Gastrostomy Insertion In Children Research Articles

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.

Rate of paediatric gastrostomy insertion in England and relationship to epidemiology of cerebral palsy

Background and objectivesGastrostomy tubes are commonly used to provide an alternative route for enteral nutrition. Most of the gastrostomies are inserted in children with cerebral palsy. Previous studies have shown...

Feasibility of percutaneous endoscopic gastrostomy insertion in children receiving peritoneal dialysis.

Peritoneal dialysis (PD) is the preferred dialysis modality for paediatric patients with end-stage kidney disease. Frequently, malnutrition is encountered. Percutaneous endoscopic gastrostomy (PEG) is the preferred mode of feeding because of its minimal invasive mode of placement and easy handling in daily life. However, reports of a high risk for early post-interventional peritonitis hampered this procedure during PD and controlled studies on the benefit of peri-interventional management to prevent peritonitis are lacking. Here, we report the safety profile of PEG insertion among a cohort of children on PD by using a prophylactic antibiotic and antifungal regimen as well as modification of the PD programme. We performed a single-centre analysis of paediatric PD patients receiving PEG placement between 2015 and 2020. Demographic data, peri-interventional prophylactic antibiotic and antifungal treatment as well as modification of the PD programme were gathered and the incidence of peritonitis within a period of 28 days after PEG was calculated. Eight PD patients (median weight 6.7 kg) received PEG insertion. Antibiotic and antifungal prophylaxis were prescribed for median time of 4.0 and 5.0 days, respectively. After individual reduction of PD intensity, all patients continued their regular PD programme after a median of 6 days. One patient developed peritonitis within 24 h after PEG insertion and simultaneous surgery for hydrocele. Applying an antibiotic and antifungal prophylactic regime as well as an adapted PD programme may reduce the risk for peritonitis in paediatric PD patients who receive PEG procedure.

Endoscopic vs laparoscopic paediatric gastrostomies: Time to change our practice?

Background: Gastrostomy insertion is a common procedure for paediatric surgeons, with the percutaneous endoscopic gastrostomy (PEG) technique long favoured for its simplicity and speed. However, there is growing evidence to suggest that primary laparoscopic balloon gastrostomy (LBG) insertions may have lower complication rates. This study aimed to determine the relative safety and healthcare resource burden of PEG and LBG. Methods: A retrospective review of all primary gastrostomy insertions (2011–2019). Primary outcome measures included return to theatre for emergency laparotomy and healthcare burden (total gastrostomy-related admissions, length of stay and total theatre utilisation). Results: 338 PEGs and 277 LBGs were inserted with a minimum follow-up period of six months. Following PEG insertion 12/338(3.6%) children required an emergency laparotomy for gastrostomy-related complications. This compared to 2/277(0.7%) following LBG insertion (ARR2.8% (95%CI0.6–5.0), p < 0.0267).When considering all gastrostomy related admissions, there was no significant difference in total theatre utilisation (PEG = 85 [IQR58–117] minutes, LBG = 86 [IQR75–105] minutes, p = 0.12). However, PEGs were found to have an overall longer length of stay 4 [IQR3–7] vs 3 [IQR2–4] days. Conclusions: LBGs carry a significantly lower rate of major complications and are not associated with an increased healthcare burden. LBG should be considered as the first line method of gastrostomy insertion in children.

Survival of children and adolescents with intellectual disability following gastrostomy insertion.

Positive health outcomes have been observed following gastrostomy insertion in children with intellectual disability, which is being increasingly used at younger ages to improve nutritional intake. This study investigated the effect of gastrostomy insertion on survival of children with severe intellectual disability. We used linked disability and health data of children and adolescents who were born in Western Australia between 1983 and 2009 to compare survival of individuals with severe intellectual disability by exposure to gastrostomy status. For those born in 2000-2009, we employed propensity score matching to adjust for confounding by indication. Effect of gastrostomy insertion on survival was compared by pertinent health and sociodemographic risk factors. Compared with children born in the 1980s-1990s, probability of survival following first gastrostomy insertion for those born in 2000-2009 was higher (2years: 94% vs. 83%). Mortality risk was higher in cases than that in their matched controls (hazard ratio 2.9, 95% confidence interval 1.1, 7.3). The relative risk of mortality (gastrostomy vs. non-gastrostomy) may have differed by sex, birthweight and time at first gastrostomy insertion. Respiratory conditions were a common immediate or underlying cause of death among all children, particularly among those undergoing gastrostomy insertion. Whilst gastrostomy insertion was associated with lower survival rates than children without gastrostomy, survival improved with time, and gastrostomy afforded some protection for the more vulnerable groups, and earlier use appears beneficial to survival. Specific clinical data that may be used to prioritise the need for gastrostomy insertion may be responsible for the survival differences observed.

