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Sa1602 Outcomes of Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement in Small Infants
Abstracts
Sa1600 Colonoscopy As a New Tool in Determining the Transition Zone in Endoanal Pull-Through in Hirschsprung’s Disease Preliminary Results Erika P. Ortolan, Pedro L. Lourenção, Gisele O. Orsi, Bonifácio K. Takegawa Surgery, Botucatu Medical School UNESP - Univ Estadual Paulista, Botucatu, Brazil Background: Surgical treatment of Hirschsprung’s disease (HD) has changed in recent decades, with attempts to reduce extensive surgical dissections. Independent of the technique used, the surgery consists in colectomy of the aganglionic region, beyond the transition zone. Since De la Torre & Ortega first described the exclusive transanal endorectal pull-through (TEPT) technique in 1998, it has become the technique of choice, especially in short aganglionic segments. However, recognizing the transition zone during TEPT is very difficult, leading to a procedure involving several frozen section biopsies and that requires an experienced pathologist. Kohno et al (2005) described the use of colonoscopy in determining a landmark for the location of pull-through with relatively accuracy, denominated the “shorebreak” finding, based on the principle that while normal bowel exhibits peristaltic movements, aganglionic bowel does not. He developed a retrospective study comparing the shorebreak finding in colonoscopy marked with India ink with pathological findings in frozen section biopsies. Based on this single report, our group decided to test this new approach, in a prospective study. The purpose of this work was to report our preliminary results concerning the prospective use of colonoscopy as a new tool to determine the transition zone in HD. Patients and Methods: Colonoscopy was prospectively performed on four patients with HD diagnosis, previously confirmed by anorectal manometry, contrast enema and suction biopsies. The exam was performed just prior to TEPT, using the same anesthetic and bowel prep procedure. The area marked with India ink was chosen following observation of colon motility during colonoscopy, in which the absence of motility identified the beginning of the aganglionic area. For endoscopic tattooing, physiological saline was injected locally submucosally to raise the mucosa, followed by the injection of India ink. All the exams were performed by the same pediatric surgery team member (main author), who was unaware of the contrast enema results. Informed consent to perform the exam was obtained. Results: In all patients, the shorebreak finding marked with India ink was equivalent to the aganglionic segment length and transition zone in contrast enemas. The patients were submitted to TEPT beyond this marked area. The excised colon was opened and the transition zone was macroscopically equivalent to the marked area. These results were confirmed by anatomopathological findings using HE, acetylcholinesterase and calretinin stains. Conclusion: Given these preliminary results, it is our conclusion that endoscopic marking of the shorebreak finding provides an important new tool for determining the point of TEPT in the treatment of HD, especially in hospitals that cannot depend on intraoperative frozen sections or experienced pathologists.
