gastrostomy in children dr osama bawazir assistant professor, consultant pediatric surgeon frcsi,...

Gastrostomy In

Children

Dr Osama BawazirAssistant Professor , Consultant Pediatric

surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC,

FAAP,FACS.

Indications for Tube Feeding

• Patients who cannot or will not eat

• Patients who have a functional gut

• Safe method of access is possible.

• Mechanical obstruction is the only absolute contraindication to enteral feeding.

Methods of Feeding

Gastrostomy Methods

• Percutaneous Endoscopic (PEG)– First choice of gastric access

• Radiological

• Surgical– Comparable to PEG, but is more expensive and requires

more recovery time

• Accidental

First “Gastrostomy”Diagram of Alexis St. Martin's wound (from Dr. Beaumont's book, Experiments and Observations on the Gastric Juice and the Physiology of Digestion, 1833)"This engraving represents the appearance of the aperture with the valve depressed.A A A Edges of the aperture through the integuments and intercostals, on the inside and around which is the union of the lacerated edges of the perforated coats of the stomach with the intercostals and skin.B The cavity of the stomach, when the valve is depresed.C Valve, depressed within the cavity of the stomach.E E E E Cicatrice of the original wound."

DESCRIPTION OF WOUND: The hole in St. Martin's side was a permanent open gastric fistula, large enough that Beaumont could insert his entire forefinger into the stomach cavity.

Percutaneous Endoscopic Gastrostomy

Button-PEGs

Radiologic Gastrostomy

T-Fasteners to pull the stomach against the abdominal wall

Commonly used tubes

Surgical gastrostomy: Witzel or Stamm

The methods compared

Measure Surgical

GastrostomyPEG Radiologic

GastrostomyNo. of patients 721 4,194 837No. of series 11 48 9Success rate, % 100 95.7 99.2Procedural mortality rate, % 2.5 0.5 0.3Major complication rate, % 19.9 9.4 5.9Minor complication rate, % 9 5.9 7.8

PEG costs least

• Barkmeier JM, Trerotola SO, Wiebke EA, et al: Percutaneous radiologic, surgical endoscopic, and percutaneous endoscopic gastrostomy/gastrojejunostomy: comparative study and cost analysis. Cardiovasc Intervent Radiol 1998 Jul-Aug; 21(4): 324-8

 Procedure Surgical Cost, $Endoscopic

Cost, $Radiologic

Cost, $Gastrostomy 3694 1861 1985Gastrojejunostomy 3045 3158 2201

Advantages of P.E.G.

• Direct endoscopic visualization of upper GI tract… Why is that important?

• More likely to be successful in an operated stomach

• Allows larger caliber tubes

• Allows conversion with jejunal extension tube

Before I forget:When PEGs come out

• Put a Foley in

• Put a Foley in

• Put a Foley in• Recommended size: 12-14 Fr, 5 cc balloon

When Should a Gastrostomy Be Used?

• Requires prolonged tube feeding (>30 days)

• Adequate function and structure of stomach and low esophageal sphincter– No history of :

• Recurrent aspiration of gastric contents• Esophageal dysmotility or regurgition• Delayed gastric emptying

Adavntages of Gastrostomy

• More physiological

• Ease of placement

• Convenience– Bolus feeding– Greater flexibility in choosing formula

Disadavntages of Gastrostomy

• Delayed gastric emptying– Continueous feeding– Prokinetic drug

• Gastroesophageal reflex and aspiration– Elevation of head– Reduce feeding rate and volume– More hydrolyzed or lower osmolarity

formula

Jejunostomy

PEG/PEJ Conversion

Problems with PEG/PEJ conversion(jejunal extension tube):

“The tube that keeps coming back”

• Placement arduous, difficult and not always successful

• Small tubes prone to clogging

• Jejunal tube migrates back into the stomach

• Staff often does not understand the plumbing, tubes come out “accidentally”

Surgical (laparoscopic) jejunostomy Stamm type

Witzel Modification

Direct percutaneous endoscopic

jejunostomy tube placement

Complications & Pitfalls

Complications of Tube Feeding

InfectionAspirationDiarrheaAlterations in drug absorption and metabolismMetabolic disturbances

