Gastrostomy Tube Removal Research Articles

Over-the-scope clip for closure of persistent gastrocutaneous fistula after gastrostomy tube removal: a multicenter pediatric experience

BackgroundPercutaneous endoscopic gastrostomy is commonly used for enteral nutritional access, but gastrocutaneous fistulae (GCF) may persist after tube removal, posing clinical challenges. The use of endoscopic closure devices, including over-the-scope clips (OTSC), has shown promise in managing non-healing fistulae, although data in the pediatric population are limited.MethodsA retrospective multicenter study analyzed pediatric patients who underwent GCF closure following gastrostomy tube removal. Data from seven centers across multiple countries were collected, including patient demographics, procedural details, complications, and outcomes. Closure techniques were compared between OTSC and surgical closure.ResultsOf 67 pediatric patients included, 21 underwent OTSC closure and 46 had surgical closure. Surgical closure demonstrated a higher success rate (100%) compared to OTSC closure (61.9%, P < 0.001). While procedural duration was shorter for OTSC closure (25 vs. 40 min, P = 0.002), complications, and scar quality were comparable between techniques. A subsequent sub-analysis did not reveal differences based on center experience.ConclusionOTSC closure is feasible and safe in pediatric patients, but surgical closure remains superior in achieving sustained GCF closure, although OTSC offers benefits, such as shorter procedural duration, potentially reducing the duration of general anesthesia exposure. Non-operative approaches, including OTSC, may be a valuable alternative to surgical closure.Graphical abstract

Development of a novel technique for esophageal reconstruction via oral-vestibule-enteral anastomosis

BackgroundNarrowing, trauma, tumors, and systemic diseases can cause esophageal dysfunction. Severe cases resist traditional surgery, leading to long-term gastrostomy or jejunostomy tubes, affecting patients negatively. No established surgery ensures both airway and oral function with proper speech. This article introduces the oral-vestibule-enteral anastomosis (OVEA) technique, targeting patients with compromised epiglottic closure competence and loss of cervical esophagus, where conventional methods fall short. MethodsTechnique description study evaluated in 13 patients in a single tertiary referral center in Mexico City treated with OVEA from January 1990 to July 2023. ResultsOf the 13 patients (69% male; mean age, 37.14 ± 12.907 years), preoperative conditions included a mean body mass index of 17.78 ± 2.66 kg/m2, 46% with previous abdominal surgeries, and 31% with a smoking history. After OVEA, complications affected 46%, primarily pneumonia (23%), abscess formations (15%), intestinal necrosis (8%), and airway fistula (8%). Reoperation was needed in 38%, addressing functionality loss, necrosis, stenosis, and jawbone remodeling. No fatalities occurred within the first 6 months after surgery; 84% had successful gastrostomy tube removal, and 8% retained a tracheostomy tube. Currently 13 patients (92%) use the OVEA as their main enteral route of feeding. ConclusionThe OVEA technique seems promising for cases involving esophageal loss or impaired epiglottic function, enhancing patients’ quality of life by enabling oral feeding and restoring regular eating habits. Further research should focus on long-term results and identifying optimal candidates for this innovative surgical method.

P327 Dietitians experiences of gastrostomy tube removal among people with cystic fibrosis on highly effective modulator therapy

P327 Dietitians experiences of gastrostomy tube removal among people with cystic fibrosis on highly effective modulator therapy

The "cut and push" method of removing percutaneous endoscopic gastrostomy tube is not safe in paediatric patients.

A "cut and push" (CP) approach has been described in the literature for removal of percutaneous endoscopic gastrostomy (PEG) tubes. The aim of this study is to investigate the safety profile of this method in children. Our study included all children who underwent CP procedure for either removal or replacement of Freka PEG tube at our centre between January 2016 and August 2021. Parents contacted to establish if the internal component had been seen in the stools post-procedure. If not seen, a plain film of chest, abdomen and pelvis was arranged followed by computerised tomography (CT) scan. The presence of the internal component as a retained foreign body on imaging was evaluated along with any complication. Of the 27 patients included, six (22.2%) patients had the internal component seen in the stool. Five (18.5%) patients in total had a retained internal component with three (11.1%) patients had major complications requiring complex surgical interventions, and two (7.4%) patients required endoscopic retrieval. Our study reports more severe complications that required complex surgical interventions compared to the previous studies. We believe that this method of removal is not safe in children and should be abandoned. Also, patients with Down syndrome might be at higher risk of retention and complications.