Implementing an early feeding pathway post gastrostomy insertion reduces inpatient stay

BackgroundThere is no consensus regarding optimal postoperative feeding strategy following gastrostomy insertion in children. The aim of this study was to determine whether implementing an early postoperative feeding pathway reduces length of stay (LOS) without increasing complications. MethodsA retrospective case note review of all children having a new gastrostomy inserted during a one-year period prior to (July 2016–July 2017) and following (July 2017–July 2018) pathway introduction was performed. Children unable to follow the pathway for coexisting medical or nutritional reasons were excluded. The pathway comprised feeding 50% of normal feed 2 hours postprocedure, followed by 100% of normal feed at 5 and 8 h. Previously, patients were fed postoperatively according to surgeon preference. Results116 cases met inclusion criteria, 55 prior to and 61 after pathway implementation. Children following the early feeding pathway had a shorter postoperative LOS than the historical group (median 28 vs 33 h, p < 0.003), while immediate (<72 h) and early (<30 day) complication rates were similar (8.2 vs 7.3%, p = 1.00 and 12 vs 16%, p = 0.59, respectively). ConclusionsEarly postoperative feeding after gastrostomy insertion is safe and reduces LOS. Type of studyQuality improvement. Level of evidenceIII

Do gastrostomies prevent hospitalizations?

Children with intellectual disability frequently undergo gastrostomy in order to continue enteral feeds. Indications for gastrostomy include failure to thrive, dysphagia and pulmonary aspiration, or even oral aversion. These children often have complex, comorbid conditions, such as cerebral palsy, seizures, or cardiopulmonary dysfunction. Parents are thus often challenged by the decision whether to proceed with gastrostomy, as a feeding tube will change daily care and long-term outcome for their child. Do gastrostomies help keep children out of the hospital? In this volume of The Journal, Jacoby et al use retrospective databases from 2 Australian states to examine the frequency of hospital admissions before and after gastrostomy insertion in children with severe intellectual disability. The incidence of all-cause and epilepsy hospitalizations declined years after the procedure, but not hospitalizations specific to acute lower respiratory tract infection. Fundoplication did appear to lower the relative incidence of acute lower respiratory tract infection admissions. Overall, gastrostomy was associated with some health benefits, but was not a failsafe to prevent hospitalizations from respiratory illnesses. Children with intellectual disability are still often susceptible to aspiration of their own secretions and that could explain the lack of benefit. Other changes in the delivery of overall care following the procedure might also influence positively or negatively the chance of a child being hospitalized. This study makes clear that gastrostomy is not a panacea for feeding the child with severe intellectual disability, and indeed a management decision for which families and providers must carefully weigh risks and benefits and also consider family values. Article page 131 ▸ Risk of Hospitalizations Following Gastrostomy in Children with Intellectual DisabilityThe Journal of PediatricsVol. 217PreviewTo examine the frequency of hospital admissions before and after gastrostomy insertion in children with severe intellectual disability. Full-Text PDF

Risk of Hospitalizations Following Gastrostomy in Children with Intellectual Disability

