-PEG) has become increasingly popular over recent years as an alternative to the “pull-technique” gastrostomy (P-PEG). This study aimed to compare P-PEG and T-PEG complications.
Materials and Methods A retrospective observational study of pediatric patients who underwent percutaneous endoscopic gastrostomy (PEG) placement. P-PEG was performed using the standard Ponsky technique and was replaced after 6 months by a balloon gastrostomy under sedation. T-PEG was performed using three percutaneous T-fasteners (that allow a primary insertion of a balloon gastrostomy). The balloon was replaced by a new one after 6 months without sedation. Complications were recorded.
Results In total, 146 patients underwent PEG placement, 70 P-PEG and 76 T-PEG. The mean follow-up was 3.9 years (standard deviation = 9.6). Age, weight, and associated comorbidities were comparable (p > 0.05). The overall complications were 17 (24.2%) in the P-PEG group and 16 (21.0%) in the T-PEG group (p > 0.05). P-PEG was associated with more sedation for button replacement (97 vs. 2.6% [p < 0.05]). P-PEG was associated with more early tube dislodgement during the first replacement (7.2 vs. 1.4% [p = 0.092]). Two of the five dislodged gastrostomies in the P-PEG group underwent laparotomy due to peritonitis, whereas the only dislodged gastrostomy in the T-PEG group was solved endoscopically. Altogether, P-PEG was associated with more complications that required urgent endoscopy, laparotomy, or laparoscopy (18.6 vs. 6.6% [p < 0.05]).
Conclusions P-PEG was associated with more sedation, complications during first button replacement, and complications requiring urgent endoscopy, laparotomy, or laparoscopy compared with T-PEG.
Purpose
Various complications are associated with percutaneous endoscopic gastrostomy (PEG) procedures in children. The push technique is being increasingly used, but its complications are insufficiently characterized. We aimed to assess all complications related to PEG procedures and compare the safety of the pull and push techniques.
Methods
Retrospective review of consecutive pediatric patients who underwent PEG between 2002 and 2020.
Results
In total, 216 children underwent 217 PEG procedures. The push technique was used in 138 (64%) cases, and the pull technique in 79 (36%) cases. The median follow-up time was 6.1 (0.1–18.3) years. The complication rate was high (57%) and patients experienced complications years after the procedure. Overall, 51% and 67% of patients experienced complications in the push and pull groups, respectively. The rates of minor and major complications were higher in the pull group than in the push group (63% vs 48%, p =0.028; and 11% vs 6%, p =0.140, respectively). Reoperation was also more common in the pull group (17% vs 7%, p =0.020).
Conclusions
The overall complication rate of PEG procedures is high. Fortunately, most complications are mild and do not require reoperations. The increasing push technique appears to be safer than the traditional pull technique. Significant long-term morbidity is related to gastrostomies in children.
Indocyanine green (ICG) is a water-soluble fluorescent dye that is minimally toxic and widely used in gastrointestinal surgery. ICG facilitates anatomical identification of structures (e.g., ureters), assessment of lymph nodes, biliary mapping, organ perfusion and anastomosis assessment, and aids in determining the adequacy of oncological margins. In addition, ICG can be conjugated to artificially created antibodies for tumour markers, such as carcinoembryonic antigen for colorectal, breast, lung, and gastric cancer, prostate-specific antigen for prostate cancer, and cancer antigen 125 for ovarian cancer. Although ICG has shown promising results, the optimization of patient factors, dye factors, equipment, and the method of assessing fluorescence intensity could further enhance its utility. This review summarizes the clinical application of ICG in gastrointestinal surgery and discusses the emergence of novel dyes such as ZW-800 and VM678 that have demonstrated appropriate pharmacokinetic properties and improved target-to-background ratios in animal studies. With the emergence of robotic technology and the increasing reporting of ICG utility, a comprehensive review of clinical application of ICG in gastrointestinal surgery is timely and this review serves that aim.
Objective:
De novo percutaneous placement of radiologically inserted low-profile or 'button-type' gastrostomy catheters (LPG) is infrequently reported in adults. This study compares the safety and clinical outcomes of primary percutaneous placement of LPG catheters and traditional balloon-retention gastrostomy catheters (TG) using image guidance at a single institution.
