Extraperitoneal Closure of Persistent Gastrocutaneous Fistula in Children

Background and Objectives:

Gastrostomy feeding in children is well established for nutritional support. Gastrostomy tubes may be permanent or temporary. After removal, spontaneous closure may occur, but persistence of the tract requires surgical repair. Laparotomy with gastric repair and fascial closure is the standard technique for treatment of a persistent gastrocutaneous fistula. We describe a technique of extraperitoneal excision of the fistulous tract and our results using this method.

Methods:

We reviewed 21 cases of extraperitoneal gastrocutaneous fistula closure in which a Foley catheter traction technique was used and were performed over the last 8 y. The technique involves insertion of a small Foley catheter with traction applied to the fistulous tract and core excision with electrocautery. Closure of the tract without fascial separation was accomplished and early feedings were allowed.

Results:

Ten males and 11 females underwent closure with this technique. The duration of the gastrostomy ranged from 1 y to 6 y, with a mean of 3.3 y. The time from removal to surgical repair was 3 wk to 1 y, with a mean of 4.3 mo; 15 had gastrostomy alone, and 6 had gastrostomy in combination with Nissen fundoplication. Open gastrostomy had been done in 10 patients and laparoscopic gastrostomy in 11 patients. Half of the patients had an ambulatory procedure. One patient developed a superficial wound infection, and there was 1 recurrence requiring intraperitoneal closure.

Conclusion:

Extraperitoneal closure for gastrocutaneous fistula is safe and effective. The technique allows for rapid resumption of feeds and a shortened length of stay. Minimal morbidity occurs with this technique, and it is well tolerated in the pediatric population.     

Analysis of factors affecting the spontaneous closure of a gastrocutaneous fistula

Background/purpose

Few reports have documented the rate of persistence of a gastrocutaneous fistula (GCF) after gastrostomy removal or the reason for the persistence of a GCF. The purpose of this report was to analyze a large group of pediatric patients with a persistent GCF to determine the rate of persistence and any factors that correlate with the persistence of a GCF.

Methods

This was a retrospective review of 1,042 children from The Children’s Hospital, Denver, Colorado who had a gastrostomy constructed between 1992 and 2002. The charts of all children with a persistent GCF after gastrostomy catheter removal were analyzed for correlation between 13 clinical parameters and the persistence of a GCF.

Results

There were 150 children with a persistent GCF for an incidence of 34%. Time elapsed between the creation of the GCF and removal of the gastrostomy appliance (≤8 months versus >8 months) was the only parameter that showed any correlation with persistence of a GCF (P < .05). None of the other parameters studied showed any conclusive correlation with persistence of a GCF.

Conclusions

Time was the only factor that determined whether a surgically created GCF would persist after removal of a gastrostomy appliance.     

Gastrostomy tube insertion into intestinal-cutaneous tract fistulas is a new technique to improve fistula control

BACKGROUND: The management of gastrointestinal-cutaneous fistulas may be complicated by the difficulty in obtaining adequate control of the fistula tract. This study describes a new method to obtain better fistula control utilizing a semi-rigid stent in the form of a gastrostomy tube. METHODS: Consecutive patients with intestinal-cutaneous fistulas of at least 3 weeks duration and treated by the new technique were analyzed. The technique involved the insertion of a guide wire into the fistula tract from the luminal side using an endoscope, snaring the wire with a Dormia basket inserted into the fistula tract from the cutaneous side and then exteriorized. The gastrostomy tube was then pulled with the guide wire from the lumen along the fistula tract and out through the skin. RESULTS: Five patients had had fistulas for a median duration of 42 (range 26-140) days before insertion of the gastrostomy tube. The gastrostomy tube was replaced with a smaller diameter tube in 4 of the patients (range 1-3 changes). The patients were discharged from the hospital at a median of 14 (range 12-23) days after the tube insertion but with the tube in situ. The median time from the insertion of the tube to its removal was 42 (range 32-108) days. CONCLUSIONS: Gastrostomy tube insertion using minimally invasive techniques may improve fistula control enabling patients to be discharged home sooner than otherwise and improve the rate of healing.     

