Matjaž Homan1, Jorge Amil-Dias2, Bruno Hauser3, Claudio Romano4, Christos Tzivinikos5, Filippo Torroni6, Frédéric Gottrand7, Iva Hojsak8, Luigi Dall'Oglio6, Mike Thomson9, Patrick Bontems10, Priya Narula9, Raoul Furlano11, Salvatore Oliva12. 1. Faculty of Medicine, University Children's Hospital, University of Ljubljana, Ljubljana, Slovenia 2. Centro Hospitalar S. João, Porto, Portugal 3. KidZ Health Castle UZ Brussel, Brussels, Belgium 4. Department of Human Pathology in Adulthood and Childhood “G. Barresi”- University of Messina, Italy 5. Al Jalila Children‘s Specialty Hospital , Dubai , UAE 6. Digestive Endoscopy and Surgery Unit, Bambino Gesù Children’s Hospital IRCCS, Rome. Italy 7. Univ. Lille, CHU Lille, Infinite U1286, Lille, F-59000, France 8. Children's Hospital Zagreb, University of Zagreb School of Medicine, Zagreb Croatia, University J.J. Strossmayer, School of Medicine, Osijek, Croatia 9. Sheffield Children’s Hospital NHS Foundation Trust, Sheffield, South Yorkshire, UK 10. Université Libre de Bruxelles, Hôpital Universitaire des Enfants Reine Fabiola, Belgium 11. University Children’s Hospital Basel, Division of Pediatric Gastroenterology & Nutrition, University of Basel, Switzerland 12. Maternal and Child Health Department, Sapienza, University of Rome, Italy
Abstract
BACKGROUND: The ESPGHAN position paper from 2015 on percutaneous endoscopic gastrostomy (PEG) required updating in the light of recent clinical knowledge and data published in medical journals since 2014. METHODS: A systematic review of medical literature from 2014 to 2020 was carried out. Consensus on the content of the manuscript, including recommendations, was achieved by the authors through electronic and virtual means. The expert opinion of the authors is also expressed in the manuscript when there was a lack of good scientific evidence regarding PEGs in children in the literature. RESULTS: The authors recommend that the indication for a PEG be individualized, and that the decision for PEG insertion is arrived at by a multidisciplinary team (MDT) having considered all appropriate circumstances. Well timed enteral nutrition is optimal to treat faltering growth to avoid complications of malnutrition and body composition. Timing, device choice and method of insertion is dependent on the local expertise and after due consideration with the MDT and family. Major complications such as inadvertent bowel perforation should be avoided by attention to good technique and by ensuring the appropriate experience of the operating team. Feeding can be initiated as early as 3 hours after tube placement in a stable child with iso-osmolar feeds of standard polymeric formula. Low- profile devices can be inserted initially using the single stage procedure or after 2-3 months by replacing a standard peg tube, in those requiring longer term feeding. Having had a period of non-use and reliance upon oral intake for growth and weight gain - typically 8-12 weeks - a PEG may then safely be removed after due consultation. In the event of non-closure of the fistula the most successful method for closing it, to date, has been a surgical procedure, but the Over-The-Scope-Clip (OTSC®) has recently been used with considerable success in this scenario. CONCLUSIONS: A multidisciplinary approach is mandatory for the best possible treatment of children with PEGs. Morbidity and mortality are minimized through team decisions on indications for insertion, adequate planning and preparation before the procedure, subsequent monitoring of patients, timing of change to low-profile devices, management of any complications, and optimal timing of removal of the PEG.
BACKGROUND: The ESPGHAN position paper from 2015 on percutaneous endoscopic gastrostomy (PEG) required updating in the light of recent clinical knowledge and data published in medical journals since 2014. METHODS: A systematic review of medical literature from 2014 to 2020 was carried out. Consensus on the content of the manuscript, including recommendations, was achieved by the authors through electronic and virtual means. The expert opinion of the authors is also expressed in the manuscript when there was a lack of good scientific evidence regarding PEGs in children in the literature. RESULTS: The authors recommend that the indication for a PEG be individualized, and that the decision for PEG insertion is arrived at by a multidisciplinary team (MDT) having considered all appropriate circumstances. Well timed enteral nutrition is optimal to treat faltering growth to avoid complications of malnutrition and body composition. Timing, device choice and method of insertion is dependent on the local expertise and after due consideration with the MDT and family. Major complications such as inadvertent bowel perforation should be avoided by attention to good technique and by ensuring the appropriate experience of the operating team. Feeding can be initiated as early as 3 hours after tube placement in a stable child with iso-osmolar feeds of standard polymeric formula. Low- profile devices can be inserted initially using the single stage procedure or after 2-3 months by replacing a standard peg tube, in those requiring longer term feeding. Having had a period of non-use and reliance upon oral intake for growth and weight gain - typically 8-12 weeks - a PEG may then safely be removed after due consultation. In the event of non-closure of the fistula the most successful method for closing it, to date, has been a surgical procedure, but the Over-The-Scope-Clip (OTSC®) has recently been used with considerable success in this scenario. CONCLUSIONS: A multidisciplinary approach is mandatory for the best possible treatment of children with PEGs. Morbidity and mortality are minimized through team decisions on indications for insertion, adequate planning and preparation before the procedure, subsequent monitoring of patients, timing of change to low-profile devices, management of any complications, and optimal timing of removal of the PEG.
Authors: Sonia Bianchini; Erika Rigotti; Sara Monaco; Laura Nicoletti; Cinzia Auriti; Elio Castagnola; Giorgio Conti; Luisa Galli; Mario Giuffrè; Stefania La Grutta; Laura Lancella; Andrea Lo Vecchio; Giuseppe Maglietta; Nicola Petrosillo; Carlo Pietrasanta; Nicola Principi; Simonetta Tesoro; Elisabetta Venturini; Giorgio Piacentini; Mario Lima; Annamaria Staiano; Susanna Esposito Journal: Antibiotics (Basel) Date: 2022-02-21