Endoscopic hand suturing for nonhealing gastrocutaneous fistula after gastrostomy tube removal.

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Complication rates associated with traction removal of percutaneous endoscopic gastrostomy tubes

Background: percutaneous endoscopic gastrostomy (PEG) tubes are removed and/or replaced for reasons such as tube malfunction, degradation, patient's device preference, and when stopping enteral feeding. Aims: to identify the types and rate of complications associated with traction removal of a PEG tube and if this is associated with the size of the PEG or length of time it had been in situ prior to removal. Methods: This retrospective study looked at the tube removal/replacement reports written by the Enteral Feeding Nursing Service over an 8-year period at a large teaching hospital trust in the north of England. Findings: the PEG tube removal reports of 127 patients were reviewed. Five types of complication were identified, categorised as retained bumper (5.5%); intraperitoneal placement of new device (3.17%); misplacement of replacement device into colon (a consequence of the insertion procedure not the removal of the PEG) (0.78%): gastrocutaneous fistula (0.78%); and inability to remove the tube (1.57%). The complication of retained bumpers was associated with an average length of time in situ prior to removal of the PEG tube of 29 months. In the cases of intraperitoneal placement, the PEG tube had been in situ for an average of 6 months. Nurses were unable to remove the PEG tube on two occasions; each had been in situ for approximately 4 years prior to attempted removal. Conclusion: the complication rates are low following removal of a PEG tube using a traction pull. There was no clear correlation between length of time in situ or tube size and complication rate.

Prophylactic vs. Reactive Gastrostomy Tube Placement in Patients Treated with Radiotherapy for Head and Neck Cancer

Radiotherapy (RT) for head and neck cancer (HNC) can cause acute toxicities resulting in weight loss warranting alterative enteral access. Some institutions favor prophylactic gastrostomy tube (GT) placement to prevent malnutrition at the forefront, while others choose to reactively place tubes if nutritional deficits arise. Though prophylactic GT placement may limit on-treatment weight loss, this approach may result in unneeded GT placement and may potentially impact long-term swallowing function. Patients with HNC treated with CRT from 2018-2021 were reviewed. GT placement prior to CRT (prophylactic [ppx] tube) was performed at the discretion of the treating radiation oncologist. The remainder of patients were treated with reactive (rx) GT placement in the event of on-treatment weight loss approaching 10-15%. Patient, disease and treatment factors were abstracted from the medical record. Primary endpoints were placement of GT in the rx group, weight change at the end of RT, and time to tube removal. In total, 278 patients were identified; 35 GT-dependent patients and 22 patients with nasal cavity/paranasal sinus cancers were excluded, yielding 221 for analysis. Baseline factors associated with GT group included age, ECOG, baseline swallowing function, primary site, T and N stage, stage group, and treatment year. Treatment factors associated with GT group were: neck target (bilateral v. unilateral/none), concurrent chemotherapy, and total dose. Of the 118 patients in the rx group, 14 (12%) required rx GT placement during or within 30 days of CRT. RT completion rates were similar between groups (95-96%, p = 1). GT was removed at last follow-up in 57% of patients in both groups (p = 1). Percent on-treatment weight loss was -8.9% (SD 6.7) and -7.2% (SD 6.1) for the ppx and rx groups, respectively (p = 0.04). Median Kaplan-Meier estimate of time to GT removal was 7.7 months (95% CI 6.0-11.3) and did not differ between groups (log-rank p = 0.87). Factors associated with the placement of rx GT include: concurrent chemotherapy (yes 20% vs. No 0%, p.0007) and baseline FOIS (5 or less 40% vs. 6 or more 9%, p = 0.02). T stage, N stage, overall stage, postoperative RT, degree of neck irradiation were not associated. Reactive gastrostomy tube placement in patients treated with chemoradiotherapy for head and neck cancer patients is feasible and results in low rates of gastrostomy tube placement. There are no observed differences in on-treatment weight loss between patients treated using a prophylactic versus reactive approach. No differences in time to gastrostomy tube removal were observed.