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     

Refractory abdominal-cutaneous fistulas or leaks: percutaneous management with a collagen plug

BACKGROUND: We report the results of abdominal-cutaneous fistula tract occlusion with a collagen plug in a series of patients with fistulas or leaks refractory to conservative therapy. STUDY DESIGN: Seven patients were found to have persistent fistula or leak after percutaneous drainage of abdominal pelvic fluid collections. All patients but one were refractory to surgical or percutaneous drainage. Under fluoroscopic guidance, modified Vasoseal (Datascope Inc, Montvale, NJ) collagen plugs were deployed into the fistulas using catheter-directed techniques. The plugs were split longitudinally to fit into an 8F or 9F peel-away sheath, placed into the fistula, and deployed. Results were tabulated and patients were followed up. RESULTS: Six of seven patients undergoing fluoroscopically guided, catheter-directed tract occlusion had resolution of the fistula, with no evidence of fistula or abscess recurrence from 30 to 180 days after closure. There were no procedural complications. The technique was unsuccessful in dosing a gastrocutaneous fistula after removal of a large-bore gastrostomy tube; this failure was believed to be secondary to the short length and large caliber of the tract in a patient with hypercortisolemia. CONCLUSIONS: Closure of abdominal-cutaneous fistula tracts by occlusion with a modified Vasoseal collagen plug shows promise in the management of fistulas refractory to catheter drainage.     

Complications after percutaneous endoscopic gastrostomy removal.

We report two cases of complications after percutaneous endoscopic gastrostomy (PEG) removal. The first was persistence of a gastrocutaneous fistula that required operative closure. The second patient developed pneumoperitoneum after an attack of vomiting 3 weeks after PEG removal. Laparotomy showed separation of the stomach from the posterior abdominal wall, with peritonitis. These cases highlight the need for careful monitoring of patients even after tube removal.     

Laparoscopic gastrostomy as an adjunctive procedure to laparoscopic fundoplication in children

Infants and children requiring fundoplication for gastroesophageal reflux frequently have significant associated medical problems necessitating placement of a gastrostomy at the time of fundoplication. This article reviews the techniques, complications, and results of 141 laparoscopic Stamm gastrostomies performed in conjunction with laparoscopic fundoplication in infants and children. The three techniques employed were the T-fastener technique (63/141) which is best utilized in patients with thick abdominal walls; the trocar-site technique (53/141) which is technically easy to perform but prone to infection and fistula formation; and the U-stitch technique (26/141). General complications of laparoscopic gastrostomy include development of gastrocutaneous fistulae (2/141), perigastrostomy cellulitis (8/141), and the formation of granulation tissue at the gastrostomy site (45/141). The only perioperative death was due to a technical error during gastrostomy tube placement. Our preferred method for laparoscopic gastrostomy in most children is the U-stitch technique. Received: 19 March 1996/Accepted: 8 May 1996     

Early experience with the Bower percutaneous endoscopic gastrostomy tube.

Percutaneous endoscopic insertion of gastrostomy tubes is a technique becoming more widely used in the UK. It allows insertion of a gastrostomy tube without laparotomy, under local anaesthesia and sedation, and so operative insertion may eventually become a rarity. We report on our successful early experience with a new gastrostomy tube (Bower PEG) which does not require endoscopy if eventual removal is required, and describe the methods of insertion and removal.     

