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Percutaneous endoscopic gastrostomy in children: a safe technique with major symptom relief and high parental satisfaction.

TL;DR: PEG is a safe technique for establishing enteral feeding, even in very sick children, although most children experience minor stoma-related problems, and parents/caregivers report that the gastrostomy is of great help for themselves and their child.
Abstract: Background: Percutaneous endoscopic gastrostomy (PEG) is widely used for establishing enteral feeding. The aim of this study was to assess immediate and long-term results after PEG insertion. Patients and Methods: A total of 121 children were retrospectively reviewed. Median age was 2.4 years (range, 4 months–13.2 years) at the time of PEG insertion. Patient morbidity, indications for PEG, preoperative findings and perioperative complications were registered retrospectively. Parents/caregivers of 85 children were interviewed for long-term results. Results: Perioperative complications were seen in 12%. Twenty-four percent died at a median of 15 months (range, 1.5 months–8 years) after PEG. Eighty-five families were interviewed with a median follow-up time of 5.6 years (range, 1–10 years). A substantial majority (94%) of parents/caregivers reported that the PEG had a positive influence on their child's situation, and 98% would have chosen PEG insertion again. Vomiting/retching improved in 61% of the children, and oral intake enhanced in 43%. Stoma-related complications were frequent (73%). The gastrostomy tube was permanently removed at a median of 3 years (range, 7 months–7.3 years) after PEG placement in 25%. Delayed closure of the gastrocutaneous fistula after gastrostomy removal occurred in 48% of them. Time from insertion to removal was not predictive of delayed closure. Conclusion: PEG is a safe technique for establishing enteral feeding, even in very sick children. Major complications are rare, although most children experience minor stoma-related problems. Parents/caregivers report that the gastrostomy is of great help for themselves and their child.

Summary (8 min read)

2. Summary

  • This thesis presents outcome after Nissen fundoplication and gastrostomy placement in children treated at the pediatric surgical departments at Oslo University Hospital.
  • The authors were able to reach more than 90% of parents whose child had undergone Nissen fundoplication (75/80) or percutaneous endoscopic gastrostomy (85/92).
  • The authors did not find that laparoscopic fundoplication was superior to open fundoplication with regard to the number or severity of early postoperative complications or hospital stay.
  • The most frequent complications were airway complications (n = 22), feeding problems (n = 17), and gastrostomy infection (n = 7).
  • Gastric emptying rate in children with gastroesophageal reflux was not significantly slower than gastric emptying in healthy children.

3. List of papers

  • This thesis is based on the following papers which in the text are referred to by their Roman numerals (I-IV) I. Åvitsland TL, Kristensen C, Emblem R, Veenstra M, Mala T, Bjørnland K. Percutaneous endoscopic gastrostomy in children: A safe technique with major symptom relief and high parental satisfaction.
  • Knatten CK, Fyhn TJ, Edwin B, Schistad O, Emblem R, Bjørnland K. 30-days outcome in children randomized to open and laparoscopic Nissen fundoplication.
  • Knatten CK, Åvitsland TL, Medhus AW, Fjeld JG, Pripp AH, Emblem R, Bjørnland K. Gastric emptying in healthy children and in children with gastroesophageal reflux.

5. Definitions

  • Gastroesophageal reflux (GER): Passage of gastric contents into the esophagus with or without regurgitation and vomiting Gastroesophageal reflux disease (GERD):.
  • When reflux of gastric contents causes troublesome symptoms and/or complications Heartburn: A burning sensation in the retrosternal area Regurgitation: Passage of refluxed gastric contents into the pharynx or mouth Reflux index: Percentage of the total measured time with pH below 4.
  • Expulsion of refluxed gastric contents from the mouth, also known as Vomiting.

6.1 Pathophysiology

  • Gastroesophageal reflux (GER) is defined as gastric contents that passes into the esophagus with or without regurgitation and vomiting (1).
  • When these mechanisms are ineffective or insufficient, GER may occur (3,6).
  • Furthermore, it has been demonstrated that delayed gastric emptying (DGE) may accentuate GER by prolonging transient lower esophageal sphincter relaxations and by increasing the volume of the refluxate (10).
  • The lower esophageal sphincter and the crural diaphragm constitute the intrinsic and extrinsic sphincters, respectively.
  • Dysfunction of the antireflux barrier, increased esophageal sensitivity, poor motor function of the esophageal body, and gastric factors (such as raised intragastric pressure and the acid pocket) all play a part.

6.2 Symptoms and complications

  • Fuzzing, crying, irritability, pulmonary symptoms, abnormal sucking and swallowing, decreased food intake, food aversion, and poor weight gain are other symptoms that may be caused by GER (3,16,17).
  • In both infants and older children GER has also been associated to symptoms such as sinusitis, dental erosions, apparent life-threatening events, asthma, pneumonia and bronchiectasis (11,16,18,20).
  • When GER causes troublesome symptoms and/or complications, it is defined as gastroesophageal reflux disease (GERD) (11).
  • Esophagitis and other esophageal complications GER may damage and cause inflammation of the esophageal mucosa, resulting in reflux esophagitis (4).
  • In some patients chronic acid exposure and inflammation may also lead to metaplasia of the esophagus, recognised as the premalignant condition Barrett`s esophagus that may progress further to esophageal adenocarcinoma (4,17,27).

