A comparison of techniques for laparoscopic gastrostomy placement in children

Background

The insertion of gastrostomy tube (GT) for children is typically accomplished using a minimally invasive approach. There is considerable variability in the technical details of this operation, depending on how much of the procedure is performed intracorporeal. The purpose of this study is to compare the outcomes and resource utilization of two differing techniques for laparoscopic GT insertion in the pediatric population.

Materials and methods

A single-center retrospective review of all patients who underwent a laparoscopic GT insertion from 2001–2011 was conducted and analyzed based on technique of insertion. This was laparoscopy plus either an intracorporeal Seldinger technique, or an extracorporeal insertion approach, (mini-open technique; [MOT]). Outcomes investigated included short-term complications within the first mo (dislodgement, infection), long-term complications (infection, need for revision, dislodgement), and measures of resource utilization (operative time, material cost, and GT-related hospital visits).

Results

A total of 129 insertions were performed; 87 (67.4%) done using the Seldinger technique, and 42 underwent MOT. Overall, complication rates did not differ between the two groups. Of all patients who underwent a GT placement, 38% were treated for granulation tissue, 27.1% experienced dislodgement, and 23.3% were reported to have a GT-related infection. The MOT approach was associated with a 29% reduction in disposable operating room costs and a 57% reduction in emergency department visits (P < 0.05).

Conclusions

Pediatric patients undergoing laparoscopic gastrostomy tube insertion via the Seldinger or MOT method have similar morbidity risks, although MOT was associated with less overall resource utilization in this study.     

Whipple术中应用改良式胃造瘘术的临床研究

目的探讨Whipple术中应用改良式胃造瘘术的临床意义。方法总结2004年11月至2006年12月收治的36例Whipple术中行改良式胃造瘘术加空肠造瘘术（治疗组）患者的临床资料,并与24例同期Whipple术中行传统胃造瘘术加空肠造瘘术（对照1组）及22例同期行Whipple术加空肠造瘘术（对照2组）的患者进行对照研究。对3组患者的手术时间,术后开始行肠内营养时间,术后留置鼻胃引流管时间以及术后胃瘫、胰瘘、胆瘘、腹腔感染等并发症的发生率进行统计学分析。结果治疗组及对照2组术后胃瘫发生率明显低于对照1组（P〈0．05）;治疗组术后留置鼻胃引流管时间明显短于对照2组（P〈0．01）;3组的手术时间、术后开始行肠内营养时间、胰瘘、胆瘘及腹腔感染发生率的差异无统计学意义（P〉0．05）。结论Whipple术中行改良式胃造瘘术安全、可靠,可以明显缩短术后鼻胃引流管留置时间;与传统胃造瘘方法相比,可明显降低术后胃瘫的发生率。     

Implementation of a standardized procedural checklist in a children's hospital

Background

The aim of this study was to examine the implementation and sustainability of checklist use among procedural-based specialties in a pediatric hospital and to survey perceptions of checklist efficacy among staff members and physicians.

Methods

A modified World Health Organization procedural checklist was implemented. Percentage daily compliance was collected for all procedures over a 12-month period. Clinical staff members participated in a survey regarding the checklist. Associations among gender, clinical role, and years of experience were evaluated.

Results

Compliance at 12 months was significantly higher than at inception (94% vs 88%, P < .001) with average monthly compliance of 92%. Compliance deteriorated on weekends and holidays. Surgeons had more positive perceptions of using the checklist compared with nurses and anesthesiologists, independent of experience and gender (P = .001).

Conclusions

The implementation of a procedural checklist can be sustained across specialties with high compliance. Off-hours utilization remains problematic. Perceptions of checklist efficacy are disparate among roles in the operating room.     

