Pediatric SurgeryDo Ventriculoperitoneal Shunts Increase Complications After Laparoscopic Gastrostomy in Children?
Introduction
Laparoscopic gastrostomy tube placement was introduced in the 1990s and is one of the most common procedures performed in children. In 2006, an estimated 11,000 gastrostomy tubes were placed in children less than 18 y of age in the United States.1 Laparoscopic gastrostomy is a safe and frequently performed procedure for patients who are incapable of sufficient oral intake. Gastrostomy feeds has become the method of choice for providing nutrition to children who require long-term nutritional support.2, 3 Given the association of neurologic disorders and swallowing difficulties, gastrostomies are frequently needed in patients with ventriculoperitoneal (VP) shunts.
The presence of a VP shunt in children undergoing gastrostomy placement raises concerns regarding VP shunt integrity or infections as well as increased operative complexity. The postoperative course of these children may differ as well, and their rate of complications postoperatively is unknown. Currently, there is a paucity of data on the outcomes of children with VP shunts who undergo gastrostomy placement. The literature is conflicting with regard to the safety of percutaneous endoscopic gastrostomies and the literature addressing the laparoscopic approach is scarce.4, 5
As part of an effort to standardize postoperative protocols and feeding regimens after gastrostomy placement, we sought to determine whether this subset of patients had a similar risk profile after gastrostomy placement and should be included in a standardized pathway. The objective of this study was to evaluate the outcomes and early complications of children with VP shunts undergoing gastrostomy placement.
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Materials and methods
After approval by the Institutional Review Board at Texas Children's Hospital (H-39576), medical records of children 18 y old or younger who underwent a laparoscopic gastrostomy tube placement between January 2014 and October 2016 were retrospectively reviewed. At our institution, almost all gastrostomies are carried out laparoscopically with the exception of children with congenital heart defects which require cardiovascular anesthesiologist and are carried out open. This cohort of patients
Patient characteristics
There were 270 children who underwent laparoscopic gastrostomy tube placement by 15 pediatric surgeons. Although there may be attending variation in care, there are no systematic differences in children in the intraoperative care of children with and without VP shunts. The median age was 2.7 y, and 50% were male. The median weight was 11.4 kg with a median BMI of 15.5. Based on the American Society of Anesthesiologists physical status classification (ASA), most (76%) patients were an ASA class
Discussion
We have previously shown significant variation in the postoperative care of children undergoing gastrostomy placement.6 Reducing variation through implementation of guidelines and treatment protocols is important for the improvement of clinical care and reduction in costs.7, 8, 9 Care pathways are the most widely researched intervention to reduce variability and have been shown to be effective in reducing variations.7, 8, 9 However, a systematic review by Howell et al. found that of 20 studies
Acknowledgment
Authors' contributions: Study design was contributed by E.H.R., Y.R.Y., J.G.N., and S.R.S. Data collection was performed by E.H.R., K.M., A.S.D., and A.K. Analysis was carried out by E.H.R. Drafting and editing of article was carried out by E.H.R., Y.R.Y., S.R.S., J.G.N., K.M., A.S.D., and A.K.
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Cited by (7)
Evaluation of Risk of Gastrostomy and Ventriculoperitoneal Shunt Placement in Pediatric Patients: A Systematic Review of the Literature
2021, World NeurosurgeryCitation Excerpt :Of the 5 studies in which antibiotic prophylaxis was used, only 1 study found a significant increase in risk of complications in patients with both VPS and GT compared with patients with VPS or GT alone (hazard ratio, 2.0; 95% confidence interval 1.1–3.3 P < 0.05).19,30 These data seemingly support continued adherence to the 2013 Surgical Infection Society Guidelines that recommend antibiotic prophylaxis for this study population.29 The strength of evidence for antibiotic prophylaxis for both VPS and GT placement are Level A. However, more nuanced guidelines that address antibiotic usage and duration for patients requiring both procedures are not published.
CSF-diverting shunts: Implications for abdominal and pelvic surgeons; a review and pragmatic overview
2019, Annals of Medicine and SurgeryCitation Excerpt :The authors recommended shunt externalisation in dirty surgeries with purulent material present. Similarly, a retrospective review of 25 children with VP shunts undergoing gastrostomy tube placement showed a similar post-operative course and no higher risk of complications within a 90-day follow up period compared to non-shunted children undergoing the same procedure [6]. Two retrospective studies into patients undergoing abdominal surgery showed a low incidence of post-operative shunt infection in two patients each – these patients had undergone emergency surgery; either ‘dirty’ surgery (appendectomies for peritonitis), or clean-contaminated surgery [7,8].
Laparoscopic Fundoplication in Patients with Ventriculoperitoneal Shunts: A Systematic Review and Our Experience
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