The effects and efficacy of (laparoscopic) gastrostomy tube placement in children

Gastrostomy placement (GP) is a surgical procedure frequently performed in children with chronic feeding problems. The majority of patients suffer from severe neurologic impairment. This thesis focuses on the efficacy and adverse effects of GP. Currently, GP is performed by minimally invasive techniques, either by laparoscopic GP or percutaneous endoscopic gastrostomy (PEG). In the systematic review and meta-analysis comparing both techniques, analyzing 483 laparoscopic and 550 PEG procedures, PEG was associated with significantly more adjacent bowel injuries, early tube dislodgements and complications that required reintervention under general anesthesia. A large retrospective survey of 300 children who underwent laparoscopic GP was performed, showing that GP was successful in providing a long-lasting route for enteral tube feeding in 96% of patients. Nutritional status also improved after GP, as weight-for-height z-scores significantly increased. Evaluation of adverse events in this study showed that laparoscopic GP was a relatively safe procedure, with no procedure related mortality and a major complication rate of 2.0%. However, minor complications occurred very frequently: in 221 out of 300 patients, a total of 408 minor complications occurred, mainly including hypergranulation, infection and/or leakage at the gastrostomy site and dislodgement of the catheter. A prospective, longitudinal cohort study was presented including 50 patients that investigated the influence of GP on gastric emptying. All patients underwent a “13C-gastric emptying breath test” before and 3 months after laparoscopic GP. Gastric half-emptying time significantly increased from the 57th percentile to the 79th percentile after gastrostomy (p95th percentile) after GP (p=0.01). The development of GER is a widely discussed complication of GP, but current evidence has been inconsistent. A prospective, longitudinal cohort study was presented including 50 patients who underwent 24-hour multichannel intraluminal impedance - pH metry before and 3 months after operation. Total acid exposure in the esophagus did not change significantly after GP: from 6.2% to 6.1%. The number of reflux episodes did not change, neither for liquid and mixed liquid-gas reflux, nor for acid and weakly acid reflux. GER symptoms reported in reflux questionnaires were present in a comparable number of patients before (44%) and after GP (40%; p = 0.73). Antireflux surgery secondary to GP was indicated in only 2 out of the 300 patients in the retrospective study. Additionally, the sensitivity of preoperative 24-hour pH monitoring for predicting GER was only 17.5%. Improving health-related quality of life (HRQoL) is one of the main aims of GP in children. No previous studies had been performed on HRQoL. A cross-sectional study was performed including 126 patients. Caregivers filled out the validated HRQoL questionnaires. HRQoL was mainly influenced by the underlying medical conditions.A prospective, longitudinal cohort study including 50 patients comparing HRQoL before and 3 months after GP, showed that psychosocial HRQoL increased from 55.8 to 61.2 (p=0.03) after operation. In the majority of patients, the benefits of GP outweigh the potential side effects of GP

Treatment Options for Weight Regain or Insufficient Weight Loss After Sleeve Gastrectomy: a Systematic Review and Meta-analysis

Weight failure after sleeve gastrectomy (SG) is frequently observed. Consensus on the most effective treatment is lacking. The aim of this meta-analysis was to assess revisional strategies for weight regain (WR) or insufficient weight loss (IWL) following SG. The included studies reported on endoscopic gastroplasty (ESG), re-sleeve gastrectomy (re-SG), Roux-en-Y gastric bypass (RYGB), one-anastomosis gastric bypass (OAGB), single-anastomosis duodeno-ileal bypass (SADI), and duodenal switch (DS). All techniques resulted in clinically relevant weight loss. Although our data suggest that revisional OAGB was the most effective procedure, the lack of direct comparisons precludes strong conclusions. All procedures were feasible but differed regarding complication rates. Choice of procedure is depending on patient’s characteristics and surgeons’ expertise. Graphical abstract: [Figure not available: see fulltext.

Laparoscopic versus percutaneous endoscopic gastrostomy placement in children: Results of a systematic review and meta-analysis

Background: Percutaneous endoscopic gastrostomy (PEG) and laparoscopic-assisted gastrostomy (LAG) are widely used in the paediatric population. The aim of this study was to determine which one of the two procedures is the most effective and safe method. Methods: This systematic review was conducted according to the preferred reporting items for systematic reviews and meta-analyses statement. Primary outcomes were success rate, efficacy of feeding, quality of life, gastroesophageal reflux and post-operative complications. Results: Five retrospective studies, comparing 550 PEG to 483 LAG placements in children, were identified after screening 2347 articles. The completion rate was similar for both procedures. PEG was associated with significantly more adjacent bowel injuries (P = 0.047), early tube dislodgements (P = 0.02) and complications that require reintervention under general anaesthesia (P < 0.001). Minor complications were equally frequent after both procedures. Conclusions: Because of the lack of well-designed studies, we have to be cautious in making definitive conclusions comparing PEG to LAG. To decide which type of gastrostomy placement is best practice in paediatric patients, randomised controlled trials comparing PEG to LAG are highly warranted