Feeding problems

  • Symptoms and complications of GER such as esophagitis, esophageal strictures, vomiting, regurgitation, and airway infections may cause or aggravate feeding problems by causing dysphagia, food aversion, expulsion of ingested food, and infection related increased caloric need related to infections.
  • Thus, there are many plausible explanations why GER may cause or contribute to feeding problems in children.
  • Severe feeding problems necessitating tube feeding is usually a complex problem (28).
  • Neurologically impaired children have an increased risk of developing severe, chronic GER which may affect feeding, but they are also at risk of developing severe feeding problems because of their underlying condition which may affect the child`s medical condition, motility of the gastrointestinal tract, and sensory and motor coordination of the oral cavity (28–30).
  • In neurologically normal children with severe feeding problems requiring insertion of a gastrostomy, the two most common diagnosis are congenital heart conditions and cancer (28,30).

Respiratory symptoms

  • Respiratory complications associated to GER include conditions such as chronic cough, asthma, pneumonia, and apparent life-threatening events (1,18,31).
  • Aspiration of gastric contents may cause recurrent pneumonias (32).
  • In addition, acid reflux in the esophagus may induce bronchial constriction leading to respiratory symptoms (1).
  • The literature generally report limited benefits of surgical and pharmacological antireflux treatment on respiratory symptoms (31–33).
  • Nevertheless, the current treatment guidelines on GER from NASPGHAN and ESPGHAN recognises that some patients may benefit from treatment, and recommend that antireflux treatment should be considered in children with concomitant respiratory symptoms and GER (1).

6.3 Risk factors

  • There are some conditions that increase the risk of GER and GERD.
  • These include neurological impairment and anatomical foregut abnormalities such as esophageal atresia and malrotation (1,11,27).
  • Furthermore, conditions that increase the intraabdominal pressure, such as obstructive lung disease, seizures, and obesity are associated with an elevated risk of GER (27).
  • There are also studies showing an association between DGE and GER (12–14).
  • Some of the disorders associated with GER are also associated to feeding disorders (28).

6.4 Prevalence

  • The overall prevalence of GER in French children between 0-17 years was recently estimated to be 10.3%.
  • The highest frequency was found in infants aged 0-23 months, where physiological GER was diagnosed in 24.4% (20).
  • After this age, regurgitation gradually decreases and often resolves spontaneously by 12-24 months of age (15,20,25,36).
  • The prevalence of GERD, defined as children having symptoms of GER impairing their daily lives, was assessed in the French cross-sectional study.

6.5 Diagnosing gastroesophageal reflux

  • Diagnostic tests are usually combined with medical history and physical examination to exclude conditions that may have similar symptoms as GER and to identify complications of GER (1,23,24).
  • PH monitoring 24-hour esophageal pH monitoring has long been the recommended test in investigating patients with suspected GER (1,37).
  • The test may be useful in correlating symptoms to acid reflux episodes and to evaluate the effect of medical antireflux therapy.
  • In addition, there are potential technical errors, the reproducibility is suboptimal, and some patients change diet and behaviour because of discomfort from the pH probe (27,38,40).
  • Combined pH monitoring and impedance is useful to quantify and detect reflux, particularly in the postprandial period or at other times when gastric contents are nonacidic (1,43).

Endoscopy

  • Endoscopy offers direct visualization of the esophageal mucosa and stomach.
  • Macroscopic lesions such as erosions, ulcerations, strictures, and changes consistent with Barrett`s esophagus can be detected directly (1).
  • Microscopic lesions, including esophagitis, are diagnosed by taking multiple biopsies.
  • Esophageal lesions are not common in children with GER, and their absence does not rule out GER (1).
  • Endoscopy can be useful to rule out conditions that may mimic GERD, such as coeliac disease, eosinophilic esophagitis, and intestinal malabsorption (51).

6.6 Treatment of gastroesophageal reflux

  • Parental education, reassurance and anticipatory guidance are generally recommended for infants with GER symptoms that are not severe and where spontaneous resolution can be expected.
  • In infants and children with GERD, treatment should be started to avoid complications if the diagnostic and clinical findings are consistent with GER (17).
  • Conservative treatment using non-pharmacological and pharmacological treatment is the main approach.
  • If this fails to relieve symptoms, one may consider surgical treatment.

Conservative treatment

  • Non-pharmacological treatment such as dietary modifications and positioning therapy are often recommended and used in infants and children with GER (20,34).
  • The effect of thickened food is moderate and side effects such as weight gain, coughing, and reduction or termination of breast feeding have been reported (34,54,56).
  • The effect of positioning therapy on GER has been assessed in a few studies.
  • It seems that placing the child in the horizontal prone position or the left lateral position significantly reduce the number of reflux episodes compared to placing the child in the supine, the right lateral position, or in an infant seat inclined at 60° (55,57,58).
  • Medical treatment for children includes altering the viscosity of feeds by alginates , reduce gastric acid (antacids, histamine H2- antagonists and proton pump inhibitors), and change the gut motility by prokinetics (metoclopramide, domperidone, cisapride, erythromycin, bethanechol) (60).

