Percutaneous Endoscopic Gastrostomy: A lo-Year Experience With 220 Children By Michael
W.L. Gauderer
Cleveland, l This series analyzes 224 percutaneous endoscopic gastrostomies placed in 220 children. Our experience indicates that the percutaneous endoscopic gastrostomy has a wide range of indications, is advantageous in high-risk patients, end, if properly performed, compares favorably with traditional gastrostomies. Copyright
o 7997 by W.B. Saunders Company
INDEX WORDS: Gastrostomy, percutaneous endoscopic; swallowing disorders; gastroesophageal reflux.
I
N THE
LAST decade, pediatric surgeons and gastroenterologists have been called with increased frequency to evaluate children with swallowing difficulties and to provide long-term enteral access. Percutaneous endoscopic gastrostomy (PEG) was developed for this heterogeneous, high-risk group of pediatric patients to avoid celiotomy and its attendant morbidity.‘,’ However, the numerous publications on PEG deal almost exclusively with the adult patient population. Our review of this series aims at establishing the indications, safety, and effectiveness of PEG in children and critically focusing on its complications and their prevention. MATERIALS
AND METHODS
From June 1979 to September 1989, 224 PEGS were placed in 220 pediatric patients at Rainbow Babies and Childrens Hospital. One child had three PEGS; another two had two placements each. Data were obtained from an ongoing log, office and hospital records, as well as personal and telephone contacts with parents, guardians, and chronic care institutions.
Indications Total or near total inability to swallow was the main indication for a PEG in 159 patients (72%). Central nemous system lesions, including 65 with anoxic brain injury, were the most common defects seen among the 26 different types of pre-PEG diagnoses in this population. Other diagnoses included complex congenital orophaIyngea1 and laryngotracheal malformations, facial clefts, facial trauma, chromosomal and metabolic abnormalities, myopathies, and unclassified neurological disorders.
From the Division of Pediatric Surgery, Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH. Presented at the 21st Annual Meeting of the American Pediatric Surgical Association, Vancouver, British Columbia, May 19-22, 1990. Address reprint requests to Michael W.L. Gauderer, MD, Chiej Division of Pediatric Surgery, Rainbow Babies and Childrens Hospital, 2074 Abington Rd, Cleveland, OH 44106-5000. Copyrzght 0 1991 by W.B. Saunders Company 0022.3468/91/2603-0009$03.00/O
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Ohio In 41 children (18%), a PEG was used for the administration of supplemental feedings, because oral intake was grossly inadequate despite a normal swallowing mechanism. Included were patients with severe failure to thrive, congenital heart disease, bronchopulmonary dysplasia, malignancy,’ esophageal dysmotility, biliary atresia and AIDS. A PEG was used in 13 individuals (6%) with complex small bowel disorders (short gut syndrome, Crohn’s disease, malabsorption, intestinal pseudoobstruction) to deliver enteral nutrients by continuous intragastric infusion. Five children (three with Alagille syndrome requiring long-term cholestyramine and two with chronic renal failure receiving nonpalatable diets) had a PEG to assure compliance with these medications. A PEG was used solely for gastric decompression4 in a 21-yearold man with radiation enteritis and bony deformities. Intestinal obstruction and enteric fistulae led to 15 intraabdominal operations, resulting in near total loss of duodenum, small and large bowel. His gastric remnant was small, retrohepatic, and firmly adherent to surrounding structures. A conventional gastrostomy for decompression was impossible. The PEG catheter that was deliberately placed through a liver segment successfully decompressed his gastric pouch until his death 2 years later.* Because of multiple-system organ disease, including ventilator dependency and hepatomegaly with abnormal liver enzymes, a S-year-old boy with sickle cell disease underwent a Stamm gastrostomy’ and a feeding jejunostomy. He bled continuously for 5 days after the procedure. Multiple therapies, including traction on the initial catheter, proved insufficient to control the hemorrhage. This catheter (de Pezzer) was replaced by a 20F large, flat head silastic catheter (Bard Interventional Products, Billerica, MA) using the PEG technique at the bedside. Traction on the larger catheter effectively controlled the bleeding. The catheter was removed 2 years later when it was no longer needed.
Patient Characteristics Among the 220 children, there were 119 boys and 101 girls. The ages ranged from 1 month to 21 years. Eighty-six (39%) were under 1 year of age, and 49 of these were 6 months of age or younger. Forty-two patients (19%) weighed less than 5 kg including three infants weighing only 2.5 kg. Thirty-four children (15%) had previous abdominal operations,’ mainly ventriculoperitoneal shunts. In 20 (9%), a concomitant procedure such as tracheostomy or tympanostomy tube placement was performed. Malnutrition; musculoskeletal abnormalities including contractures, kyphosis, and scoliosis; and seizure disorders were common. Nine children had severe cardiac lesions. Two others had a mild coagulopathy. One child had esophageal varices. Most patients were on multiple medications, including steroids and other immunosuppressive agents. Some of the infants had bronchopulmonary dysplasia and chronic respiratory failure. In two patients referred for PEG, the attending surgeon preferred an open method: one child had a tight fundoplication, the other one was the patient described previously who bled after the Stamm gastrostomy. In a third child (3 months old) no procedure was performed because of inability to establish an airway. Although all patients underwent one or more studies to evaluate
Journal
of Pediatric Surgery, Vol26, No 3 (March), 1991: pp 288-294
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gastric emptying and gastroesophageal reflux, these were not applied in a standardized fashion early in this series. Since September 1987, all referred children were evaluated with an upper gastrointestinal barium study, pH probe, manometry, and, in select cases, gastric emptying studies. Only patients with severe reflux, defined as unable to tolerate nasogastric feedings, underwent an antireflux procedure with a Stamm gastrostomy rather than a PEG.