The Effect of Gastrostomy Placement on Gastric Function in Children : a Prospective Cohort Study

Background: A gastrostomy placement is frequently performed in pediatric patients who require long-term enteral tube feeding. Unfortunately, postoperative complications such as leakage, feeding intolerance, and gastroesophageal reflux frequently occur. These complications may be due to postoperative gastric dysmotility. Our aim was to evaluate the effect of gastrostomy placement on gastric emptying in children. Methods: A prospective study was performed including 50 children undergoing laparoscopic gastrostomy. Before and 3 months after gastrostomy, assessment was performed using the 13C-octanoic acid breath test, 24-h pH monitoring, and reflux symptom questionnaires. Results: Gastric half-emptying time significantly increased from the 57th to the 79th percentile (p 95) after gastrostomy (p = 0.01). Most patients (≥75%) with leakage and/or feeding intolerance after gastrostomy had DGE after operation. A decrease in gastric emptying was associated with an increase in esophageal acid exposure time (r = 0.375, p < 0.001). Conclusion: Gastrostomy placement in children causes a significant delay in gastric emptying. Postoperative DGE was associated with gastroesophageal reflux and was found in most patients with postoperative leakage and feeding intolerance. These negative physiologic effects should be taken into account when considering gastrostomy placement in children

The Effect of Gastrostomy Placement on Health-Related Quality of Life in Children

Background and purpose: A gastrostomy placement (GP) aims to improve nutritional status and health-related quality of life (HRQoL) in children who require long-term enteral tube feeding. We evaluated the effect of GP on HRQoL. Methods: A prospective, longitudinal cohort study was performed including patients referred for laparoscopic GP. Children and/or caregivers were asked to fill out the validated PedsQL™ questionnaire before and 3 months after surgery. The aim was to compare preoperative with postoperative HRQoL and to identify predictors of HRQoL. Results: Fifty patients were included with a median age of 3.4 years (interquartile range 1.4–5.6). After GP, total HRQoL did not significantly increase (p = 0.30). However, psychosocial health significantly increased: 55.8 (standard deviation ± 20.8) to 61.2 (± 19.6; p = 0.03) on a 100-point scale. This was mainly owing to an increase in social HRQoL: 58.2 (± 32.3) to 68.3 (± 27.9; p = 0.04). HRQoL both before and after GP was significantly lower in children with neurologic impairment (p < 0.0005). However, neurologic impairment did not influence the effect of surgery on HRQoL (p = 0.66). Low preoperative body mass index was a predictor for improvement in HRQoL after GP. Conclusions: After GP in children, psychosocial HRQoL improved significantly. This was mainly owing to an improvement in social HRQoL. Level of evidence: I

Efficacy and adverse events of laparoscopic gastrostomy placement in children : results of a large cohort study

Introduction: A gastrostomy placement is frequently performed in pediatric patients who require long-term enteral tube feeding. However, data on efficacy, perioperative complications and postoperative gastroesophageal reflux (GER) after laparoscopic gastrostomy (LAG) placement is limited. The aim of this study is to evaluate long-term efficacy and adverse events after LAG in a large cohort and determine whether routine preoperative 24-h pH monitoring should be used to predict postoperative GER. Method: A retrospective observational cohort study was performed including 300 patients (75 % neurologically impaired) that underwent LAG. Results: After a median follow-up of 2.63 years, feeding was successful in 95.9 % of patients. Weight-for-length z-scores significantly increased (p

Health-related quality of life in children after laparoscopic gastrostomy placement

