Push-PEG or Pull-PEG: Does the Technique Matter? A Prospective Study Comparing Outcomes After Gastrostomy Placement.

BACKGROUND: Push-PEG (percutaneous endoscopic gastrostomy) with T-fastener fixation (PEG-T) allows one-step insertion of a balloon tube or button, and avoids contamination of the stoma by oral bacteria. However, PEG-T is a technically more demanding procedure with a significant learning curve. The aim of the present study was to compare outcomes after PEG-T and pull-PEG in a setting where both procedures were well established. MATERIALS AND METHODS: The study is a prospective cohort study including all patients between 0 and 18 year undergoing PEG-T and pull-PEG between 2017 and 2020 at a combined local and tertiary referral center. Complications and parent reported outcomes were recorded during hospital stay, after 14 days and 3 months postoperatively. RESULTS: 82 (93%) of eligible PEG-T and 37 (86%) pull-PEG patients were included. The groups were not significantly different with regard to age or weight. Malignant disorders and heart conditions were more frequent in the pull-PEG group, whilst neurodevelopmental disorders were more frequent in the PEG-T group (p < 0.001). 54% in both groups had a complication within 2 weeks. Late complications (between 2 weeks and 3 months postoperatively) occurred in 63% PEG-T vs 62% pull-PEG patients (p = 0.896). More parents in the pull-PEG group (49%) reported that the gastrostomy tube restricted their child's activity, compared to PEG-T (24%) (p = 0.01). At 3 months follow-up, more pull-PEG patients (43%) reported discomfort from the gastrostomy compared to PEG-T (21%) (p = 0.03). CONCLUSION: Overall complication rates were approximately similar, but pull-PEG was associated with more discomfort and restriction of activity. LEVELS OF EVIDENCE: Treatment study level II.

Congenital Duodenal Obstruction: National Trends in Management and Outcomes during the Last Quarter of a Century in Norway.

INTRODUCTION: During the last quarter of a century, new surgical techniques in neonates have been introduced, and neonatal intensive care has developed. Few studies have explored the implementation of new techniques and if outcomes in neonates undergoing gastrointestinal surgery have improved in the last decades. Therefore, this study aimed to investigate possible changes in postoperative outcomes and surgical techniques in all neonates operated for congenital duodenal obstruction (CDO) 1995 to 2020 in Norway. MATERIAL AND METHODS: This is a national multicenter retrospective study of all neonates undergoing surgery for CDO in Norway from 1995 to 2020. Results from three periods (1995-2003, 2004-2012, and 2013-2020) were compared. The study was approved by the local data protection officers (2020/13386) and (2020/15125). RESULTS: We included 186 patients: 41 in period 1 (1995-2003), 83 in period 2 (2004-2012), and 62 in period 3 (2013-2020). Seventy (38%) neonates had Down syndrome and 104 (62%) had additional malformations/disorders. Birth weight, gender, frequency of Down syndrome, and other malformations/disorders did not differ between the three periods. We observed an increased rate of prenatal diagnosis throughout the study period (p < 0.001). The only change in surgical technique was the increased use of transanastomotic feeding tubes (p < 0.001). Length of stay, postoperative complication rate, days with parenteral nutrition, and 30-day mortality rate were stable over time. CONCLUSION: Perioperative treatment and postoperative outcomes in neonates with CDO have been surprisingly unchanged during the last quarter of a century. Only an increased rate of prenatal diagnosis and more frequent use of transanastomotic feeding tubes were observed.

Reduced complication rate after implementation of a detailed treatment protocol for percutaneous endoscopic gastrostomy with T-fastener fixation in pediatric patients: A prospective study.