Technique All procedures, except one, were performed in the operating room. General anesthesia was used in 122 of the 224 procedures (54%) primarily because of anticipated difficulties with the airway management during endoscopy in the younger age group. The remaining patients had various combinations of local anesthesia and sedation. All PEGS were placed by a pediatric surgeon. Endoscopic assistance was provided by a pediatric surgeon, a surgical endoscopist, or a gastroenterologist. PEG is performed as initially described’.* with minor modifications. A single dose of a broad-spectrum intravenous antibiotic is given shortly before the procedure is begun. The gastric and abdominal walls are loosely approximated and the catheter is not routinely sutured to the skin. In 149 children, a 16F modified de Pezzer catheter was used. The remaining catheter sizes used were 12F (1); 14F (30); 15F (24); 18F (14); and 20F (6). Since the development of a new 15F silicone rubber pediatric PEG catheter (Bard Interventional Products, Billerica, MA), a detachable inner cross bar is no longer used. In the last 2 years, a lower esophageal mucosal biopsy has been routine as part of the reflux study. Enteral feedings were started following 12 to 24 hours of gastric decompression. Granulation tissue was controlled as needed. Until 1986, the original catheters were left in situ until latex deterioration occurred after 1 to 1% years. We now substitute the PEG catheter for a gastrostomy “button”6 3 to 6 months after the procedure. Except for two large-head 20F silicone rubber catheters, removal of PEG tubes was by simple external traction. RESULTS
PEG was attempted but not performed in a l-yearold child because of failure to demonstrate transillumination and gastrostomy site identification. The following complications occurred in this series of 224 PEGS. 1. Two deaths secondary to cardiac failure, 24 hours following technically correct procedures. The first child, a lo-month-old with a single ventricle and failure to thrive, required general anesthesia for a concomitant procedure. The second patient, a 4-year-old also requiring general anesthesia, had myocardiopathy. 2. Four minor catheter tract infections. All occurred early in this experience (in two patients, prior to the routine administration of the intravenous antibiotic). 3. Two operative catheter changes, 3 weeks and 2 months post-PEG. In both, there was external migration of the mushroom head secondary to excessive tension on the catheter. This occurred in the first two patients, prior to the addition of
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the inner cross bar. In retrospect, both celiotomies were unnecessary. 4. One early partial gastric separation 1 month after PEG in a 9-month-old child with cyanotic congenital heart disease. A small leak was identified and corrected using a limited celiotomy. 5. One late partial gastric separation 3 years postPEG in a 3%year-old child with short gut syndrome, during insertion of a button. Again, a small leak was promptly identified and corrected using a limited celiotomy. 6. One celiotomy 1 week post-PEG for peritoneal irritation and suspected leak in a patient with a ventriculoperitoneal shunt. At operation, there was good approximation of gastric and abdominal walls. The child was treated with antibiotics and the suspected shunt infection resolved. 7. Intestinal obstruction 10 months following PEG in a 2%year-old dwarf weighing 4 kg. The latex PEG catheter had been removed and replaced with a button. The internal cross bar had become lodged in a Meckel’s diverticulum leading to erosion, walled off perforation, bowel angulation, and obstruction. The affected segment was resected and a primary anastomosis performed. The child recovered uneventfully. 8. Five gastrocolic fistulae, 4,6,29,5, and 4 months post-PEG. The first three occurred early in our experience, whereas the last two occurred after a change in the endoscopy team. The first patient was on high doses of steroid, the second had abnormal bowel anatomy after left-sided diaphragmatic hernia repair, the third had severe kyphoscoliosis, and no obvious predisposing factors could be identified in the last two. The first child, a 4-year-old boy, was treated with removal of the initial catheter and placement of a second PEG higher in the stomach and away from the colon. The fistula closed spontaneously. The second catheter was eventually removed because the child’s oral intake improved. Five years after the first PEG, he required a third PEG, again because of deterioration in swallowing. The second child, with a malrotation, had the PEG at 4 months of age because of failure to thrive and chronic respiratory insufficiency. The fistula was closed operatively after its diagnosis. The third patient, a 17-year-old with cerebral palsy, severe scoliosis, and a high subcostal stomach, had the catheter in place for over 2 years before the gastrocolic fistula was suspected, after a traumatic catheter change at another institution. The tube was removed and the fistula closed spontaneously.
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In the last two patients, ages 8 and 9 years, we suspect that because of inadequate gastric insufflationand, therefore, inadequate downward displacement of the colon, the PEG catheter was placed too close to the greater curvature, eventually eroding into the colon. In one child, the catheter was simply removed; in the second an operative closure was performed. Three of these five patients have since died of their disease, long after resolution of the gastrocolic fistula. Placement of the catheter through the edge of the left lobe of the liver (documented at subsequent unrelated celiotomy in two) and extrusion of a small piece of omentum in two very small infants were without consequence. Although pneumoperitoneum is probably a common occurrence following PEG, only one patient, a teenager with intestinal pseudoobstruction, complained of discomfort for 48 hours. External catheter migration with imbedding of the cross bar or mushroom tip in the abdominal wall was observed five times. In these instances, the tubes were removed and a new catheter or a button was inserted. Only one child, a 2-year-old with Alagille syndrome, had peristomal site drainage secondary to chronic formation of granulation tissue. The gastrostomy was relocated’ 1 year post-PEG but the problem only ceased when a button was inserted.6 Endoscopic mishaps, esophageal damage, bleeding, or early catheter removal did not occur in these 224 placements. One hundred ninety-four patients (88%) were available for long-term evaluation. PEGS were in place from 1 month to 10 years (mean, 20 months). In this group of 194 children, 25 eventually required either an antireflux procedure or conversion of the PEG to a jejunostomy when judged too ill to undergo a fundoplication. All these patients had neurological impairment. DISCUSSION
PEG is based on the simple principle of sutureless approximation of a hollow viscus to the peritoneum by a catheter.1,2 Continuous apposition leads to firm adhesions between the stomach and the abdominal wall around the tract. By eliminating the celiotomy, the surgeon circumvents several of the complications associated with open gastrostomies in children.238-10 Several modifications of PEG have been introduced since our original publication.’ This so-called “pull” technique’ has several advantages over the other modalities, particularly in small children: in the guide wire or “push” technique,” a rather large catheter with a stiff tube segment is used; in the introducer or “poke” technique,‘* the stomach can be
pushed away during insertion or the balloon catheter may deflate prematurity; and, in the nonendoscopic or radiological techniques,13 early dislodgement of rather thin catheters can occur. The two deaths in this series, although not directly related to the performance of the PEG, underscore the importance of appropriate patient selection and choice of anesthetic technique. This 0.9% mortality compares favorably with series of open gastrostomies in childrens~‘Oand with PEG series in adults.‘4-‘7If the first seven patients (who received no antibiotics) are excluded, the infection rate in this series is an acceptable 0.9%. No infections have been observed since the length of the skin incision was increased enough to allow easy drainage of any fluid accumulation around the catheter. The two operative catheter changes in our early experience were prompted by external migration (extrusion) of the catheter tip, a complication that can be prevented by avoiding tension on the catheter at the time of the procedure. On the other hand, the early separation of the stomach from the abdominal wall 1 month following an uneventful procedure in the 9-month-old child is of some concern. We believe that this problem was a combination of two factors: excessive tube mobility in a small child with impaired healing secondary to congenital heart disease. Late gastric separation secondary to traumatic catheter change is a well-known complication of open gastrostomies.* The 2.2% incidence of gastrocolic fistulae deserves critical analysis. Although a gastrocolic fistula can occur following an open gastrostomy,” the PEG is particularly prone to this mishap.19.20Because appropriate catheter placement requires gastric approximation to the abdominal wall as well as downward displacement of the colon, any untoward changes in the local anatomy render the patient more susceptible to this complication. In the second patient who developed a gastrocolic fistula, the abnormal position of the colon following repair of a left diaphragmatic hernia clearly contributed to the iatrogenic tract. In the third child, because of anatomical abnormalities, technical difficulties related to a very high, subcostal stomach were encountered during PEG. We postulate that in the remaining two patients, the stomach was insufficiently inflated and the colon remained high. Thus, the PEG was placed too close to the colon. This problem may have been compounded by a lengthy upper endoscopy leading to excessive inflation of the small bowel pushing the colon and the stomach cranially. Gastric overinflation with entrapment of the colon between the stomach and the abdominal wall has also been suggested as a cause of gastrocolic fistula.”