Surgical treatment

  • Different surgical procedures can be performed if conservative treatment fails to resolve GERD, such as gastrostomy feeding, jejunal tube feeding, and fundoplication (65–69).
  • In children with GER and severe feeding problems it is debated which surgical treatment is most feasible as first line treatment (70–72).
  • Currently, gastrostomy placement without fundoplication is commonly used as the primary approach in these patients (73–75).
  • If GER remains a problem after gastrostomy placement, fundoplication should be considered (76).

Gastrostomy

  • A gastrostomy may be indicated if the child requires exclusive or supplemental nasogastric tube feeding for more than 1-3 months (77).
  • It has been established as a safe device for enteral feeding, and the gastrostomy can also be used for gastric decompression and administration of medications (77).
  • Furthermore, the data on complication rates after PEG and laparoscopic-assisted gastrostomy techniques are generally of low quality as only a few prospective trials have been published (79,83).
  • One study reported that more patients receiving an open gastrostomy developed GER postoperatively than those receiving a PEG (76).

Fundoplication

  • Fundoplication should be considered in children who have significant symptoms of GER despite optimal conservative treatment (1).
  • These procedures are all based on folding the cranial part of the fundus around the esophagus.
  • Patient comorbidity affects early and late outcome, and it is generally accepted that children with esophageal atresia and neurological impairment have the highest complication rate and poorest outcome (100,110–112).
  • Since there are no clear recommendations on which patients that should have a pyloromyotomy concomitantly with a fundoplication, further studies on the occurrence of DGE in GER patients and whether DGE affects outcome after surgery should be performed before children are selected for a drainage procedure.

Short-term results

  • Non-randomized studies comparing analgesia demand after LNF and ONF generally conclude that LNF patients require significantly less analgesia postoperatively than ONF patients (130,132,133).
  • In line with this, a meta-analysis from 2011 comparing LNF and ONF in children concluded that 30-day morbidity was significantly lower after LNF than ONF (129).
  • One of these studies also assessed analgesia requirements, and found no difference between LNF and ONF groups (96).

Long-term results

  • Adhesions after abdominal surgery may cause small bowel obstruction.
  • The incidence of this complication after LNF and ONF was compared in a retrospective study including 232 patients.
  • Adhesional bowel obstruction occurred in 4.8% of patients, with no significant difference between the groups (104).
  • In the randomized trial from Great Ormond Street Hospital for Sick Children comparing LNF and ONF in children, a similar redo and recurrence rate among the groups was reported (96).
  • Recurrence of GER was a secondary outcome measure in this study, and the small number of patients renders the study with low power to detect differences in outcome.

6.8 Evaluating outcome after surgery

  • Traditionally, studies evaluating outcome after surgery have reported morbidity and mortality related to the surgical procedure as assessed by the surgeon or by other professional health care workers.
  • The focus in such studies has mainly been to assess severity and frequency of various postoperative complications, comparison of surgical techniques, whether the surgical procedure improved the condition as judged by the surgeon, and whether a successful outcome can be predicted by specific patient demographics, choice of surgical technique, or other clinical variables (75,76,81,94,109,138).
  • Patient reported outcome measures can be classified as diseasespecific measures, generic measures, and measures of patient satisfaction (137).
  • Questionnaires are frequently used in research assessing patient reported outcome, and the questionnaires may contain questions assessing one or more constructs such as organ specific symptoms, functioning, quality of life, and health-related quality of life.

1. Gastrostomy improves feeding problems and the child’s overall condition

  • Nissen fundoplication improves GER symptoms and the child’s overall condition 2.
  • Hospital stay is shorter and complication rate is lower after LNF than after ONF 3.
  • Children with GER have DGE compared to healthy children.

8. Aims

  • To study short and long-term outcome of gastrostomy placement and fundoplication with particular emphasis on parents’ assessment of postoperative outcome 2.
  • To study whether children with GER had slower gastric emptying than healthy children.

Subjects

  • Patients in this study were children accepted for Nissen fundoplication from 2003 to 2009 or gastrostomy insertion from 2003 to 2006 at Rikshospitalet.
  • Predefined exclusion criteria were previous antireflux surgery, major abdominal surgery within the last six months prior to referral, and parents that did not speak Norwegian.
  • Half of these patients (n = 51) were excluded for the following reasons; parents reporting any form of cow’s milk intolerance or allergy, unable to lie still, or parents refusing participation.
  • Twenty-five healthy children with no symptoms suggestive of GER including heartburn, regurgitation, vomiting, and feeding difficulties, were recruited among children of the hospital staff as a control group.
  • One healthy child was excluded because it did not cooperate during the scintigraphy.

Method

  • Gastric emptying was examined in 51 GER patients and 24 healthy children using scintigraphy and a test meal of cow’s milk.
  • Patients having a gastrostomy or a nasogastric tube were fed through the tube using the same criteria.
  • After intake of the test meal, the children were immediately placed in the supine position under the gamma camera.
  • Serial scintigrams in ventral and dorsal position over the abdomen were acquired at 90 second intervals for 90 minutes.