Sa1601 Are Biopsies Indicated in Colonoscopic Normal Areas? Erika P. Ortolan, Pedro L. Lourenção, Paula Angeleli, Gisele O. Orsi Surgery, Botucatu Medical School, Botucatu, Brazil Colonoscopy is nowadays one of the most important tools in diagnostic and therapeutic colorectal pathologies in adults and children. There is a lack of publications evaluating the indication of biopsies in pediatric patients. The colonoscopic multiple biopsies in macroscopically normal areas, increases the costs, the duration of the procedure and enhances morbidity. So, the clarification of the real necessity of biopsies is imperative. Objective: to investigate the agreement between the macro and microscopical findings in a retrospective study of the pediatric colonoscopies conducted between February 2007 and November 2010 in a single center. Methods: retrospective analysis of pediatric colonoscopies (0-18 years of age), performed by the same examiner, with attention to age, indication of the procedure, macro and microscopical findings. Patients with inadequate bowel prep were excluded from the study. The study was approved by the local Ethics Committee and an assigned consent form was obtained from each parent. Statistic analysis was performed using kappa indice and p value, beyond the sensitivity and specificity analysis. Results: in that period 63 exams were performed. 12 were considered with inadequate bowel prep and excluded from the study. 51 patients were included in the study, with ages ranging from 5 to 200 months (mean 119,14). In 28 cases (54.9%) the exam was indicated by suspicious or for control of IBD, in 10 (19.6 %) for digestive hemorrhage, in 8 (15.6%) for investigation and control of polyposes, 1 for control after colectomy for FAP, 1 for suspicious of colon anastomosis stenosis and 3 in investigation for severe chronic bowel constipation. From a total of 51 exams, polyps were found in 16, when polipectomy was performed, reason for opting against performing multiple biopsies. These patients were excluded from the statistic analysis. The other 35 cases had been submitted to biopsies. From these, macrocospic findings were considered normal in 15 (42.8%) and in 20 some grade of alteration was recorded. In microscopic analysis, from the 15
normal exams, 10 showed alteration (eosinophilic colitis), and in the 20 with macroscopic alteration, only 1 was normal. If we consider biopsies as a gold standard for the diagnosis of bowel alterations, the sensitivity of the colonoscopy without biopsy was 65,52% and specificity was 33,3% (kappa index 0,3063, p⬍0,01), what demonstrates a low concordance between macro and microscopic findings. Our study showed great discordance between macroscopic and microscopic findings. We believe that colonoscopy is an invasive procedure and therefore its results should be maximized with biopsies, avoiding misdiagnosis. Conclusion: in pediatric population, colonoscopic routine biopsies should be considered, even in macroscopically normal areas. A multicenter study is necessary to reassure these results.
Sa1602 Outcomes of Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement in Small Infants Maireade E. McSweeney1, Melissa L. Atmadja1, Meenakshi Ganesh2, Lauren G. Fiechtner2, Dennis C. Gotto1, Jenifer R. Lightdale1 1 Gastroenterology & Nutrition, Children’s Hospital, Boston, Boston, MA; 2Medicine, Children’s Hospital, Boston, Boston, MA Percutaneous endoscopic gastrostomy (PEG) tube placement is commonly performed by pediatric gastroenterologists in patients of all ages. There is little current data on placement of PEGs in small infants (⬍4kg), an often medically vulnerable group. Aim: To review our current institutional experience with PEG placement in infants ⬍4kg. Methods: A retrospective chart review of all patients undergoing PEG placement at Children’s Hospital Boston in 2008 was conducted with human subjects approval. Our institutional protocol involves referral to and assessment by a pediatric gastroenterologist for placement of a Corflo® (Corpak, Inc; Wheeling, IL) PEG tube, using a push/pull technique, in the main operating room under general anesthesia. All patients receive peri-operative antibiotics and remain in the hospital for a minimum of 48 hours post-procedure. Major complications were defined as unplanned adverse events requiring additional hospitalization, surgical, and/or interventional radiology procedures. Results: Of 128 patients undergoing PEG placement at our institution in 2008, 16% (n⫽20; 40% (8) male; 75% ASAⱖ III) were ⬍4kg at the time of PEG placement. Mean patient weight was 3.43 kg ⫾ 0.41 (range 2.4-3.98 kg). 45% (9) infants were born prematurely (⬍37 weeks gestation); median estimated gestational age at birth was 28 4/7 weeks (range: 24-35 1/7 weeks). Other co-morbidities included: cardiac disease (35%), neurological abnormalities (30%), oropharyngeal abnormalities (15%), pulmonary disease (15%), and IUGR (5%). Indications for PEG placement included impaired growth (30%), feeding difficulties (60%), and documented aspiration by modified barium swallow (MBS) (10%). Workup prior to PEG placement included MBS in 55% (11) and UGI in 70% (14). 95% (19) of patients received nasogastric feeds prior to PEG placement and had at least 1 GI clinic visit post-PEG placement (median follow-up post-placement was 16 months, range 2-27 months). 30% (6) had documented PEG exchange at our institution to a skin-level device (MIC-KEY™; Kimberly-Clark, Inc; Dallas, TX) via traction pull with no sedation, while 15% (3) underwent complete PEG removal. 10% (2) did not tolerate feeds, prompting transition to gastro-jejunal tubes. 45% (9) were documented in 2010 to still be receiving enteral tube feeds. No major complications were noted. 10% (2) patients developed cellulitis, requiring oral antibiotics. 2 expired due to non-PEG related complications after 3.6 and 4.4 months post-placement. Conclusion: Small infants ⬍4kg at our institution underwent PEG placement safely, without intraoperative or post-procedural major complications. More longitudinal studies are needed to better assess outcomes associated with endoscopically placed gastrostomy tubes in this medically complex population.