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Malfunction and local inflammation secondary to external catheter migration (extrusion) on five occasions underscores the need for detailed instructions to caregivers and careful long-term follow-up of all children with gastrostomies.* Indeed, after adhesions between the gastric and abdominal wall are established, the catheter should be periodically checked to ascertain that the external cross bar is loose and the catheter has a small amount of “play.” Once the catheter is replaced by a button, the risk of external and internal migration is eliminated.6 Because the newer pediatric PEG catheter has no detachable parts, the danger of intestinal obstruction secondary to a detached, proportionally large inner cross bar is eliminated. When analyzing these complications, it should be noted that the majority occurred early in our experience. Although we have noticed a steady decrease in the mean age of referred patients over the last 5 years, the complication rate has decreased even further. Certain inherent advantages of PEG make this procedure particularly suitable for high risk patients (1) there is no need for abdominal wall relaxation; (2) the procedure is short; (3) it can be performed in patients with severe musculoskeletal deformities; and (4) there is practically no ileus and minimal discomfort. Reestablishment of a PEG, as performed in three of these children, is simple, with the added safety that the stomach is already adherent to the abdominal wall at the gastrostomy site. Three serious complications of open gastrostomy-wound dehiscence, bleeding, and accidental catheter removalshould be nearly impossible with PEG. Leakage, a common problem with gastrostomies* was virtually absent in this series. In studies comparing the cost of open and closed gastrostomies in adults, PEG proved less expensive.16*17However, to be performed safely, PEG does require a skilled endoscopist. We have observed an increase in nonneurologically impaired children referred for this procedure. Indeed, 24% of PEGS were placed in patients requiring supplemental or continuous enteral feedings. However, we have become more cautious in applying this procedure to children with severe cardiac abnormalities, considering that three of the nine patients in this subgroup had serious complications. Poor wound healing, poor tolerance to stress, and greater susceptibility to infection place these patients in a very high risk category. Most children selected for PEG in this series had long-term use of the catheter. Indeed, the 20-month average catheter use includes numerous patients who died early of their underlying disease. No catheter in a surviving child was in use for less than 3 months.
This study was not aimed at addressing the important question: “feeding gastrostomy or feeding gastrostomy plus antireflux procedure?“21 However, it does make several important points. Studies aimed at defining the degree of preoperative gastroesophageal reflux did not necessarily correlate with the incidence of post-PEG reflux.22 Additionally, we observed that some children who had occasional bouts of emesis in the first few months post-PEG, gradually improved, particularly after feeding regimen adjustments were made. This finding reinforces our belief that correction of malnutrition improves foregut function. Since we began studying all PEG candidates in a standardized fashion, we have observed that there is a good correlation between nasogastric tube feeding tolerance and post-PEG gastroesophageal reflux. PostPEG fundoplication or conversion to feeding jejunostomy was required solely in the group consisting of neurologically impaired children. Because antireflux procedures in this group of patients carry a substantial morbidity and recurrence rate,23,24we use a gastrostomy and fundoplication as the initial procedure only in children unable to tolerate tube feedings due to GER. Because PEG is simple and does not interfere with a possible future fundoplication, it seems logical to place it initially in children without symptomatic reflux. It can be decided later, through careful follow-up, if an additional antireflux procedure becomes necessary. This lo-year experience indicates that PEG is applicable to a diverse group of children, is advantageous in certain high-risk patients, and compares favorably with traditional open gastrostomies when specific guidelines for placement are followed. Inability to demonstrate transillumination and gastrostomy site identification continue to be absolute contraindications to PEG. In the presence of severe cardiac lesions, the risk-benefit ratio must be carefully assessed. In children with significant epigastric anatomical abnormalities, caution is advisable. All patients undergoing PEG must be carefully followed to monitor foregut dysmotility, particularly gastroesophageal reflux, and to prevent and treat stoma1 problems. ADDENDUM
Since completion of this series, an additional PEGS were performed without complications.
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ACKNOWLEDGMENT The author acknowledges the inclusion of patients of Drs M.A. Dokler and M.M. Olsen; the endoscopic assistance of Drs J.T. Boyle, S.J. Czinn, V.F. Hupertz, B.S. Kaplan, J.L. Ponsky, F.C. Rothstein, T.A. Stellato, and T.A. Williams; and the enterostomal care provided by the pediatric surgical nurse D.C. Wade.
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REFERENCES 1. Gauderer MWL, Ponsky JL, Izant RJ Jr: Gastrostomy without laparotomy: A percutaneous endoscopic technique. J Pediatr Surg 15872~8751980 2. Gauderer MWL, Stellato TA: Gastrostomies: Evolution, techniques, indications and complications. Curr Probl Surg 23:661719,1986 3. Stellato TA, Gauderer MWL: Percutaneous endoscopic gastrostomy in the cancer patient. Amer Surg 54:419-422,1988 4. Stellato TA, Gauderer MWL: Percutaneous endoscopic gastrostomy for gastrointestinal decompression. Ann Surg 205:119122,1987 5. Stellato TA, Gauderer MWL, Ponsky JL: Percutaneous endoscopic gastrostomy following previous abdominal surgery. Ann Surg 200:46-50, 1984 6. Gauderer MWL, Olsen MM, Stellato TA, et al: Feeding gastrostomy button: Experience and recommendations. J Pediatr Surg 23:24-28,1988 7. Gauderer MWL: A simple technique for correction of severe gastrostomy leakage. Surg Gynecol Obstet 22:170-172,1987 8. Haws EB, Sieber WK, Kiesewetter WB: Complications of tube gastrostomy in infants and children. Fifteen year review of 240 cases. Ann Surg 164:284-290,1966 9. Holder TM, Leape LL, Ashcraft KW: Gastrostomy: Its use and dangers in pediatric patients. N Engl J Med 286:1345-1347, 1972 10. Campbell JR, Sasaki TM: Gastrostomy in infants and children: An analysis of complications and techniques. Ann Surg 40:505-508,1974 11. Sachs BA, Vine HS, Palestrant AM, et al: A non-operative technique for establishment of a gastrostomy in the dog. Invest Radio1 18:485-487,1983 12. Russell TR, Brotman M, Norris F: Percutaneous gastrostomy. A new simplified and cost-effective technique. Am J Surg 148:132-137,1984
13. Cory DA, Fitzgerald JF, Cohen MD: Percutaneous nonendoscopic gastrostomy in children. AJR 151:995-997,1988 14. Larson DE, Burton DD, Schroeder KW, et al: Percutaneous endoscopic gastrostomy. Indications, success, complications, and mortality in 314 consecutive patients. Gastroenterology 93:48-52, 1987 15. American Society of Gastrointestinal Endoscopy: The role of percutaneous endoscopic gastrostomy in enteral feeding. Guidelines for clinical application. Gastrointest Endosc 34:358-36S, 1988 16. Grant JP: Comparison of percutaneous endoscopic gastrostomy with Stamm gastrostomy. Ann Surg 207:598-603,1988 17. Stiegman GV, Goff JS, Silas D, et al: Endoscopic versus operative gastrostomy: Final results of a prospective randomized trial. Gastrointest Endosc 36:1-5,199O 18. Cook RCM: Gastrocolic fistula: A complication of gastrostomy in infancy. J Pediatr Surg 4:346-347, 1969 19. Fernandes ET, Hollabaugh R, Hixon SD, et al: Late presentation of gastrocolic fistula after percutaneous gastrostomy. Gastrointest Endosc 34:368-369,1988 (letter) 20. Stefan MM, Holcomb GW, Ross AJ III: Cologastric fistula as a complication of percutaneous endoscopic gastrostomy. J Parenter Enter Nutr 13:554-556,1989 21. Gauderer MWL: Feeding gastrostomy or feeding gastrostomy plus anti-reflux procedure? J Pediatr Gastroenterol Nutr 7:795-796,1988 (editorial) 22. Grunow JE, Al-Hafidh AS, Tune11 WP: Gastroesophageal reflux following percutaneous endoscopic gastrostomy in children. J Pediatr Surg 24:42-45, 1989 23. Dedinsky GK, Vane DW, Black T: Complications and reoperation after Nissen fundoplication in childhood. Am J Surg 153:177-183,1987 24. Caniano DA, Ginn-Pease ME, King DR: The failed antireflux procedure: Analysis of risk factors and morbidity. J Pediatr Surg 25:1022-1026,199O