Statistics

  • Categorical variables of neurological status and feeding tube were analyzed with Fisher`s exact test or Pearson Chi-Square.
  • Age and reflux index were not normally distributed and therefore compared by Mann-Whitney U test.
  • Multivariable regression analysis was performed to determine difference in mean T1/2 between patients and controls adjusted for any confounding effect by age, neurological status, and volume received.
  • Analyses were performed with PASW Statistics version 18 (IBM SPSS, Armonk, NY).
  • A p-value < .05 was considered statistically significant.

10. Ethics

  • For all four studies the protocols were reviewed and approved by the Regional Ethical Committee.
  • Before phone interviews were conducted in study I and II, a letter was sent to parents/guardians to inform about the study.
  • In study III and IV, written informed consent was obtained from all parents/guardians before inclusion.
  • The randomized trial recruiting patients to study III and IV was registered in ClinicalTrials.gov with identifier NCT015511342.

11. Summary of main results

  • Paper I: Percutaneous endoscopic gastrostomy in children: A safe technique with major symptom relief and high parental satisfaction Parental satisfaction after PEG was high, and 94% of parents reported that the PEG had a positive influence on their child’s situation median 5.6 years (range 1-10 years) after surgery.
  • Most of these were easily treated and handled by the parents without requiring hospital admissions.
  • Of the 93 children included in the chart-review, the authors registered 10 major postoperative complications (11%): Wound infection, sepsis, pneumothorax, rupture of the wound, splenectomy, and ascites needing drainage.

12.1 Parental assessment of effects of gastrostomy insertion

  • The majority of parents in Study I reported that the child’s situation had improved after PEG and that they would have chosen gastrostomy again.
  • A nasogastric tube may increase facial defensiveness and oral aversion (148).
  • The authors have recently reported that feeding problems are associated to increased maternal distress, and that gastrostomy insertion reduces maternal psychological distress and maternal concerns for the child’s feeding problems (150).
  • In Study I the authors found that nearly half of the children had improved the degree of oral intake after PEG insertion, and one-quarter of the patients had permanently removed the gastrostomy tube at follow-up.
  • Some parents reported that they had experienced lack of knowledge among health care providers (mainly general practitioners and local hospital) about how to treat the skin problems.

12.2 Gastrostomy and gastroesophageal reflux

  • The authors found that three-quarter of the patients accepted for PEG insertion had frequent vomiting/retching preoperatively.
  • The reduction of vomiting/retching after PEG insertion may be caused by several factors.
  • It is well known that a nasogastric tube may increase GER by acting as a stent through the lower esophagus sphincter (153).
  • The number of patients undergoing fundoplication after PEG insertion corresponds well to that of other studies (71,74,75,154).

12.4 Laparoscopic versus open Nissen fundoplication

  • The results of their randomized trial comparing LNF and ONF contradict the general assumption that laparoscopy gives a shorter hospital stay and fewer complications than the open technique (129).
  • The authors found that frequency and severity of early postoperative complications and total length of hospital stay were similar after LNF and ONF.
  • Neither severity nor frequency of early complications differed between LNF and ONF groups.
  • Non-randomized trials frequently have selection bias towards patients with more severe comorbidities in ONF groups, which may explain why many trials report higher complication rates in ONF than LNF groups (135).
  • A recent meta-analysis comparing LNF and ONF concluded that duration of hospital stay is shorter with LNF than ONF (129).

12.5 Recurrence of gastroesophageal reflux after Nissen fundoplication

  • Reported recurrence rate after fundoplication varies significantly.
  • Patients with recurrent GER may present with retching and/or vomiting after feeding and complications secondary to GER such as weight loss, pneumonia, and abdominal pain (26,161).
  • Recurrence of GER is associated to neurological impairment, esophageal atresia, DGE, and young age at primary fundoplication, and thus patient selection likely affects recurrence rate (111,114,138).
  • The authors found that all patients undergoing redo fundoplication in Study II were either neurologically impaired or had repaired esophageal atresia.
  • In total, 10% of patients had been operated with a redo fundoplication, which is an acceptable recurrence rate compared to other trials with similar patient population (94,112).

12.6 Delayed gastric emptying rate and gastroesophageal reflux

  • The conflicting results regarding DGE in GER patients may be due to methodological differences.
  • There are also trials that have not given a precise information about the test meal, only reporting giving a test meal consisting of “the child`s usual formula” or a “meal appropriate for age” (114,119).
  • Another study reported that children with preoperative DGE had a higher occurrence of gas bloat and nausea after fundoplication than those with a normal gastric emptying rate (116).

Parental evaluation

  • The results after PEG and Nissen fundoplication in Study I and II were mainly obtained by asking the parents to evaluate outcome.
  • The answers may still have been influenced by the way or the intonation with which students asked the questions, as a telephone-interview was chosen as method.
  • Lastly, the parents’ satisfaction with the fundoplication may have been affected by other factors than the disease-specific outcome of surgery, and parents may mean different things when rating satisfaction.
  • A number of studies have reviewed how expectations, treatment and blinding affects outcome and effect of different treatments (200–202).
  • Nonetheless, the authors acknowledge that the placebo-effect accounted for some of the improvements parents reported, as could be expected with any treatment (202,206).