To examine the frequency of hospital admissions before and after gastrostomy insertion in children with severe intellectual disability. We conducted a retrospective cohort study using linked health administrative and disability data from Western Australia (WA) and New South Wales (NSW). Children born between 1983 and 2009 in WA and 2002 and 2010 in NSW who had a gastrostomy insertion performed (n=673 [WA, n=325; NSW, n=348]) by the end of 2014 (WA) and 2015 (NSW) were included. Conditional Poisson regression models were used to evaluate the age-adjusted effect of gastrostomy insertion on acute hospitalizations for all-cause, acute lower respiratory tract infections (LRTI), and epilepsy admissions. The incidence of all-cause hospitalizations declined at 5years after procedure (WA cohort 1983-2009: incidence rate ratio, 0.70 [95% CI, 0.60-0.80]; WA and NSW cohort 2002-2010: incidence rate ratio, 0.63 [95% CI, 0.45-0.86]). Admissions for acute LRTI increased in the WA cohort and remained similar in the combined cohort. Admissions for epilepsy decreased 4years after gastrostomy in the WA cohort and were generally lower in the combined cohort. Fundoplication seemed to decrease the relative incidence of acute LRTI admissions in the combined cohort. Gastrostomy was associated with health benefits including reduced all-cause and epilepsy hospitalizations, but was not protective against acute LRTI. These decreases in hospitalizations may reflect improved delivery of nutrition and medications.

Single Center Experience with Gastrostomy Insertion in Pediatric Patients: A 10-Year Review.

PurposeThis study was performed to review the outcomes of gastrostomy insertion in children at our institute during 10 years.MethodsA retrospective chart review was performed on 236 patients who underwent gastrostomy insertion from October 2005 to March 2015. We used our algorithm to select the least invasive method for gastrostomy insertion for each patient. Long-term follow-up was performed to analyze complications related to the method of gastrostomy insertion.ResultsOut of 236 patients, 120 underwent endoscopic gastrostomy, 79 had laparoscopic gastrostomy, and 37 had open gastrostomy procedures. The total major complication rates for endoscopic gastrostomy insertion, laparoscopic gastrostomy insertion, and open gastrostomy were 9.2%, 8.9%, and 8.1%, respectively. The most common major complication was gastroesophageal reflux requiring Nissen fundoplication (3.8%), and other complications included peritonitis (1.3%), hiatal hernia (1.3%), and bowel perforation (0.8%). Gastrostomy removal was successful in 8.6% and 5.0% of patients in the endoscopic and surgical gastrostomy groups, respectively. Gastrocutaneous fistula occurred in 60% of surgically inserted cases, requiring a second operation.ConclusionThis retrospective study was performed to review the outcome of gastrostomy insertion, as well as to introduce an algorithm that can be used for future cases. Further studies should be conducted to make a consensus on choosing the most appropriate method for gastrostomy insertion.

National trends and outcomes of pediatric gastrostomy tube placement.

National outcomes data regarding surgical gastrostomy tube (G-tube) and percutaneous endoscopic gastrostomy (PEG) tube procedures are lacking. Our objectives were to describe trends in G-tube and PEG procedures, examine regional variation, and compare outcomes. This was a retrospective study using pediatric admissions during 1997, 2000, 2003, 2006, and 2009 from the Kids' Inpatient Database. Length of stay and cost were adjusted for demographics, complexity, setting, year, and infection or surgical complication. G-tubes were placed during 64,412 admissions, increasing from 16.6 procedures/100,000 US children in 1997 to 18.5 in 2009. Surgical gastrostomy rates increased by 19% (0.17 procedures/100,000/year, P < 0.002) and, among children <1 year, they increased by 32% (2.56 procedures/100,000/year, P < 0.01). PEG rates did not increase (0.02 procedures/100,000/year, P = 0.47) in the study years. The West had an 18% higher rate than the national average for surgical G-tubes and a 10% higher rate for PEGs. When the sole procedure during the admission was gastrostomy, the G-tube was associated with a 19% (confidence interval 9.7-57.5) longer length of stay, and a 25% higher cost (confidence interval 16.4-34.5) compared with PEG. Surgical gastrostomy insertion rates have increased whereas PEG rates have not, despite evidence of better severity-adjusted outcome measures for PEG tubes. Surgical gastrostomy insertion in children <1 year of age yielded the greatest increase, which may relate to a changing patient population; however, regional variation suggests that provider preference also plays a role. Our data underline the need for more robust collection and analysis of surgical outcomes to guide decision making.