Sa1603 A Pilot Study to Assess the Safety and Efficacy of Carbon Dioxide Insufflation in Sedated Pediatric Endoscopy Mai Kusakari1, Yoshiko Nakayama1, Akira Horiuchi2, Nao Hidaka1, Sawako Kato1, Kenichi Koike1 1 Shinshu university school of medicine, Matsumoto, Japan; 2Showa Inan General hospital, komagane, Japan Background: Several studies have shown that insufflation of carbon dioxide(CO2) instead of air during endoscopy can reduce postprocedual abdominal distension in adult. However, CO2 insufflation might also lead to CO2 retention in the human body especially in sedated patients and children. Objective: This is a case-control series with a historical control to assess the safety and efficacy of CO2 insufflation instead of air insufflations during esophagogastroduodenoscopy(EGD) and colonoscopy(CS) in pediatric patients under unconscious sedation. Patients and methods: A total of 32 consecutive patients were enrolled in this study. Another 67 consecutive patients who previously received EGD, CS, and both EGD and CS sequentially by using air insufflations were included as a historical control. End-tidal carbon dioxide (EtCO2) was recorded using the microstream capnography before
AB220 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org
Sa1600 Colonoscopy As a New Tool in Determining the Transition Zone in Endoanal Pull-Through in Hirschsprung’s Disease Preliminary Results Erika P. Ortolan, Pedro L. Lourenção, Gisele O. Orsi, Bonifácio K. Takegawa Surgery, Botucatu Medical School UNESP - Univ Estadual Paulista, Botucatu, Brazil Background: Surgical treatment of Hirschsprung’s disease (HD) has changed in recent decades, with attempts to reduce extensive surgical dissections. Independent of the technique used, the surgery consists in colectomy of the aganglionic region, beyond the transition zone. Since De la Torre & Ortega first described the exclusive transanal endorectal pull-through (TEPT) technique in 1998, it has become the technique of choice, especially in short aganglionic segments. However, recognizing the transition zone during TEPT is very difficult, leading to a procedure involving several frozen section biopsies and that requires an experienced pathologist. Kohno et al (2005) described the use of colonoscopy in determining a landmark for the location of pull-through with relatively accuracy, denominated the “shorebreak” finding, based on the principle that while normal bowel exhibits peristaltic movements, aganglionic bowel does not. He developed a retrospective study comparing the shorebreak finding in colonoscopy marked with India ink with pathological findings in frozen section biopsies. Based on this single report, our group decided to test this new approach, in a prospective study. The purpose of this work was to report our preliminary results concerning the prospective use of colonoscopy as a new tool to determine the transition zone in HD. Patients and Methods: Colonoscopy was prospectively performed on four patients with HD diagnosis, previously confirmed by anorectal manometry, contrast enema and suction biopsies. The exam was performed just prior to TEPT, using the same anesthetic and bowel prep procedure. The area marked with India ink was chosen following observation of colon motility during colonoscopy, in which the absence of motility identified the beginning of the aganglionic area. For endoscopic tattooing, physiological saline was injected locally submucosally to raise the mucosa, followed by the injection of India ink. All the exams were performed by the same pediatric surgery team member (main author), who was unaware of the contrast enema results. Informed consent to perform the exam was obtained. Results: In all patients, the shorebreak finding marked with India ink was equivalent to the aganglionic segment length and transition zone in contrast enemas. The patients were submitted to TEPT beyond this marked area. The excised colon was opened and the transition zone was macroscopically equivalent to the marked area. These results were confirmed by anatomopathological findings using HE, acetylcholinesterase and calretinin stains. Conclusion: Given these preliminary results, it is our conclusion that endoscopic marking of the shorebreak finding provides an important new tool for determining the point of TEPT in the treatment of HD, especially in hospitals that cannot depend on intraoperative frozen sections or experienced pathologists.