Discussion AR Campbell (PO&and, OR): Dr Gauderer has indicated that the impetus behind PEGS is to avoid the morbidity of celiotomy in high-risk patients who will benefit from permanent feeding tubes. In this series the indications and patient characteristics are similar to those of other current series of operative gastrostomies, with an increasing incidence of neurologically improved patients. The complications are also comparable except for five (2.2%) gastrocolic fistulas, a complication not frequently observed after operative gastrostomy. I do not believe that he achieved the goal of avoiding the morbidity of celiotomy in high-risk patients, in view of the 2.2% incidence of gastrocolic fistulas. Nonetheless, this technique should remain in the armamentarium of the pediatric surgeon for highly selected patients. He has also indicated that general anesthesia is not required and that the cost is reduced. However, all but one of these procedures was performed in the operative suite and more than one half were per-
formed under general anesthesia. If one truly wished to reduce the cost, this procedure would need to be performed in a less expensive gastrointestinal unit, rather than in the OR, and general anesthesia would need to be avoided. H.K Firor (Cleveland, OH): PEGS have been performed frequently since their introduction. This raises some concerns. The major one that I have Dr Campbell alluded to. Operative gastrostomy, at least in our institution, has never produced a gastrocolic fistula. Recently, one of the children from this series came to the Cleveland Clinic Children’s Hospital. He required a fundoplication after a previous PEG. On opening the abdomen, the PEG was in an unusual position; it went under the colon through the mesocolon and into the posterior midportion of his stomach, and I think it explains one of the problems. I am not clear as to how you can avoid this. A further 10 or 12 children ended up in our hospital requiring fundoplication for reflux after previous PEGS. Careful fol-
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low-up data regarding this series would be helpful in indicating if more intense study can reduce the number of children who will require subsequent antireflux procedures. R. W. Powell (Mobile, AL): Since you depend somewhat on Mother Nature to adhere the stomach to the abdominal wall, I would like you to comment on changing the PEG to a gastrostomy button, which is a much more convenient apparatus for the caretakers of these children. Could you give us some guidelines about how you go about changing to a gastrostomy button with regard to timing and technique? B.H. Harris (Boston, MA): You said that you conduct a trial of nasogastric tube feedings as a test for gastroesophageal reflux prior to putting in a PEG. How many patients do you exclude on that basis? Should we add those patients to the 22 you took back for a fundoplication after a PEG to know the real dimensions of the gastroesophageal reflux problem? A.J. Ross IZZ (Philadelphia, PA): I would like to restrict my comments to that of the gastrocolic fistula. You mentioned in your discussion that you had seen it occur due to underdeflation of the stomach. We’ve had experience with two patients that we have reported with gastrocolic fistulas, which we believe was due to over inflation of the stomach. (JPEN 13554, 1989). We postulated the pathophysiology was the stomach being overinflated; there is an upward rotation of the stomach on its transverse axis such that it rotates up pulling the colon with it. The needle goes through the abdominal wall then through the back of the colon and finally into the back wall of the stomach. This, of course, explains the finding that Dr Firor just described. I wonder if you have had any cases in your series of gastrocolic fistulas that might be explained due to the same phenomena. T. Lobe (Memphis, TN): I recently had the experience of trying to place the smallest existing percutaneous endoscopic gastrostomy tube in a newborn infant. Despite dilating the esophagus immediately before trying to place the gastrostomy tube, the transverse bar (which I had previously tailored to the size of the esophagus) stuck in the esophagus and tore the esophageal mucosa on its way into the stomach. Please tell us of your experience with newborns. Have you had any difficulties? How can one avoid injuring the esophagus of the newborn during this procedure? M. Gauderer (response): Dr Campbell, the estimated number of PEGS performed in this country alone is between 130,000 and 150,000 per year and there have been over 150 publications on this subject to date. In those series in which PEG was compared with open gastrostomies, PEG had less morbidity and
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mortality, the operative time was shorter, and the cost was lower. We did not set out to compare PEG with open gastrostomies in this study but rather to examine our own experience with PEG over a lo-year span, including the learning curves of the involved pediatric surgeons and the different endoscopists. Dr Firor, some of the patients that had a post-PEG antireflux procedure at your institution are included in the 25 that I mentioned. Obviously, there are still 12% of these patients that we lost to follow-up. All of you who take care of these sick patients know that they can move from one long-term care facility to another and that you can lose track of them. On the other hand, we have children who were followed for up to 10 years and who have actually had improved reflux post-PEG. Dr Ross, about gastrocolic fistula, which is really our most important complication, it is interesting that the same group of gastroenterologists who performed the endoscopy for the two patients in your series subsequently moved to our institution and had two gastrocolic fistulae, before the problem with the endoscopy was recognized and corrected. In the first patient that had a gastrocolic fistula, we underinflated the stomach; the second child had severe scoliosis and we had difficulty placing the PEG. We did not follow our own guidelines and had a problem 29 months later. The third patient had a previous diaphragmatic hernia repair with malrotation and abnormal epigastric anatomy. We probably should have refrained from performing a PEG in that particular child. In the last two patients, in whom the new group of gastroenterologists did the endoscopy, the guidelines had not been strictly foilowed. Whereas in most studies on gastrostomies in children the perioperative period was analyzed, we critically looked at both, the perioperative and the longterm follow-up. Dr Powell, we switch to a gastrostomy button between 3 and 6 months post-PEG. Dr Harris, although this study was not aimed at addressing the controversy-gastrostomy only or gastrostomy plus antireflux procedure-our present studies indicate that there is a direct correlation between tolerance to nasogastric feedings and results after the PEG. By and large, you can use any study such as upper gastrointestinal series, pH probe, or manometry and not find a good correlation. However, if the patient tolerates nasogastric feedings well preoperatively, regardless of the result of the studies, chances are he/she is going to tolerate the PEG very well also. PEG is so simple that if the patient requires a
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fundoplication later, it can be performed without any difficulty, usually without taking down the PEG. Furthermore, we have observed that in many patients, correction of the malnutrition will improve gastric emptying and decrease gastroesophageal reflux. Dr Lobe, the cross bar has to be proportional to the
MICHAEL W.L. GAUDERER
size of the child. If you use an adult-type PEG catheter or a catheter with a large internal cross bar in an infant, you are going to have an esophageal tear. This is one of the reasons why we developed a new 15F gastrostomy catheter that will prevent both obstruction of the intestinal tract by the inner cross bar and esophageal damage.
