ORIGINAL ARTICLE: HEPATOLOGY

AND

NUTRITION

Long-Term Outcome of Children Receiving Percutaneous Endoscopic Gastrostomy Feeding 

Arnaud Lalanne, Fre´de´ric Gottrand, yJulia Salleron, Anne Laure Puybasset-Jonquez,  Dominique Guimber, Dominique Turck, and Laurent Michaud

ABSTRACT Objectives: The aim of the present study was to analyze the long-term follow-up of children receiving percutaneous endoscopic gastrostomy (PEG) in terms of survival, nutritional outcome, and weaning from enteral nutrition. The secondary objectives were to evaluate the complications related to PEG and the outcome of patients with neurological disability. Methods: The present study was a single-center retrospective study including all of the 368 patients who underwent PEG from 1990 to 2003 in our tertiary hospital. Results: A total of 368 patients received PEG during the study period. After a median follow-up of 2.4 years (interquartile range 1.4–4.2 years), PEG was in place in 36% and was removed in 27%; 26% of patients were deceased. Two deaths could be directly related to PEG. A statistically significant weight and height catch-up was observed in patients with PEG in place in whom weight/age z score increased from 2.6 to 1.7 (P < 0.01) and height/age z score also increased from 2.1 to 1.6 (P < 0.01). In patients who had their PEG removed weight/age z score increased from 2.5 to 1.6 (P < 0.01) and height/age z score from 2.8 to 1.4 (P ¼ 0.01) at the time of weaning. Early complications occurred in 152 patients, whereas late complications occurred in 191 patients. Most complications were minor (85%). After multivariate analyses, the factors associated with late complications were digestive and ear, nose, and throat (ENT) diseases, age 2 years of follow-up) in children is scarce, arises from small series of patients, and has not addressed the outcomes directly (1,5,7–10). The primary aim of the present study was to analyze the longterm follow-up of children receiving PEG in terms of survival rate, nutritional outcome, and weaning from enteral feeding and demonstrate that the short-term benefits in terms of nutritional status previously described persist in the long term with special emphasis on height. The secondary aim was to evaluate the complications related to PEG and the outcome of patients with neurological disability.

METHODS The present study was a single-center retrospective study including all of the patients who underwent PEG placement in our tertiary hospital located in Lille, France, between 1990 and 2003. All PEGs were placed by the same team of pediatric gastroenterologists without any change in the procedure or in the type of device during the study period. No formal ethical committee approval was required in our country because the present study was an observational, nonrandomized, noninterventional study. Informed consent was obtained from parents of children at the time of PEG. PEG placement was performed in the operating room with the patient under general anesthesia. The standard pull technique was used (1); 12- and 16-F gastrostomy tubes by Ansell Medical (Cergy-Pontoise, France) or 9- and 15-F gastrostomy tubes by Fresenius (Louviers, France) were used. Prophylactic perioperative parenteral antibiotics (single dose of kefandol 15 mg/kg in the operating room) were given to all patients. As a result of our present practice, tubes were systematically replaced by a gastrostomy button 3 to 6 months after the placement. Transcutaneous pull under general anesthesia was used; the intragastric position of the gastrostomy button was verified by endoscopy. For each patient the following data were reviewed by 2 physicians (A.L., A.L.P.-J.) from medical records and by telephone contacts with parents or chronic care institutions: age, sex, underlying disease, date of PEG placement, reason(s) for the PEG placement (feeding difficulties including persistent food refusal, struggling or resisting during feeding, gagging and regurgitation of food; failure to thrive without feeding difficulties; gastric decompression, need for dietary treatment), and weight and height at the time of the placement and at last follow-up. The patients were separated into 3 groups to study the nutritional outcome: patients weaned from enteral feeding, patients receiving enteral feeding at last follow-up, and patients who died during the study. The latter group was individualized because all cases of death occurred while the patients were receiving EN via

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Volume 59, Number 2, August 2014