Sa1601 Are Biopsies Indicated in Colonoscopic Normal Areas? Erika P. Ortolan, Pedro L. Lourenção, Paula Angeleli, Gisele O. Orsi Surgery, Botucatu Medical School, Botucatu, Brazil Colonoscopy is nowadays one of the most important tools in diagnostic and therapeutic colorectal pathologies in adults and children. There is a lack of publications evaluating the indication of biopsies in pediatric patients. The colonoscopic multiple biopsies in macroscopically normal areas, increases the costs, the duration of the procedure and enhances morbidity. So, the clarification of the real necessity of biopsies is imperative. Objective: to investigate the agreement between the macro and microscopical findings in a retrospective study of the pediatric colonoscopies conducted between February 2007 and November 2010 in a single center. Methods: retrospective analysis of pediatric colonoscopies (0-18 years of age), performed by the same examiner, with attention to age, indication of the procedure, macro and microscopical findings. Patients with inadequate bowel prep were excluded from the study. The study was approved by the local Ethics Committee and an assigned consent form was obtained from each parent. Statistic analysis was performed using kappa indice and p value, beyond the sensitivity and specificity analysis. Results: in that period 63 exams were performed. 12 were considered with inadequate bowel prep and excluded from the study. 51 patients were included in the study, with ages ranging from 5 to 200 months (mean 119,14). In 28 cases (54.9%) the exam was indicated by suspicious or for control of IBD, in 10 (19.6 %) for digestive hemorrhage, in 8 (15.6%) for investigation and control of polyposes, 1 for control after colectomy for FAP, 1 for suspicious of colon anastomosis stenosis and 3 in investigation for severe chronic bowel constipation. From a total of 51 exams, polyps were found in 16, when polipectomy was performed, reason for opting against performing multiple biopsies. These patients were excluded from the statistic analysis. The other 35 cases had been submitted to biopsies. From these, macrocospic findings were considered normal in 15 (42.8%) and in 20 some grade of alteration was recorded. In microscopic analysis, from the 15
normal exams, 10 showed alteration (eosinophilic colitis), and in the 20 with macroscopic alteration, only 1 was normal. If we consider biopsies as a gold standard for the diagnosis of bowel alterations, the sensitivity of the colonoscopy without biopsy was 65,52% and specificity was 33,3% (kappa index 0,3063, p⬍0,01), what demonstrates a low concordance between macro and microscopic findings. Our study showed great discordance between macroscopic and microscopic findings. We believe that colonoscopy is an invasive procedure and therefore its results should be maximized with biopsies, avoiding misdiagnosis. Conclusion: in pediatric population, colonoscopic routine biopsies should be considered, even in macroscopically normal areas. A multicenter study is necessary to reassure these results.