W.L. Gauderer
Cleveland, l This series analyzes 224 percutaneous endoscopic gastrostomies placed in 220 children. Our experience indicates that the percutaneous endoscopic gastrostomy has a wide range of indications, is advantageous in high-risk patients, end, if properly performed, compares favorably with traditional gastrostomies. Copyright
o 7997 by W.B. Saunders Company
INDEX WORDS: Gastrostomy, percutaneous endoscopic; swallowing disorders; gastroesophageal reflux.
I
N THE
LAST decade, pediatric surgeons and gastroenterologists have been called with increased frequency to evaluate children with swallowing difficulties and to provide long-term enteral access. Percutaneous endoscopic gastrostomy (PEG) was developed for this heterogeneous, high-risk group of pediatric patients to avoid celiotomy and its attendant morbidity.‘,’ However, the numerous publications on PEG deal almost exclusively with the adult patient population. Our review of this series aims at establishing the indications, safety, and effectiveness of PEG in children and critically focusing on its complications and their prevention. MATERIALS
AND METHODS
From June 1979 to September 1989, 224 PEGS were placed in 220 pediatric patients at Rainbow Babies and Childrens Hospital. One child had three PEGS; another two had two placements each. Data were obtained from an ongoing log, office and hospital records, as well as personal and telephone contacts with parents, guardians, and chronic care institutions.
Indications Total or near total inability to swallow was the main indication for a PEG in 159 patients (72%). Central nemous system lesions, including 65 with anoxic brain injury, were the most common defects seen among the 26 different types of pre-PEG diagnoses in this population. Other diagnoses included complex congenital orophaIyngea1 and laryngotracheal malformations, facial clefts, facial trauma, chromosomal and metabolic abnormalities, myopathies, and unclassified neurological disorders.
From the Division of Pediatric Surgery, Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH. Presented at the 21st Annual Meeting of the American Pediatric Surgical Association, Vancouver, British Columbia, May 19-22, 1990. Address reprint requests to Michael W.L. Gauderer, MD, Chiej Division of Pediatric Surgery, Rainbow Babies and Childrens Hospital, 2074 Abington Rd, Cleveland, OH 44106-5000. Copyrzght 0 1991 by W.B. Saunders Company 0022.3468/91/2603-0009$03.00/O
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Ohio In 41 children (18%), a PEG was used for the administration of supplemental feedings, because oral intake was grossly inadequate despite a normal swallowing mechanism. Included were patients with severe failure to thrive, congenital heart disease, bronchopulmonary dysplasia, malignancy,’ esophageal dysmotility, biliary atresia and AIDS. A PEG was used in 13 individuals (6%) with complex small bowel disorders (short gut syndrome, Crohn’s disease, malabsorption, intestinal pseudoobstruction) to deliver enteral nutrients by continuous intragastric infusion. Five children (three with Alagille syndrome requiring long-term cholestyramine and two with chronic renal failure receiving nonpalatable diets) had a PEG to assure compliance with these medications. A PEG was used solely for gastric decompression4 in a 21-yearold man with radiation enteritis and bony deformities. Intestinal obstruction and enteric fistulae led to 15 intraabdominal operations, resulting in near total loss of duodenum, small and large bowel. His gastric remnant was small, retrohepatic, and firmly adherent to surrounding structures. A conventional gastrostomy for decompression was impossible. The PEG catheter that was deliberately placed through a liver segment successfully decompressed his gastric pouch until his death 2 years later.* Because of multiple-system organ disease, including ventilator dependency and hepatomegaly with abnormal liver enzymes, a S-year-old boy with sickle cell disease underwent a Stamm gastrostomy’ and a feeding jejunostomy. He bled continuously for 5 days after the procedure. Multiple therapies, including traction on the initial catheter, proved insufficient to control the hemorrhage. This catheter (de Pezzer) was replaced by a 20F large, flat head silastic catheter (Bard Interventional Products, Billerica, MA) using the PEG technique at the bedside. Traction on the larger catheter effectively controlled the bleeding. The catheter was removed 2 years later when it was no longer needed.
Patient Characteristics Among the 220 children, there were 119 boys and 101 girls. The ages ranged from 1 month to 21 years. Eighty-six (39%) were under 1 year of age, and 49 of these were 6 months of age or younger. Forty-two patients (19%) weighed less than 5 kg including three infants weighing only 2.5 kg. Thirty-four children (15%) had previous abdominal operations,’ mainly ventriculoperitoneal shunts. In 20 (9%), a concomitant procedure such as tracheostomy or tympanostomy tube placement was performed. Malnutrition; musculoskeletal abnormalities including contractures, kyphosis, and scoliosis; and seizure disorders were common. Nine children had severe cardiac lesions. Two others had a mild coagulopathy. One child had esophageal varices. Most patients were on multiple medications, including steroids and other immunosuppressive agents. Some of the infants had bronchopulmonary dysplasia and chronic respiratory failure. In two patients referred for PEG, the attending surgeon preferred an open method: one child had a tight fundoplication, the other one was the patient described previously who bled after the Stamm gastrostomy. In a third child (3 months old) no procedure was performed because of inability to establish an airway. Although all patients underwent one or more studies to evaluate
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gastric emptying and gastroesophageal reflux, these were not applied in a standardized fashion early in this series. Since September 1987, all referred children were evaluated with an upper gastrointestinal barium study, pH probe, manometry, and, in select cases, gastric emptying studies. Only patients with severe reflux, defined as unable to tolerate nasogastric feedings, underwent an antireflux procedure with a Stamm gastrostomy rather than a PEG.
