Hello, everyone. Welcome back to the Stay Current podcast. I'm Cecilia Jigena and I'm, I'm Tom Bash. And we are research fellows at Cincinnati Children's Hospital, and along with Stay Current, we are sharing knowledge to improve child health around the globe. And we are back. With another episode in a series, Case-based Journal Reviews with Doctor Jose Campos. He's a pediatric surgeon from Chile, and along with the Chilean Society of Pediatric Surgery, they have a group of volunteers called the Journal Hive that review articles every month, and they are the ones who provide us with the articles that we are going to listen today. As a reminder, we are going to have a case and Along the way, we are going to answer questions about this case based on the latest literature about a topic. And today's topic is G tubes and find applications for gastroesophageal reflux. The articles are listed and linked in the description below. Follow along and read with us. OK, so let's start. You are requested to play a gastrostomy in a 15 month old patient with neurological impairment who has this coordinated swallowing and has been fed via nasogastric tube or NG tube will last 3 months. The pediatrician of the patient is unsure whether to do a find application in this patient or not. But do you order any routine studies before proceeding with a findation test? My algorithm is, I get called for a G tube. Are they asking me because of the mouth and swallowing and intake, or are they asking me because of feeding intolerance that they're vomiting? If it's the mouth only, I would decide whether it's a nasal gastric tube or a G tube. But if they're asking me for vomiting and reflux, then I would get an upper GI and I would do NG feeds. And if they tolerate, then I would place a G tube. If they're not tolerating the NG feeds, then what I do is an NJ tube. And if they tolerate the NJ tube, then they might be a good candidate for a Nissan fundation or a GJ tube. Cool. So what I hear you're very selective on what your studies are and you have a clear pathway or algorithm to navigate this problem with G tubes and fund obligation. And what do you think, Jose? We see a huge variation in care in this problem, like any gastroenterologist you. Ask any surgeon you ask, they might have a different pathway. I'm, I'm very happy about the pathway that you have. It's something I do as well. I don't do a contrast study to assess for reflux. I just do it to rule out secondary causes of reflux. This is an important point. The only reason that I think an upper GI is needed is to rule out secondary causes of reflux such as malrotation or a web. That is it. So, I determined that they need to be treated for reflux based on clinical evaluation, not a test. OK, so this is the first article of the day, pediatric gastroesophageal reflux, clinical Practice guidelines. These are the recommendations of the North American and European Society for Pediatric Gastroenterology and Pathology. and nutrition, and they published this in March 2018 in the Journal of Pediatric Gastroenterology and Nutrition. And they basically look at every complementary study that you can do for assessing gastroesophageal reflux in patients and what they find is that Not barium imaging or the upper GI contrast, ultrasonography, endoscopy, biomarkers, manometry, centigraphy, basically, every study. None of them is enough to say that a patient has gastroesophageal reflux disease, and because of that, they need a fund application. So you have to assess these patients basically in a clinical way. I just want to highlight two things about this guideline. The first thing is that It's very uncommon for Europe and North America to agree on something, and this is a joint guideline between the two biggest gastroenterology societies. So that's one thing. Great. And the second thing is this is a beautiful document. It's really long, so we only brought one of the questions. Which is, is there any value in adding studies? And the bottom line is, no, even with the best settings, the best resources, there's no good laboratory test or radiological test to answer to these questions. So this just confirms what we said. OK. So let's go on. The patient is now on your waiting list for a G tube, and they informed you he had an episode of aspiration pneumonia. Todd, does this change your approach? Yeah, so this is what I use instead of an impedance. I use this to determine that the feeding into the stomach in its current form is not gonna be sufficient. So now, assuming that the baby has already been maximized on medical therapy, Then the next step is going to either be post pyloric feeding, or a fundoplication. Look, in my case, I think I would go down the pathway of studying whether this patient has reflux and whether this patient has reflux refractory to maximum medical therapy, which would be my indication for fund duplication, but I was always told that you could avoid aspiration pneumonias with these interventions like post-polaric feeds or fund applications, and I'm not. So sure about that. In order to decide what are we going to do, Jose brought us a paper about this effectiveness of phone application at the time of gastrostomy in infants with neurologic impairment. This paper is from JAMA Pediatrics from October 2013. So, in this paper, they wanted to find an answer for whether there is a benefit in adding a phone application to a gastrostomy in infants with neurologic impairment. So this is a retrospective observational cohort study starting from January 1st, 2005 to December 31st, 2010, including 42 children's hospitals in the United States. In this cohort, they had more than 4000 infants. 