Design:
This was a retrospective, single-institution review comparing initial LPG and TG radiologically inserted catheter placements in a 36-month time period. The age, gender, indication, catheter type and method of anaesthesia of 139 consecutive initial gastrostomy placement procedures were recorded. Total catheter days without intervention, major and minor complications, reasons for reintervention, and procedure fluoroscopy times were compared.
Results:
During the 36-month study period, 61 LPG and 78 TG catheters were placed. Mean total catheter days prior to intervention was 137 days in the LPG group and 128 days in the TG group (p=0.70). Minor complications including cellulitis, pericatheter leakage and early catheter occlusion occurred in 4.9% (3/61) in the LPG group and 9% (7/78) in the TG group (p=0.5). Major complications including early catheter dislodgement and bleeding requiring transfusion (in one patient) occurred in 4.9% (3/61) in the LPG group and 7.7% (6/78) in the TG group (p=0.4). Procedure fluoroscopy time was lower in the LPG group (2.56 min) compared with the TG group (4.21 min) (p<0.005).
Conclusion:
Primary placement of low-profile or 'button-type' gastrostomy catheters is technically feasible with a low complication rate similar to that of traditional radiologically inserted gastrostomy catheters.
Children and adolescents with inflammatory bowel disease (IBD) often suffer the consequences of malnutrition and growth failure. Enteral nutrition as a therapy has been discussed prior to this chapter. Enteral access either via nasogastric tube (NGT) feedings or direct enteral access via a gastrostomy tube (G-tube) is an option for children with inflammatory bowel disease. Once it is clear that a patient requires supplemental calories to support growth and development, a trial of feedings via NGT is often done prior to more invasive percutaneous feeding tube placement. The trial of NGT feedings demonstrates tolerance of supplemental enteral formula and allows the patient and family to become familiar with the feeding delivery system, particularly the feeding bag setup and the pump. It is essential that families are educated regarding NGT placement, feeding administration, and maintenance of the tube and equipment.
Background/Aims
: Percutaneous endoscopic gastrostomy with push technique (PEG-T) is increasingly used in pediatric patients. In a retrospective study of PEG-T (cohort 1) we reported frequent complications related to T-fasteners and tube dislodgment. The aim of this study was to assess complications after implementation of a strict treatment protocol, and to compare these with the previous retrospective study.
Materials and Methods
: The study is a prospective study of PEG-T placement performed between 2017 and 2020 (cohort 2) in pediatric patients (0-18 years). Complications were recorded during hospital stay, fourteen days and three months postoperatively, graded according to the Clavien-Dindo classification and categorized as early (<30 days) or late (>30 days).
Results
: In total 82 patients were included, of which 52 (60%) had neurologic impairments. Median age and weight were 2.0 years [6 months-18.1 years] and 13.4 kg [3.5-51.5 kg], respectively. There was a significant reduction in median operating time from 28 min [10-65 min] in cohort 1 to 15 min [6-35 min] in cohort 2 (p<0.001), number of patients with early tube dislodgement (cohort 1: 9 (10%) vs cohort 2: 1 (1%), p=0.012), and number of patients with late migrated T-fasteners (cohort 1: 11 (13%) vs cohort 2: 1 (1%), p=0.004).
Conclusion
: We experienced less migrated T-fasteners and tube dislodgment after implementation of strict treatment protocol.
Background:
The ESPGHAN position paper from 2015 on percutaneous endoscopic gastrostomy (PEG) required updating in the light of recent clinical knowledge and data published in medical journals since 2014.
Methods:
A systematic review of medical literature from 2014 to 2020 was carried out. Consensus on the content of the manuscript, including recommendations, was achieved by the authors through electronic and virtual means. The expert opinion of the authors is also expressed in the manuscript when there was a lack of good scientific evidence regarding PEGs in children in the literature.