Technique All procedures, except one, were performed in the operating room. General anesthesia was used in 122 of the 224 procedures (54%) primarily because of anticipated difficulties with the airway management during endoscopy in the younger age group. The remaining patients had various combinations of local anesthesia and sedation. All PEGS were placed by a pediatric surgeon. Endoscopic assistance was provided by a pediatric surgeon, a surgical endoscopist, or a gastroenterologist. PEG is performed as initially described’.* with minor modifications. A single dose of a broad-spectrum intravenous antibiotic is given shortly before the procedure is begun. The gastric and abdominal walls are loosely approximated and the catheter is not routinely sutured to the skin. In 149 children, a 16F modified de Pezzer catheter was used. The remaining catheter sizes used were 12F (1); 14F (30); 15F (24); 18F (14); and 20F (6). Since the development of a new 15F silicone rubber pediatric PEG catheter (Bard Interventional Products, Billerica, MA), a detachable inner cross bar is no longer used. In the last 2 years, a lower esophageal mucosal biopsy has been routine as part of the reflux study. Enteral feedings were started following 12 to 24 hours of gastric decompression. Granulation tissue was controlled as needed. Until 1986, the original catheters were left in situ until latex deterioration occurred after 1 to 1% years. We now substitute the PEG catheter for a gastrostomy “button”6 3 to 6 months after the procedure. Except for two large-head 20F silicone rubber catheters, removal of PEG tubes was by simple external traction. RESULTS
PEG was attempted but not performed in a l-yearold child because of failure to demonstrate transillumination and gastrostomy site identification. The following complications occurred in this series of 224 PEGS. 1. Two deaths secondary to cardiac failure, 24 hours following technically correct procedures. The first child, a lo-month-old with a single ventricle and failure to thrive, required general anesthesia for a concomitant procedure. The second patient, a 4-year-old also requiring general anesthesia, had myocardiopathy. 2. Four minor catheter tract infections. All occurred early in this experience (in two patients, prior to the routine administration of the intravenous antibiotic). 3. Two operative catheter changes, 3 weeks and 2 months post-PEG. In both, there was external migration of the mushroom head secondary to excessive tension on the catheter. This occurred in the first two patients, prior to the addition of
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the inner cross bar. In retrospect, both celiotomies were unnecessary. 4. One early partial gastric separation 1 month after PEG in a 9-month-old child with cyanotic congenital heart disease. A small leak was identified and corrected using a limited celiotomy. 5. One late partial gastric separation 3 years postPEG in a 3%year-old child with short gut syndrome, during insertion of a button. Again, a small leak was promptly identified and corrected using a limited celiotomy. 6. One celiotomy 1 week post-PEG for peritoneal irritation and suspected leak in a patient with a ventriculoperitoneal shunt. At operation, there was good approximation of gastric and abdominal walls. The child was treated with antibiotics and the suspected shunt infection resolved. 7. Intestinal obstruction 10 months following PEG in a 2%year-old dwarf weighing 4 kg. The latex PEG catheter had been removed and replaced with a button. The internal cross bar had become lodged in a Meckel’s diverticulum leading to erosion, walled off perforation, bowel angulation, and obstruction. The affected segment was resected and a primary anastomosis performed. The child recovered uneventfully. 8. Five gastrocolic fistulae, 4,6,29,5, and 4 months post-PEG. The first three occurred early in our experience, whereas the last two occurred after a change in the endoscopy team. The first patient was on high doses of steroid, the second had abnormal bowel anatomy after left-sided diaphragmatic hernia repair, the third had severe kyphoscoliosis, and no obvious predisposing factors could be identified in the last two. The first child, a 4-year-old boy, was treated with removal of the initial catheter and placement of a second PEG higher in the stomach and away from the colon. The fistula closed spontaneously. The second catheter was eventually removed because the child’s oral intake improved. Five years after the first PEG, he required a third PEG, again because of deterioration in swallowing. The second child, with a malrotation, had the PEG at 4 months of age because of failure to thrive and chronic respiratory insufficiency. The fistula was closed operatively after its diagnosis. The third patient, a 17-year-old with cerebral palsy, severe scoliosis, and a high subcostal stomach, had the catheter in place for over 2 years before the gastrocolic fistula was suspected, after a traumatic catheter change at another institution. The tube was removed and the fistula closed spontaneously.
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In the last two patients, ages 8 and 9 years, we suspect that because of inadequate gastric insufflationand, therefore, inadequate downward displacement of the colon, the PEG catheter was placed too close to the greater curvature, eventually eroding into the colon. In one child, the catheter was simply removed; in the second an operative closure was performed. Three of these five patients have since died of their disease, long after resolution of the gastrocolic fistula. Placement of the catheter through the edge of the left lobe of the liver (documented at subsequent unrelated celiotomy in two) and extrusion of a small piece of omentum in two very small infants were without consequence. Although pneumoperitoneum is probably a common occurrence following PEG, only one patient, a teenager with intestinal pseudoobstruction, complained of discomfort for 48 hours. External catheter migration with imbedding of the cross bar or mushroom tip in the abdominal wall was observed five times. In these instances, the tubes were removed and a new catheter or a button was inserted. Only one child, a 2-year-old with Alagille syndrome, had peristomal site drainage secondary to chronic formation of granulation tissue. The gastrostomy was relocated’ 1 year post-PEG but the problem only ceased when a button was inserted.6 Endoscopic mishaps, esophageal damage, bleeding, or early catheter removal did not occur in these 224 placements. One hundred ninety-four patients (88%) were available for long-term evaluation. PEGS were in place from 1 month to 10 years (mean, 20 months). In this group of 194 children, 25 eventually required either an antireflux procedure or conversion of the PEG to a jejunostomy when judged too ill to undergo a fundoplication. All these patients had neurological impairment. DISCUSSION
PEG is based on the simple principle of sutureless approximation of a hollow viscus to the peritoneum by a catheter.1,2 Continuous apposition leads to firm adhesions between the stomach and the abdominal wall around the tract. By eliminating the celiotomy, the surgeon circumvents several of the complications associated with open gastrostomies in children.238-10 Several modifications of PEG have been introduced since our original publication.’ This so-called “pull” technique’ has several advantages over the other modalities, particularly in small children: in the guide wire or “push” technique,” a rather large catheter with a stiff tube segment is used; in the introducer or “poke” technique,‘* the stomach can be
pushed away during insertion or the balloon catheter may deflate prematurity; and, in the nonendoscopic or radiological techniques,13 early dislodgement of rather thin catheters can occur. The two deaths in this series, although not directly related to the performance of the PEG, underscore the importance of appropriate patient selection and choice of anesthetic technique. This 0.9% mortality compares favorably with series of open gastrostomies in childrens~‘Oand with PEG series in adults.‘4-‘7If the first seven patients (who received no antibiotics) are excluded, the infection rate in this series is an acceptable 0.9%. No infections have been observed since the length of the skin incision was increased enough to allow easy drainage of any fluid accumulation around the catheter. The two operative catheter changes in our early experience were prompted by external migration (extrusion) of the catheter tip, a complication that can be prevented by avoiding tension on the catheter at the time of the procedure. On the other hand, the early separation of the stomach from the abdominal wall 1 month following an uneventful procedure in the 9-month-old child is of some concern. We believe that this problem was a combination of two factors: excessive tube mobility in a small child with impaired healing secondary to congenital heart disease. Late gastric separation secondary to traumatic catheter change is a well-known complication of open gastrostomies.* The 2.2% incidence of gastrocolic fistulae deserves critical analysis. Although a gastrocolic fistula can occur following an open gastrostomy,” the PEG is particularly prone to this mishap.19.20Because appropriate catheter placement requires gastric approximation to the abdominal wall as well as downward displacement of the colon, any untoward changes in the local anatomy render the patient more susceptible to this complication. In the second patient who developed a gastrocolic fistula, the abnormal position of the colon following repair of a left diaphragmatic hernia clearly contributed to the iatrogenic tract. In the third child, because of anatomical abnormalities, technical difficulties related to a very high, subcostal stomach were encountered during PEG. We postulate that in the remaining two patients, the stomach was insufficiently inflated and the colon remained high. Thus, the PEG was placed too close to the colon. This problem may have been compounded by a lengthy upper endoscopy leading to excessive inflation of the small bowel pushing the colon and the stomach cranially. Gastric overinflation with entrapment of the colon between the stomach and the abdominal wall has also been suggested as a cause of gastrocolic fistula.”