Inclusion and exclusion criteria

  • The majority of patients included in these four studies were recruited at Rikshospitalet, which is a tertiary care centre.
  • The pediatric gastroesophageal reflux clinical practice guidelines from NASPGHAN and ESPGHAN state that a child may be considered as a candidate for fundoplication if it has troublesome symptoms and/or complications of GER despite optimal conservative treatment, or if it is likely to depend on medical therapy for a long time period (1).
  • Different selection criteria among surgical centres also likely results in differences in the patient populations accepted for PEG or fundoplication, and may limit the generalizability of the obtained results.
  • There was no significant difference in the number of neurologically impaired children between the included and the excluded patients, but the age difference was close to statistically significant.
  • Severe complications requiring prolonged medical treatment, surgical intervention or causing mortality will be reported, but minor complications such as urinary tract infection and wound infections might not be referred in the charts and are therefore not identified and included in the complication rate.

In Study I and II complications were graded as “minor” or “major” by a subjective

  • Evaluation of the publishing authors, whereas a predefined classification system was used to classify complications in Study III.
  • Therefore, the authors applied this system when comparing ONF and LNF groups.
  • The Clavien Dindo Classification has not been validated for children and there remains a need to develop and validate a classification system for the pediatric patient group (135,147).
  • The expert laparoscopic surgeons performed some of the open operations, and the senior author either operated or assisted in the majority of both the open and laparoscopic operations.
  • It generally underestimates the number of patients with recurrence of GER.

Gastric emptying

  • When examining gastric emptying, it is important that the volume is sufficiently large to induce a postprandial motor response (209).
  • The minimum volume that is necessary is not known in different age groups.
  • According to these, pictures are taken hourly, and the patient is free to move out of the camera field between these time-points (185).
  • Scintigraphy is non-invasive, provides a direct and quantitative measurement of gastric emptying, and is considered the gold standard (185).
  • The authors reached a sufficient number of included patients determined by this calculation.

14. Conclusions

  • An overwhelming majority of parents assessed that Nissen fundoplication and PEG insertion had benefited their child 2.
  • Early outcome is similar after LNF and ONF except for operating time 3.
  • Children with GER have similar gastric emptying rate as healthy children.

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Content maybe subject to copyright    Report

Outcome of Nissen fundoplication and placement of
a gastrostomy in children
Charlotte Kristensen Knatten
Department of Pediatric Surgery, Oslo University Hospital
and
Faculty of Medicine, University of Oslo
2013

© Charlotte Kristensen Knatten, 2014
Series of dissertations submitted to the
Faculty of Medicine, University of Oslo
No. 1714
ISBN 978-82-8264-711-3
All rights reserved. No part of this publication may be
reproduced or transmitted, in any form or by any means, without permission.
Cover: Inger Sandved Anfinsen.
Printed in Norway: AIT Oslo AS.
Produced in co-operation with Akademika Publishing.
The thesis is produced by Akademika Publishing merely in connection with the
thesis defence. Kindly direct all inquiries regarding the thesis to the copyright
holder or the unit which grants the doctorate.

3
Contents
1. Acknowledgements ................................................................................................................... 5
2. Summary ................................................................................................................................... 6
3. List of papers ............................................................................................................................. 9
4. Abbreviations .......................................................................................................................... 10
5. Definitions ............................................................................................................................... 10
6. Gastroesophageal reflux ......................................................................................................... 11
6.1 Pathophysiology ................................................................................................................ 11
6.2 Symptoms and complications ........................................................................................... 13
Esophagitis and other esophageal complications ............................................................... 14
Feeding problems ................................................................................................................ 14
Respiratory symptoms ........................................................................................................ 14
6.3 Risk factors ........................................................................................................................ 15
6.4 Prevalence ......................................................................................................................... 15
6.5 Diagnosing gastroesophageal reflux ................................................................................. 16
pH monitoring ..................................................................................................................... 16
Combined pH monitoring and multichannel intraluminal impedance ............................... 17
Upper gastrointestinal contrast study ................................................................................ 17
Endoscopy ........................................................................................................................... 18
Scintigraphy .................................................................................................................. ....... 18
6.6 Treatment of gastroesophageal reflux .............................................................................. 18
Conservative treatment ...................................................................................................... 19
Surgical treatment ............................................................................................................... 20
Gastrostomy ........................................................................................................................ 20
Jejunostomy ........................................................................................................................ 21
Fundoplication ..................................................................................................................... 22
6.7 Laparoscopy ...................................................................................................................... 23
Laparoscopic versus open Nissen fundoplication ............................................................... 24
Short-term results ............................................................................................................... 25
Long-term results ................................................................................................................ 25
6.8 Evaluating outcome after surgery ..................................................................................... 26
7. Hypotheses .............................................................................................................................. 28
8. Aims ......................................................................................................................................... 28