PERITONITIS FOLLOWING PERCUTANEOUS GASTROSTOMY IN CHILDREN: MANAGEMENT GUIDELINES

Background : To establish the incidence, timing and outcome of peritonitis following percutaneous gastrostomy (PEG) insertion in children. Methods : Patients developing peritonitis after PEG insertion during a 5-year period (1990–95) were identified. Variables analysed included clinical presentation, management, operative findings and outcome. Results : One hundred and twenty paediatric patients received 130 PEG in the 5-year period. Eight children developed peritonitis: 4 within 24 h of PEG insertion and 4 following routine PEG tube change (3–18 months later). All four patients developing early peritonitis underwent laparotomy in whom three had sustained major damage to adjacent viscera. The fourth patient had a negative laparotomy, but died from continued overwhelming sepsis. All four patients who developed peritonitis after a routine tube change underwent a tube contrast study. In two children a gastrocolic fistula was identified and surgically repaired. Contrast studies in two patients detected an intraperitoneal leak. This problem resolved with conservative management in both cases. Conclusions : Peritonitis immediately following PEG insertion is rarely due to the air leakage during insertion (benign pneumoperitoneum) and warrants early laparotomy to identify and correct the likely associated visceral trauma. Following PEG tube change peritonitis may result from stomal separation or tube malposition and an urgent study is indicated to identify the cause.     

General Paediatric Surgical Provision of Percutaneous Endoscopic Gastrostomy in a District General Hospital – A 12-Year Experience

INTRODUCTION

A small, but significant, number of children require long-term nutritional support. The aim of this study was to demonstrate the safety and efficacy of providing a percutaneous endoscopic gastrostomy (PEG) service for children in a district general hospital and to raise awareness of the suitability of the procedure to be performed on paediatric surgery lists in similar hospitals across the UK.

PATIENTS AND METHODS

A multidisciplinary paediatric nutrition team was established and all children accepted for PEG insertion between 1995 and 2007 were entered onto a database prospectively and are included in this study. PEG tubes were inserted by the standard pull-through technique under general anaesthetic.

RESULTS

A total of 172 procedures were performed in 76 children. The median age at first tube insertion was 3 years (range, 0.5–18 years). Length of follow-up ranged from 1 month to 12.6 years. Fifty-eight children (76%) had a neurological abnormality, the commonest being cerebral palsy. All but one procedure were performed successfully, of which 63 (37%) were new insertions, 99 change of tube, 4 changed from surgical gastrostomy and 6 from PEG to button gastrostomy. The median hospital stay was 2 days (range, 2–7 days) for new insertions and 1 day for tube changes. There were 10 (6%) early complications within 30 days, the commonest being peritubal infection (6). The 39 late complications included 16 peritubal infection/granulomata, 9 ‘buried bumpers’, 4 worsening of gastro-oesophageal reflux disease, 2 gastrocolic fistulae, 3 gastrocutaneous fistulae and 4 tubal migration. There was no mortality.

CONCLUSIONS

We have demonstrated that paediatric PEG procedures and continuing management by a supporting team can be successfully and efficiently provided in the district general hospital. It should be possible for the majority of similar hospitals to provide local access and increase the availability of PEG feeding for children.     

A new endoscopic technique for the buried bumper syndrome

Background The Buried Bumper Syndrome is a well-recognized long-term complication of percutaneous endoscopic gastrostomy (PEG). Overgrowth of gastric mucosa over the inner bumper of the tube will cause mechanical failure of feed delivery, rendering the tube useless. Endoscopic removal is usually attempted but fails in most cases. Therefore, most of the buried inner bumpers are removed by making an external incision over the PEG site under local anaesthesia or at laparotomy. These approaches can be associated with pain, wound infection, or a gastrocutaneous fistula. Technique A new method to facilitate the removal of a PEG tube, where the inner bumper is buried in the gastric mucosa, is described. A length of ureteric catheter, or similar tube, is passed through the shortened external PEG tube into the gastric cavity and is then tied to the tube above the skin. The intragastric part of that tube helps to identify the site of the buried bumper and is then trapped within an endoscopic snare. Traction is then applied to the snare, inverting the tube and dislodging the bumper with minimum disruption to the stomach wall. This avoids the need for repair and allows for immediate reinsertion of a fresh PEG tube. Conclusions A PEG tube in a patient with buried bumper syndrome can be safely removed endoscopically, without a skin incision or gastric wall disruption. A novel, simple, and safe endoscopic removal technique is described. Presented as a poster at the 13th meeting of the EAES, Venice, Italy, June 2005     