BACKGROUND/AIMS: Percutaneous endoscopic gastrostomy with push technique (PEG-T) is increasingly used in pediatric patients. In a retrospective study of PEG-T (cohort 1) we reported frequent complications related to T-fasteners and tube dislodgment. The aim of this study was to assess complications after implementation of a strict treatment protocol, and to compare these with the previous retrospective study. MATERIALS AND METHODS: The study is a prospective study of PEG-T placement performed between 2017 and 2020 (cohort 2) in pediatric patients (0-18 years). Complications were recorded during hospital stay, fourteen days and three months postoperatively, graded according to the Clavien-Dindo classification and categorized as early (<30 days) or late (>30 days). RESULTS: In total 82 patients were included, of which 52 (60%) had neurologic impairments. Median age and weight were 2.0 years [6 months-18.1 years] and 13.4 kg [3.5-51.5 kg], respectively. There was a significant reduction in median operating time from 28 min [10-65 min] in cohort 1 to 15 min [6-35 min] in cohort 2 (p<0.001), number of patients with early tube dislodgement (cohort 1: 9 (10%) vs cohort 2: 1 (1%), p = 0.012), and number of patients with late migrated T-fasteners (cohort 1: 11 (13%) vs cohort 2: 1 (1%), p = 0.004). CONCLUSION: We experienced less migrated T-fasteners and tube dislodgment after implementation of strict treatment protocol. LEVEL OF EVIDENCE: Treatment study level III.

Is postoperative transanastomotic feeding beneficial in neonates with congenital duodenal obstruction?

PURPOSE: We aimed to evaluate possible positive and negative effects of postoperative use of transanastomotic feeding tube (TAFT) in neonates operated for congenital duodenal obstruction (CDO). METHODS: This is a retrospective study reviewing medical records of neonates operated for CDO during 2003-2020 and comparing postoperative feeding outcomes and complications in patients with and without TAFT. Approval from the hospital's data protection officer was obtained. RESULTS: One hundred patients, 59% girls, were included, and 37% received TAFT. Mean birth weight and gestational age were 2628 (675.1) grams and 36.6 (2.4) weeks, respectively. Furthermore, 45% had no other malformations, and 36% had Down syndrome. Patient demographics were similar for TAFT and not-TAFT patients, except that not-TAFT neonates weighed median 335 g less (p = 0.013). The TAFT group got parenteral nutrition 2 days shorter (p < 0.001) and started enteral feeds 1.5 days earlier (p < 0.001) than the not-TAFT group. Fewer neonates with TAFT got a central venous catheter [65 vs 89%, (p = 0.008)]. In the TAFT group, 67% were breast fed at discharge compared to 49% in the not-TAFT group (p = 0.096). CONCLUSION: Neonates with TAFT had earlier first enteral feed, fewer days with parenteral nutrition and fewer placements of central venous catheters.

Trichobezoar. / Trikobesoar.

BACKGROUND: Rapunzel syndrome refers to a gastric bezoar with post-pyloric extension. CASE PRESENTATION: A child of primary school age presented with four days of abdominal pain, nausea, vomiting and a non-tender palpable mass in the upper part of the abdomen. The child had a history of trichotillomania and trichotillophagia. Preoperative imaging including abdominal ultrasound and upper gastrointestinal series was suggestive of gastric bezoar extending into the duodenum. At laparotomy and gastrotomy a large trichobezoar which had taken the shape of the stomach with a 60 cm long tail extending into the jejunum was removed. The child had an uneventful recovery and was discharged home on the fifth postoperative day. INTERPRETATION: Although rare, trichobezoar should be considered as a differential diagnosis for abdominal pain in young patients with a known history of trichotillomania and trichotillophagia.

Surgical treatment for urinary incontinence in children. / Kirurgisk behandling ved urininkontinens hos barn.

Only a small proportion of children with urinary tract malformations are incontinent, but it is important to identify those children for whom surgical treatment can eliminate or reduce urinary leakage.

Neurogenic bladder dysfunction in children. / Nevrogene blæreforstyrrelser hos barn.

Neurogenic bladder dysfunction is the cause of a small proportion of urinary problems in children. Various neurological conditions can result in a change in neural control of the bladder, and also the colon. Some of these conditions are apparent at birth; others are discovered later, and it is important that the primary health service be aware of them, so that targeted treatment can be provided.

Lower urinary tract dysfunction in children - a practical approach. / Vannlatingsforstyrrelser hos barn ­ en praktisk tilnærming.

More than 10 % of schoolchildren suffer from lower urinary tract dysfunction, often leading to contact with the healthcare system. The problem is socially limiting as well as mentally and physically demanding for children and their parents, and it is important to offer treatment. This article describes a structured approach that can form the basis for correct diagnosis and treatment.