1400 of them went through gastrostomy and found application together. With the propensity score matching, we had two groups of infants who had just gastrostomy and who had gastrostomy and fund duplication together, each 1,027 infants in total of 2,054. According to this study, we can say that infants with neurological impairment who underwent fundation at the time of gastrostomy placement did. Not have a reduced rate of reflux related hospitalization during the first year compared to the who underwent gastrostomy placement alone. If you try to answer this question, there's at least 5 to 7 retrospective single series. Todd, one actually has your name on it. It's the best we got and it's been 10 years. That's the bottom line. But I think this study is a bit better in terms. Of the study size, so it's 42 children's hospital, 4000 patients in a retrospective fashion, this article proposed here is as good as we get. There's no prospective study to answer this question, so this is a good methodology, and they made all the variables completely comparable, so the, the groups are completely equal and they did not find a benefit. In adding a fund application. I don't think that this is enough. I'm hoping that someone will do the prospective study and that we, we'll get this answer. I agree with you. That's an interesting point to make. This is a really hard thing to show. We wrote a review article that just got accepted on all the studies available on this topic. Should we be more aggressive with doing fundos in the beginning? Upfront and the, we did a 10-year follow-up to see how many patients ended up getting a follow-up fundo of all the G tubes that were placed, and it's a tiny percentage. So, most of the G tubes we did ended up having a G tube for life. They never ended up needing a fundo. I think, in general, the fundo topic always swings left to right on the pendulum. Right now, things are swinging towards minimal amount of fundo. Coming back to the aspiration pneumonia thing, I think many times patients with neurological impairment and discoordinated swallowing, they, they just get their aspiration pneumonia from, from their saliva. Exactly, but it's, it's still very common for people to indicate fun applications just to save a child from an a following aspiration pneumonia episode, and that's what I brought. This, this article here, like I've, I've just lost that hope that I will save this child from pneumonia or for aspiration pneumonia from my funduplication. Jose, I, I agree with you, and two comments about that. Actually, if you do a fundo in someone who's aspirating from above, it'll make them worse. But the, the question is, that's why I do a nasal jejunal tube. Yeah, because if that shuts off their aspiration. That's a helpful diagnostic tool. I think one of the important things about this study that Jose and Todd also mentioned that we have lack of data, we have lack of studies, and even though this is one of the most recent ones, it's been 10 years since this study. OK, so you decide to go ahead with the gastrostomy without fundification. In which would be your preferred technique for doing the gastrostomy? Todd, which technique do you usually use? I do lap because I believe that the peg was invented before laparoscopy was advanced in kids. And so it went the reverse. We had the endoscopic approach was actually discovered before we really had advanced laparoscopy. I don't see the advantage of a pure endoscopic approach when you can simply put a camera in through the opening of the G tube itself, even, which is what I do, and grab the stomach and pull it up with visualization rather than blind. What about you, Jose? I do lap as well. I don't like percutaneous. When I first saw it in adult general surgery, I said this is perfect. It's for usually a patient in ICU that would not tolerate an anesthesia, and they will just do it with a little bit of sedation. It would be done without anything, but I, I agree with you. I don't think many people would do a percutaneous gastrostomy in children without anesthesia, and you do need another anesthetic to replace the peg for a button. So with a laparoscopic gastrostomy. You can choose the, the side of your stomach better and you can do a primary button. I'm looking at Todd here in this podcast and he's sitting in his office and I can see the first peg right behind him. Let's not forget that. Mr. Ponsky Senior was the one who invented the percuanis endoscopic gastrostomy, so I think that's, it talks really good on you, thought that you're humble enough to change your technique, putting aside your heritage. Seems that we all agree. Yeah, this is a ding ding ding question. They both use laparoscopy and regarding to this question, here's another paper called a gastrostomy tube using. Pediatrics, a systematic review. This is from the Pediatrics Journal from June 2022, and they were