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A small, but significant, number of children require long-term nutritional support. The aim of this study was to demonstrate the safety and efficacy of providing a percutaneous endoscopic gastrostomy (PEG) service for children in a district general hospital and to raise awareness of the suitability of the procedure to be performed on paediatric surgery lists in similar hospitals across the UK.
A multidisciplinary paediatric nutrition team was established and all children accepted for PEG insertion between 1995 and 2007 were entered onto a database prospectively and are included in this study. PEG tubes were inserted by the standard pull-through technique under general anaesthetic.
A total of 172 procedures were performed in 76 children. The median age at first tube insertion was 3 years (range, 0.5–18 years). Length of follow-up ranged from 1 month to 12.6 years. Fifty-eight children (76%) had a neurological abnormality, the commonest being cerebral palsy. All but one procedure were performed successfully, of which 63 (37%) were new insertions, 99 change of tube, 4 changed from surgical gastrostomy and 6 from PEG to button gastrostomy. The median hospital stay was 2 days (range, 2–7 days) for new insertions and 1 day for tube changes. There were 10 (6%) early complications within 30 days, the commonest being peritubal infection (6). The 39 late complications included 16 peritubal infection/granulomata, 9 ‘buried bumpers’, 4 worsening of gastro-oesophageal reflux disease, 2 gastrocolic fistulae, 3 gastrocutaneous fistulae and 4 tubal migration. There was no mortality.
We have demonstrated that paediatric PEG procedures and continuing management by a supporting team can be successfully and efficiently provided in the district general hospital. It should be possible for the majority of similar hospitals to provide local access and increase the availability of PEG feeding for children.
A small, but significant, number of children in the community have feeding difficulties and require long-term nutritional support. Percutaneous endoscopic gastrostomy (PEG) was first introduced in 19801 and has become the procedure of choice for long-term enteral therapy in patients who cannot maintain adequate nutrition with oral intake alone. The British Artificial Nutrition Survey (2005)2 reported a steady rise in paediatric home enteral tube feeding. It is reported that ‘in contrast to adults, nasogastric feeding (68%) was more common than gastrostomy (31%) in newly registered children and may reflect inadequate access for gastrostomy insertion’. Few studies report on PEG in children and those that do are from specialist paediatric units where most of these procedures are performed.
We introduced a PEG service for children in 1995. The aim was to make PEG more accessible to the local population and convenient for children and their families.
The aim of this study was to demonstrate the safety and efficacy of 12 years' experience of providing this PEG service for children in a district general hospital and to raise awareness of the suitability of the procedure to be performed on paediatric surgery lists in similar hospitals across the UK.
The study included all children who underwent PEG insertions performed between April 1995 and December 2007. A database was established to record prospectively patients' details, indication for PEG, mode of referral, procedure, complications (early, within 30 days, and late) and their management and follow-up.
Selection of children for PEG feeding was decided by a multidisciplinary team comprising of paediatrician, nutrition nurse specialist, dietician and general paediatric surgeon. During selection, the risk of aspiration secondary to gastro-oesophageal reflux was assessed clinically and, in children with significant symptoms, by pH study and barium meal. Children with severe gastro-oesophageal reflux requiring fundoplication were referred to a specialist paediatric unit. A small number of children who needed tertiary level anaesthetic care and paediatric intensive care support postoperatively were referred directly to a tertiary centre.
The PEG insertions were performed on the general paediatric operating list under general anaesthetic given by a paediatric-trained anaesthetist. The PEG tube was inserted using the standard pull-through (Gauderer–Ponsky) technique.1 An adult gastroscope (Olympus, XQ-20 until 2000, XQ-240 after 2000; Keymed, Southend, UK) was used for children weighing > 8 kg. A flexible bronchoscope was used in smaller children. The standard tube used was 9-F (Fresenius Kabi, Runcorn, UK). Early in the study, a few 15-F tubes were used because of unfounded concerns that a smaller calibre tube would block. The children tolerated these poorly and all were replaced with 9-F tubes. Very few children and their parents/carers chose replacement with a button gastrostomy (Mickey; Vygon UK Ltd, Cirencester, UK), except the children with progressive neurological conditions who were at high risk from repeated anaesthesia.
The children remained in hospital until they were clinically stable and their parents/carers learned to manage the PEG tube. After discharge, they were followed-up by their paediatrician and continuing support was provided by members of the multidisciplinary team.