Severe respiratory distress secondary to pharyngeal perforation during endoscopic gastrostomy tube removal: a clinical case report

We present the case of a 60-year-old patient with advanced chronic obstructive pulmonary disease (COPD), who presented for planned endoscopic removal of her gastrostomy feeding tube, which was inserted for nutritional status optimization prior to lung transplantation. The procedure was complicated by accidental blockage of the device at the pharyngeal level, causing a transmural laceration. Rapid respiratory distress developed with subcutaneous emphysema that led to the intubation of the patient. A new endoscopic retrieval was attempted but failed, and the patient was sent to the operating room after a cervical and thoracic CT scan that showed the blocked piece in the cervical wall, in addition to diffuse subcutaneous emphysema, a large pneumomediastinum, and a left pneumothorax. The surgery consisted of a left cervicotomy, a pharyngeal incision, and retrieval of the trapped parts. The patient was sent to the intensive care unit (ICU) where she could be weaned and extubated 1 week later.

S2834 Gastro-Cutaneous Fistula Closure Using Novel Tack Suture System

Introduction: Gastro-cutaneous fistulas that develop at prior gastrostomy sites are usually successfully closed by the use of endoscopic suturing or the over-the-scope clips (OTSC). However, the endoscopic suturing device and the OTSC device measure approximately 16 mm and 14 mm, respectively, resulting in them not able to pass through narrow esophageal strictures. The endoscopic tack suture system is a novel technique that includes a through the scope suture-based device that was recently designed for the closure of large and irregular defects in the gastrointestinal tract. Even more advantageous is the ability for the tack suture system to be passed through the working channel of a standard gastroscope. Case Description/Methods: A 61-year-old male with past medical history of head and neck cancer presented with persistent gastro-cutaneous fistula drainage following gastrostomy tube removal. On endoscopic evaluation, a benign appearing esophageal stenosis in the upper esophagus required downgrading the scope from a therapeutic scope to a gastroscope. A gastric fistula was noted in the gastric body, but the exact site of the fistula was unclear as there were 2 defects side by side (Figure A). Both defects were treated with APC and the entire area was closed with a single tack suture system with 4 tacks drilled in healthy tissue surrounding the defect (Figure B). Following tack placement, a single suture was used to cinch down and close the defect (Figure C). On follow up the patient had no further fistula drainage. Discussion: Our case presents the use of a novel tack suturing system to close a persistent gastro-cutaneous fistula in the setting of an esophageal stricture. Commonly used defect closing devices such as the OTSC and endoscopic suturing device can be too large to navigate severe esophageal strictures. The endoscopic tack suture system has the ability to aid in the closure of fistulas, perforations, anastomotic leaks and submucosal dissections. While preclinical data reported no adverse events, possibilities include wound dehiscence, delayed perforation, and bleeding if the tacking system is improperly placed. Mahmoud et al. conducted the first and only multi-center study describing the feasibility and safety of the endoscopic tack suturing device in the clinical setting and found successful closure of defects in approximately 90% of cases. This novel tack suture system is a useful tool in cases that are confined to the parameters of a standard gastroscope.Figure 1.: A: Gastric fistula. B: Fistula following APC with 4 tacks drilled in healthy tissue surrounding the defect. C. Cinching of single suture with closure of gastric fistula.

Complication rates associated with traction removal of percutaneous endoscopic gastrostomy tubes.