Long-Term Outcome of Children Receiving PEG Feeding

PEG. It was therefore impossible to predict whether weaning would have been possible and what would have been the outcome after weaning; we therefore collected data at the time of death. Patients who died during the study were considered to be a special group with a severe condition in which the nutritional outcome was believed to be different from other groups and strongly influenced with the underlying condition. The cause of death was identified from medical charts. We also checked with home services that provided EN in these patients the date and cause of death, when death occurred at home. Nutritional outcome was studied by comparing the weight/height z score, height/age z score, and weight/age z score at the time of PEG placement and at the time of last follow-up for children receiving gastrostomy feeding, at the time of death for patients who died, and at the time of weaning for patients weaned from EN. Complications were classified as early when they occurred during the first 7 days after PEG placement and as late when they occurred >7 days after PEG placement. Minor and major complications were also distinguished. Minor complications included local problems (erythema defined by redness of the skin 24 hours, pain requiring more than level 1 analgesics (ie, acetaminophen), and leakage. Major complications included infections (ie, cellulitis requiring parenteral antibiotics), aspiration pneumonia, gastric bleeding, failure of placement, intragastric buried or extruded tube, catheter migration, gastric ulcer, gastrocolic fistula, cutaneous necrosis, or need for surgical closure of the gastrocutaneous fistula after PEG removal. Until 1999, data were collected retrospectively from medical reports. From 1999 onward, data concerning complications were recorded prospectively.

Statistical Analysis Results are expressed as frequencies and percentages for categorical variables or mean and standard deviation for numerical variables. The comparisons between the groups about nutritional outcome and the predictive factors of early and late complications

were investigated by bivariate analyses, using x2 or Fisher exact test, or Student t test. For each outcome, variables with a P < 0.2 in bivariate analysis were introduced in multivariable logistic regression with a stepwise selection (results expressed with the odds ratio and its confidence interval). Statistical analyses were performed using SAS version 9.1 (SAS Institute, Cary, NC), and the cmprsk package of R software was used for survival analysis. P < 0.05 were considered statistically significant.

RESULTS A total of 368 patients (209 boys, 159 girls) received PEG during the study period. Characteristics of the patients are reported in Table 1. Data from 326 patients (89%) were available for long-term evaluation; 42 were lost to follow-up. From 1998 onward, the annual number of PEG placements remained stable, between 40 and 60 PEG per year. The median age at the time of PEG placement was 2.3 years (interquartile range [IQR] 6 months– 9 years; range 1 month–25 years). A total of 120 patients (33%) were younger than 1 year of age at the time of PEG placement; 190 (52%) were ages 1 to 12 years, and 44 (12%) were adolescents (12–18 years); 14 patients were older than 18 years of age, and were included in the present study because they had been studied from childhood in our clinics, experienced severe polyhandicap, and had growth retardation. Most of our patients (n ¼ 208; 56%) had a neuromuscular disease. Among the others, 54 patients (14%) had a respiratory disease, 32 patients (9%) a digestive disease, 26 (7%) an ear, nose, and throat (ENT) disease, and 48 patients (13%) experienced various other diseases (cancer, kidney diseases, and metabolic disorders). The reasons for PEG placement were as follows: feeding difficulties with or without failure to thrive (n ¼ 232; 63%), failure to thrive without feeding difficulties (n ¼ 121; 33%), gastric decompression (n ¼ 11; 3%), and special dietary treatment for type I glycogenosis (n ¼ 4; 1%). A total of 72 children (19%) had a history of abdominal surgery before PEG placement. Among these, 18 had undergone a Nissen fundoplication before being referred for PEG.

Nutritional Outcome Weight was available in all of the patients at the time of the placement, in 90% of the children at the last follow-up. Height

TABLE 1. Characteristics of the patients

Characteristics of the patients Sex, male, n ¼ 209 (%) Diseases, n ¼ 368 (%) Neurological Respiratory Digestive ENT Others Age at the time of placement, y Age

Long-term outcome of children receiving percutaneous endoscopic gastrostomy feeding.

The aim of the present study was to analyze the long-term follow-up of children receiving percutaneous endoscopic gastrostomy (PEG) in terms of surviv...
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