Introduction: A gastrostomy placement (GP) is an established treatment to provide enteral feeding in pediatric patients with feeding difficulties aiming to improve nutritional status and health-related quality of life (HRQoL). The aim of this study was to evaluate HRQoL in children with severe feeding difficulties who have undergone GP. Materials and methods: A cross-sectional study was performed including 128 patients who had undergone laparoscopic GP (2004–2011). HRQoL was evaluated using the validated Pediatric Quality of Life 4.0 Inventory. Multiple regression analysis was performed to identify predictors of HRQoL. Results: After a mean follow-up of 4.0 years (interquartile range 2.9–6.2) after GP, mean HRQoL was 53.0 out of 100 (standard deviation 21.1). HRQoL was significantly lower in children with neurologic impairment, with a mean difference of −21.4 points between neurologically impaired and neurologically normal children (p < 0.001). HRQoL was also lower in children with cardiac disease (−19.0 points; p = 0.01) and in children with a history of previous gastrointestinal surgery (−15.2 points; p = 0.03). Feeding through a gastrojejunostomy tube (−33.0 points; p = 0.01) and higher age at the time of operation (−1.2 points per year; p = 0.03) were also associated with lower HRQoL. GP-related complications requiring reintervention were associated with lower HRQoL, although this association was not statistically significant (p = 0.06). Conclusions: Children with severe feeding difficulty, who have undergone GP, have significantly lower HRQoL compared to a healthy pediatric population. Neurologic impairment, cardiac disease, a history of gastrointestinal surgery, older age, and the need for jejunal feeding through the gastrostomy were predictive of even lower HRQoL

Gastro-esophageal reflux after laparoscopic gastrostomy placement in children

OBJECTIVES: Gastrostomy placement is frequently performed in pediatric patients who require long-term enteral tube feeding. Evidence on the influence of gastrostomy placement on gastro-oesophageal reflux disease has been inconsistent. The aim of this study was to investigate the influence of gastrostomy on gastro-oesophageal reflux. METHODS: A prospective, longitudinal cohort study was performed including 50 patients who underwent laparoscopic gastrostomy between May 2012 and April 2014. Before and 3 months after surgery 24-hour multichannel intraluminal impedance pH monitoring was performed and caregivers filled out reflux symptom questionnaires. RESULTS: Gastro-oesophageal reflux symptoms were present in a comparable number of patients before (44%) and after gastrostomy placement (40%; P = 0.73). Twenty-five of the patients (50%) underwent both the preoperative and postoperative tests and were included in impedance-pH analysis. Acid exposure time (percentage of time with pH below 4) did not change significantly after gastrostomy placement: from 6.2% (3.0-18.1) to 6.1% (2.6-14.9). The number of reflux episodes did not significantly change, for either liquid [mean difference 4.3 (-4.5 to 13.2)] or mixed liquid-gas reflux [mean difference 2.0 (-9.3 to 13.3)]. Before gastrostomy placement, 18 out of 25 patients had pathological reflux (72%) on pH-impedance measurement. In 4 patients, pathological reflux dissolved, whereas 4 patients newly developed pathological reflux. A low preoperative weight-for-height percentile was associated with increased acid exposure after gastrostomy placement. CONCLUSIONS: Overall, gastrostomy placement was not associated with an increase in acid exposure on 24-hour multichannel intraluminal impedance pH monitoring. Similarly, the prevalence of gastro-oesophageal reflux-related symptoms did not change after gastrostomy

Gastro-esophageal reflux after laparoscopic gastrostomy placement in children

OBJECTIVES: Gastrostomy placement is frequently performed in pediatric patients who require long-term enteral tube feeding. Evidence on the influence of gastrostomy placement on gastro-oesophageal reflux disease has been inconsistent. The aim of this study was to investigate the influence of gastrostomy on gastro-oesophageal reflux. METHODS: A prospective, longitudinal cohort study was performed including 50 patients who underwent laparoscopic gastrostomy between May 2012 and April 2014. Before and 3 months after surgery 24-hour multichannel intraluminal impedance pH monitoring was performed and caregivers filled out reflux symptom questionnaires. RESULTS: Gastro-oesophageal reflux symptoms were present in a comparable number of patients before (44%) and after gastrostomy placement (40%; P = 0.73). Twenty-five of the patients (50%) underwent both the preoperative and postoperative tests and were included in impedance-pH analysis. Acid exposure time (percentage of time with pH below 4) did not change significantly after gastrostomy placement: from 6.2% (3.0-18.1) to 6.1% (2.6-14.9). The number of reflux episodes did not significantly change, for either liquid [mean difference 4.3 (-4.5 to 13.2)] or mixed liquid-gas reflux [mean difference 2.0 (-9.3 to 13.3)]. Before gastrostomy placement, 18 out of 25 patients had pathological reflux (72%) on pH-impedance measurement. In 4 patients, pathological reflux dissolved, whereas 4 patients newly developed pathological reflux. A low preoperative weight-for-height percentile was associated with increased acid exposure after gastrostomy placement. CONCLUSIONS: Overall, gastrostomy placement was not associated with an increase in acid exposure on 24-hour multichannel intraluminal impedance pH monitoring. Similarly, the prevalence of gastro-oesophageal reflux-related symptoms did not change after gastrostomy