Overuse of training increases mechanoreceptors in supraspinatus tendon of rats SHR

The presence of mechanoreceptors in tendon after overuse activities can be a further step to learn about tendinopathy and overuse. Studies of tendons mechanoreceptors in rats are rare. We studied 12 isogenic spontaneous hypertensive rats (SHR), which underwent an overuse protocol consisting of an hour per daily session of treadmill running at a speed of 17 m/min, 5 times/week for 4 months. Supraspinatus tendons were evaluated with immunohistochemistry using S100 protein antibodies and histological protocol. Supraspinatus tendons at the end of 4 months of overuse protocol had a high number of media mechanoreceptors (4.3) than controls (0.6). The overexpression of S100 protein antibody in overuse activities maybe could represent a adaptative effort to tendon before the tear. © 2011 Orthopaedic Research Society Published by Wiley Periodicals, Inc. J Orthop Res 29:1771–1774, 2011     

超声引导下经皮胃腔穿刺充气术在经皮胃造瘘术中的应用

正经皮胃造瘘术主要用于吞咽困难、需长期肠内营养支持的患者,其引导方式主要为胃镜引导(percutaneous endoscopy gastrostomy,PEG)、透视引导(percutaneous radiologic gastrostomy,PRG)及透视联合CT引导。经皮胃造瘘术操作简单、费用低廉,已成为临床建立肠内营养通道的首选方法[1-4];但对于食管严重狭窄、闭塞患者,因胃镜或导管不能通过梗阻段、不能用气体充盈胃     

A complication of T-fasteners in percutaneous endoscopic gastrostomy (PEG) placement

Two patients with sinus tracts from retained T-fasteners following PEG tube placement are reported. Both patients had the PEG tubes subsequently removed and presented with purulent discharge and granulations near well-healed gastrostomy sites. The management of this complication and a possible method of prevention are discussed.     

Complications of gastrostomy feeding in children receiving peritoneal dialysis

 Gastrostomy tube (g-tube) feeding is recognized to improve the nutritional delivery to children with end-stage renal disease. A retrospective study was undertaken assessing the complications of g-tube feeding in children receiving peritoneal dialysis (PD). Twenty-three patients, mean age 3.8±3.2 years received PD and g-tube feeding for 758 patient-months, with 127 patients receiving PD for 1,969 patient-months used as controls. Peritonitis occurred every 18.4 patient-months in controls and 7.8 patient-months in those with a g-tube. Peritonitis occurred every 6.0 patient-months before and 8.1 patient-months after g-tube insertion in those undergoing g-tube insertion on PD. PD catheter exit site infection (PDESI) occurred every 18.7 patient-months in controls and 16.8 patient-months in those with a g-tube. PDESI occurred every 126 patient-months before and 16.2 patient-months following g-tube insertion. PD catheter replacement secondary to infection occurred every 109.4 patient-months in controls and 39.9 patient-months in those with a g-tube. It did not occur before g-tube insertion and occurred every 32.5 patient-months following insertion. Thirty-four episodes of g-tube exit site infection occurred, in 10 the same organism caused concurrent peritonitis. G-tube replacement occurred on 37 occasions. Hemodynamically significant gastrointestinal bleeding occurred in 3 patients, being terminal in 1. We conclude that, although not without risk, g-tube feeding in patients receiving PD is not contraindicated. Received: 15 May 1998 / Revised: 8 September 1998 / Accepted: 9 September 1998     

Communicating esophageal tubular duplication in a newborn infant

We describe a communicating esophageal duplication in a newborn infant, without any other associated congenital anomalies. The diagnosis of esophageal duplication was achieved by a contrast study of the esophagus with diatrizoate and computed tomographic scan. Surgical excision of the esophageal duplication was carried out. At the 1-year follow-up examination, the patient was doing well.     