Tracheoesophageal Fistula from Carcinoma of the Esophagus

The records of the patients with tracheoesophageal fistula from carcinoma of the esophagus treated from 1970 to 1983 were reviewed to assess the length and quality of their survival. Twenty-four patients with malignant tracheoesophageal fistula were treated during this period. The site of the carcinoma was the middle third of the esophagus in 18 patients, the lower third in 5, and the upper third in 1. Three patients received only supportive treatment, and 1 had only radiation therapy. Nine patients underwent insertion of a Mousseau-Barbin or Celestin tube with or without gastrostomy, and 7 patients had gastrostomy alone. Four patients had exclusion of the tracheoesophageal fistula, 3 with esophagogastrostomy and 1 with colon interposition. The 3 patients who received only supportive treatment survived 5 days, 1 week, and 2 weeks. The 7 patients who had gastrostomy lived 3 days to 18 weeks (mean, 6 weeks). The 9 patients with a Mousseau-Barbin or Celestin tube lived 1 week to 6 months (mean, 8 weeks). The 4 patients who had exclusion of the tracheoesophageal fistula survived 5 weeks, 4 months, 7 months, and 26 months following operation. This study suggests that the treatment for patients with tracheoesophageal fistula from carcinoma of the esophagus should be individualized and that in selected patients, exclusion of the fistula with esophagogastrostomy improves the quality of life and prolongs survival.     

A Simple and Safe Minimally Invasive Technique for Laparoscopic Gastrostomy

Introduction:

Percutaneous endoscopic gastrostomy (PEG) is the procedure of choice in the nutritional management of patients requiring gastrostomies. However, PEG tubes are not always feasible. The aim of the present study was to determine the feasibility, complications, and adequacy of feeding support of a novel laparoscopic gastrostomy technique in adults where PEG tubes were neither feasible nor safe.

Methods:

A retrospective chart review of patients who underwent a laparoscopic gastrostomy from August 2007 to July 2008 was performed. Demographic and outcome data were abstracted.

Results:

Fourteen patients underwent laparoscopic gastrostomy. Nine had obstructing head/neck cancer, 2 had severe head trauma, and one was morbidly obese. Nine patients had previous abdominal surgery. The mean operative time was 29.8 minutes (±7.2). There were no conversions to open gastrostomy. Two ports (5mm and 10mm) were used in the majority of patients (78.5%). No major complications were observed. The mean follow-up was 3.1 months (range, 2 to 8).

Conclusion:

This innovative 2-port laparoscopic technique for gastrostomy tube placement is safe and effective. It allows for the quick, accurate, and safe insertion of the feeding tube under direct visualization and avoids open techniques in patients where PEG tubes are not feasible.     

Patient selection for pediatric gastrostomy tubes: Are we placing tubes that are not being used?

IntroductionIdentifying pediatric patients who may benefit from gastrostomy tube (GT) placement can be challenging. We hypothesized that many GTs would no longer be in use after 6 months.MethodsInpatient GT placements in patients < 18 years old at a tertiary children's hospital from 9/2014 to 2/2020 were included. The primary outcome was GT use <6 months (short-term). Secondary outcomes included age at placement, indication for GT, and operations for GT-related issues.ResultsFifteen percent (22/142) of GTs were used for <6 months post-operatively. The median duration of short-term GT use was 1.6 months (IQR 0.9–3.4 months). Short-term GTs were more likely to be placed in patients with traumatic brain injury (TBI) (18.2% vs. 4.2%, p = 0.03) and adolescents (≥12 years old, 22.7% vs. 4.0%, p = 0.005). Gastrocutaneous fistula closure was required in 33.3% of short-term patients who had their GTs removed (n = 6/18), with median total hospital charges of $29,989 per patient.ConclusionFifteen percent of pediatric GTs placed as inpatients were used for <6 months, more commonly among adolescents and in TBI patients. One-third of patients with short-term GTs required gastrocutaneous fistula closure. Adolescents and TBI patients may benefit from consideration of short-term nasogastric tube (NGT) feeds rather than surgical GT placement.Level of EvidenceIII     

Outcomes after laparoscopic surgery in neonates with hypoplastic heart left heart syndrome

Background/Purpose

Laparoscopy has advanced the care of children for a variety of pediatric surgical diseases. However, complication rates for laparoscopic interventions in neonates with hypoplastic left heart syndrome (HLHS) have not been well described. The purpose of this study is to present the largest reported series of laparoscopic surgery performed in patients with HLHS.

