Optimal enteral feeding in children with gastric dysfunction: surgical jejunostomy vs image-guided gastrojejunal tube placement

Purpose

Long-term feeding access in children who fail initial gastrostomy is a management quandary. Although image-guided gastrojejunal feeding tube placement (IGJ) is becoming the access of choice in many centers, few studies have compared long-term results with surgical jejunostomy (SJ). The authors compare outcomes with these 2 techniques.

Method

A retrospective review of 20 children requiring jejunal feeding access after failing initial gastrostomy was done. Procedures were performed at a tertiary referral center by interventional radiologists (IGJ) or board-certified pediatric surgeons (SJ).

Results

Initially, patients underwent IGJ (n = 14) or SJ (n = 6). Image-guided gastrojejunal feeding tube placement patients required gastrostomy at an average age of 23.8 months, with conversion to IGJ an average of 17.2 months later. SJ patients required gastrostomy at average age of 16.2 months, with conversion to SJ 30.7 months later. Of 14 patients undergoing IGJ, 7 (50%) eventually required SJ because of recurring tube management issues. Thus, 13 patients ultimately had SJ, with 11 (85%) Roux-en-Y jejunostomies. Mean operating time for SJ was 158 minutes, with an average of 5.1 days to initiation of feeds, 11 days to full feeds, and 19.9 days to discharge (range, 3-66 days). Image-guided gastrojejunal feeding tube placement patients averaged 4.6 tube adjustments per year requiring fluoroscopic guidance. Surgical jejunostomy averaged 1.5 tube adjustments per year requiring outpatient hospital visits. Image-guided gastrojejunal feeding tube placement patients averaged 3.9 hospital d/y secondary to feeding tube management issues, whereas SJ patients averaged 1.4 hospital days per year.

Conclusion

In this group of children with long-term jejunal feeding access, half of those with IGJ eventually required SJ. Surgical jejunostomy required fewer adjustments and hospitalizations per year. Although initially more invasive than IGJ, SJ may provide more stable feeding access with fewer complications. This represents the first published report comparing long-term outcomes between IGJ and SJ.     

Guidelines for gastrostomy tube placement and enteral nutrition in patients with severe,refractory hypoglycemia after gastric bypass

BackgroundPostbariatric hypoglycemia (PBH) affects up to 38% of Roux-en-Y gastric bypass (RYGB) patients. Severe cases are refractory to diet and medications. Surgical treatments including bypass reversal and pancreatectomy are highly morbid and hypoglycemia often recurs. We have developed a highly effective method of treatment by which enteral nutrition administered through a gastrostomy (G) tube placed in the remnant stomach replaces oral diet: if done correctly this reverses hyperinsulinemia and hypoglycemia, yielding substantial health and quality of life benefits for severely affected patients.ObjectivesTo provide clinical guidelines for placement of a G-tube to treat postRYGB hypoglycemia, including candidate selection, preoperative evaluation, surgical considerations, and post-RYGB management.SettingStanford University Hospital and Clinics.MethodsBased on our relatively large experience with placing and managing G-tubes for PBH treatment, an interdisciplinary task force developed guidelines for practitioners.ResultsA team approach (endocrinologist, dietitian, surgeon, psychologist) is recommended. Appropriate candidates have a history of RYGB, severe hypoglycemia refractory to medical-nutrition therapy, and significantly affected quality of life. Preoperative requirements include education and expectation setting, determination of initial enteral feeding program, and establishing service with a home enteral provider. Close postoperative follow-up is needed to ensure success and may require adjustments in formula and mode/rate of delivery to optimize tolerance and meet nutritional goals. G-tube nutrition must fully replace oral nutrition to prevent hypoglycemia.ConclusionsG-tube placement in the remnant stomach represents a relatively well-tolerated and effective treatment for severe, refractory hypoglycemia after RYGB.     

Benefit of feeding tube placement for refractory malnutrition after bariatric surgery

Background

Bariatric surgery provides durable weight loss and decreases the incidence of co-morbid conditions for people with obesity. Most patients benefit from resultant weight loss, but some are at risk for postoperative refractory malnutrition, a serious but poorly understood complication.