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Malfunction and local inflammation secondary to external catheter migration (extrusion) on five occasions underscores the need for detailed instructions to caregivers and careful long-term follow-up of all children with gastrostomies.* Indeed, after adhesions between the gastric and abdominal wall are established, the catheter should be periodically checked to ascertain that the external cross bar is loose and the catheter has a small amount of “play.” Once the catheter is replaced by a button, the risk of external and internal migration is eliminated.6 Because the newer pediatric PEG catheter has no detachable parts, the danger of intestinal obstruction secondary to a detached, proportionally large inner cross bar is eliminated. When analyzing these complications, it should be noted that the majority occurred early in our experience. Although we have noticed a steady decrease in the mean age of referred patients over the last 5 years, the complication rate has decreased even further. Certain inherent advantages of PEG make this procedure particularly suitable for high risk patients (1) there is no need for abdominal wall relaxation; (2) the procedure is short; (3) it can be performed in patients with severe musculoskeletal deformities; and (4) there is practically no ileus and minimal discomfort. Reestablishment of a PEG, as performed in three of these children, is simple, with the added safety that the stomach is already adherent to the abdominal wall at the gastrostomy site. Three serious complications of open gastrostomy-wound dehiscence, bleeding, and accidental catheter removalshould be nearly impossible with PEG. Leakage, a common problem with gastrostomies* was virtually absent in this series. In studies comparing the cost of open and closed gastrostomies in adults, PEG proved less expensive.16*17However, to be performed safely, PEG does require a skilled endoscopist. We have observed an increase in nonneurologically impaired children referred for this procedure. Indeed, 24% of PEGS were placed in patients requiring supplemental or continuous enteral feedings. However, we have become more cautious in applying this procedure to children with severe cardiac abnormalities, considering that three of the nine patients in this subgroup had serious complications. Poor wound healing, poor tolerance to stress, and greater susceptibility to infection place these patients in a very high risk category. Most children selected for PEG in this series had long-term use of the catheter. Indeed, the 20-month average catheter use includes numerous patients who died early of their underlying disease. No catheter in a surviving child was in use for less than 3 months.
This study was not aimed at addressing the important question: “feeding gastrostomy or feeding gastrostomy plus antireflux procedure?“21 However, it does make several important points. Studies aimed at defining the degree of preoperative gastroesophageal reflux did not necessarily correlate with the incidence of post-PEG reflux.22 Additionally, we observed that some children who had occasional bouts of emesis in the first few months post-PEG, gradually improved, particularly after feeding regimen adjustments were made. This finding reinforces our belief that correction of malnutrition improves foregut function. Since we began studying all PEG candidates in a standardized fashion, we have observed that there is a good correlation between nasogastric tube feeding tolerance and post-PEG gastroesophageal reflux. PostPEG fundoplication or conversion to feeding jejunostomy was required solely in the group consisting of neurologically impaired children. Because antireflux procedures in this group of patients carry a substantial morbidity and recurrence rate,23,24we use a gastrostomy and fundoplication as the initial procedure only in children unable to tolerate tube feedings due to GER. Because PEG is simple and does not interfere with a possible future fundoplication, it seems logical to place it initially in children without symptomatic reflux. It can be decided later, through careful follow-up, if an additional antireflux procedure becomes necessary. This lo-year experience indicates that PEG is applicable to a diverse group of children, is advantageous in certain high-risk patients, and compares favorably with traditional open gastrostomies when specific guidelines for placement are followed. Inability to demonstrate transillumination and gastrostomy site identification continue to be absolute contraindications to PEG. In the presence of severe cardiac lesions, the risk-benefit ratio must be carefully assessed. In children with significant epigastric anatomical abnormalities, caution is advisable. All patients undergoing PEG must be carefully followed to monitor foregut dysmotility, particularly gastroesophageal reflux, and to prevent and treat stoma1 problems. ADDENDUM
Since completion of this series, an additional PEGS were performed without complications.
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ACKNOWLEDGMENT The author acknowledges the inclusion of patients of Drs M.A. Dokler and M.M. Olsen; the endoscopic assistance of Drs J.T. Boyle, S.J. Czinn, V.F. Hupertz, B.S. Kaplan, J.L. Ponsky, F.C. Rothstein, T.A. Stellato, and T.A. Williams; and the enterostomal care provided by the pediatric surgical nurse D.C. Wade.
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REFERENCES 1. Gauderer MWL, Ponsky JL, Izant RJ Jr: Gastrostomy without laparotomy: A percutaneous endoscopic technique. J Pediatr Surg 15872~8751980 2. Gauderer MWL, Stellato TA: Gastrostomies: Evolution, techniques, indications and complications. Curr Probl Surg 23:661719,1986 3. Stellato TA, Gauderer MWL: Percutaneous endoscopic gastrostomy in the cancer patient. Amer Surg 54:419-422,1988 4. Stellato TA, Gauderer MWL: Percutaneous endoscopic gastrostomy for gastrointestinal decompression. Ann Surg 205:119122,1987 5. Stellato TA, Gauderer MWL, Ponsky JL: Percutaneous endoscopic gastrostomy following previous abdominal surgery. Ann Surg 200:46-50, 1984 6. Gauderer MWL, Olsen MM, Stellato TA, et al: Feeding gastrostomy button: Experience and recommendations. J Pediatr Surg 23:24-28,1988 7. Gauderer MWL: A simple technique for correction of severe gastrostomy leakage. Surg Gynecol Obstet 22:170-172,1987 8. Haws EB, Sieber WK, Kiesewetter WB: Complications of tube gastrostomy in infants and children. Fifteen year review of 240 cases. Ann Surg 164:284-290,1966 9. Holder TM, Leape LL, Ashcraft KW: Gastrostomy: Its use and dangers in pediatric patients. N Engl J Med 286:1345-1347, 1972 10. Campbell JR, Sasaki TM: Gastrostomy in infants and children: An analysis of complications and techniques. Ann Surg 40:505-508,1974 11. Sachs BA, Vine HS, Palestrant AM, et al: A non-operative technique for establishment of a gastrostomy in the dog. Invest Radio1 18:485-487,1983 12. Russell TR, Brotman M, Norris F: Percutaneous gastrostomy. A new simplified and cost-effective technique. Am J Surg 148:132-137,1984
13. Cory DA, Fitzgerald JF, Cohen MD: Percutaneous nonendoscopic gastrostomy in children. AJR 151:995-997,1988 14. Larson DE, Burton DD, Schroeder KW, et al: Percutaneous endoscopic gastrostomy. Indications, success, complications, and mortality in 314 consecutive patients. Gastroenterology 93:48-52, 1987 15. American Society of Gastrointestinal Endoscopy: The role of percutaneous endoscopic gastrostomy in enteral feeding. Guidelines for clinical application. Gastrointest Endosc 34:358-36S, 1988 16. Grant JP: Comparison of percutaneous endoscopic gastrostomy with Stamm gastrostomy. Ann Surg 207:598-603,1988 17. Stiegman GV, Goff JS, Silas D, et al: Endoscopic versus operative gastrostomy: Final results of a prospective randomized trial. Gastrointest Endosc 36:1-5,199O 18. Cook RCM: Gastrocolic fistula: A complication of gastrostomy in infancy. J Pediatr Surg 4:346-347, 1969 19. Fernandes ET, Hollabaugh R, Hixon SD, et al: Late presentation of gastrocolic fistula after percutaneous gastrostomy. Gastrointest Endosc 34:368-369,1988 (letter) 20. Stefan MM, Holcomb GW, Ross AJ III: Cologastric fistula as a complication of percutaneous endoscopic gastrostomy. J Parenter Enter Nutr 13:554-556,1989 21. Gauderer MWL: Feeding gastrostomy or feeding gastrostomy plus anti-reflux procedure? J Pediatr Gastroenterol Nutr 7:795-796,1988 (editorial) 22. Grunow JE, Al-Hafidh AS, Tune11 WP: Gastroesophageal reflux following percutaneous endoscopic gastrostomy in children. J Pediatr Surg 24:42-45, 1989 23. Dedinsky GK, Vane DW, Black T: Complications and reoperation after Nissen fundoplication in childhood. Am J Surg 153:177-183,1987 24. Caniano DA, Ginn-Pease ME, King DR: The failed antireflux procedure: Analysis of risk factors and morbidity. J Pediatr Surg 25:1022-1026,199O