Sa1602 Outcomes of Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement in Small Infants Maireade E. McSweeney1, Melissa L. Atmadja1, Meenakshi Ganesh2, Lauren G. Fiechtner2, Dennis C. Gotto1, Jenifer R. Lightdale1 1 Gastroenterology & Nutrition, Children’s Hospital, Boston, Boston, MA; 2Medicine, Children’s Hospital, Boston, Boston, MA Percutaneous endoscopic gastrostomy (PEG) tube placement is commonly performed by pediatric gastroenterologists in patients of all ages. There is little current data on placement of PEGs in small infants (⬍4kg), an often medically vulnerable group. Aim: To review our current institutional experience with PEG placement in infants ⬍4kg. Methods: A retrospective chart review of all patients undergoing PEG placement at Children’s Hospital Boston in 2008 was conducted with human subjects approval. Our institutional protocol involves referral to and assessment by a pediatric gastroenterologist for placement of a Corflo® (Corpak, Inc; Wheeling, IL) PEG tube, using a push/pull technique, in the main operating room under general anesthesia. All patients receive peri-operative antibiotics and remain in the hospital for a minimum of 48 hours post-procedure. Major complications were defined as unplanned adverse events requiring additional hospitalization, surgical, and/or interventional radiology procedures. Results: Of 128 patients undergoing PEG placement at our institution in 2008, 16% (n⫽20; 40% (8) male; 75% ASAⱖ III) were ⬍4kg at the time of PEG placement. Mean patient weight was 3.43 kg ⫾ 0.41 (range 2.4-3.98 kg). 45% (9) infants were born prematurely (⬍37 weeks gestation); median estimated gestational age at birth was 28 4/7 weeks (range: 24-35 1/7 weeks). Other co-morbidities included: cardiac disease (35%), neurological abnormalities (30%), oropharyngeal abnormalities (15%), pulmonary disease (15%), and IUGR (5%). Indications for PEG placement included impaired growth (30%), feeding difficulties (60%), and documented aspiration by modified barium swallow (MBS) (10%). Workup prior to PEG placement included MBS in 55% (11) and UGI in 70% (14). 95% (19) of patients received nasogastric feeds prior to PEG placement and had at least 1 GI clinic visit post-PEG placement (median follow-up post-placement was 16 months, range 2-27 months). 30% (6) had documented PEG exchange at our institution to a skin-level device (MIC-KEY™; Kimberly-Clark, Inc; Dallas, TX) via traction pull with no sedation, while 15% (3) underwent complete PEG removal. 10% (2) did not tolerate feeds, prompting transition to gastro-jejunal tubes. 45% (9) were documented in 2010 to still be receiving enteral tube feeds. No major complications were noted. 10% (2) patients developed cellulitis, requiring oral antibiotics. 2 expired due to non-PEG related complications after 3.6 and 4.4 months post-placement. Conclusion: Small infants ⬍4kg at our institution underwent PEG placement safely, without intraoperative or post-procedural major complications. More longitudinal studies are needed to better assess outcomes associated with endoscopically placed gastrostomy tubes in this medically complex population.
Sa1603 A Pilot Study to Assess the Safety and Efficacy of Carbon Dioxide Insufflation in Sedated Pediatric Endoscopy Mai Kusakari1, Yoshiko Nakayama1, Akira Horiuchi2, Nao Hidaka1, Sawako Kato1, Kenichi Koike1 1 Shinshu university school of medicine, Matsumoto, Japan; 2Showa Inan General hospital, komagane, Japan Background: Several studies have shown that insufflation of carbon dioxide(CO2) instead of air during endoscopy can reduce postprocedual abdominal distension in adult. However, CO2 insufflation might also lead to CO2 retention in the human body especially in sedated patients and children. Objective: This is a case-control series with a historical control to assess the safety and efficacy of CO2 insufflation instead of air insufflations during esophagogastroduodenoscopy(EGD) and colonoscopy(CS) in pediatric patients under unconscious sedation. Patients and methods: A total of 32 consecutive patients were enrolled in this study. Another 67 consecutive patients who previously received EGD, CS, and both EGD and CS sequentially by using air insufflations were included as a historical control. End-tidal carbon dioxide (EtCO2) was recorded using the microstream capnography before
AB220 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org