Percutaneous gastric tube placement: Comparison of trans-abdominal and trans-oral approach in patients with chronic ascites

Purpose

The purpose of this study was to compare the trans-abdominal (TA) and trans-oral (TO) approaches for fluoroscopic-guided gastrostomy tube placement in patients with chronic ascites.

肠内营养置管技术及营养输入装置的应用

虽然问世于20世纪60年代的肠外营养给许多临床情况带来了曙光．但由于存在感染及代谢并发症的危险．加之。近年肠内营养在置管、喂养及成分等方面均取得了长足发展．使问世已有400多年历史的肠内管饲再度受到广泛关注与接受。本文就食管外科肠内管饲的有关问题作了阐述。     

Esophagectomy in patients with prior percutaneous endoscopic gastrostomy tube placement

Background

The impact of preoperative percutaneous endoscopic gastrostomy (PEG) tube placement in patients undergoing esophagectomy is uncertain.

Methods

A retrospective review was performed in consecutive patients who underwent esophagectomy. Patients were divided into groups based on whether or not they had preoperative PEG placement.

Results

One hundred seventeen patients were studied, 102 without (PEG−) and 15 with PEG+ before PEG tube placement. The overall morbidity and mortality rates were 38% and 3%, respectively. The use of a gastric conduit was similar between groups (94% PEG− vs 87% PEG+, P = .27), and the presence of a PEG before PEG tube placement was not prohibitive in any case. Anastomotic leak rates were similar between groups (11% PEG− vs 15% PEG+, P = .65), and there were no leaks from previous PEG sites.

Conclusion

It appears that preoperative PEG tube placement has no adverse effect on the performance of esophagectomy and may be considered in highly selected patients with poor nutritional status.     

Stomal seeding of head and neck cancer by percutaneous endoscopic gastrostomy tube placement

Background: Percutaneous endoscopic gastrostomy (PEG) tubes have replaced nasogastric tubes and Stamm gastrostomy tubes as a preferred means of feeding for patients with head and neck cancers, as recommended by the results of large series. A patient with stomal seeding of squamous cell carcinoma of the upper aerodigestive tract by PEG placement was reported. A review of literature was performed. Methods: A Medline search of implantation of squamous cell carcinoma from the upper aerodigestive tract to PEG exit site since the introduction of PEG was performed. Results: Two reports of implantation of squamous cell carcinoma of the upper aerodigestive tract to PEG exit site were found. Both patients and our patient were staged T4. Conclusions: Implantation of squamous cell carcinoma from the upper aerodigestive tract to the PEG exit site is a rare and late complication. Its prevalence is not known. For patients with a significant amount of squamous cell carcinoma in the upper aerodigestive tract, we recommend Stamm gastrostomy over PEG insertion by the pull technique. There is no report of such late complication by the push technique.     

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.     

Primary laparoscopic placement of gastrostomy buttons for feeding tubes

Background: During a 4-year period, 240 gastrostomy buttons were placed in children, as the initial surgical feeding tube, using laparoscopic techniques. Materials and methods: 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 ∼5–10 min to the time for the procedure. Results: There were no intraoperative complications and five (2.1%) postoperative complications. Conclusions: 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. Received: 11 February 1999/Accepted: 27 April 1999     

Impact of practice change on intestinal perforation risk for pediatric gastrojejunostomy tube placement

