Tag Archives: gastrostomy tube

Pre-PEG UGIs -Low Yield If No Major Malformations or Cystic Fibrosis

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From JPGN online and NASPGHAN twitter feed, bit.ly/19q99Y8 :

Journal of Pediatric Gastroenterology & Nutrition:
doi: 10.1097/MPG.0000000000000282

Abstract: “We studied the utility of a preoperative upper gastrointestinal series in children with and without major congenital anomalies undergoing gastrostomy tube (G-tube) placement. Of 1163 children evaluated, 743 had major anomalies and a total of 39 episodes of malrotation were found. All of the children with malrotation either had major congenital anomalies or cystic fibrosis. Our study suggests that an upper gastrointestinal series may be unnecessary prior to G-tube placement in children without other congenital anomalies or cystic fibrosis.”

Comment: while I agree with the conclusions of the abstract, it is worth noting that upper gastrointestinal series will pick up other abnormalities as well, including duodenal stenosis (which I have seen picked up on two separate occasions).

Long-term Outcomes with Pediatric PEG Placement

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As noted about a week ago in this blog, gastrostomy tube (gtube) placement in children is much different from gtube placement in adults.

A retrospective study from Boston Children’s followed 138 patients who had PEG tube placed between 1999-2000 (JPGN 2013; 57: 663-67).  The median followup was approximately 5 years.

Results:

  • Median time to elective tube removal was 10.2 years.
  • ~50% of patients continued with gastrostomy tube 10 years after placement.
  • 11% (n=15) had at least 1 major complication related to gastrostomy placement.  Major complication was defined as any unplanned adverse events requiring hospitalization, surgery (eg. fundoplication) or interventional radiology (eg. gastrojejunal tube placement). Most major complications occurred during the first 6-12 months following placement with the most common being cellulitis (n=10).
  • 18% of the cohort died during the 10-year study period because of non-gastrostomy-related issues.  No deaths were attributed to gastrostomy tube placement.

Bottomline: The need for gastrostomy tube placement is associated with frequent comorbidities.  A significant number of patients undergoing gastrostomy tube placement experience major complications.

Also noted:

JPGN 2013; 57: 659-62. This prospective study of 69 patients showed that early reintroduction of feedings after gastrostomy placement, 4 hours postoperatively, was safe and compared favorably to those fed 12 hours postoperatively.  Early feedings were associated with hospital duration, on average, of 6.7 hours. At this center, prophylactic antibiotics were not administered without apparent increase in infections.

JPGN 2013; 57: 668-72. This retrospective study of 77 children with feeding disorders showed that inpatient behavioral interventions are effective in transitioning children from gastrostomy tube feeding to oral feeding.

Related blog entries:

PEG Decisions

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In pediatric gastroenterology, percutaneous endoscopic gastrostomy (PEG) tube placement is not typically a palliative measure and there is a very low mortality rate.  In adult medicine, PEG tube placements are often part of palliative care and used to allow easier management in nursing homes.

A few studies this past month highlight the mortality and potential ethical dilemmas focused around PEG tube placement.

Clin Gastroenterol Hepatol 2013; 11: 1437-44.  “In-hospital mortality was 10.8% among 181,196 patients who underwent PEG in 2006.”

Clin Gastroenterol Hepatol 2013; 11: 1445-50.  Between 2004-2010, among 1327 patients with prospectively collected data from 2 UK hospitals, 344 (23%) did not undergo gastrostomy placement after multidisciplinary team discussion. This group had 35.5% mortality at 30 days compared with 11.2% of the 1027 who proceeded with PEG.  Age >60 and low albumin were predictors of 30-day mortality.

Clin Gastroenterol Hepatol 2013; 11: 1451-52.  The editorial on these two studies tries to redirect the focus from futility to quality of life in terms of PEG decision-making.  “An objective scoring system to predict survival, minimize futility, and promote justice in the allocation of resources toward PEG placement is not the direction endoscopists should be taking.” If, for example, PEG tube provides palliative decompression for outlet obstruction or allows transfer to nursing home, this may align with the principle of patient autonomy.  The editorial argues that if the potential goals of PEG placement can be met, this is the key factor.

Bottomline: Information on outcomes and potential futility should be discussed as part of the informed consent process.  But, I bet this will not make those decisions any easier.

Related blog entries:

Gastrostomy Tubes for Children with Cystic Fibrosis

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A recent report indicates that gastrostomy tubes (Gtubes) can be safe and useful for supplemental nutrition in children with cystic fibrosis (CF) and portal hypertension (JPGN 2013; 57: 245-47).

This small study from Australia was a retrospective study of their CF database from 1991-2011.  During this timeframe, 60 CF patients had gastrostomy tubes.  7 children had CF and portal hypertension.  The mean age of insertion was 10.6 years and all of these patients were pancreatic insufficient. Six of these 7 patients had percutaneous endoscopic gastrostomy (PEG); one had open surgical placement due to preexisting varices.  The median length of followup was 4 years.

Results:

  • No patients developed stomal varices
  • One patient had minimal cellulitis in the perioperative period, otherwise no complications were noted.
  • Two patients died related to advanced pulmonary disease
  • Three patients developed varices during the course of their care
  • Overall, there was improvement in BMI z-score at 2 years from -1.07 ± 0.87 to -0.58 ± 0.81 (p=0.05) and also at w years there was improvement in pulmonary function in 6 patients with mean FEV-1 going from 49.5 ± 12.6 to 62.3 ± 20.3 (P=0.04)

Take-home message: in a select group of 7 patients with Cystic Fibrosis and portal hypertension, gtube placement was safe and associated with better nutrition and lung function.

Related blog links:

Websites recommended by GI families

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Some useful websites that I recommend have been identified by patient’s or their families. They include the following:

As an unrelated aside, a recent commercial might be of interest to anyone who enjoys a little ‘potty humor:’  Kmart’s ‘Ship My Pants’ Commercial [HD] – YouTube

Related blog post:

Oley: Check it out | gutsandgrowth

Less stress after gastrostomy tube placement

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It has been said that it is easier to feed a child with a gastrostomy tube (GT) than by mouth.  Now a study reports improved maternal stress after GT placement (JPGN 2012; 55: 562-66), perhaps because it is easier to provide nutrition.

34 mothers from Norway took part in questionnaires (before, 6 months after, and 18 months after) as part of a study (2003-2005) to see how gastrostomy placement in a child affects maternal stress levels.  Median maternal age was 32 years.  The study was limited by a suboptimal response rate of 59% (34 of 59) and only 19 mothers answered questionnaires at all 3 timepoints.

While all of the children had some peristomal complications, 85% of the mothers reported that their preoperative expectations were met and that their child had improved quality of life.  Mothers had reduced psychological  distress at 6 and 18 months following placement, including less anxiety.

Related blog entries:

Oley: Check it out

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Recently, I received a post from Oley Foundation (Linda May) asking me whether I was going to its convention.  While I am not, I did want to share that link:

http://www.oley.org/annualconf.html
The conference is in lovely Redono Beach, CA, right on the beach. We have miles of running paths, beautiful beaches, on site tennis courts, and swimming pool . To quote other MDs, “the Oley Annual conference is the most important clinical conference I attend all year…”

Also, Oley website is a good link for patients with enteral tubes, ostomies, and central lines. http://oley.org/

Many questions and how-to advice available.  For example, look at this link if interested in advice about swimming with central line, or enteral tube: http://www.oley.org/Swimming.html