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CASE REPORT Table of Contents   
Year : 2019  |  Volume : 16  |  Issue : 1  |  Page : 38-39
How replace the gastrostomy tube in children with extremely compromised general conditions


Maternal and Child Health Department, Paediatric Surgery Unit, Salesi Children Hospital, Ancona, Italy

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Date of Submission23-Dec-2017
Date of Acceptance19-Feb-2018
Date of Web Publication16-Sep-2020
 

   Abstract 


The percutaneous endoscopic gastrostomy is the best technique to use in case of children requiring long-time enteral nutrition. The first replacement of the tube is easy in most of the patient, but this step can be extremely problematic in patients with compromised general conditions. The authors report their experience in some cases. Two boys with endoscopic gastrostomy had a deterioration in the general conditions, when replacing the probe, these conditions contraindicated anaesthesia for which the “cut-and-push” technique was adopted in a patient with heart malformation and a local anaesthetic in a neuropathic patient. Both the boys died a few days after this procedure. In our opinion, in children who are not using anaesthesia to reposition the gastrostomy probe, it is best to continue feeding through the nasogastric probe.

Keywords: endoscopy, gastrostomy, percutaneous endoscopic gastrostomy

How to cite this article:
Noviello C, Romano M, Rossi L, Cobellis G, Martino A. How replace the gastrostomy tube in children with extremely compromised general conditions. Afr J Paediatr Surg 2019;16:38-9

How to cite this URL:
Noviello C, Romano M, Rossi L, Cobellis G, Martino A. How replace the gastrostomy tube in children with extremely compromised general conditions. Afr J Paediatr Surg [serial online] 2019 [cited 2020 Sep 19];16:38-9. Available from: http://www.afrjpaedsurg.org/text.asp?2019/16/1/38/295184



   Introduction Top


Gastrostomy feeding is the best way for enteral nutrition in children with several neurological impaired. Most of the time these patients have important cardiac problems too. Gauderer et al. described an endoscopic technique in 1980.[1] Actually, percutaneous endoscopic gastrostomy (PEG) is widely accepted as a safe and easy procedure for children requiring long-term enteral nutrition. For this technique, a particular tube is necessary with an internal bumper to avoid dislocation. The use of gastrostomy for long time requires the replacement of the tube because of damage so that a new anaesthesia is necessary to remove endoscopically the bumper. Often, these patients have a general condition that contraindicates anaesthesia, and then, other methods must be used to remove the bumper. The authors report their experience in these problematic cases.


   Case Reports Top


Case 1

A male presented with Simpson–Golabi–Behmel syndrome, congenital heart malformation (Type IV truncus arteriosus with interrupted aortic arch) and diaphragmatic hernia. After surgical correction of diaphragmatic hernia, he had a palliative surgical treatment for congenital heart malformation (pulmonary artery banding). When he was 3 months old, a PEG was performed because of alimentary problems (enteral feeding only by nasogastric tube). Later, the patient had some cardiovascular complication (cerebral ischemic attack, inferior vena cava thrombosis and fungal sepsis), so that a definitive heart correction was considered impossible. Six months later, he had a “cut-and-push” technique to change the gastrostomy tube because it was broken, and general conditions of the patient did not allow a safe anaesthesia (American Society of Anaesthesiologists [ASA] IV). One month later, the boy had bowel occlusion [Figure 1] and a surgical operation was necessary to remove the bumper (by little enterotomy in the distal ileum where a stenosis was present). The immediate post-operative period was regular, but 5 days after the operation, he died because of acute heart failure (autopsy report).
Figure 1: X-ray of the abdomen: bumper blocked in the distal ileum (white arrow)

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Case 2

a male presented with spastic tetraparesis and serious food problems. When he was 1 year old, PEG was necessary because of exclusively nasogastric tube feeding. Later, general conditions became worst: the patient developed a sepsis and was admitted to another centre for the treatment. During this hospitalisation, he had problem to use the gastric tube so that a new one was necessary. A nasogastric tube was positioned until general condition improved. Two months later, the boy came to our emergency room for accidentally removing of the gastrostomy tube and narrowing of the stoma. Anaesthesiologist classified an ASA III risk so that a dilatation of the stoma was performed with local anaesthesia until to insert a new tube with balloon (14 CH). General condition was stable, but 48 h later, he died because of acute heart failure (autopsy report).


   Discussion Top


The PEG procedure for gastrostomy placement is safe, easy and universally accepted in children because of the low risk, especially in case of generally compromised conditions. Most of the tube used for this procedure has a small and soft intragastric device that keeps in place the gastrostomy. The management of this device is quite easy in children who may be undergoing anaesthesia: endoscopic removing or external traction removal.[2] Important problems arise in patients with complex cardiac malformations or in case of general conditions extremely compromised where anaesthesiological risk is high. Sometimes, the general conditions of these patients get worse so that it is more risky to handle the bumper than to place the PEG. Some authors reported a safe way to manage the tube gastrostomy in adults: the “cut-and-push” technique[3],[4] that is a cutting of the tube at skin level, pushing the bumper into the stomach and wait until the expulsion in the faeces. This technique is well reported in the adult although some complications are possible, especially in particular patients.[5],[6] The “cut and push” is rarely used in children because serious complications are possible.[7] We managed in this way, with a bad result, the first case because it was a severely cardiopathic patient, declared inoperable and with sepsis. In the second one, we tried what we do in anaesthesia (external traction removal) using less invasiveness, but obviously, the technique has caused such a stress to lead the patient to death. In our opinion, similar children need a nasogastric tube for enteral nutrition until general conditions improve for a safe anesthesia.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Gauderer MW, Ponsky JL, Izant RJ Jr. Gastrostomy without laparotomy: A percutaneous endoscopic technique. J Pediatr Surg 1980;15:872-5.  Back to cited text no. 1
    
2.
Ponsky JL. Techniques of removal and replacement. Gastrointest Endosc Clin North Am 1992;2:215-21.  Back to cited text no. 2
    
3.
Merrick S, Harnden S, Shetty S, Chopra P, Clamp P, Kapadia S, et al. An evaluation of the “cut and push” method of percutaneous endoscopic gastrostomy (PEG) removal. JPEN J Parenter Enteral Nutr 2008;32:78-80.  Back to cited text no. 3
    
4.
Agha A, AlSaudi D, Furnari M, Abdulhadi Ali MM, Morched Chakik R, Alsaudi I, et al. Feasibility of the cut-and-push method for removing large-caliber soft percutaneous endoscopic gastrostomy devices. Nutr Clin Pract 2013;28:490-2.  Back to cited text no. 4
    
5.
Harrison E, Dillon J, Leslie FC. Complications of the cut-and-push technique for percutaneous endoscopic gastrostomy tube removal. Nutr Clin Pract 2011;26:230-1.  Back to cited text no. 5
    
6.
Brown JN, Borrowdale RC. Small bowel perforation caused by a retained percutaneous endoscopic gastrostomy tube flange. Nutr Clin Pract 2011;26:227-9.  Back to cited text no. 6
    
7.
Okpechi JC, Schenkman KA. Bronchoesophageal fistula after gastrostomy tube removal by the “cut and push” method. Gastrointest Endosc 2003;58:134-7.  Back to cited text no. 7
    

Top
Correspondence Address:
Dr. Carmine Noviello
Pediatric Surgery Unit, Salesi Children Hospital, Via Corridoni, 11, 60128, Ancona
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajps.AJPS_100_17

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