BackgroundGastrojejunostomy tubes (GJTs) have been associated with intestinal perforation in children < 6 months or < 6 kg. This study evaluated the impact of an institutional practice change recommending a new soft tip GJT for children < 10 kg.MethodsWe performed a single-center review of GJT placements among children < 10 kg before (1/1/2010–12/31/2013) and after (7/1/2014–12/31/2016) the practice change. Intestinal perforation, nasojejunal tube (NJT) for > 30 days, and GJT replacement were assessed.ResultsSixty GJTs were placed in 35 children (54% male; 17.2 ± 9.0 months old) after compared to 147 GJTs in 77 children (44% male, p = 0.32; 14.1 ± 11.8 months, p = 0.08) before the practice change. Use of soft tip GJT was adhered to in 19 placements (32%). There were no intestinal perforations after the practice change (before: 6 (4.1%); p = 0.11). NJT remained > 30 days in 15 patients (65%) after the practice change (before: 13 (35%); p = 0.02). Replacement was required for 53% with soft tip GJT and 18% with standard GJT (p = 0.006).DiscussionA reduction in intestinal perforation with an institutional practice change may be explained by fewer GJT placements in high-risk children and longer length of NJT placement. Future protocols may consider age and size restrictions rather than alternative tube types.Type of studyTreatment study.Level of evidenceLevel III.     

Postoperative bezoar ileus after early enteral feeding

Postoperative enteral nutrition is a widely accepted route of application for nutrition formulas due to a low complication rate, a good acceptance by patients. and a favorable cost-effectiveness. We report three cases of bezoar ileus after early postoperative enteral nutrition, using a fine needle jejunostomy (FNJ) in two cases and a nasoduodenal tube in one case. A male patient who underwent gastric resection for a gastrointestinal stroma tumor and was nourished through an fine needle jejunostomy developed an acute abdomen on the seventh postoperative day. Surgical exploration revealed a mechanical ileus caused by denaturated nutrition formula distal to the catheter tip. The second case, a female patient, underwent gastric resection for a gastric cancer and on the fourth postoperative day developed acute onset of abdominal pain. Intraoperative findings were the same as described in the first case. The third case, a male patient with necrotizing cholecystitis, underwent open cholecystectomy. Postoperative enteral feeding was performed using a nasoduodenal tube. He developed a small bowel obstruction on the 17th postoperative day that was caused by an intraluminal bezoar. In conclusion, bezoar formation represents an underestimated complication of postoperative enteral feeding. Acute onset of abdominal pain and the development of small bowel obstruction are the main clinical symptoms of this severe complication. The pathogenesis of bezoar formation remains unclear.     

Surgical feeding gastrostomy: Are we overdoing it?

Feeding gastrostomy is a commonly performed procedure in North America. Our aim was to study the outcome of patients undergoing feeding gastrostomy to better define patients who will benefit from the procedure as opposed to those in whom it may be futile. A cohort of the most recent 100 consecutive patients undergoing feeding gastrostomy in a community teaching hospital was retrospectively studied. The main indication for gastrostomy was neurologic disorder interfering with eating/swallowing (group A—54 patients), followed by debilitating systemic disease (group B—26 patients) and obstructive malignancy of the head and neck or esophagus (group C—20 patients). Forty-one patients died within 30 days of the procedure (41%). The overall 30-day survival rates in groups A, B, and C were 70%, 15%, and 85%, respectively. In four patients death was caused by intraperitoneal leak from the gastrostomy site; the remaining patients died of their underlying disease. Five patients required reoperation for gastric leakage around the gastrostomy within 30 days. Only nine patients could be traced who were alive and still using the gastrostomy a year after its placement: two in group A, none in group B, and seven in group C. APACHE II scores at tube insertion also predicted survival; 30-day survival rates in patients with scores of 10 and below, 11 to 15, 16 to 20, and over 20 were 96%, 71%, 48%, and 18%, respectively. No patient with an APACHE score above 15 belonging to group B (debilitating disease) survived more than 30 days. We conclude that to have a beneficial therapeutic effect feeding gastrostomy should be performed selectively. Severe debilitating systemic conditions that interfere with normal eating, when combined with a high APACHE II score, indicate the futility of gastrostomy.     

