Complications of retained internal bolster after pediatric percutaneous endoscopic gastrostomy.

PURPOSE: Percutaneous endoscopic gastrostomy (PEG) has been widely accepted as an efficacious means of nutritional support in the infant and child. A well-described technique uses the Gauderer-Ponsky tube (CR Bard Incorporated, Tewksbury, MA) drawn antegrade through the gastric wall and secured by an internal and external SILASTIC (Dow Corning; Midland, MI) bolster. The majority of reported complications attendant to its use occur secondary to insertion. This report details a less well-described complication of tube removal. METHODS: Since 1992, 234 pediatric PEGs have been performed using a Gauderer-Ponsky tube. Approximately 6 weeks after the procedure, all catheters were removed and replaced with gastric buttons. The internal bolster was left within the stomach to pass spontaneously. RESULTS: Five children (2.1%), ages 6 months to 5 years, failed to pass this crossbar. Three subsequently presented with dysphagia and drooling with the internal bolster wedged in the proximal esophagus. All were left with significant residual stricture after endoscopic removal of the crossbar. Two required dilatation and the third underwent operative stricturoplasty. A fourth child returned with intermittent gastric outlet obstruction. The internal bolster was retained in the stomach 4 months after catheter removal. Endoscopic retrieval resulted in resolution of the symptomatology. The final case was found to have an asymptomatic bolster in the stomach approximately 18 months after catheter removal. CONCLUSIONS: These cases highlight a potential sequelae of pediatric percutaneous endoscopic gastrostomy not previously acknowledged. The significant complications associated with the retained bolster in four of these five children suggests that follow-up should be altered to monitor prompt passage of the crossbar after tube removal.

Acute abdomen. The teenage girl.

The evaluation of abdominal pain in the adolescent female is a common and often challenging problem. The unique anatomy and biology of the postmenarcheal teenager necessitates the consideration of a broad variety of additional genitourinary problems not encountered in the male. Further complicating this issue, the differential diagnoses involves not only pathological considerations, but normal physiological processes that may, in and of themselves, be symptomatic. One must be skillful enough to avoid unnecessary intervention, while aggressively pursuing significant intraabdominal problems. Occasionally, however, only invasive modalities will enable definitive diagnosis, and facility with these techniques significantly enhances both diagnostic and therapeutic capabilities in these patients.

Critical care of the injured child.

Critical care of the injured child should be an effective extension of aggressive resuscitation, stabilization, and definitive care. In the hours and days after acute injury, initially unnoticed lesions may emerge, secondary organ dysfunction may develop, and complications of primary injury or initial management may occur. We approach critical care of the severely injured child as a continuation of care begun in the trauma center. We follow an organ system, problem oriented protocol, and attempt to anticipate problems before they occur. This article defines our approach in general terms, with specific emphasis on the more common problems encountered in caring for seriously injured children.

Selective management of pediatric esophageal foreign bodies.

Esophageal foreign body is a relatively common consultation from the Pediatric Emergency Room. This study evaluates optimal selective management of esophageal foreign bodies in the pediatric patient. Eighty-six children have been referred for esophageal foreign body. Fifteen had been symptomatic for 48 or more hours before being seen. In eight, there was a known history of previous repair for esophageal atresia. In 88%, the foreign body was opaque, most frequently a coin. The most common nonopaque foreign body was retained food. Upon diagnosis, 72 children were taken to radiology, where balloon extraction under fluoroscopic control was attempted. Fourteen children went directly to the operating room for endoscopy and foreign body removal. Balloon extraction was successful in 62 cases (86%), and the children were discharged directly from the Emergency Department. The foreign body was successfully removed at esophagoscopy in the 10 cases that failed attempts at balloon extraction. Since 1990, successful extraction has been accomplished in 100% of cases (29/29). Neither balloon extraction nor endoscopy was associated with morbidity or mortality. Endoscopy was, however, associated with total hospital charges approximately 400% higher than balloon extraction. Fluoroscopically guided balloon extraction of appropriate esophageal foreign bodies is a safe and cost-effective alternative to endoscopy. Failure of nonoperative management does not complicate subsequent endoscopic removal. Patients with symptoms > 48 hours, a history of prior esophageal atresia, and/or nonopaque esophageal foreign bodies do not preclude attempt at balloon extraction.

Feeding gastrostomy button: experience and recommendations.

To circumvent the common problems and complications of long-term gastrostomy management, a skin-level nonrefluxing nonreactive gastrostomy "button" (GB) was designed. This silicon device is self-retaining, employing a one-way (in) valve. For feeding purposes, an adapter is inserted. Since initial results with five prototypes were encouraging, our experience with 90 buttons over a 20-month period forms the basis of this report. The GB is commercially available in three sizes: "small" (1.5 cm shaft length), medium (2.7 cm), and long (4.3 cm). A new narrow shafted prototype with an intermediary shaft length of 2.3 cm is under evaluation. We have analyzed our experience with the GB in 50 children (average age 4.1 years, average weight 12.8 kg) and six adults (average age 75 years) during this span. Ninety GBs were employed (small 46, medium 31, long 7, prototype 6) for a total of 485 patient months. In the pediatric age group, the average time with one or more GBs in place was 8.9 months. Of the 50 children, 30 had one GB only, 11 had two, six had three, and three had four GBs (total 82 GBs). The performance of each GB was under 1 month, 3 (mechanically defective); 1 to 3 months, 20; 3 to 6 months, 25; 6 to 12 months, 26; and over 12 months, 8 (two at 20 months). There were 31 changes in 20 children: leakage through GB shaft, 23 (valve incompetence); accidentally pulled out, 4; leakage around shaft (poor stoma), 2; and deterioration at feeding connection end, 2. One additional GB was purposely temporarily removed when the child underwent a colostomy closure. Seven GBs in children were removed since they were no longer needed. In two children, the GBs were replaced by a conventional catheter at 1 and 6 months post-GB insertion (chronic intermittent bowel obstruction requiring frequent drainage in one and multiple removals of the GB by the child in the other). Difficulties with early feeding adapters (frequent disconnections or shaft stretching) were encountered in five, but this is no longer a problem.(ABSTRACT TRUNCATED AT 250 WORDS)

The impact of computed tomography scanning on the child with renal trauma.

A six-year experience using computed tomography (CT) in the diagnosis of blunt abdominal trauma was reviewed to assess the impact of CT scanning on a patient with renal injury. Three questions were evaluated: Does the increased sensitivity of the CT scan alter the indications for surgery? Does the CT scan help predict the course and eventual outcome of nonoperative therapy? Are there circumstances when the CT scan is not the most efficient and cost effective method of diagnosis? One hundred seventy six consecutive patients with suspected renal trauma were reviewed. One hundred thirty eight were evaluated by CT scan and IVP, the other 38 by excretory urogram alone. Forty four renal injuries were identified. Four of these patients required urgent surgery and four others required later operation for unsuspected congenital anomalies. The injuries sustained by the other 36 cases resolved without surgery. Each patient has been followed for 1 to 5 years following their trauma, and their status assessed by questionnaire and physical examination. The CT technique provides better definition of the injury upon which to base the decision to operate or to enter the patient into nonoperative management. The extravasation seen on CT scan is frequently exaggerated and should not be an absolute indication for exploration. The scan provides improved follow-up data as to completeness of healing and allows directions to be given to the parents concerning resumption of full physical activities. The patients with asymptomatic posttraumatic hematuria, have in our experience, a very low incidence of intraperitoneal or retroperitoneal injuries. Therefore, these patients do not require the advantages of CT scan and may be screened by the less expensive intravenous pyelogram.