4:42 PM; Abstract No. 283 - Percutaneous CT-guided vertebral biopsies in children

Purpose: To investigate the technical success and safety of a standardised radiological antegrade primary gastrostomy insertion technique in children weighing 5 kg or less. Materials and Methods: A retrospective analysis of all gastrostomies inserted at a single centre over a ten year period between 2003 and 2013 recognized 596 patients undergoing antegrade gastrostomy insertion. Of these 25 patients weighing less than 5 kg were identified. The standardised technique for primary antegrade gastrostomy insertion included the use of a 9Fr Freka gastrostomy, general anaesthesia, biplane fluoroscopy and oral barium prior to the procedure to visualise the colon. Indications, patient characteristics, technical details and complications were recorded prospectively at the time of procedure using a proforma. Results: The mean age of the children weighing less than 5kg was 6 months, range (2-20m). 20 males, 5 females. Patients weighed from 3-5kg (mean 4.5kg). Antegrade gastrostomy insertion was successful in 24/25 patients with no major complications. The unsuccessful procedure was a result of hepatomegaly preventing a safe route for access to the stomach despite distension with air. 3 patients (13%) had minor complications. 2 exit site infections & 1 exit site leakage. All resolved without sequelae with conservative management. No deaths occurred within 30 days of procedure. The results are comparable to those in this centre for children weighing45kg and those in the published literature for gastrostomy insertion in children of all weights and ages. Conclusion: Some endoscopists and surgeons consider the lower limit of body weight to insert gastrostomies to be 10kg but gastrostomies can be inserted safely into smaller children. The results of this study suggest antegrade gastrostomy insertion in infants less tan 5kg is technically feasible and safe with comparable technical success and complication rates to radiological or endoscopic gastrostomy insertion in larger children.

4:24 PM; Abstract No. 281 - The IR antegrade approach. Safety of an interventional radiological approach to gastrostomy insertion in children

4:24 PM; Abstract No. 281 - The IR antegrade approach. Safety of an interventional radiological approach to gastrostomy insertion in children

Comparison of percutaneous endoscopic, laparoscopic and open gastrostomy insertion in children

To compare the outcomes and complications between percutaneous endoscopic gastrostomy (PEG), laparoscopic gastrostomy (LAPG) and open gastrostomy (OG) in children. Retrospective review of 369 patients from July 1998 to December 2010 who had their gastrostomies inserted at a single tertiary paediatric institution. Patients who were lost in follow-up (59) and had insufficient data (23) were excluded from this study. Results were analysed using descriptive statistics. Of the 369 included in our study, 260 patients underwent LAPG, 86 PEG and 23 open gastrostomy (OG) procedures. The early complication rate for PEGs was 10.5%, and for LAPGS 2.7% (p=0.006). The late complication rate was 41.9% for PEGs and 43.1% for LAPGs (p=NS). The overall complication rate for PEG was 54.7% and it was 44.6% for LAPG (p=NS). Major complications occurred only in the PEG group: gastro-colonic fistula (1), peritonitis (1), and "buried bumper syndrome" (1). The overall complication rate for OG was 78.3% (p=0.01, when this was compared to LAPGs and PEGs together), although there were no early complications in the OG group. PEGs had a significantly higher early complication rate than LAPGs and the only major complications occurred in the PEG group. PEGs also had a higher overall complication rate than LAPGs, although the difference was not statistically significant. Both PEGs and LAPGs were significantly superior to OG in terms of overall complication rates.

Operative technique: single-incision gastrostomy in pediatric patients

Operative technique: single-incision gastrostomy in pediatric patients Dayang A Aziz,1 Mahmud M Nor21Paediatric Surgery Unit, Department of Surgery, UKM Medical Centre, Bandar Tun Razak, Jalan Yaacob Latif, Cheras, Kuala Lumpur, Malaysia; 2Department of Surgery, Universiti Sains Islam Malaysia, Kuala Lumpur, MalaysiaIntroduction: Use of minimally invasive techniques for gastrostomy insertion in children is well documented. Laparoscopic placement is fast becoming the method of choice. However, it is important to note that there are still many centers in developing and under-developed countries in which laparoscopic or endoscopic facilities are not readily available.Methods: Here, we describe a less than 2 cm, single-incision open gastrostomy technique successfully performed on seven infants and one child who were all malnourished. A nasogastric tube was inserted to assist the technique.Results: All patients had a wound measuring less than 2 cm. Mean operating time was 30 minutes. Gastrostomy tube feeding was established after 6 hours post-surgery. No complications occurred in any of the patients.Conclusions: This technique is an excellent minimally invasive approach. It is simple, safe, and feasible.Keywords: minimally invasive, laparoscopic placement, children, single incision

