- Email: [email protected]
Sa2075 Use of Peroral Endoscopic Myotomy (POEM) in Pediatric Patients as a Primary or Rescue Therapy for Achalasia
Abstracts
(UCEIS-max). A global assessment of endoscopic lesion severity for the entire colon (GELS) was also recorded using a visual analogue scale. Inter-rater reliability (IRR) was measured using Intraclass correlation coefficients (ICCs). Correlation between scoring tools was measured using Spearman’s test of correlation (r). Results: There was a broad range of endoscopic severity (median UCEIS 6 (Range 3 – 8). The IRR for each aspect of the UCEIS are displayed in Table 1. The tool performed well throughout the colon, with ‘bleeding’ being the variable demonstrating the most disagreement. When comparing standard UCEIS and UCEIS-max, in 33% of patients the maximally affected segment was proximal to the rectosigmoid. In 10% of these subjects the difference in UCEIS score was greater than 1 point. (p Z <0.001). Correlation with GELS was better for UCEIS-max (r Z 0.79, p <0.001), than for standard UCEIS (r Z 0.68, p <0.001). Conclusions: UCEIS is a valuable tool in the assessment of endoscopic disease severity in paediatric UC. UCEIS, when applied in standard fashion to the recto-sigmoid shows excellent IRR amongst IBD physicians. The tool can be applied across the colon, with only a small decrease in consistency. In this group of patients diagnosed with UC, one third of patients will have the maximally affected area proximal to the rectosigmoid, highlighting the importance of complete colonoscopy in assessing disease activity in UC.
Table 1 – Inter-rater reliability for UCEIS variables across anatomical segments UCEIS Location Standard Rectosigmoid Descending Colon Transverse Colon Ascending Colon
Total
Vascular Pattern
Bleeding
Erosions/Ulcers
0.87 (0.74 – 0.95) p Z <0.001 0.81 (0.73 – 0.96) p Z <0.001 0.79 (-0.60 – 0.85) p Z 0.02 0.74 (0.25 – 0.95) p Z 0.01
0.80 (0.60 – 0.91) p Z <0.001 0.89 (0.77 – 0.95) p Z <0.001 0.90 (0.72 – 0.98) p Z <0.001 0.85 (0.53 – 0.97) p Z <0.001
0.50 (0.11 – 0.77) p Z 0.01 0.61 (0.25 - 0.82) p Z <0.001 0.74 (0.26 – 0.91) p Z 0.01 0.69 (0.25 – 0.88) p Z 0.01
0.88 (0.76 – 0.95) p Z <0.001 0.86 (0.71 – 0.94) p Z <0.001 0.69 (0.2 – 0.77) p Z 0.02 0.77 (0.1 – 0.94) P Z 0.05
Sa2074 Recurrent Abdominal Pain in Children: When Should Colonoscopy Be Performed? Harveen Singh, Looi C. Ee* Lady Cilento Children’s Hospital, Brisbane, Queensland, Australia Introduction: Recurrent abdominal pain in children is common, and may result from a multitude of conditions including functional disorders, celiac disease, constipation and inflammatory bowel disease (IBD). While pain is not considered to be an indication for colonoscopy, many are performed to exclude significant pathology. Several reviews have reported abdominal pain to be the primary indication for colonoscopy in 13-20% of pediatric patients. The utility of colonoscopy in recurrent abdominal pain in children remains unclear. Our aim was to assess the diagnostic yield and role of colonoscopy when assessing children with recurrent abdominal pain. Methods: Retrospective review of all colonoscopies between November 2011 and October 2015 in a tertiary pediatric hospital was performed. All patients in whom abdominal pain was an indication for colonoscopy were included in this study. Patient demographics, reason for procedure, secondary indications, endoscopic findings and histology were noted. Stool calprotectin and serum inflammatory markers, if performed were also recorded. Results: 652 colonoscopies were performed during this period, of which 65 (10%) had abdominal pain as one of the indicators for procedure. Median age of the patients was 12 (2-16) years, and 42/65 (65%) were female. Photographs and/or biopsy were used to confirm the extent of colonoscopy in 99.2% of patients, with cecal intubation rate 96.3% (628/652) and ileal intubation rate 92.5% (602/652). Only 2% (15/652) of procedures were performed for isolated abdominal pain, while the rest had other indications including altered bowel habit (nZ15), weight loss (nZ14), significant family history of IBD or polyps (nZ8), iron deficiency anemia (nZ7), food allergy (nZ3), and rectal bleeding (nZ3). All patients had serum inflammatory markers measured (CRP or ESR) and 52% (34/65) had stool calprotectin performed. 6% (4/65) of patients with abdominal pain had elevated stool calprotectin or inflammatory markers. Only 11% (7/65) of patients had positive findings at colonoscopy, which included Crohn’s disease (nZ3), polyps (nZ2), and microscopic colitis (nZ2). No patient with isolated abdominal pain had positive findings. Patients with associated altered bowel habit or weight loss were more likely to have positive findings; these patients also had abnormal calprotectin and inflammatory markers. Conclusion: The likelihood of significant findings on colonoscopy in children with abdominal pain is low, 11%, and unlikely in the absence of other symptoms or findings. Colonoscopy is not warranted in children with isolated abdominal pain in the absence of secondary symptoms or abnormal calprotectin or inflammatory markers.