Increasing podiatry referrals for patients with inflammatory arthritis at a tertiary hospital in Singapore: A quality improvement project

BackgroundFoot disease is highly prevalent in people with inflammatory arthritis and is often under-recognized. Podiatry intervention can significantly reduce foot pain and disability, with timely access being the key factor. The aim of this study was to plan and implement a quality improvement project to identify the barriers to, and improve, uptake of podiatry services among patients with inflammatory arthritis-related foot problems seen at a tertiary hospital in Singapore.MethodA 6-month quality improvement program was conducted by a team of key stakeholders using quality improvement tools to identify, implement and test several interventions designed to improve uptake of podiatry services. The number of patients referred for podiatry assessment was recorded on a weekly basis by an experienced podiatrist. The criterion for appropriate referral to podiatry was those patients with current or previous foot problems such as foot pain, swelling and deformity.ResultsInterventions included education initiatives, revised workflow, development of national guidelines for inflammatory arthritis, local podiatry guidelines for the management of foot and ankle problems, routine use of outcome measures, and introduction of a fully integrated rheumatology-podiatry service with reduced cost package. Referral rates increased from 8% to 11%, and were sustained beyond the study period. Complete incorporation of podiatry into the rheumatology consultation as part of the multidisciplinary team package further increased referrals to achieve the target of full uptake of the podiatry service.ConclusionThrough a structured quality improvement program, referrals to podiatry increased and improved the uptake and acceptance of rheumatology-podiatry services.     

Effects of a hospital based Wellness and Exercise program on quality of life of children with severe burns

Objective

To examine the effect of a 12-week Wellness and Exercise (W&E) program on the quality of life of pediatric burn survivors with burns of ≥40% total body surface area. We hypothesized this comprehensive regimen would improve physical and psychosocial outcomes.

Methods

Children were recruited for participation upon their discharge from the ICU. They were not taking anabolic/cardiovascular agents. Seventeen children participated in the W&E group and 14 children in the Standard of Care (SOC) group. Quality of life was assessed with the Child Health Questionnaire (CHQ) at discharge and 3 months. Children completed the CHQ-CF 87 and caregivers completed the CHQ-PF 28.

Results

The mean age of children in the W&E group was 14.07 ± 3.5 years and mean TBSA was 58 ± 11.8%. The mean age of children in the SOC group was 13.9 ± 3.1 years and mean TBSA was 49 ± 7.8%. ANOVA did not reveal statistically significant differences between the groups. Matched paired t-tests revealed that parents with children in the W&E group reported significant improvements with their children's physical functioning, role/social physical functioning, mental health, overall physical and psychosocial functioning after exercise.

Conclusions

These results are clinically relevant in that a comprehensive W&E program may be beneficial in promoting physical and psychosocial outcomes.     

经皮内镜胃联合空肠造瘘在普通外科疾病中的应用(附12例报告)

目的:探讨经皮内镜胃造瘘(percutaneous endoscopic gastrostomy,PEG)联合经皮内镜空肠造瘘(percutaneous endoscopic jejunostomy,PEJ)用于治疗普通外科多种疾病的价值。方法:2003年10月至2008年6月我院为12例普通外科疾病患者行PEG联合PEJ治疗,其中术后胃瘫2例,胆汁回输4例,胰头癌致胃十二指肠不全梗阻6例。结果:12例PEG及PEJ均一次性完成,手术成功率100%。2例造瘘管周围感染,患者PEG/J管发挥作用后逐步停用原有鼻胃(肠)管,改静脉营养补液为肠内营养补液,患者病情明显好转,9例带管出院,3例病情恢复后拔除PEG/J管,瘘口愈合,起到了替代原有鼻胃(肠)管的治疗作用;患者带管期间原有的咽喉部不适等症状消失,满意度高于传统的经鼻胃(肠)管。结论:PEG/J管是建立胃(肠)腔与外界通道的一种非常微创、有效和安全的方法,PEG置管可替代普通外科中大部分较长期的经鼻置胃(肠)管和手术胃(肠)造瘘置管,值得推广。     