Methods

We conducted a single-institution, retrospective chart review for all neonates with HLHS who underwent a laparoscopic procedure from September 2002 to March 2005. Data regarding patient characteristics, intraoperative monitoring, previous cardiac surgery, perioperative complications, and postoperative mortality were assessed.

Results

Twelve patients with HLHS underwent a total of 13 operations during the study period (8 combined Nissen fundoplication and gastrostomy tubes, 3 isolated gastrostomy tubes, 1 Ladd procedure, and 1 combined Nissen fundoplication and gastrocutaneous fistula closure). All cases were completed laparoscopically. Patients had undergone palliative cardiac surgery but were not completely corrected; therefore, they were cyanotic. Perioperative complications were observed in 6 patients (3 gastrostomy tube site infections, 1 small bowel obstruction, 1 postoperative sepsis, and 1 urinary tract infection). There was no mortality in this series.

Conclusions

From this experience, it appears that laparoscopy can be performed safely and with satisfactory outcomes in patients with HLHS. However, a multidisciplinary approach, including the availability of a skilled and experienced cardiac anesthesia team, is believed to be critical to optimize outcomes in these critically ill children.     

Laparoscopically supervised PEG at time of Nissen fundoplication: a safe option

BACKGROUND/PURPOSE: Children with gastroesophageal reflux disease (GERD) often have associated feeding difficulties that warrant the insertion of a feeding gastrostomy at the time of the antireflux procedure. Options for gastrostomy tube insertion at the time of laparoscopic Nissen fundoplication (LNF) include laparoscopic gastrostomy, percutaneous endoscopic gastrostomy (PEG), and classic open gastrostomy. The complication rate of PEG may be decreased if it is placed under laparoscopic supervision. The purpose of this paper is to describe our experience with laparoscopically supervised PEG tube placement at the time of antireflux procedure. METHODS: A retrospective chart review was conducted on all children undergoing a PEG tube placement at the time of the LNF. Perioperative complications were recorded. RESULTS: Forty-four patients had attempted PEG tube placement at the time of the LNF. In 3 (7%) cases, laparoscopic supervision was crucial in the prevention of a complication. No major PEG-related complications were recorded. In 43% of patients, minor PEG tube problems arose in the postoperative period: all were transient and/or easily correctable. Management of all these problems was in an outpatient setting. Follow-up ranged from 11 to 41 months. CONCLUSIONS: PEG tube placement at the time of a LNF is safe and effective. A combined laparoscopic and endoscopic approach minimizes complications. This method also allows for an intra- and extraluminal evaluation of the fundoplication at its completion.     

Fundoplication and gastrostomy versus image-guided gastrojejunal tube for enteral feeding in neurologically impaired children with gastroesophageal reflux