Results:
The authors recommend that the indication for a PEG be individualized, and that the decision for PEG insertion is arrived at by a multidisciplinary team (MDT) having considered all appropriate circumstances. Well timed enteral nutrition is optimal to treat faltering growth to avoid complications of malnutrition and body composition. Timing, device choice and method of insertion is dependent on the local expertise and after due consideration with the MDT and family. Major complications such as inadvertent bowel perforation should be avoided by attention to good technique and by ensuring the appropriate experience of the operating team. Feeding can be initiated as early as 3 hours after tube placement in a stable child with iso-osmolar feeds of standard polymeric formula. Low- profile devices can be inserted initially using the single stage procedure or after 2-3 months by replacing a standard peg tube, in those requiring longer term feeding. Having had a period of non-use and reliance upon oral intake for growth and weight gain - typically 8-12 weeks - a PEG may then safely be removed after due consultation. In the event of non-closure of the fistula the most successful method for closing it, to date, has been a surgical procedure, but the Over-The-Scope-Clip (OTSC®) has recently been used with considerable success in this scenario.
Conclusions:
A multidisciplinary approach is mandatory for the best possible treatment of children with PEGs. Morbidity and mortality are minimized through team decisions on indications for insertion, adequate planning and preparation before the procedure, subsequent monitoring of patients, timing of change to low-profile devices, management of any complications, and optimal timing of removal of the PEG.
Single‐stage percutaneous endoscopic gastrostomy (PEG) is a novel adaptation of the preexisting technique. Single‐stage PEG is used in patients who are at high anesthetic risk and experience chronic problems with feeding, requiring long‐term or lifetime enteral nutritional support, such as neurologically impaired children. These are the same as for standard PEG placement. Relative contraindication: small child due to potential reduced surface area for triangulation around the stoma site with gastropexy needles. There are several advantages for the patient: no additional anesthetic session or hospitalization, cosmetically better than a long tube, durable device with a significantly longer interval between device changes. Complications are the same as the standard PEG although pneumoperitoneum has a slightly higher incidence. Once enteral access is no longer required, the button can be removed in an outpatient setting or at home and the gastrostomy site can be allowed to close by itself.
Placement of gastrostomy tubes in infants and children has become increasingly commonplace. A historical emphasis on use of open gastrostomy has been replaced by less invasive methods of placement, including percutaneous endoscopic gastrostomy and laparoscopically assisted gastrostomy procedures. Various complications, ranging from minor to the more severe, have been reported with all methods of placement. Many pediatric patients who undergo gastrostomy tube placement will require long-term enteral therapy. Given the prolonged time pediatric patients may remain enterally dependent, further quality improvement and education initiatives are needed to improve long-term care and outcomes of these patients.
Percutaneous endoscopic gastrostomy has been a valuable tool in nutritional rehabilitation since its inception in 1980. Although it was originally described in children, a large sector of the adult population is dependant on it for nutritional support. Percutaneous endoscopic gastrostomy tube insertion is generally a safe procedure. Nevertheless, variable incidence rates of complications have been reported. The present review highlights the up-to-date indications, contraindications and complications of percutaneous endoscopic gastrostomy in children, along with a discussion of issues that need further exploring through future research.
In children, a gastrostomy button was placed as the initial feeding tube, using laparoscopy and a modified surgical technique. The aim of this study was to test the hypothesis that a new surgical procedure developed at our institution would result in fewer postoperative complications.
Sixty-two consecutive children with nutritional problems underwent a video-assisted gastrostomy operation (VAG). The technique requires the use of a 2 or 3 mm laparoscope optic and a 5 mm trocar placed at the exit site chosen for the gastrostomy. A continuous double U-stitch absorbable suture created a purse string suture around the gastrostoma on the stomach and fixated the stomach to the abdominal wall. For comparison, we used a control group of 68 children with nutritional problems operated on with our previously published VAG technique. After surgery, the children were followed up at one and six months and all complications were documented according to a protocol.
The two groups of children were comparable with regard to their demographic data. There were no serious intra-operative or postoperative intra-abdominal complications requiring reoperation. There was a significantly lower incidence of the minor complication of granuloma around the gastrostoma in the study group compared with the control group.
This variation of the surgical technique is simple and effective. It allows primary placement of a gastrostomy button that is functionally and cosmetically comparable to a gastrostomy tube surgically placed by other methods. In this study, the patients had fewer postoperative problems than the control group.