4
9. Materials and methods ........................................................................................................... 29
Study I ...................................................................................................................................... 29
Subjects ............................................................................................................................... 29
Method ........................................................................................................................ ........ 29
Statistics .............................................................................................................................. 29
Study II ..................................................................................................................................... 30
Subjects ............................................................................................................................... 30
Method ........................................................................................................................ ........ 30
Statistics .............................................................................................................................. 30
Study III .................................................................................................................................... 30
Subjects ............................................................................................................................... 30
Method ........................................................................................................................ ........ 31
Statistics .............................................................................................................................. 31
Study IV ................................................................................................................................... 32
Subjects ............................................................................................................................... 32
Method ........................................................................................................................ ........ 32
Statistics .............................................................................................................................. 33
10. Ethics ..................................................................................................................................... 33
11. Summary of main results ...................................................................................................... 34
12. Discussion .............................................................................................................................. 37
12.1 Parental assessment of effects of gastrostomy insertion ............................................... 37
12.2 Gastrostomy and gastroesophageal reflux ..................................................................... 38
12.3 Parental assessment of results after Nissen fundoplication ........................................... 39
12.4 Laparoscopic versus open Nissen fundoplication ........................................................... 43
12.5 Recurrence of gastroesophageal reflux after Nissen fundoplication .............................. 43
12.6 Delayed gastric emptying rate and gastroesophageal reflux .......................................... 44
13. Methodological considerations ............................................................................................. 47
Parental evaluation ............................................................................................................. 47
Inclusion and exclusion criteria ........................................................................................... 49
Complication rate after gastrostomy and fundoplication ................................................... 50
Gastric emptying ................................................................................................................. 51
14. Conclusions............................................................................................................................ 54
15. References ............................................................................................................................. 55

5
1. Acknowledgements
The present work was carried out at the Department of Pediatric Surgery, Oslo
University Hospital Rikshospitalet. The project received its financial support primarily
from Forskerlinjen at Faculty of Medicine, University of Oslo, the Norwegian
ExtraFoundation for Health and Rehabilitation through EXTRA funds and the
Norwegian Cerebral Palsy Association, and the Department of Pediatric Surgery, Oslo
University Hospital Rikshospitalet. Contributions in the form of awards for abstract
presentation were given by The Norwegian Pediatric Surgeons Association, The
Norwegian Thoraco-Laparoscopic Association, and the EUPSA-BAPS Joint Congress
Committee 2012. I highly appreciate the financial support given from all these sources.
I would like to thank my supervisors, Kristin Bjørnland and Ragnhild Emblem, for
initiating this project. I am sincerely grateful to my main supervisor Kristin Bjørnland
for her enthusiastic and close guidedance throughout these years. I have been lucky to
have such a committed and energetic supervisor as Kristin. I am most grateful to
Ragnhild Emblem for her support, scientific advices and for providing me a clinical
position at the Department of Pediatric Surgery.
I would also like to thank Tone Lise Åvitsland, Thomas J Fyhn, Bjørn Edwin, Are Hugo
Pripp, Asle W Medhus, Jan G Fjeld, Ole Schistad, Tom Mala, Marijke Veenstra,
Sigvald Refsum, Margaretha Nicolaysen, Kjetil J Stensrud and Lars Mørkrid for their
contribution. Moreover, I would like to thank coordinator Bente Kibuuka as well as the
nursing staff at the at the ward for Pediatric Surgery and the Department of Nuclear
Medicine, Oslo University Hospital Rikshospitalet, for their collaboration during
recruitment and data-collection.
A special thanks to all the parents, patients, and healthy children participating in this
study.
My warmest thanks to my colleagues, family, and friends for their support given in
various ways. Lastly, I would like to thank my husband Anders Schau Knatten and my
daughter Kristiane Knatten for their love and enjoyable company.

Citations
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Journal ArticleDOI
TL;DR: A clinical practice guide to enteral nutrition support is provided, urging the development and application of procedural protocols that include scrupulous attention to hygiene, as well as regular monitoring by a multidisciplinary nutrition support team to minimise the risk of EN-associated complications.
Abstract: Enteral nutrition support (ENS) involves both the delivery of nutrients via feeding tubes and the provision of specialised oral nutritional supplements. ENS is indicated in a patient with at least a partially functioning digestive tract when oral intake is inadequate or intake of normal food is inappropriate to meet the patients' needs. The aim of this comment by the Committee on Nutrition of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition is to provide a clinical practice guide to ENS, based on the available evidence and the clinical expertise of the authors. Statements and recommendations are presented, and future research needs highlighted, with a particular emphasis placed on a practical approach to ENS.Among the wide array of enteral formulations, standard polymeric feeds based on cow's-milk protein with fibre and age adapted for energy and nutrient content are suitable for most paediatric patients. Whenever possible, intragastric is preferred to postpyloric delivery of nutrients, and intermittent feeding is preferred to continuous feeding because it is more physiological. An anticipated duration of enteral nutrition (EN) exceeding 4 to 6 weeks is an indication for gastrostomy or enterostomy. Among the various gastrostomy techniques available, percutaneous endoscopic gastrostomy is currently the first option. In general, both patients and caregivers express satisfaction with this procedure, although it is associated with a number of well-recognised complications. We strongly recommend the development and application of procedural protocols that include scrupulous attention to hygiene, as well as regular monitoring by a multidisciplinary nutrition support team to minimise the risk of EN-associated complications.

250 citations


Cites background from "Percutaneous endoscopic gastrostomy..."