Background: Neurologically impaired children with gastroesophageal reflux (GER) usually are treated with a fundoplication and gastrostomy (FG); however, this approach is associated with a high rate of complications and morbidity. The authors evaluated the image-guided gastrojejunal tube (GJ) as an alternative approach for this group of patients. Methods: A retrospective review of 111 neurologically impaired patients with gastroesophageal reflux was performed. Patients underwent either FG (n = 63) or GJ (n = 48). All FGs were performed using an open technique by a pediatric surgeon, and all GJ tubes were placed by an interventional radiologist. Results: The 2 groups were similar with respect to diagnosis, age, sex and indication for feeding tube. Patients in the GJ group were followed up for an average of 3.11 years, and those in the FG group for 5.71 years. The groups did not differ statistically with respect to most complications (bleeding, peritonitis, aspiration pneumonia, recurrent gastroesophageal reflux [GER], wound infection, failure to thrive, and death), subsequent GER related admissions, or cost. Children in the GJ group were more likely to continue taking antireflux medication after the procedure (P [lt ] .05). Also, there was a trend for GJ patients to have an increased incidence of bowel obstruction or intussusception (20.8% v 7.9%). Of the FG patients 36.5% experienced retching, and 12.7% experienced dysphagia. Eighty-five percent of patients in the GJ group experienced GJ tube-specific complications (breakage, blockage, dislodgment), and GJ tube manipulations were required an average of 1.68 times per year follow-up. Nine patients (14.3%) in the FG group had wrap failure, with 7 (11.1%) of these children requiring repeat fundoplication. In the GJ group, 8.3% of patients went on to require a fundoplication for persistent problems. A total of 14.5% of GJ patients had their tube removed by the end of the follow-up period because they no longer needed the tube for feeding. Conclusions: Image-guided gastrojejunal tubes are a reasonable alternative to fundoplication and gastrostomy for neurologically impaired children with GER. The majority can be inserted without general anesthesia. This technique failed in only 8.3% patients, and they subsequently required fundoplication. A total of 14.5% of GJ patients showed some spontaneous improvement and had their feeding tube removed. Each approach, however, still is associated with a significant complication rate. A randomized prospective study comparing these 2 approaches is needed.     

Management of premature removal of the percutaneous gastrostomy

Percutaneous endoscopic gastrostomy (PEG) has become the preferred method of enteral access for nutritional support. With increased use of this modality, complications are encountered more frequently. Premature withdrawal, inadvertent removal of the gastrostomy tube within the first seven days after insertion, before adherence of the gastric serosa to the parietal peritoneum, has been an indication for laparotomy. This report describes the treatment of premature withdrawal by immediate endoscopic replacement. Over an 18-month period, 271 patients underwent insertion of a PEG. Five patients (1.8%) who inadvertently removed their gastrostomy tube within seven days of insertion were treated with immediate replacement using the retrograde string technique, avoiding laparotomy. All five PEGs were successfully replaced through the same gastrostomy site. Despite the presence of pneumoperitoneum, no patient developed peritonitis or other septic complications. Premature gastrostomy tube withdrawal is safely managed by endoscopic replacement and observation. Laparotomy is unnecessary and potentially meddlesome.     

Evaluating complication rates and outcomes among infants less than 5 kg undergoing traditional percutaneous endoscopic gastrostomy insertion: A retrospective chart review

Purpose

Percutaneous endoscopic gastrostomy (PEG) enables enteral nutrition for patients with inadequate oral intake. Laparoscopic guidance of PEG insertion is used for high-risk populations, including in infants less than 5 kg at insertion. This study aimed to assess complication rates with traditional PEG tube insertion in infants less than 5 kg at a single tertiary care center.

Timing of percutaneous endoscopic gastrostomy tube placement after cervical esophageal reconstruction with free jejunal transfer

The timing of percutaneous endoscopic gastrostomy (PEG) tube placement in patients who undergo cervical esophageal reconstruction using free jejunal transfer is controversial. The purpose of this study was to review the authors' experience with pharyngeal reconstruction using free jejunal transfer to establish useful guidelines for enteral tube placement. A retrospective analysis of all patients treated with free jejunal autografts for reconstruction of cervical esophageal defects during a 12-year period was performed. A total of 105 patients underwent 108 esophageal reconstructions using these techniques. Sixty-three patients (60%) did not have enteral tube placement at any time, whereas 42 patients had gastrostomy or PEG tubes placed preoperatively (n = 12), intraoperatively (n = 8), or postoperatively. The majority of patients were able to resume per-oral feeds and avoid long-term tube feeds (86.7%). Most patients who underwent preoperative or intraoperative enteral tube feed placement had them removed postoperatively (82%). Only patients who required postoperative placement of feeding tubes required prolonged feeding tube support. In conclusion, most patients who undergo esophageal reconstruction using free jejunal transfer recover the ability to swallow and maintain adequate nutrition without supplemental enteral tube feeds. Preoperative gastrostomy tube placement is not necessary in most patients unless severe preoperative nutritional compromise is present.