A percutaneous endoscopic gastrostomy remains the first choice when oral feeding is difficult. In some patients however an endoscopic placement of a gastrostomy tube is not possible. As an alternative, a laparoscopic-assisted insertion of a gastric button was performed to provide enteral feeding in seven patients. Enteral feeding could be resumed within one or two days after the procedure and no complications were encountered. This minimal invasive technique has certain advantages over a surgical gastrostomy by laparotomy. Therefore, a laparoscopically inserted gastric button should be considered a valuable alternative if percutaneous endoscopic gastrostomy is no longer possible.
The objectives of this study were to report our experience with the laparoscopic video-assisted gastrostomy technique in infants operated during their first year of life. A total of 53 infants (35 males, 18 females) aged 6 +/- 3 months, varying from 3 weeks to 11 months, underwent video-assisted gastrostomy. They were prospectively followed up. Included are infants with neurological dysfunction, chromosomal anomalies, metabolic disorders, cardiac anomalies or respiratory insufficiency. All the infants were operated under general and local anaesthesia. Gastrostomy tube feeding began within 4 h after the operation. The infants were followed with a scheduled control at 1 and 6 months postoperatively documenting complications and weight gain. The main outcome measure was the number and type of complications as well as weight gain using the age-adjusted Z-score of weight to normalize the data relative to a reference population. The weight before and 6 months after the video-assisted gastrostomy was 5.5 +/- 1.6 and 8.5 +/- 1.6 kg, respectively. The Z-score increased significantly (P < 0.001) from -2.7+/-1.5 to -1.7 +/- 1.0. This illustrates the postoperative weight gain and catch-up. Short and long-term complications included minor local wound infection, leakage around the gastrostomy tube and granuloma, but no severe complications. Our results encourage the use of video-assisted gastrostomy as a safe technique to provide a route for long-term nutritional support even in infants less than 1 year.
Neurologic patients suffering swallowing disorders are preferentially nurished during rehabilitation using the percutaneous endoscopic gastrostomy (PEG) method. For 36 of our patients suffering from cerebral brain damage, an average PEG duration of 156 days was required. During rehabilitation, an average of 87 days was required until food could be swallowed and 123 days until liquids could be swallowed. Serious complications must be expected in 1 - 2% of the PEG tube removals if no endoscopic control is performed. We observed two cases of PEG-end-piece adhesion through gastric epithelium which subsequently required surgical intervention. In another case, the PEG bumper remained in the pylorus which caused severe vegetative symptomes later on. We recommend that all PEG tubes should be removed under endoscopic surveillance and that all end-pieces should be retrieved without exception.
Percutaneous endoscopic gastrostomy (PEG) is a relatively safe and minimally invasive surgical method for providing enteral access in children. In pediatrics, the indications for PEG placement frequently include malnutrition or failure to thrive, as well as oropharyngeal dysphagia, especially in children with neurological impairment (NI). The risk for postoperative complications is low. However, among children with NI, gastroesophageal reflux disease (GERD) may necessitate fundoplication prior to gastrostomy tube placement. Preoperative pH probe testing has not been shown to be an effective screening tool prior to PEG placement among patients with GERD. Laparoscopic gastrostomy tube insertion was introduced in pediatric patients in an attempt to decrease complications associated with PEG. Although outcomes were reported to be similar to or better than PEG alone, future comparative studies are needed to better define the optimal patient demographic for this technique.
Novel approaches to percutaneous gastrostomy have evolved because of catheter clogging and displacement, which is commonly seen with currently available gastrostomy catheters. Low-profile button gastrostomy catheters, designed to be inserted into mature tracts, have recently been inserted into fresh gastrostomy tracts. Catheter clogging rarely occurs with these low-profile devices. Catheter displacement remains a problem but new buttons can be inserted at the patient's bedside without the need for a return visit to the radiology department. A 90 to 100% success rate has been shown for placement of gastrostomy buttons. Pull-type endoscopic gastrostomy catheters can be placed radiologically using a standard puncture of the stomach and cannulation of the gastroesophageal junction. A guide wire is manipulated up the esophagus and out the mouth. The pull-type gastrostomy catheter is then attached and pulled down through the esophagus and out through the anterior abdominal wall. These catheters have very good retention devices and rarely become dislodged. Catheter clogging is also rarely seen, provided larger devices are used. Radiological placement of percutaneous endoscopic gastrostomy tubes has been termed the "hybrid method" and has been shown to be cheaper than endoscopic and other fluoroscopic methods of gastrostomy.