  • ...A retrospective review of 121 children undergoing PEG found a high rate of parental and caregiver satisfaction with the procedure (98)....

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Journal ArticleDOI
TL;DR: The importance of this work is to reinforce and indicate that malnutrition in children with cancer should not be accepted at any stage of the disease or tolerated as an inevitable process.

195 citations


Cites background from "Percutaneous endoscopic gastrostomy..."

  • ...Methods of enteral nutritional support (tube feeding and percutaneous endoscopic gastrostomy) Algorithms for nutritional strategies in children and adults with malignancies have been proposed in the literature with the objective to treat rather than to anticipate weight loss (8,116,120,130,131)....

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Journal ArticleDOI
TL;DR: This paper recommends the use of standard adult duodenoscopes for performing ERCP in children who weigh at least 10 kg and the placement of 12F or 16F percutaneous endoscopic gastrostomy tubes inChildren who weigh less than 50 kg.

189 citations

Journal ArticleDOI
TL;DR: The aim was to identify factors associated with PEG outcome and found that definable preoperative clinical factors predict the need for further intervention to provide enteral access after PEG.
Abstract: BACKGROUND AND OBJECTIVES Factors predicting outcome after percutaneous endoscopic gastrostomy (PEG) in large pediatric cohorts are not well defined. We hypothesized that definable preoperative clinical factors predict the need for further intervention to provide enteral access after PEG. Our aim was to identify factors associated with PEG outcome. MATERIALS AND METHODS A retrospective review of 760 (407 boys and 353 girls) patients was performed after PEG at the Johns Hopkins Children's Center from 1994 to 2005. Logistic or multiple linear regression was used to analyze indication; diagnosis; age; prematurity; neurological impairment; weight-for-age z scores; modified barium swallow; postoperative complications; need for fundoplication (FP), gastrojejunal tube, or jejunostomy; and length of hospital stay. RESULTS The median age was 1 year (range 0-26 years). The most common indications given for PEG were failure to thrive (n = 373) and dysphagia (n = 27). Postoperative FP, gastrojejunal tube, or jejunostomy were performed in 66 (10%), 24 (4%), and 9 (1%) patients, respectively. Preoperative report indicated that dysphagia and direct aspiration on modified barium swallow was strongly associated with patients undergoing FP after PEG, 10.6% of patients (P = 0.008, odds ratio 2.4) and 11.2% of patients (P = 0.013, odds ratio 2.8), respectively. Younger preoperative age was also associated with the need for FP (P = 0.0006; median age of 5.8 vs 14 months). Patients with preoperative dysphagia had a longer median length of hospital stay: 8 versus 3 days (P < 0.00001). Patients with neurological impairment demonstrated greater weight gain than neurologically normal patients after PEG (P = 0.04). Minor postoperative complications (most commonly wound infection) were observed in 4% (27/747) of children before hospital discharge from PEG and in 20% of children (138/682) after discharge. There were only 2 major complications (gastric separation and gastrocolonic fistula.). There were no fatalities. CONCLUSIONS Preoperative diagnosis, indication, prematurity, and neurological impairment did not influence postoperative complications.

102 citations

Journal ArticleDOI
TL;DR: Comparing the incidence of major complications after PEG with the incidence in other centers, and identifying risk factors for major complications, is compared and laparoscopically assisted PEG procedures seem to be associated with a lesser major complication rate.

97 citations

References
More filters
Journal ArticleDOI
TL;DR: A new technique has been developed to establish a tube feeding gastrostomy without a laparotomy, which has been employed in 12 children and 19 adults with minimal morbidity and no mortality.

1,922 citations


"Percutaneous endoscopic gastrostomy..." refers background or methods in this paper

  • ...The PEG was inserted under general anaesthesia using the pull-through technique as described by Gauderer et al (1)....

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  • ...Stomal infection 14 (16) Tube dislodgment 1 (1) Skin problemsy 34 (40) Painz 25 (29) Leakage 29 (34) Hypergranulationk 42 (49)...

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  • ...INTRODUCTION The aim of the present study is to evaluate perioperative findings and long-term follow-up results of PEG Percutaneous endoscopic gastrostomy (PEG) was introduced 25 years ago (1), and is now widely used for enteral feeding in patients unable to feed satisfactorily orally....

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Journal ArticleDOI
TL;DR: Almost all parents reported a significant improvement in their child's health after this intervention and a significant reduction in time spent feeding and Statistically significant and clinically important increases in weight gain and subcutaneous fat deposition were noted.
Abstract: We report a longitudinal, prospective, multicentre cohort study designed to measure the outcomes of gastrostomy tube feeding in children with cerebral palsy (CP). Fifty-seven children with CP (28 females, 29 males; median age 4y 4mo, range 5mo to 17y 3mo) were assessed before gastrostomy placement, and at 6 and 12 months afterwards. Three-quarters of the children enrolled (43 of 57) had spastic quadriplegia; other diagnoses included mixed CP (6 of 57), hemiplegia (3 of 57), undiagnosed severe neurological impairment (3 of 57), ataxia (1 of 57), and extrapyramidal disorder (1 of 57). Only 7 of 57 (12%) could sit independently, and only 3 of 57 (5%) could walk unaided. Outcome measures included growth/anthropometry, nutritional intake, general health, and complications of gastrostomy feeding. At baseline, half of the children were more than 38D below the average weight for their age and sex when compared with the standards for typically-developing children. Weight increased substantially over the study period; the median weight z score increased from -3 before gastrostomy placement to -2.2 at 6 months and -1.6 at 12 months. Almost all parents reported a significant improvement in their child's health after this intervention and a significant reduction in time spent feeding. Statistically significant and clinically important increases in weight gain and subcutaneous fat deposition were noted. Serious complications were rare, with no evidence of an increase in respiratory complications.