[Surgical treatment of pyloric stenosis]. / Kirurgisk behandling av pylorusstenose.

BACKGROUND: Pyloric stenosis is one of the most common surgical conditions in infants. This study aims to investigate diagnostics and results of surgical treatment for pyloric stenosis at Oslo University Hospital Ullevål. MATERIAL AND METHOD: A retrospective review of patient records for those undergoing surgery for pyloric stenosis in the period 2004-2016 was conducted. Preoperative symptoms and findings, diagnostics, treatment and postoperative results were recorded. Postoperative complications were classified according to the Clavien-Dindo classification. RESULTS: We identified 140 patients, 123 boys and 17 girls. The sensitivity for ultrasound examination at Oslo University Hospital was 96 % (135/140). Pyloromyotomy was curative in all the patients. A total of 12 perioperative and 12 postoperative complications were determined in 22 patients (16 %). There were four serious postoperative complications (grade IIIb and grade IVa), none of which caused sequelae. Mucosal perforation occurred in two patients and was diagnosed and sutured postoperatively. Postoperative wound infection occurred in seven patients. INTERPRETATION: The diagnosis of pyloric stenosis was confirmed by ultrasound examination in 96 % of the patients who underwent surgery for pyloric stenosis. Pyloromyotomy was curative in all the patients and there were few serious complications.

Initial experience with percutaneous endoscopic gastrostomy with T-fastener fixation in pediatric patients.

BACKGROUND AND STUDY AIMS: Insertion of a percutaneous endoscopic gastrostomy (PEG) with push-through technique and T-fastener fixation (PEG-T) has recently been introduced in pediatric patients. The T-fasteners allow a primary insertion of a balloon gastrostomy. Due to limited data on the results of this technique in children, we have investigated peri- and postoperative outcomes after implementation of PEG-T in our department. PATIENTS AND METHODS: This retrospective chart review included all patients below 18 years who underwent PEG-T placement from 2010 to 2014. Main outcomes were 30-day postoperative complications and late gastrostomy-related complications. RESULTS: In total, 87 patients were included, and median follow-up time was 2.4 years (1 month - 4.9 years). Median age and weight at PEG-T insertion were 1.9 years (9.4 months - 16.4 years) and 10.4 kg (5.4 - 33.0 kg), respectively. Median operation time was 28 minutes (10 - 65 minutes), and 6 surgeons and 3 endoscopists performed the procedures. During the first 30 days, 54 complications occurred in 41 patients (47 %). Most common were peristomal infections treated with either local antibiotics in 11 patients (13 %) or systemic antibiotics in 11 other patients (13 %). 9 patients (10 %) experienced tube dislodgment. Late gastrostomy-related complications occurred in 33 patients (38 %). The T-fasteners caused early and late complications in 9 (10 %) and 11 patients (13 %), respectively. Of these, 4 patients (5 %) had subcutaneously migrated T-fasteners which were removed under general anesthesia. CONCLUSION: We found a high rate of complications after PEG-T. In particular, problems with the T-fasteners and tube dislodgment occurred frequently after PEG-T insertion.

Maternal psychological responses during pregnancy after ultrasonographic detection of structural fetal anomalies: A prospective longitudinal observational study.

In this longitudinal prospective observational study performed at a tertiary perinatal referral centre, we aimed to assess maternal distress in pregnancy in women with ultrasound findings of fetal anomaly and compare this with distress in pregnant women with normal ultrasound findings. Pregnant women with a structural fetal anomaly (n = 48) and normal ultrasound (n = 105) were included. We administered self-report questionnaires (General Health Questionnaire-28, Impact of Event Scale-22 [IES], and Edinburgh Postnatal Depression Scale) a few days following ultrasound detection of a fetal anomaly or a normal ultrasound (T1), 3 weeks post-ultrasound (T2), and at 30 (T3) and 36 weeks gestation (T4). Social dysfunction, health perception, and psychological distress (intrusion, avoidance, arousal, anxiety, and depression) were the main outcome measures. The median gestational age at T1 was 20 and 19 weeks in the group with and without fetal anomaly, respectively. In the fetal anomaly group, all psychological distress scores were highest at T1. In the group with a normal scan, distress scores were stable throughout pregnancy. At all assessments, the fetal anomaly group scored significantly higher (especially on depression-related questions) compared to the normal scan group, except on the IES Intrusion and Arousal subscales at T4, although with large individual differences. In conclusion, women with a known fetal anomaly initially had high stress scores, which gradually decreased, resembling those in women with a normal pregnancy. Psychological stress levels were stable and low during the latter half of gestation in women with a normal pregnancy.