looking to answer the question, which technique of gastrostomy is better for children. This is a systematic review including 58 publications and basically they are trying to compare open versus PEG, PEG versus laparoscopy, open versus laparoscopy. And we'll look into the section where they compared PEG versus laparoscopy, which includes 12 studies and more than 2000 patients, and according to this systematic review, we can say that the complication rates of laparoscopic approach versus PEG. Significantly favored the laparoscopic group, 1.2% compared to 5.4%. I must add to this that this, these were not minor complications when we're comparing 1 versus 5%. The leaks were not included, the dislodgements were not included. The granuloma was not included. We're talking about re-operation for colonic perforation or a colony cutaneous fistula. So that these were major complications. Clearly seeing the things instead of doing just with radioscopy are safer. So we're not even considering open. Low and middle-income countries that don't have the abilities to do a PEG or a laparoscopic G tube, it's perfectly fine. But if you're not in a low to middle income country, you should be doing laparoscopy or PET. There are some criticism to this article. This is a meta-analysis done based on a single serious retrospective study. So I think, let's not be unfair, and I'm sure there are some people who favor the percutane technique and have good reasons for it, but this is the data we have. OK. So you did the gastrectomy in your patient. He has a G tube. He's back in his room. What are your postoperative orders for feeding advancement after placing it? Sad. We keep getting shorter on this curve. We used to admit them and wait till the next day and start slowly. We do it immediately after, and even sometimes send them home the same day. Yeah, I, I agree with that curve. It took me 5 days and I started. continuous feeds and then once they reach continuous, I started compressing the time over 3 hours, 2 hours, and only after 5 days I would try bolus feeds and send them home. And now we're doing faster and faster. So, in my case, if the child came for his gastrostomy, I just do 50% of the volume first time. If it's tolerated, I just go and jump to 100% and send them home after 2 or 3 feeds that it's been tolerated. OK, so let's go to the last article. This is called bolus versus continuous feeding regimens Post gastrostomy tube placement in Children. This is an article from the Mock Children's Hospital and Ann Arbor, Michigan, US is a randomized prospective study that compares outcomes between bolus and continuous feeding. The bolus feeding means that you have a syringe and you put a certain amount of feed through the gastrostomy tube and then you close it. And for the continuous is that you have to like place a continuing dropping of the feeding and so it goes in a continuing way. So what they found is that patients that receive bolus feeding had more leakage and More feeding modifications. But mainly, they achieve the total feeds pretty much the same. And what they are saying is that there are no significant difference that will change your patient's outcomes between bolus or continuous feeding. So the summary here is the reason people start with continuous is because they're afraid to go straight to bolus, but when they go home, they're going to need bolus at home. So, the question is, do you need to first go into continuous as a ramp up to bolus, and this study shows there's really no reason to start with continuous to ramp to bolus, that you could probably go straight to bolus. Yep, that's right. OK. So there you have it. We talked about gastrostomy tubes and find implications in patients. First, we address the question, if we need a complementary study to assess gastroesophageal reflux and we get to the conclusion that there is no need to do anything else that clinical evaluation. Because none of the studies completely ensure us of the diagnosis. Then we went through a study to decide if after an aspiration, the final application was needed in patients with neurological impairment. And what we saw is that there's no need for that because after the FAD applications, most of the patients still have aspiration pneumonia due to bad management of their secretions. After that, we Talk about surgical technique in the placement of a gastrostomy tube, and we all agree that laparoscopic approach is the safer and best way to do it. And finally, we talked about feeding regimens, concluding that Even Bolu's feeding regimen has a little bit more leakage and some feeding modifications. Both of the regimens are OK and are able to reach their complete enteral feeding after 24 hours. So, that was all for today. If you liked this episode, don't forget to follow us on social media, subscribe to our YouTube channel. Listen to previous episodes of this podcast or other podcasts, wherever you get your podcast from, and don't forget to download the Stake Current app on App Store or Play Store. And, I'm Cecilia Kikena and I'm, I'm Tom Bash. And we are research fellows at Cincinnati Children's Hospital, and along with Stay Current, we are sharing knowledge to improve child health around the globe.
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