Timing of gastrostomy insertion in children with a neurodisability: a cross-sectional study of early versus late intervention

ObjectivesThe aim of the study was to assess whether gastrostomy placement before 18 months of age results in a greater increase in z-score for weight and to assess whether admission...

Gastrostomy insertion in children: percutaneous endoscopic or percutaneous image-guided?

Background/Purpose Gastrostomy insertion in children can be performed in many ways, but which is the best technique remains uncertain. This study evaluates the outcome of percutaneous endoscopic gastrostomy (PEG) and image-guided gastrostomy (IG). Methods We reviewed children who had either PEG (n = 136) inserted by pediatric surgeons or IG (n = 195) inserted by interventional radiologists in our hospital between May 2004 and July 2008. Gastrostomy-related complications were given scores ranging from 20 for major complications (eg, peritonitis, gastrointestinal bleed, and visceral injury) to 1 for minor (eg, site infection and tube migration), and total score per month of follow-up was calculated per patient. Results Conversion to laparoscopic or open gastrostomy was more frequent in PEG versus IG ( P = .001). Fewer PEG patients (28%) had complications than did IG (47%) ( P = .001). One PEG patient developed a gastrocolic fistula. In the IG group, 2 patients had transverse colon puncture, 1 had intraperitoneal tube detachment, and 1 had upper gastrointestinal bleeding. When scored and adjusted by length of follow-up, PEG had lower scores compared with IG, indicating a better outcome ( P = .03). These findings were supported by zero-inflated Poisson regression analysis. Conclusion Major complications were rare and observed more frequently after IG. Minor complications were observed in both procedures but were significantly less common in PEG.

Outcomes After Percutaneous Endoscopic Gastrostomy Insertion in Children

Percutaneous endoscopic gastrostomy (PEG) insertion is indicated for provision of enteral nutrition when oral feeding is not possible or inadequate. The aim of this study was to review the early and late morbidity of percutaneous gastrostomy insertion in children including major and minor complications. Methods: A retrospective chart review of children who underwent percutaneous endoscopic gastrostomy by the Dept of Gastroenterology, RCH in the last 4 years was undertaken. Patient demographics, indications for gastrostomy, and the incidence of major and minor complications were recorded. Early complications were defined as those occurring within one week of insertion and late complications as those occurring after the first week. Results: 60 patient charts have been reviewed to date. The median age of insertion was 5 years (range 2months-15.5years). Indications for PEG insertion included inadequate intake (39/60, 65%), unsafe swallow or aspiration risk (19/60, 32%), and complicated metabolic requirements (2/60, 3%) in two patient's with glycogen storage disorders. Four patients (6.6%) developed major complications after insertion. Two patients developed early complications with presumed peritonitis after the procedure requiring intravenous antibiotics and gut rest. Late complications included one patient with buried bumper syndrome at the time of conversion to a skin level device 3 months after initial PEG placement. The other patient developed pneumoperitoneum on conversion to gastrostomy button. Minor complications however were common and occurred in 80% (48) of patients. Most occurred late and included granulation tissue formation (56%, 34), site infection (8%, 5), inadvertent device avulsion (8%, 5), gastric ulcer related to the gastrostomy device (1.5%,1) and skin stomal pressure ulcer (5%, 3). All patients with major complications (6.6%) were managed successfully without any surgical intervention. Patients with inadvertent tube avulsion were able to be converted easily to a skin level device and did not require any further intervention. Other minor complications were managed conservatively. All patients were still alive at 12 months follow up. Conclusions: Major complications after PEG insertion are rare and do not impact significantly on long-term patient morbidity. Minor complications however are common and usually occur late, of which granulation tissue formation is the most frequent. PEG insertion is a safe procedure in children for the provision of enteral nutrition.