Paternal psychological response after ultrasonographic detection of structural fetal anomalies with a comparison to maternal response: a cohort study.

BACKGROUND: In Norway almost all pregnant women attend one routine ultrasound examination. Detection of fetal structural anomalies triggers psychological stress responses in the women affected. Despite the frequent use of ultrasound examination in pregnancy, little attention has been devoted to the psychological response of the expectant father following the detection of fetal anomalies. This is important for later fatherhood and the psychological interaction within the couple. We aimed to describe paternal psychological responses shortly after detection of structural fetal anomalies by ultrasonography, and to compare paternal and maternal responses within the same couple. METHODS: A prospective observational study was performed at a tertiary referral centre for fetal medicine. Pregnant women with a structural fetal anomaly detected by ultrasound and their partners (study group,n=155) and 100 with normal ultrasound findings (comparison group) were included shortly after sonographic examination (inclusion period: May 2006-February 2009). Gestational age was >12 weeks. We used psychometric questionnaires to assess self-reported social dysfunction, health perception, and psychological distress (intrusion, avoidance, arousal, anxiety, and depression): Impact of Event Scale. General Health Questionnaire and Edinburgh Postnatal Depression Scale. Fetal anomalies were classified according to severity and diagnostic or prognostic ambiguity at the time of assessment. RESULTS: Median (range) gestational age at inclusion in the study and comparison group was 19 (12-38) and 19 (13-22) weeks, respectively. Men and women in the study group had significantly higher levels of psychological distress than men and women in the comparison group on all psychometric endpoints. The lowest level of distress in the study group was associated with the least severe anomalies with no diagnostic or prognostic ambiguity (p < 0.033). Men had lower scores than women on all psychometric outcome variables. The correlation in distress scores between men and women was high in the fetal anomaly group (p < 0.001), but non-significant in the comparison group. CONCLUSION: Severity of the anomaly including ambiguity significantly influenced paternal response. Men reported lower scores on all psychometric outcomes than women. This knowledge may facilitate support for both expectant parents to reduce strain within the family after detectionof a fetal anomaly.

Parenting stress and emotional wellbeing in mothers and fathers of preschool children.

AIMS: The aims of the study were to compare parenting stress and emotional wellbeing in mothers and fathers of preschool children, to look for predictors of different aspects of parenting stress in mothers and fathers, and to discriminate parenting stress from psychological distress and anxiety. METHODS: We studied 256 mothers and 204 fathers of children aged 1-7 years. The Swedish Parenthood Stress Questionnaire (SPSQ) assesses stress related to parenting. Emotional wellbeing was defined by the General Health Questionnaire-28 (GHQ-28) and the State Anxiety Inventory (STAI-X1) that measures psychological distress and anxiety, respectively. RESULTS: Fathers reported significantly more social isolation than mothers (P < 0.001). On all other parameters mothers, had higher scores, representing more stress and less wellbeing than fathers. Anxiety and psychological stress were strong predictors of parental stress in both mothers and fathers. Furthermore, maternal parental stress was predicted by birth of subsequent children and younger child age. Higher educational attainment predicted increased role restriction in fathers and more health problems in mothers. A principal component analysis (PCA) of the SPSQ, GHQ-28, and STAI-X1 showed that all endpoints of the analysis are positively correlated. CONCLUSIONS: Fathers reported significantly more social isolation, but less role restriction, incompetence and state anxiety than mothers. The SPSQ together with GHQ-28 and STAI-X1 allow a targeted screening aimed at contrasting parents who experience reduced emotional wellbeing with those who struggle with stress directly related to their parenting role.