Percutaneous endoscopic gastrostomy (PEG) tubes are removed and/or replaced for reasons such as tube malfunction, degradation, patient's device preference, and when stopping enteral feeding. To identify the types and rate of complications associated with traction removal of a PEG tube and if this is associated with the size of the PEG or length of time it had been in situ prior to removal. This retrospective study looked at the tube removal/replacement reports written by the Enteral Feeding Nursing Service over an 8-year period at a large teaching hospital trust in the north of England. The PEG tube removal reports of 127 patients were reviewed. Five types of complication were identified, categorised as retained bumper (5.5%); intraperitoneal placement of new device (3.17%); misplacement of replacement device into colon (a consequence of the insertion procedure not the removal of the PEG) (0.78%): gastrocutaneous fistula (0.78%); and inability to remove the tube (1.57%). The complication of retained bumpers was associated with an average length of time in situ prior to removal of the PEG tube of 29 months. In the cases of intraperitoneal placement, the PEG tube had been in situ for an average of 6 months. Nurses were unable to remove the PEG tube on two occasions; each had been in situ for approximately 4 years prior to attempted removal. the complication rates are low following removal of a PEG tube using a traction pull. There was no clear correlation between length of time in situ or tube size and complication rate.

Over-the-Scope Clip Closure of Persistent Gastrocutaneous Fistula After Percutaneous Endoscopic Gastrostomy Tube Removal: A Report of Two Cases (secondary publication)

Over-the-Scope Clip Closure of Persistent Gastrocutaneous Fistula After Percutaneous Endoscopic Gastrostomy Tube Removal: A Report of Two Cases (secondary publication)

Factors and Growth Trends Associated With the Need for Gastrostomy Tube in Neonates With Congenital Diaphragmatic Hernia.

A third of infants with congenital diaphragmatic hernia (CDH) require a gastrostomy tube (GT) for nutritional support. We compared CDH infants who are GT-dependent to those able to meet their nutritional needs orally, to identify factors associated with requiring a GT and evaluate their long-term growth. Patients with CDH repaired at a single institution between 2012 and 2020 were included. Charts were retrospectively reviewed for demographic, surgical, and post-operative details. Mann-Whitney test and Fischer exact test were performed to compare GT-dependent neonates (n = 38, experimental) with orally fed neonates (n = 63, control). Significance was set at <0.05. Thirty-eight percent received a GT (median 67 days, interquartile range [IQR] 50-88). GT-dependent neonates were significantly more likely to have a lower lung-to-head ratio (median 1.2, IQR 0.9-1.4, vs 1.6, IQR 1.3-2.0, IQR P < 0.0001), undergone patch or flap repair (79% vs 33%, P < 0.0001), and been hospitalized longer (median 47, IQR 24-75 vs 28 days, P < 0.0001). Fourteen of 38 had their GT removed (median 26 months, IQR 14-36). GT-dependent neonates initiated oral feeds (calculated as time since extubation) later (median 21, IQR 8-26, vs 8 days, IQR 4-13, P = 0.006). Height-for-age z scores remained stable after GT removal, while weight-for-age z scores dropped initially and began improving a year later. The need for a gastrostomy for nutritional support is associated with more severe CDH. Over a third of patients no longer needed a GT at a median of 26 months. Linear growth generally remains stable after removal. These results may help counsel parents regarding nutritional expectations.

Delayed percutaneous endoscopic gastrostomy tube removal in patients with oropharyngeal carcinoma

Early nutritional intervention through enteral feeding can reduce treatment alterations and complications in patients with Oropharyngeal Cancer (OPC) undergoing Chemoradiation Treatment (CRT).

S2374 Getting Closure: Gastrocutaneous Fistula Repair in the Era of Endoscopic Suturing