In the 12-year period, 172 procedures were performed in 76 children. The median age at first tube insertion was 3 years (range, 6 months to 18 years). After 18 years of age, the care was transferred to the adult services. The male:female ratio was 1.6:1. Length of follow-up varied from 1 month to 12.6 years with a mean of 52 months (4.3 years).
The majority of children had significant co-morbidity resulting in their need for enteral nutrition (Table 1). Fifty-eight children (76%) had a neurological abnormality, the commonest being cerebral palsy (n = 25). Before PEG tube insertion, the majority of children had been fed by nasogastric tube alone (n = 39; 51%; Table 2). These methods had been used for a median of 3 years (range, 0.5–9 years).
All but one of the procedures was performed successfully (Table 3). The standard tube used was 9-F Freka for all new insertions. In three patients, 15-F Freka tubes were used initially and subsequently replaced with 9-F tubes. Six patients had 12-F Corflo tubes.
PEG tubes were changed after a median of 2 years (range, 3 months to 3 years). The main indications for changing the tube were intermittent blocking of the tube, deterioration of the tube material and accidental damage. When tubes were replaced, a new site was used on ten occasions in nine children. This was due to recurrent infections and overgranulation at the original site in six, awkward position of an original surgical gastrostomy and a buried bumper within the abdominal wall, which was removed surgically. On two occasions in one child, the tube was changed to a different site after he was discovered to have a gastrocolic fistula.
The median hospital stay for new insertions was 2 days (range, 2–7 days) in order to train parents to use the feeding tube. Most children undergoing change of PEG tube were managed as day-cases.
Twenty-three children had 49 complications (28%) of which 10 were early procedure-related and 39 were late tube-related complications (Table 4). There were no deaths within 30 days of the procedure.
Six cases had peritubal infection and were treated with antibiotics. One 8-month-old child weighing 6 kg had peritubal leakage of gastric content due to a very thin abdominal wall, which resolved after 7 days. The only major early complication was bowel obstruction in a child due to small bowel twisting around the tube that had entered the posterior wall of the stomach. This was treated by laparotomy and it was assumed that inflation of the stomach during the procedure resulted in volvulus of the stomach causing the tube to enter through the posterior wall of the stomach. There was no case of peritonitis or haemorrhage.
There were 39 late gastrostomy-related complications. The commonest problem was skin infection and granuloma formation around the tube that occasionally needed treatment with antibiotics.
Other problems included ‘buried bumper’ (n = 9), worsening of gastro-oesophageal reflux disease (GORD; n = 4), migration of the tube (n = 4), gastrocolic fistula in one patient (n = 2) and gastrocutaneous fistula (n = 3).
Tube migration occurred in four children due to loosening of the external fixation device. They presented with sudden shortening of the PEG tube accompanied by abdominal pain and vomiting. In the first patient, a contrast study through the tube revealed that the tube had migrated through the pylorus into the duodenum. This was corrected by pulling back the tube. In the other cases, this corrective manoeuvre was performed without performing any investigations.
During the study period, 14 children resumed oral feeding and had their gastrostomy tubes removed. Currently, 34 children have their PEG tube active. Seventeen (22%) children died of their underlying condition at a median of 24 months after PEG insertion (range, 10–56 months). Eight, all with neurodevelopmental disability, were transferred to the adult service and three children lived or moved out of the area and were lost to follow-up.
The indication for gastrostomy placement in children has changed over the years from being placed as surgical adjuncts in neonatal surgery to being adopted for optimisation of nutritional status in a wide variety of chronic diseases. The technique has similarly undergone change from a tube being placed at an operation to the percutaneous technique.3
Percutaneous endoscopic gastrostomy, first described by Gauderer et al.1 in 1980, has revolutionised enteral feeding and now is an established technique for facilitating enteral nutrition. It is safe, quick to perform, requires a shorter hospital stay and recovery period and has a low complication rate when compared with open gastrostomy.4 PEG tube feeding does not have the disadvantages of long-term nasogastric feeding such as irritation of the hypopharynx, frequent dislocation and unsightly appearance and there is better compliance.5
As access to endoscopy is largely limited to overstretched specialist paediatric units, most children are not referred for PEG tube insertion at the right time.2 The PEG service for children was introduced in 1995, with the aim of making provision available locally. A survey conducted in 1996 found that 75 patients in the area were receiving home enteral tube feeding, giving a prevalence of 261 per million.6 Forty-four (58%) were children and many had endured prolonged nasogastric feeding. On starting the PEG service, 12 new tubes were inserted in the first year. In the steady state, the number of new insertions per year is about six. The initial higher number was due to previously unmet local demand.