Underlying correlation structures of parental stress, general health and anxiety.

A partial least square regression (PLSR) was performed on the Swedish Parenthood Stress Questionnaire (SPSQ) sum score and subscales on incompetence, role restriction, social isolation, spouse relationship and health problems, using 42 items from the General Health Questionnaire (GHQ) and 20 items from the State Anxiety Inventory (STAI-X1). The dataset contained 227 fathers and 301 mothers of children aged 1.0-6.6 years from a population-based study on parental psychological distress in the general Norwegian population, and all items correlated positively with SPSQ. Subscales on spouse relationship, incompetence, social isolation and role restriction related to items on state anxiety and depression. The SPSQ subscale on health problems related to GHQ items on somatic symptoms and social dysfunction. The STAI-X1 item "not feeling rested" had a particularly important effect on parental stress. Underlying correlation structures between parental stress and items from STAI-X1 and GHQ were explored, but only the SPSQ sum score could be acceptably predicted. PLSR as a statistical methodology was found useful for health and psychometric data.

Long-term parental psychological distress among parents of children with a malformation--a prospective longitudinal study.

We previously reported that prenatal diagnosis of malformations is associated with increased parental psychological distress after birth compared to distress in parents with postnatal diagnosis. We have now extended our earlier study to include a long-term follow-up of mothers and fathers 9 years after birth. Psychological responses were measured by General Health Questionnaire (GHQ-28), State Anxiety Inventory (STAI-X1), and Impact of Event Scale (IES) in 118 mothers and 100 fathers of 124 children with malformations 0-7 days (T1), 6 weeks (T2), 6 months (T3), and 9 years postpartum (T4). At T4 we observed no significant differences in psychological responses comparing parents with and without prenatal foreknowledge of their child's malformation. At T4 30.2% and 27.8% of the parents reported clinically important psychological distress and clinically important state anxiety, respectively. Intrusive stress decreased from T1 to T3, but increased significantly from T3 to T4. At T4 25.6% of the parents reported severe intrusive stress, with a higher proportion among mothers than fathers (32.8% vs. 17.2%, P = 0.029). In the multivariate analysis, unemployment predicted clinically important psychological distress at T4, whereas, clinically important state anxiety at T4 was predicted by low educational level. This study shows that prenatal diagnosis is associated with significantly increased psychological distress in the acute postnatal phase. However, there was no long-term increase in psychological distress among parents with prenatal foreknowledge of their child's malformation. The significantly increased intrusive stress at 9-year follow-up might reflect long-term challenges related to having a child with a malformation.

Congenital diaphragmatic hernia: a survey of practice in Scandinavia.

There is no consensus on the treatment of congenital diaphragmatic hernia (CDH), and practice seems to vary between centres. The main purpose of the present study was to survey current practice in Scandinavia. Thirteen paediatric surgical centres serving a population of about 22 million were invited, and all participated. One questionnaire was completed at each centre. The questionnaire evaluated management following prenatal diagnosis, intensive care strategies, operative treatment, and long-term follow-up. Survival data (1995-1998) were available from 12 of 13 centres. Following prenatal diagnosis of CDH, vaginal delivery and maternal steroids were used at eight and six centres, respectively. All centres used high-frequency oscillation ventilation (HFOV), nitric oxide (NO), and surfactant comparatively often. Five centres had extracorporeal membrane oxygenation (ECMO) facilities, and four centres transferred ECMO candidates. The majority of centres (7/9) always tried HFOV before ECMO was instituted. Surgery was performed when the neonate was clinically stable (11/13) and when no signs of pulmonary hypertension were detected by echo-Doppler (6/13). The repair was performed by laparotomy at all centres and most commonly with nonabsorbable sutures (8/13). Thoracic drain was used routinely at seven centres. Long-term follow-up at a paediatric surgical centre was uncommon (3/13). Only three centres treated more than five CDH patients per year. Comparing survival in centres treating more than five with those treating five or fewer CDH patients per year, there was a tendency towards better survival in the higher-volume centres (72.4%) than in the centres with lower volume (58.7%), p =0.065.