INTRODUCTION: Formation of a gastrocutaneous fistula (GCF) is an uncommon complication following gastrostomy tube removal. GCFs rarely close spontaneously leading to nutrition support challenges and poor patient quality of life. Methods for endoscopic closure include glue injection, banding, and use of endoclips, however limited data exists about the efficacy of endoscopic suturing for GCF management. We aimed to evaluate the success of endoscopic suturing in closure of gastro-cutaneous fistulae after gastrostomy tube removal. CASE DESCRIPTION/METHODS: We performed a retrospective study using our electronic endoscopy database between 2018 and 2019. All patients during the study period who underwent endoscopic suture for closure of GCF after gastrostomy tube removal were identified. Data was collected regarding patient characteristics, co-morbid conditions as well as technical success, clinical success and procedure complication rate. Endoscopic suturing of GCF using the Apollo Overstitch system was performed six times in four patients. The average age was 69 years and 75% of patients were female. All patients had previous attempt for closure of GCF with either suturing of the skin (n = 3), bedside debridement (n = 1) or over-the-scope clip (n = 1). Debridement of the fistulous tract was performed in all patients undergoing endoscopic suturing using argon plasma coagulation and/or cytology brush. Endoscopic suturing was technically successfully in 100% of the cases and immediate post-procedure clinical success was achieved in 100% of cases. Long-term clinical success rate was achieved in 3 out of 4 patients (75%) with median follow up of 124 days. No procedure-related complications were observed. The only patient without durable clinical success had an over the scope clip in place which wasn’t able to be removed prior to suturing. DISCUSSION: Our initial experience suggests that endoscopic suturing is a safe and effective modality for closure of gastrocutaneous fistulae following gastrostomy tube removal and may be considered as first line therapy in these challenging clinical cases.Table 1.: Patient demographic data, surgical history, and periprocedural information.Table 2.: Procedural information and outcomes

Novel Feeding Method Allows Enteral Nutrition in Infants and Children Undergoing Advanced Endoscopic Esophageal Therapy

Abstract Objectives To describe a novel method of feeding infants and children undergoing treatment for esophageal perforation. Endoscopic vacuum sponge (EVAC) therapy is a modified wound vacuum device that is inserted via gastrostomy site into the esophageal lumen in order to treat perforation. EVAC generally requires gastrostomy tube removal and loss of access for enteral nutrition (EN), obligating parenteral nutrition (PN) for the duration of therapy. In these patients, EN is preferable to PN as their distal GI tracts are functional. Our team devised a novel feeding tube device to allow for post-pyloric EN during EVAC therapy. Our hypothesis was that the feeding tube modification to the EVAC could safely and feasibly reduce PN use, avoid central line placement, and increase EN delivery. Methods Retrospective chart review of medical records in our cohort of pediatric patients who received EN during EVAC therapy for esophageal perforation between August 2018 and November 2019. Reason for EVAC therapy, delivery and timeline of prescribed EN, and complications were recorded. Results During this study period, 10 cases received EN support during EVAC therapy. Six (60%) underwent EVAC placement due to esophageal perforation encountered during planned endoscopy. All six avoided central line placement and none received PN. Four (40%) received EVAC therapy after identification of unexpected post-surgical perforation; all required a central line and two received PN initially until the feeding tube device was placed during EVAC exchange. Of the full cohort of 10 cases, 7 (70%) reached prescribed EN rate by POD#2 and received a mean of 72% prescribed volume. Two (20%) did not reach prescribed EN rate before EVAC removal. Complications included tube migration into the stomach (1 case, 10%) and excessive leaking of gastric contents (1 case, 10%). Conclusions Our novel EVAC and post-pyloric feeding tube device allows for safe and feasible provision of EN and has become the new standard for our infants and children undergoing EVAC therapy for esophageal perforation. Increased ability to provide EN may reduce infection risk, lower hospital costs, and support normal gut structure and function. This device shows promise in reducing the need for PN and central line as well as increasing EN delivery. A larger study with historical controls is planned. Funding Sources None.

Management of gastrocutaneous fistulas following gastrostomy: surgery as a therapeutic option.

Gastrocutaneous fistulas (GCF) following removal of gastrostomy tubes are an uncommon complication with many therapeutic options. It is a drawback that concerns both patient and surgeon, hindering the decision to perform an invasive treatment. Despite emerging minimally invasive procedures, we must not forget that surgery continues to be the standard treatment when they all fail.