The purpose of this study was to determine the number and types of complications experienced by children with gastrostomy tubes.
This is a prospective study of children with gastrostomy tube complications. Enrollment occurred on the first 24 months of the study. Data were collected for 4 years, beginning at the enrollment of the first participant. Demographic data and information on infections, granulation tissue formation, and major complications were recorded.
Infections occurred in 37% of patients, with most experiencing a single infection that occurred within the first 15 days after tube placement. Granulation tissue developed in 68% of patients, with 17% experiencing recurrent granulation tissue despite treatment. There was no difference in infection rates or granulation tissue formation between subgroups based on gender, ethnicity, or parents' education level. Major complications occurred in 4% of the patients.
Complications of infection and granulation tissue occur frequently and likely are a cause of stress and increased burden of care for these children and families. Improved strategies for care are needed.
A new technique has been developed to establish a tube feeding gastrostomy without a laparotomy. The procedure is particularly useful in high risk patients because general anesthesia is not usually required. The procedure is simple, safe, and rapid. It has been employed in 12 children (and 19 adults) with minimal morbidity and no mortality.
Granulation tissue above the periwound area is usually considered an impediment to wound healing. Although there is very little in the literature regarding hypergranulation tissue, the fact that there are numerous treatments by various wound clinicians demonstrates the recognition of its presence as a clinical problem. The paucity of published information prompted the authors to design a study to collect objective data on a treatment method they had found useful in their practices. This article explores the issue of hypergranulation and offers a nontraumatic method of management. A prospective non-controlled correlational study was undertaken with ten patients and twelve wounds using a polyurethane foam dressing to reduce hypergranulation tissue. The results demonstrated a significant decrease in height of 2 mm of granulation tissue from initial measurements to measurements taken two weeks later (p < 0.01).
Button gastrostomy (BG) insertion has been a secondary procedure after initial open Stamm or percutaneous endoscopic tube gastrostomy. Previous attempts at primary open BG have been limited by the difficulty in bringing the BG "wings" through the abdominal wall. We employed an innovative technique for primary BG, which eliminates many of the disadvantages inherent in tube gastrostomy.
From June 1993 to April 1994, primary BG insertion was performed in 34 children, using a silicon BG in a tapered peel-away sheath. Seventeen children had percutaneous endoscopic insertion of the BG. Six (35%) weighed less than 10 kg. Simultaneous laparoscopic guidance was used for percutaneous BG insertion in two children who had had multiple previous abdominal procedures. Open BG was performed during concomitant abdominal procedures in 15 patients and after unsuccessful percutaneous BG in two patients. Twelve patients (71%) weighed less than 10 kg. The standard Stamm technique was used for open BG insertion, and the tapered peel-away sheath was readily brought out through a remote incision in the abdominal wall.
The mean operative time for percutaneous primary BG was 12 minutes from needle insertion (range, 10 to 22 minutes). The mean time until BG feeding was 18 hours after insertion (range, 12 to 48 hours). No serious complications occurred in any of the 34 patients. Follow-up (1 to 10 months) has shown minor tissue reaction, minor leakage, and enthusiastic patient and parent satisfaction.
This innovative technique has proven safe and effective and allows for insertion of a skin-level, nonrefluxing, nonreactive, self-retaining feeding device, which eliminates the need for initial open or percutaneous tube gastrostomy and the associated complications. Potential cost savings may result through elimination of secondary button insertion procedures and the radiological studies often used to confirm proper button placement.