经皮内镜下胃造口、空肠造口及十二指肠造口120例临床分析

目的　探讨经皮内镜下胃造口、空肠造口及十二指肠造口的技术操作及适应证。方法2 0 0 1年 5月— 2 0 0 4年 4月间 ,共行 12 0例经皮内镜下胃肠造口 ,其中 75例经皮内镜下胃造口 (PEG) ,4 2例经皮内镜下空肠造口 (PEJ) ,2例经皮内镜下十二指肠造口 (PED) ,1例直接法经皮内镜下空肠造口(DPEJ)。操作均采用经典经腹壁拉出法技术。结果　采用上述方法共行长期肠内营养 88例 ;胃肠减压 2 5例 ;肠内营养联合胆汁回输 5例 ;围手术期应用PEG 2例 ,术前行胃肠减压 ,术后行长期肠内营养。PEG操作时间平均 (9± 4 )min ,PEJ平均 (17± 6 )min ,DPEJ为 2 0min ,2例PED分别为 10和 12min。技术成功率 98 4 % (12 0 / 12 2 )。严重并发症发生率为 0 8% (1/ 12 0 ) ,轻微并发症发生率为 7 5 %(9/ 12 0 )。结论　经皮内镜下胃肠造口操作简便、有效 ,并发症少。     

A standardized trauma care protocol decreased in-hospital mortality of patients with severe traumatic brain injury at a teaching hospital in a middle-income country

Introduction

Standardized trauma protocols (STP) have reduced morbidity and in-hospital mortality in mature trauma systems. Most hospitals in low- and middle-income countries (LMICs) have not implemented STPs, often because of financial and logistic limitations. We report the impact of an STP designed for the care of trauma patients in the emergency department (ED) at an LMIC hospital on patients with severe traumatic brain injury (STBI).

Methods

We developed an STP based on generally accepted best practices and damage control resuscitation for a level I trauma centre in Colombia. Without a pre-existing trauma registry, we adapted an administrative electronic database to capture clinical information of adult patients with TBI, a head abbreviated injury score (AIS) ≥3, and who presented ≤12 h from injury. Demographics, mechanisms of injury, and injury severity were compared. Primary outcome was in-hospital mortality. Secondary outcomes were Glasgow Coma Score (GCS), length of hospital and ICU stay, and prevalence of ED interventions recommended in the STP. Logistic regression was used to control for potential confounders.

Results

The pre-STP group was hospitalized between August 2010 and August 2011, the post-STP group between September 2011 and June 2012. There were 108 patients meeting inclusion criteria, 68 pre-STP implementation and 40 post-STP. The pre- and post-STP groups were similar in age (mean 37.1 vs. 38.6, p = 0.644), head AIS (median 4.5 vs. 4.0, p = 0.857), Injury Severity Scale (median 25 vs. 25, p = 0.757), and initial GCS (median 7 vs. 7, p = 0.384). Post-STP in-hospital mortality decreased (38% vs. 18%, p = 0.024), and discharge GCS increased (median 10 vs. 14, p = 0.034). After controlling for potential confounders, odds of in-hospital mortality post-STP compared to pre-STP were 0.248 (95%CI: 0.074–0.838, p = 0.025). Hospital and ICU stay did not significantly change. The use of many ED interventions increased post-STP, including bladder catheterization (49% vs. 73%, p = 0.015), hypertonic saline (38% vs. 63%, p = 0.014), arterial blood gas draws (25% vs. 43%, p = 0.059), and blood transfusions (3% vs. 18%, p = 0.008).

Conclusions

An STP in an LMIC decreased in-hospital mortality, increased discharge GCS, and increased use of vital ED interventions for patients with STBI. An STP in an LMIC can be implemented and measured without a pre-existing trauma registry.     

Push versus pull gastrostomy in cancer patients: A single center retrospective analysis of complications and technical success rates

Purpose

To compare the technical success and complication rates of push versus pull gastrostomy tubes in cancer patients, and to examine their dependence on operator experience.

An organizational process for promoting home fire safety in two community settings

The purpose of this study was to describe the home fire safety quality improvement model designed to aid organizations in achieving institutional program goals. The home fire safety model was developed from community-based participatory research (CBPR) applying training-the-trainer methods and is illustrated by an institutional case study. The model is applicable to other types of organizations to improve home fire safety in vulnerable populations. Utilizing the education model leaves trained employees with guided experience to build upon, adapt, and modify the home fire safety intervention to more effectively serve their clientele, promote safety, and meet organizational objectives.     