Outpatient Curettage and Electrocautery as an Alternative to Primary Surgical Closure for Pediatric Gastrocutaneous Fistulae

BACKGROUND The development of a gastrocutaneous fistula (GCF) after gastrostomy tube removal is a frequent complication that occurs 5%-45% of the time. Conservative therapy with chemical cauterization is frequently unsuccessful, and surgical GCF repair with open primary layered closure of the gastrotomy is often required. We describe an alternative approach of GCF closure that is an outpatient, less invasive procedure that allows patients to avoid the comorbidities of general endotracheal anesthesia and intraabdominal surgery. METHODS This is an Institutional Review Board approved retrospective review of all patients who underwent GCF closure from January 2010 to July 2016 at a tertiary care children's hospital. Demographics including age, weight, body mass index, comorbidities, and initial indication for gastrostomy tube were recorded. Operative details such as ASA score, operative duration, type of anesthesia, and airway were noted. Based on surgeon preference, two types of operative closure were used during that time frame: primary layered closure or curettage and cautery (C&C). The latter is a procedure in which the fistula tract is first scraped with a fine curette, and then the fistula opening and tract are cauterized circumferentially. Finally, the presence of a persistent fistula and the need for formal reoperation were determined. RESULTS Sixty-five unique patients requiring GCF closure were identified. Of those, 44 patients (67.6%) underwent primary closure and 21 patients (32.3%) underwent C&C. The success rate of primary closure was 97% with one patient experiencing wound breakdown with persistent fistula. The overall success rate of C&C was 66.7% (14/21). Among those 14 patients, 11 (52.4%) GCF patients were closed by 1 mo. An additional two patients' gastrocutaneous fistulae were closed by 4 mo (61.9%). One GCF was successfully closed with a second C&C procedure. Seven of the 21 patients (33.3%) required subsequent formal layered surgical closure. C&C had significantly shorter operative times (13.5 ± 14.7 min versus 93.4 ± 61.8, P <0.0001) and significantly shorter times in the postanesthesia care unit (101.8 ± 42.4 min versus 147 ± 86, P <0.0001). Patients were intubated with an endotracheal tube 88.6% of the time for primary closure and 23.8% of the time for C&C.Among patients admitted for an elective procedure, the average length of stay for primary closure was 1.9 d as compared to 0 d for the C&C group. Among patients who underwent C&C with a persistent fistula, there were no significant differences in time since initial creation of gastrostomy, age, body mass index, or ASA score. CONCLUSIONS Our study verifies that primary closure remains the gold standard for persistent GCF. However, C&C is a safe, outpatient procedure that effectively treats a GCF the majority of the time in children. We suggest that in select patients, it may be an appropriate initial and definitive procedure for GCF closure.

Outpatient curettage and electrocautery as an alternative to primary surgical closure for pediatric gastrocutaneous fistulae

BackgroundThe development of a gastrocutaneous fistula (GCF) after gastrostomy tube removal is a frequent complication that occurs 5%-45% of the time. Conservative therapy with chemical cauterization is frequently unsuccessful, and surgical GCF repair with open primary layered closure of the gastrotomy is often required. We describe an alternative approach of GCF closure that is an outpatient, less invasive procedure that allows patients to avoid the comorbidities of general endotracheal anesthesia and intraabdominal surgery. MethodsThis is an Institutional Review Board approved retrospective review of all patients who underwent GCF closure from January 2010 to July 2016 at a tertiary care children's hospital. Demographics including age, weight, body mass index, comorbidities, and initial indication for gastrostomy tube were recorded. Operative details such as ASA score, operative duration, type of anesthesia, and airway were noted. Based on surgeon preference, two types of operative closure were used during that time frame: primary layered closure or curettage and cautery (C&C). The latter is a procedure in which the fistula tract is first scraped with a fine curette, and then the fistula opening and tract are cauterized circumferentially. Finally, the presence of a persistent fistula and the need for formal reoperation were determined. ResultsSixty-five unique patients requiring GCF closure were identified. Of those, 44 patients (67.6%) underwent primary closure and 21 patients (32.3%) underwent C&C. The success rate of primary closure was 97% with one patient experiencing wound breakdown with persistent fistula. The overall success rate of C&C was 66.7% (14/21). Among those 14 patients, 11 (52.4%) GCF patients were closed by 1 mo. An additional two patients’ gastrocutaneous fistulae were closed by 4 mo (61.9%). One GCF was successfully closed with a second C&C procedure. Seven of the 21 patients (33.3%) required subsequent formal layered surgical closure. C&C had significantly shorter operative times (13.5 ± 14.7 min versus 93.4 ± 61.8, P <0.0001) and significantly shorter times in the postanesthesia care unit (101.8 ± 42.4 min versus 147 ± 86, P <0.0001). Patients were intubated with an endotracheal tube 88.6% of the time for primary closure and 23.8% of the time for C&C.Among patients admitted for an elective procedure, the average length of stay for primary closure was 1.9 d as compared to 0 d for the C&C group. Among patients who underwent C&C with a persistent fistula, there were no significant differences in time since initial creation of gastrostomy, age, body mass index, or ASA score. ConclusionsOur study verifies that primary closure remains the gold standard for persistent GCF. However, C&C is a safe, outpatient procedure that effectively treats a GCF the majority of the time in children. We suggest that in select patients, it may be an appropriate initial and definitive procedure for GCF closure.