Prevention of hypergranulation tissue after gastrostomy tube placement: A randomised controlled trial of hydrocolloid dressings

Hypergranulation tissue formation is a common complication after gastrostomy tube (G‐tube) placement, occurring in 44%–68% of children. Hydrocolloid dressings are often used in the treatment of hypergranulation tissue but have not been studied for the prevention of postoperative hypergranulation tissue. An institutional review board (IRB)‐approved, prospective, randomised study was performed in paediatric patients who underwent G‐tube placement at a single, large children's hospital from January 2011 to November 2016. After placement, patients were randomly assigned to (1) standard postoperative G‐tube care, (2) standard hydrocolloid G‐tube dressing, or (3) silver‐impregnated hydrocolloid G‐tube dressing, and the incidences of postoperative hypergranulation tissue formation, tube dislodgement, infection, and emergency department use were compared. A total of 171 patients were enrolled; 128 patients (75%) had at least 4 months of follow up and were included in the analyses. Eighty‐nine patients (69.5%) developed hypergranulation tissue during the postoperative period, with no significant differences in incidence among the three treatment arms. Of those who developed hypergranulation tissue, 46 (56%) visited the emergency department, compared with 6 of the 39 patients (19%) who did not develop hypergranulation tissue. Hydrocolloid dressings (standard or silver‐impregnated) do not prevent the development of hypergranulation tissue or other complications after G‐tube placement in paediatric patients.     

食管电极联合食管电图用于鼻胃管置入

目的观察食管电极引导鼻胃管置入的有效性及安全性。方法将94例接受鼻胃管置入患者按随机数字表法分为观察组(49例)及对照组(45例)。对照组采用传统方法置管和判断胃管置入位置;观察组在食管电极引导下进行鼻胃管置入,并以食管电图判断胃管置入位置。结果观察组操作时间、操作次数、一次置管成功率与对照组比较,差异有统计学意义(P<0.05,P<0.01);两组并发症发生率比较,差异无统计学意义(P>0.05)。4例未描记出食管电图的患者胃管置入位置有误。结论食管电极引导鼻胃管置入简便、易行,描记食管电图能准确反映胃管置入位置是否正确。     

Preoperative prediction of need for fundoplication before gastrostomy tube placement in children

Purpose

Percutaneous endoscopic gastrostomy (PEG) tube placement is a common procedure performed for children with oral aspiration and failure to thrive. The concurrent presence of gastroesophageal reflux (GER) may be difficult to diagnose in these children and may dictate the need for an antireflux procedure. The purpose of this study was to review our preoperative evaluation of children undergoing PEG placement to better elucidate preoperative factors that may require eventual fundoplication.

Methods

A retrospective review at a tertiary care, children's hospital between May 2002 and August 2007 was performed of patients undergoing PEG placement. Patients were identified through database search by operative procedure codes. Patient groups were defined as those undergoing PEG alone (group 1) and those requiring fundoplication after prior PEG (group 2). Comparison of patient demographics and radiologic qualitative results of GER was analyzed using χ² analysis, with significance determined at P < .05.

Results

A total of 863 patients underwent PEG placement over this 64-month period. A sampled cohort of patients undergoing PEG over a year comprised group 1. Forty-four patients (5.1%) underwent Nissen fundoplication after prior PEG placement (group 2). Patient demographics were similar between the groups. Comparison of comorbid conditions and qualitative indicators of GER between the groups showed only cerebral palsy had a significantly higher associated risk of GER that required antireflux surgery. Preoperative clinical assessment had a 95% positive predictive value in identifying children who required only PEG.

Conclusions

Despite the high predictive value of individualized clinical assessment in the ultimate decision for gastrostomy without need of fundoplication, further studies are needed to determine whether children with conditions such as cerebral palsy may require a concurrent antireflux surgery at the time of gastrostomy.     

Safety and efficacy of uninterrupted perioperative enteral feeding in pediatric burn patients

Introduction

Burn injuries are a significant cause of morbidity. Early enteral nutrition has been shown to improve outcomes, however enteral nutrition is often held for procedures receiving general anesthesia. Limited data is available on uninterrupted perioperative nutrition in pediatric burn patients.