Pneumoperitoneum after PEG

• Expected event– Up to 36%

• Contributing factors– Excessive air insufflation

– Prolonged procedure time

– Multiple percutaneous needle punctures of the stomach

• Peritonitis– <1% of PEGs

– ~30% mortality

Pneumoperitoneum after PEG

• No additional studies warranted unless signs of inflammation, peritonitis

• Contrast study– May detect gross extravasation

• CT Scan Abdomen– Extravasation– Lack of apposition with abdominal wall– Free fluid, suggestive of visceral

perforation, hemorrhage

ComplicationsSpecific to PEG

Exit Site Infection

Dislodgement of PEG Tube

• Concern when occurs prior to maturation of gastrocutaneous tract

• Initial Rx– Nasogastric suction– Broad spectrum antibiotics

• Surgery– Failure to improve– Overt peritonitis, sepsis

Buried Bumper Syndrome

• Excessive traction on PEG tube

• Overtightening of skin disk– Ischemic necrosis of the

gastric mucosa– Migration of the internal

bolster into the gastric or abdominal wall

• Prevention– Confirm some laxity at

initial insertion

Buried Bumper Syndrome

• Findings– Resistance to flow– PEG tube fixed, with

surround subcutaneous erythema

• Endoscopy– Ulceration, mucosal

dimpling– Nonvisualization internal

bumper

Buried Bumper Syndrome

• Treatment– Dissection of the buried

appliance from the abdominal wall

– Replace with new gastrostomy tube

– Large gastrocutaneous fistula may warrant laparotomy/resection

Peristomal Wound Infection

• 5-30% of cases

• Prophylactic Antibiotics

– Single dose 30 minutes before procedure

– Narrow spectrum (e.g. cefazolin)

• Skin incision

– Large enough to easily admit tube

– Smaller incision allows entrapment of bacteria postop infection

Necrotizing Fasciitis

• Rare, devastating complication

• 43% mortality

• Initial presentation with cellulitis

• Source control essential– May mandate surgical closure of PEG

site

Hypergranulation tissue

• ? result of an extended inflammatory response

• ? reaction to the tube

• Pressure, moisture and friction

• Treatment with either silver nitrate sticks

Gastrocolocutaneous Fistula• Early presentation

– Drainage of feculant material at PEG site

• Late– Detected after tube

replacement: diarrhea

• Colonic interposition during placement– Dx: gastrograffin

study, CT scan

Hemorrhage

• 2.5% of cases

• Repeat endoscopy indicated for Dx, possible Rx

• Often related to gastric ulceration under internal bumper– Pressure necrosis– Friction

• Caution in patients with coagulopathy

Aspiration

• Clinically evident aspiration rare

• 50-60% mortality rate

• Related to– Initial illness– Positioning and sedation during

procedure

• Monitor residuals, appropriate interventions if increased

Tube Migration• Inadequate stabilization

• Proximal migration– Vomiting, aspiration

• Migration into distal stomach– Gastric outlet obstruction– Distention, vomiting

• Distal migration (small bowel)– Dumping syndrome

Postoperative Care

Postoperative Nursing

• Local care to prevent complications– Especially important while

gastrocutaneous fistula is maturing

• Allow slack on tubing to prevent pressure/traction complications

Resumption of Enteral Nutrition• Immediate resumption of enteral

nutrition is possible following PEG placement

• Some surgeons maintain NPO, straight drainage for 12-24 hours

• Postop “ileus” may be related to degree of insufflation– Should suction air prior to endoscope

removal

Tube Replacement• Replace for occlusion, leakage,

cosmesis• May wish to replace with “low

profile” tube• Can also use foley, Malecott,

dePezzer – Inflate foley with water not

saline to prevent crystallization• When fistula matured, simple

replacement through existing hole possible– Consider gastrograffin study to

confirm position

PEG Removal

• Removed when indication for placement resolved

• Gastrocutaneous fistula should be mature

• Removal technique dependent on PEG features

PEG Removal

• Rigid internal bumper– Mandates repeat endoscopy– PEG tube cut at skin– Bumper snared endscopically– Bumper may be obstructive, must be