Oncologic and functional outcomes of pretreatment tracheotomy in advanced laryngeal squamous cell carcinoma: A multi-institutional analysis

ObjectivesDescribe the influence of pretreatment tracheotomy and treatment modality (surgical versus non-surgical) on oncologic and functional outcomes. Materials and methodsRetrospective study of previously untreated advanced-stage laryngeal squamous cell carcinoma patients at two academic tertiary care institutions from 1995 to 2014. ResultsPrimary outcomes evaluated were disease-free survival, disease-specific survival, and overall survival of pretreatment tracheotomy versus no pretreatment tracheotomy cohorts. Functional status, measured by tracheotomy decannulation and gastrostomy tube placement/removal, was assessed. Of the 226 patients, 31.4% underwent pretreatment tracheotomy. Five-year disease-specific survival was 72.9%, and overall survival was 48.8% for entire cohort. There was a statistically significant decrease in overall survival (p = .03) and disease-free survival (p = .02) for the pretreatment tracheotomy group compared to no pretreatment tracheotomy, which was largely explained by primary tumor stage. Pretreatment tracheotomy was associated with gastrostomy tube placement and was an independent predictor of worse odds of gastrostomy tube removal. Disease stage, distant metastasis, and age independently conferred worse odds of gastrostomy tube removal. ConclusionPatients undergoing pretreatment tracheotomy for primary T4 laryngeal cancer had decreased overall survival compared to patients without pretreatment tracheotomy. There was no difference in local recurrence rates based on tracheotomy status. Organ preservation with chemotherapy and radiation did not result in better functional outcomes than surgery in the pretreatment tracheotomy group as nearly half of patients treated with organ preservation remained tracheotomy dependent. Based on this data, pretreatment tracheotomy may impact oncologic and functional outcomes in advanced disease, and it should be a consideration in an informed decision-making process.

Replacing gastrostomy tubes with collapsible bumpers in pediatric patients: Is it safe to "cut" the tube and allow the bumper to pass enterally?

The "cut and push" technique for removal of percutaneous endoscopic gastrostomy (PEG) tubes with collapsible bumpers offers an alternative to the standard traction method of removal. This study compared the outcomes of these techniques. We completed a research ethics board-approved retrospective cohort study, identifying all patients less than 18years of age who underwent PEG tube removal at a children's hospital between December 2013 and December 2016. Outcomes included need for sedation and complications. We identified 127 children who had PEG tubes removed. Significantly fewer children required sedation with the cut and push group (1.1% vs. 60.6%, p≤0.001). Ten complications occurred, including 9 in the cut and push group (9.6% vs. 3%, p=0.23). Mean age at time of complication was significantly younger in the cut and push group (2.2 vs. 6.3years p=0.004). This is the largest reported series comparing the cut and push vs. traction removal methods. The cut and push technique significantly reduced the need for procedural sedation but was associated with increased risk of complications. While these data suggest that the technique is safe in older children, caution should be taken in younger children who appear to be more likely to vomit the residual bumper. Level III-Treatment study, Retrospective comparative study.