Enteral nutrition is the preferred route for nutritional support compared with parenteral nutrition if the gastrointestinal tract is functionally preserved. Long-standing nasogastric or nasoenteric feeding tubes are not well tolerated. Alternative routes are gastrostomy and jejunostomy. Percutaneous endoscopic gastrostomy/jejunostomy or those guided by fluoroscopy, sonography or tomography should be the first choices. Laparoscopy or laparotomy gastrostomy/jejunostomy routes should be reserved for specific situations. Insufflation of the stomach with air or saline solution facilitates the placement of nasoenteric feeding tubes or percutaneous sonographic-guided gastrostomy. The gastrostomy button is a safe and aesthetic alternative, at least in children. Comparison between percutaneous endoscopic gastrostomy and surgical gastrostomy performed either via laparotomy or laparoscopy favours the first in terms of costs and risks. Whenever associated intra-abdominal procedures or anatomic difficulties arise, a laparoscopic or an open access becomes necessary. Complications with feeding tubes are not uncommon and should be promptly recognized and treated.
During a 4-year period, 240 gastrostomy buttons were placed in children, as the initial surgical feeding tube, using laparoscopic techniques.
The technique requires the use of a minilaparoscope (1.6-mm) and a single 5-mm trocar placed at the exit site for the gastrostomy button. It can also be performed in addition to a laparoscopic fundoplication using the same trocar sites. The technique requires no special instrumentation or kits. When performed alone, operative times average 15 min. When performed with fundoplication, it adds approximately 5-10 min to the time for the procedure.
There were no intraoperative complications and five (2.1%) postoperative complications.
This technique has proven to be simple and effective. It allows primary placement of a gastrostomy button that is cosmetically and functionally superior to a gastrostomy tube.
The aim of this study was to report the late morbidity of percutaneous endoscopic gastrostomy (PEG) in a pediatric population and to identify possible risk factors for complications developing after PEG insertion.
A PEG was placed in 110 children between 1 May 1990 and 1 January 1997 using the pull technique. A retrospective study of late-onset complications was performed, with a follow-up period ranging from 1 to 8 years. All the complications occurring more than 6 days after PEG insertion were recorded, except for gastrostomy tube obstruction and accidental tube dislodgement.
The prevalence of late-onset complications related to PEG in our patients varied from 3.8 to 4.4 per 10 5 days. The overall rate of late-onset complications was 44% (48 complications observed in 29 patients [26%]). Seventy-five percent of the complications appeared during the first 2 years after PEG insertion. Nine different types of complication have been identified: intragastric buried or extruded gastrostomy (n = 24), gastric metaplasia granulation tissue around the site of gastrostomy (n = 8), intragastric pseudotumoral proliferative gastric mucosa (n = 4), intragastric mucosal ulceration (n = 3), cutaneous necrosis (n = 3), cologastric fistula (n = 2), gastrostomy closure delay after tube removal (n = 2), subcostal neuralgia (n = 1), and peritonitis (n = 1). Wilcoxon and chi-square tests were used to compare the clinical characteristics of the patients and the type of material used in the two populations, with and without complications. No clinical risk factor for the development of complications could be identified. Intragastric buried or extruded gastrostomy appeared more frequently with the use of one type of button than with the use of tubes.
The authors' experience suggests that PEG is associated with significant late morbidity, which is mainly observed within the first 2 years after PEG insertion. However, no risk factor for the development of such complications could be identified.
This paper looks at some of the wound-care issues surrounding enteral tube feeding, and questions the evidence base for current practices, which can be ritualistic
Setting the external bolster at the time of placement of percutaneous endoscopic gastrostomy (PEG) is a key factor in the spectrum of morbidity and complications related to the procedure. Setting the bolster too tight results in various gradations of buried bumper syndrome, whereas setting the bolster too loose can lead to leakage and acute peritonitis. Aspects of the initial technique, awareness of contributing factors, and strategies for monitoring and surveillance of the PEG once placed are all important in preventing more serious sequelae.
Gastrostomy without laparotomy: a percutaneous endoscopic technique. 1980
- M Gauderer
- J Ponsky
Laparoscopic gastrostomy in children
- Gme Humphreys
- A Najmaldin
Managing overgranulation tissue around gastrostomy sites
- L Warriner
- P Spruce