192 citations

Journal ArticleDOI
TL;DR: A significant, measurable improvement in the quality of life of carers after insertion of a gastrostomy feeding tube is demonstrated.
Abstract: The aim of this prospective cohort study was to evaluate the impact of gastrostomy tube feeding on the quality of life of carers of children with cerebral palsy (CP). Short-Form 36 version II was used to measure quality of life in carers of 57 Caucasian children with CP (28 females, 29 males; median age 4y 4mo, range 5mo to 17y 3mo) six and 12 months after insertion of a gastrostomy tube. Responses were calibrated against a normative dataset (Oxford Healthy Life Survey III). Six months after gastrostomy feeding was started, a substantial rise in mean domain scores for mental health, role limitations due to emotional problems, physical functioning, social functioning, and energy/vitality were observed. At 12 months after gastrostomy placement, carers reported significant improvements in social functioning, mental health, energy/vitality (mean increase >9.8 points;p<0.03), and in general health perception (mean increase 6.35 points;p=0.045) compared with results at baseline. Moreover, the values obtained for these domains at 12 months were not significantly different from the normal reference standard. Carers reported a significant reduction in feeding times, increased ease of drug administration, and reduced concern about their child's nutritional status. This study has demonstrated a significant, measurable improvement in the quality of life of carers after insertion of a gastrostomy feeding tube.

191 citations


"Percutaneous endoscopic gastrostomy..." refers background in this paper

  • ...Similarly, problems with handling a nasogastric tube for long periods have been published (13), and caregivers reported reduced concerns about their child’s nutritional status 6 months after insertion of a gastrostomy (12)....

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Journal ArticleDOI
TL;DR: PEG in paediatric patients should be considered a major surgical undertaking and Neurologically impaired children are at risk of acquiring symptomatic GOR, but the risk does not warrant routine fundoplication.

187 citations


"Percutaneous endoscopic gastrostomy..." refers background in this paper

  • ...Preoperative expectations fulfilled 78 (92) 7 (8) Child’s situation bettery 80 (94) 5 (6) Would choose PEG again 83 (98) 2 (2)...

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Journal ArticleDOI
TL;DR: There is no major difference between SG, PEG, and PRG concerning procedure-related complications and tube function tends to be inferior after radiological tube placement, although the difference was not statistically significant.
Abstract: Objectives To evaluate and compare outcomes and complications in patients having undergone gastrostomy by surgical (SG), percutaneous endoscopic (PEG), or percutaneous radiological (PRG) procedure. Design Retrospective analysis. Setting University-based tertiary care center. Patients Of 82 patients who met inclusion criteria, 14 patients (median age, 40 years) received a surgical tube placement (SG), in 24 patients (median age, 55 years) a PEG procedure was performed, and in 44 patients (median age, 57 years) the tube was placed under fluoroscopic guidance (PRG). Indications for gastrostomy were similar in all groups, representing mainly cancer of the oropharyngeal, head and neck region (51 [61%]) as well as the upper gastrointestinal tract (6 [8%]), neurological disorders (15 [18%]), and others (10 [13%]). Main Outcome Measures Catheter function rates, major and minor procedure-related complications, and survival. Results Median follow-up was 17.2 months. Ten patients (71%) died in the SG group 7 to 855 days (median, 67 days) after the procedure, 7 patients (29%) died 5 to 263 days (median, 103 days) after PEG placement, and 30 patients (68%) died within 3 to 621 days (median, 112 days) after PRG, of their underlying disease or disease-related complications; 1 procedure-related death occurred 6 days after radiological tube placement. We observed a rate of minor complications of 43% (6 patients), 33% (8), and 36% (16) and a major complication rate of 14% (2 patients), 17% (4), and 11% (5) in the SG, PEG, and PRG groups, respectively. Tube function rates at 1 year were 67% (9 patients) and 68% (20) in the SG and PEG groups, respectively, and 10% lower (39) in the PRG group, although the difference was not statistically significant. Conclusions There is no major difference between SG, PEG, and PRG concerning procedure-related complications. Tube function tends to be inferior after radiological tube placement.

160 citations


"Percutaneous endoscopic gastrostomy..." refers background in this paper

  • ...When complications are reported after review of medical records, complication rates seem lower (16,17)....

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  • ...Other diseases 23 (19) 5 (17) 10 (48) Cancer 5 3 1...

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Frequently Asked Questions (1)
Q1. What have the authors contributed in "Charlotte kristensen knatten" ?

In this paper, an overwhelming majority of parents assessed that Nissen fundoplication and PEG insertion had benefited their child.