The decision to use PEG feeding requires an in-depth assessment by a multidisciplinary team of the potential benefits to the individual. Parent training begins prior to tube insertion, continues on the ward using written learning goals and continues in the home or school with support from the community nursing team.
The commonest indication for PEG in children is for nutritional supplementation in those with neurological impairment. In our series, 58 children (76%) had a neurological abnormality, the commonest being cerebral palsy. In these children, gastrostomy significantly reduces feeding time, feed-related choking episodes and frequency of chest infections.7,8
Complications following gastrostomy are common with rates ranging up to 70%,9 which compares favourably with our overall rate of 28%. Most complications with this procedure are fairly common and their management straightforward. In a study of 130 PEG procedures,10 a major complication rate of 17.5% was reported including eight cases of peritonitis, three of haemorrhage, three of intestinal obstruction, four gastrocolic fistulae and one death. This contrast with our experience as we had no cases of peritonitis, haemorrhage or death related to the procedure and no need to change to a surgical gastrostomy. Other paediatric series have similarly emphasised the significant risks involved with this procedure.11,12
Gastrocolic fistula is an interesting complication; in our study, it occurred twice in the same child diagnosed 14 months and 17 months after PEG insertions at different sites. A similar delay in presentation has been reported13,14 and is postulated to be due to progressive loosening of the tube between the internal and external buttresses allowing the fistula tract to open. Our patient had previous abdominal surgery and kyphoscoliosis, both of which are considered risk factors for this problem.15
The exact incidence of ‘buried bumper’ syndrome is unknown and is not specific to any particular type of PEG tube.16 Buried bumpers have been implicated in the development of serious complications including gastrointestinal bleeding, perforation, peritonitis and death.17 Traditionally, the bumper is removed by open operation but different techniques (laparoscopic18, endoscopic19 and radiological20 methods) have been described. In one case, the retained bumper resulted in an abscess in the abdominal wall and was removed surgically. In another patient, the bumper was successfully snared through the remaining pinhole in the gastric mucosa. Subsequently, tubes with buried bumpers have been removed successfully by passing a guide-wire through the gastrostomy tube into the stomach, snaring it endoscopically and pulling while holding the tube firmly on the wire. We found a significant reduction with this problem by routinely changing PEG tubes every 2 years.
Gastro-oesophageal reflux occurs in up to 70–75% of children with cerebral palsy. Whether antireflux surgery should be routinely performed at the time of gastrostomy is debatable. Some argue that these children should be screened for occult GORD as this will determine the need for fundoplication.21 Gastrostomy has been implicated in causation or exacerbation of gastro-oesophageal reflux.21–23
Gastrocutaneous fistula resulting from the removal of the PEG tube usually takes 1–2 days to close spontaneously. Tubes inserted percutaneously (PEG) are less likely to develop fistula than those performed surgically.24 Surgical closure should be considered when a fistula has not closed spontaneously 1 month after removal of the gastrostomy tube.25
Infection around the PEG tube may be as minor as cellulitis or serious as necrotising fasciitis.4 It can be difficult to differentiate between true infection and erythema or granuloma around the stomal site. Our peritubal infection rate is likely to be lower than the actual infection rate as minor infection would be expected to be treated in the community. We have changed to routine antibiotic prophylaxis for the procedure though there are advocates for26 and against.27 Infection or persistent purulent discharge alone was not an indication for change of tube.
The majority of paediatric PEG procedures are performed in specialist paediatric units, which have long waiting lists and involve considerable travelling for families for the initial procedure and for tube changes. Most hospitals in the UK have a nutrition service with support for paediatric patients and a recent ASGBI survey28 has shown that 66% of district general hospitals in England and Wales provide general paediatric surgery. Therefore, it should be feasible for the majority of these hospitals to provide local access and increased availability of PEG feeding for children.
This study shows that percutaneous endoscopic gastrostomy can be safely performed in children in a district general hospital. The multidisciplinary team provides a key role in the careful selection of patients, early recognition and management of complications, parent training and continuing support. Paediatric PEG procedures should be made available in similar hospitals across the UK.