A simple method for endoscopic placement of a nasoduodenal feeding tube

The key to short-term enteral feeding in patients with gastroparesis is to deliver the nutrition beyond the pylorus. Endoscopic assisted methods allow the precise placement of the feeding tube to the small bowel. However, the main difficulty in association with these procedures is feeding-tube migration into the stomach during the withdrawal of the endoscope. We have developed an endoscopic method with a high success rate which prevents this problem. A reusable angiocatheter guidewire was threaded through the feeding tube, passing beyond the distal opening prior to the withdrawal of the scope. Counterpressure was applied to the feeding tube during the withdrawal of the endoscope. We have successfully placed feeding tubes in 22 out of 23 patients with no complications.Work was performed at Royal University Hospital, University of Saskatchewan     

Percutaneous endoscopic gastrostomy: the preferred method of elective feeding tube placement in trauma patients.

PURPOSE: The purpose of this study was to determine whether gastric feeding tubes placed by the percutaneous endoscopic route resulted in fewer and less severe complications than open surgical gastrostomy (SG). METHODS: Charts for all trauma patients admitted 1/94 to 12/98, which had an electively placed feeding tube, were individually reviewed. All tube-related complications were recorded. Of 8119 patients screened, 158 (1.9%) met inclusion criteria. Percutaneous endoscopic gastrostomies (PEGs) were placed in 95 (60.1%) and surgical gastrostomies in 63 (39.9%). Most patients (79.1%) had AIS 3 or greater head or spinal cord injury as the primary diagnosis leading to tube placement. RESULTS: Overall, SG patients were 5.4 times more likely than PEG patients to have a complication from their gastrostomy tube (95% CI, 2.1-13.8). They were 2.6 times more likely to have a major complication (internal leakage, dehiscence, peritonitis, and fistula), and 5.5 times more likely to have a minor complication (unplanned removal, dislodgment, external leak, skin infection, and nonfunction). The groups did not differ on ISS, ICU LOS, total LOS, or mortality (p > 0.05). Overall, a total of 39 individual complications related to tube placement were noted in 26 separate patients (PEG, 7; SG, 19). All four of the major complications requiring operative intervention were in the SG group. There were 31 minor complications, 8 in the PEG group and 27 in the SG group. Mean total charges for placement were also significantly lower in the PEG group than the SG group ($1271 vs. $2761, p < 0.001) CONCLUSION: Gastrostomy tubes placed via the percutaneous endoscopic route had a significantly lower complication rate than surgically placed tubes. In addition, the charges incurred for their placement were also significantly less. Based on the findings of this study, PEG should be considered as the method of choice for gastric feeding tube placement for trauma patients who do not have specific contraindications to the procedure.     

Chest tube placement in children during extracorporeal membrane oxygenation (ECMO)

Background

Pleural collections of air and fluid are frequent in infants and children treated with extracorporeal membrane oxygenation (ECMO). In this anticoagulated population, chest tube placement is potentially hazardous, and catastrophic hemorrhage has been reported. We sought to define the risks associated with chest tube placement in a large population of children managed with ECMO.

Methods

The records of 189 consecutive children managed with ECMO at two children’s hospitals were reviewed. Demographics, indications for ECMO, and ECMO courses were reviewed. In particular, the occurrence of pleural collections and the frequency and technique of chest tube placement were evaluated. The incidence of complications and mortality were determined.

Results

The median age of the subjects was 2 days. The overall mortality was 26.5%. A pneumothorax was found in 19 (10.1%), a pleural effusion in 26 (13.8%), and a hemothorax in 2 (1.0%). A chest tube was placed in 27 (19 by a needle-guide wire technique and 8 by cut-down). Major bleeding complications occurred in 6 subjects (22%).

Conclusions

There was a significant incidence of major bleeding complications and death in subjects in whom chest tubes were placed. The placement of a chest tube during ECMO should be done only if it is likely to improve pump flow or promote weaning of support.     

The effect of enteral tube feeding in cystic fibrosis: A registry based study

Background

Long-term effect of enteral tube feeding (ETF) in cystic fibrosis (CF) remains equivocal.