Colocutaneous fistula after percutaneous endoscopic gastrostomy in a remnant stomach

An 82-year-old woman underwent percutaneous endoscopic gastrostomy (PEG) 5 years after partial gastrectomy for cancer. Four months after PEG insertion, a colocutaneous fistula was noted at exchange of the PEG tube. Colocutaneous fistula is a rare and major complication of PEG with 10 reported cases to date. In eight of the 11 reported cases, including this case, fistulas appeared late (>6 weeks) after PEG insertion. This complication may heal after removal of the PEG alone, if the fistula has formed completely; otherwise a surgical approach is necessary for the treatment. Since five of the 11 reported patients had previously undergone abdominal surgery, prior abdominal surgery may increase the risk of a colonic injury after PEG. Open surgical gastrostomy is a wiser option when performing gastrostomy in patients with prior abdominal surgery. Received: 26 June 1997/Accepted: 8 May 1998     

Adopting best practices in post-operative analgesia prescribing in a safety-net hospital: Residents as a conduit to change

BackgroundSafety-net hospitals frequently underperform on surgical quality measures. To achieve equitable surgical care, creative strategies are needed to improve care for this vulnerable population.MethodsWe designed a trainee-led quality improvement (QI) program to promote evidence-based analgesia prescribing. The program included a collaborative resident leadership model and used educational interventions and performance feedback.ResultsBefore the QI program, 48% of patients were discharged on acetaminophen post-operatively, and 0% were discharged on ibuprofen. In the most recent month since the QI program was launched, 100% of patients were discharged on acetaminophen, and 81% on ibuprofen.ConclusionOur trainee-led quality improvement program demonstrates that surgical trainees can accelerate change and may be a powerful force for improving health equity through safer post-operative discharge prescribing practices at a safety-net hospital.     

A comparison of laparoscopic and open Nissen fundoplication and gastrostomy placement in the neonatal intensive care unit population

Introduction

The aim of this study was to compare outcomes after laparoscopic and open techniques for Nissen fundoplication and gastrostomy placement in the neonatal intensive care unit (NICU) population.

Methods

The medical records for NICU inpatients who underwent laparoscopic and open Nissen fundoplication and gastrostomy placement from August 2002 to August 2008 were reviewed after Institutional Review Board approval. Each technique was compared with regard to operative time, estimated blood loss, postoperative 24-hour narcotic requirements, time to goal feeds, and complication rates. Analysis of variance was used to determine statistical significance. Data are quoted as mean ± SEM.

Results

Fifty-seven NICU patients underwent fundoplication and gastrostomy placement (25 laparoscopic and 32 open). The time to goal feeds was significantly shorter for the laparoscopic group (4.3 ± 0.4 vs 6.1 ± 0.6 days, P = .04). The 24-hour postoperative narcotic requirement was significantly lower in the laparoscopic group (0.24 ± 0.05 vs 0.55 ± 0.08 mg/kg, P = .007). Operation times (111 ± 5 [open] vs 113 ± 5 minutes, P = .76) and estimated blood loss (13 ± 2 [open] vs 11 ± 1 mL, P = .33) were comparable for both groups.

Conclusion

Laparoscopic and open techniques for Nissen fundoplication with gastrostomy placement are safe and appropriate treatment methods with equivalent operating times for the treatment of gastroesophageal reflux in the NICU population.     

The establishment of a child abuse unit in a children's hospital.

The recognition of the child abuse syndrome in the Republic of Sout Africa is briefly mentioned. The aims of setting up a Child Abuse Unit in a children's hospital are detailed; the procedure for the education of staff, details of training and the establishment of a programme are outlined, and the outcome is considered. The co-operation of the medical profession is sought in setting up programmes for the prevention of child abuse.