removed

PEG Removal

• Malleable internal bumper

– Remove via traction technique

– Initially rotate tube to disengage from fibrous tract

PEG Removal

• Secure tube in one hand

• Continuous steady traction– Caution: “spray”

of gastric fluids

• May wrap tube around hand

• Bumper inverts and PEG removed

PEG Removal

• Fistula closes within 24 hours

• Persistant fistula– Granulation tissue/inflammation– Silver nitrate sticks– Rarely require resection/operative

closure

PEG Tube Exit Site Infection

• Frequent occurrence

• External retention device pulled too tight against abdominal wall (skin necrosis)

• Initial skin incision not long or deep enough (tube itself exerts pressure leading to necrosis/infection)

• Severely debilitated patients with impaired immune response

How to deal with exit site infections• Make sure PEG rotates easily, bumper is

not too tight• Meticulous local wound care (Betadine,

diluted peroxide solution, light non-occlusive dressing frequently changed)

• Broad spectrum oral antibiotics (Bactrim has a surprisingly good activity against many skin organisms)

• If there is frank pus, obtain a culture

The leaking PEG

• Most common reason– Chronic low grade exit site infection

• The biggest mistake– Exchanging existing tube for one with a

larger diameter (the “Plumber’s Choice”)

• The second most common mistake– Attaching a Colostomy bag (creating the

Petry dish environment, bacteria, molds and fungi LOVE THAT)

The leaking PEG

• If it just leaks a little, it is possible to salvage it (see under exit site infections)

• If it looks like Alexis St. Martin’s gastrostomy, the tube needs to come out

PEGs:A Haven for YeastsGottlieb K, DeMeo M, Borton P, Mobarhan S.

Gastrostomy tube deterioration and fungal colonization.

Am J Gastroenterol 1992 Nov;87(11):1683

Gottlieb K, Leya J, Kruss DM, Mobarhan S, Iber FL

Intraluminal fungal colonization of gastrostomy tubes.

Gastrointest Endosc 1993 May-Jun;39(3):413-5

Marcuard SP, Finley JL, MacDonald KG.

Large-bore feeding tube occlusion by yeast colonies.

JPEN J Parenter Enteral Nutr 1993 Mar-Apr;17(2):187-90

Gottlieb K, Iber FL, Livak A, Leya J, Mobarhan S.

Oral Candida colonizes the stomach and gastrostomy feeding tubes.

JPEN J Parenter Enteral Nutr 1994 May-Jun;18(3):264-7

Silicone rubber PEG tubes or replacements were recovered from 111 patients and examined for blockage, dilatations, tears, breaks, or loss of elasticity. All irregularities were stained and examined for fungus using lactophenol cotton blue stain. The intraabdominal portion of the PEG failed from obstructions, loss of elasticity, or tears related to fungus colonies in 36% of cases. An additional 34% were colonized with fungi but did not fail. On frozen section, the fungus invaded the wall of the tubing. The extraabdominal PEG tubing failed from fungi in 12, and 10 additional tubes had colonizations. Nine tubes had distal clogging with crystalline material that is believed to arise from medication. Fungus tube failure occurred in 37% of the tubes in place 250 days and in 70% of tubes in place 450 days. Fungus is an important cause of PEG failure; recommendations are provided to maintain tube patency.

Iber FL, Livak A, Patel M.Importance of fungus colonization in failure of silicone rubber

percutaneous gastrostomy tubes (PEGs).

Dig Dis Sci 1996 Jan;41(1):226-31

The deteriorating PEG

• Microbial deterioration of the silicone– Candida species and other

microorganisms can metabolize silicone/additives

• Can the tube be trimmed?• If not: Variety of replacement options

– Foley-type (with balloon)– Ponsky type (with original style bumper)– Button PEG

Summary

• What should I remember from this talk?– Enteral access options– The advantages of endoscopic PEG– Trouble shooting

Thank You