Discussion AR Campbell (PO&and, OR): Dr Gauderer has indicated that the impetus behind PEGS is to avoid the morbidity of celiotomy in high-risk patients who will benefit from permanent feeding tubes. In this series the indications and patient characteristics are similar to those of other current series of operative gastrostomies, with an increasing incidence of neurologically improved patients. The complications are also comparable except for five (2.2%) gastrocolic fistulas, a complication not frequently observed after operative gastrostomy. I do not believe that he achieved the goal of avoiding the morbidity of celiotomy in high-risk patients, in view of the 2.2% incidence of gastrocolic fistulas. Nonetheless, this technique should remain in the armamentarium of the pediatric surgeon for highly selected patients. He has also indicated that general anesthesia is not required and that the cost is reduced. However, all but one of these procedures was performed in the operative suite and more than one half were per-
formed under general anesthesia. If one truly wished to reduce the cost, this procedure would need to be performed in a less expensive gastrointestinal unit, rather than in the OR, and general anesthesia would need to be avoided. H.K Firor (Cleveland, OH): PEGS have been performed frequently since their introduction. This raises some concerns. The major one that I have Dr Campbell alluded to. Operative gastrostomy, at least in our institution, has never produced a gastrocolic fistula. Recently, one of the children from this series came to the Cleveland Clinic Children’s Hospital. He required a fundoplication after a previous PEG. On opening the abdomen, the PEG was in an unusual position; it went under the colon through the mesocolon and into the posterior midportion of his stomach, and I think it explains one of the problems. I am not clear as to how you can avoid this. A further 10 or 12 children ended up in our hospital requiring fundoplication for reflux after previous PEGS. Careful fol-
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low-up data regarding this series would be helpful in indicating if more intense study can reduce the number of children who will require subsequent antireflux procedures. R. W. Powell (Mobile, AL): Since you depend somewhat on Mother Nature to adhere the stomach to the abdominal wall, I would like you to comment on changing the PEG to a gastrostomy button, which is a much more convenient apparatus for the caretakers of these children. Could you give us some guidelines about how you go about changing to a gastrostomy button with regard to timing and technique? B.H. Harris (Boston, MA): You said that you conduct a trial of nasogastric tube feedings as a test for gastroesophageal reflux prior to putting in a PEG. How many patients do you exclude on that basis? Should we add those patients to the 22 you took back for a fundoplication after a PEG to know the real dimensions of the gastroesophageal reflux problem? A.J. Ross IZZ (Philadelphia, PA): I would like to restrict my comments to that of the gastrocolic fistula. You mentioned in your discussion that you had seen it occur due to underdeflation of the stomach. We’ve had experience with two patients that we have reported with gastrocolic fistulas, which we believe was due to over inflation of the stomach. (JPEN 13554, 1989). We postulated the pathophysiology was the stomach being overinflated; there is an upward rotation of the stomach on its transverse axis such that it rotates up pulling the colon with it. The needle goes through the abdominal wall then through the back of the colon and finally into the back wall of the stomach. This, of course, explains the finding that Dr Firor just described. I wonder if you have had any cases in your series of gastrocolic fistulas that might be explained due to the same phenomena. T. Lobe (Memphis, TN): I recently had the experience of trying to place the smallest existing percutaneous endoscopic gastrostomy tube in a newborn infant. Despite dilating the esophagus immediately before trying to place the gastrostomy tube, the transverse bar (which I had previously tailored to the size of the esophagus) stuck in the esophagus and tore the esophageal mucosa on its way into the stomach. Please tell us of your experience with newborns. Have you had any difficulties? How can one avoid injuring the esophagus of the newborn during this procedure? M. Gauderer (response): Dr Campbell, the estimated number of PEGS performed in this country alone is between 130,000 and 150,000 per year and there have been over 150 publications on this subject to date. In those series in which PEG was compared with open gastrostomies, PEG had less morbidity and
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mortality, the operative time was shorter, and the cost was lower. We did not set out to compare PEG with open gastrostomies in this study but rather to examine our own experience with PEG over a lo-year span, including the learning curves of the involved pediatric surgeons and the different endoscopists. Dr Firor, some of the patients that had a post-PEG antireflux procedure at your institution are included in the 25 that I mentioned. Obviously, there are still 12% of these patients that we lost to follow-up. All of you who take care of these sick patients know that they can move from one long-term care facility to another and that you can lose track of them. On the other hand, we have children who were followed for up to 10 years and who have actually had improved reflux post-PEG. Dr Ross, about gastrocolic fistula, which is really our most important complication, it is interesting that the same group of gastroenterologists who performed the endoscopy for the two patients in your series subsequently moved to our institution and had two gastrocolic fistulae, before the problem with the endoscopy was recognized and corrected. In the first patient that had a gastrocolic fistula, we underinflated the stomach; the second child had severe scoliosis and we had difficulty placing the PEG. We did not follow our own guidelines and had a problem 29 months later. The third patient had a previous diaphragmatic hernia repair with malrotation and abnormal epigastric anatomy. We probably should have refrained from performing a PEG in that particular child. In the last two patients, in whom the new group of gastroenterologists did the endoscopy, the guidelines had not been strictly foilowed. Whereas in most studies on gastrostomies in children the perioperative period was analyzed, we critically looked at both, the perioperative and the longterm follow-up. Dr Powell, we switch to a gastrostomy button between 3 and 6 months post-PEG. Dr Harris, although this study was not aimed at addressing the controversy-gastrostomy only or gastrostomy plus antireflux procedure-our present studies indicate that there is a direct correlation between tolerance to nasogastric feedings and results after the PEG. By and large, you can use any study such as upper gastrointestinal series, pH probe, or manometry and not find a good correlation. However, if the patient tolerates nasogastric feedings well preoperatively, regardless of the result of the studies, chances are he/she is going to tolerate the PEG very well also. PEG is so simple that if the patient requires a
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fundoplication later, it can be performed without any difficulty, usually without taking down the PEG. Furthermore, we have observed that in many patients, correction of the malnutrition will improve gastric emptying and decrease gastroesophageal reflux. Dr Lobe, the cross bar has to be proportional to the
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size of the child. If you use an adult-type PEG catheter or a catheter with a large internal cross bar in an infant, you are going to have an esophageal tear. This is one of the reasons why we developed a new 15F gastrostomy catheter that will prevent both obstruction of the intestinal tract by the inner cross bar and esophageal damage.