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Sa2075 Use of Peroral Endoscopic Myotomy (POEM) in Pediatric Patients as a Primary or Rescue Therapy for Achalasia Stavros N. Stavropoulos*1, Amanda B. Sosulski2, Rani J. Modayil2, Krishna C. Gurram2, Collin E. Brathwaite2, Charles V. Coren2, Harika Boinpally2, James H. Grendell2 1 Medicine, Winthrop Univ. Hosp.-Columbia Univ., Roslyn, NY; 2Winthrop University Hospital, Mineola, NY Background: Achalasia is rare in children with an incidence of w0.1 per 100,000 (approximately one tenth of that seen in the adult population). Historically, achalasia in children has been successfully treated with laparoscopic Heller myotomy (LHM) or pneumatic dilatation (PD). Per Oral Endoscopic Myotomy (POEM) is a minimally invasive Natural Orifice Transluminal Endoscopic Surgery (NOTES) approach to myotomy first performed in 2008, with two publications appearing in 2010 including a case report from our center. With over 5,000 procedures now having been performed there is a growing body of evidence demonstrating excellent safety and high efficacy rivaling that of LHM at mid-term follow-up of 2-3 years. Based on these promising results in adults, POEM is now gradually being introduced to the pediatric population. Five pediatric POEM series (cohorts ranging from 5 to 26 patients) have appeared in the literature over the past year from China (3), Italy (1) and India (1) (Table 1) reporting excellent outcomes that appear superior to pneumatic dilation and at least equivalent to LHM. We report herein the first US series of pediatric POEMs consisting of 10 POEMs (third largest series to date worldwide) including 2 patients in whom POEM was used as rescue therapy after prior failed LHM (only one other series from India reported also 2 such patients). Methods: From a prospectively maintained database of all POEMs performed at our center from 10/2009 to 10/2016 we extracted all POEMs performed on pediatric patients ( <18 years). Out of 318 consecutive POEMs performed during this period by a single operator, 10 pediatric POEMs were identified (3%). We analyzed procedural and patient characteristics, efficacy metrics including LES pressure, Eckardt score and timed barium emptying (TBE), adverse events (AEs), length of stay (LOS) and GERD assessments. Results: See Table 2. 10 patients, mean age 14.7 (10-17) underwent POEM from 2013 to 2016 with the first being patient #99 in our POEM series (i.e. well beyond our initial learning curve for the procedure). Mean duration of symptoms was 21 months (3-84) and 4 patients had previous treatments (2 LHM, 2 dilation). Mean POEM duration was 55 minutes (33-111) and mean LOS 1 day (12). There were no significant AEs. At mean follow-up of 15 months (1- 30) clinical success (Eckardt score 3) was 100% with marked improvements in mean Eckardt score (7.9 to 0.4), mean LES pressure (6 pts, 50 mmHg to 19 mmHg) and TBE(5 pts, 4/5 with 100% emptying at 5 min, 1/5 with 90% emptying at 5 min). pH study+ in 2/5 (40%) with mild erosive esophagitis in the same 2/5 patients (40%). GERD controlled with once a day PPI. Conclusion: POEM provides a safe and effective minimally invasive alternative to LHM in children and may be also used as rescue therapy after prior LHM or dilation.
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB285
Abstracts
Patient Characteristic Secondary Diagnosis, # (%) Aspiration Dysphagia Failure to Thrive Feeding Difficulties Feeding Problems Poor Weight Gain
Early Feeding
Controls
4 (14.8%) 6 (22.2%) 9 (33.3%) 13 (48.1%) 3 (11.1%) 2 (7.4%)
4 (14.8%) 13 (48.1%) 10 (37%) 2 (7.4%) 9 (33.3%) 2 (7.4%)
p
Table 2. Patient Outcomes by Study Group Outcome
Sa2076 Safety and Outcomes of Early Nutrition Following Percutaneous Endoscopic Gastrostomy Tube Placement in Children Katie L. Mills1, Racha T. Khalaf2, Michael Wilsey*1, Alexander D. Wilsey3, Emily Swan3 1 Gastroenterology, Hepatology, and Nutrition, Johns Hopkins All Children’s Hospital, St Petersbrg, FL; 2Medical Education, Johns Hopkins All Children’s Hospital, St. Petersburg, FL; 3Florida State University, Tallahassee, FL Background: In pediatric patients it is common practice to wait up to 24 hours to begin enteral feedings using a newly placed percutaneous endoscopic gastrostomy (PEG) tube. This delay in feeding was believed to prevent post-procedural complications. Several studies report the safety and efficacy of initiating nutrition as early as three to six hours after gastrostomy tube placement in adults. However, there are few studies that examine early feeding in the pediatric population. Patients and Methods: An IRB approved, prospective controlled trial beginning November 2015 initiating enteral nutrition less than six hours following PEG tube placement in children six months to 18 years of age. Outcomes measuring the safety and tolerability of early feedings, and hospital length of stay were recorded. Pain medication use and compications such as fever, vomiting, and leakage around the stoma, in addition to adverse events including peritonitis and aspiration were recorded. Results from the early feeing group were compared to data collection from a historical control group whose feedings had not been initiated until he first post-operative day. Results: Hospital length of stay was defind as the time of arrival to the inpatient unit following their procedure to time of hospital discharge. Participants who remained inpatient for reasons related to their primary diagnosis were excluded from the duration of hospital stay data. The Wilcoxon rank sum test was used to compare continuous characteristics and outcomes between the two groups; whereas, the chisquare test was used to compare categorical data. Twenty-seven patients per group were studied. No significant demographic difference between the groups were observed. A decrease in the median hospital length of stay was noted in the early feeing group, but there were more minor adverse events. Although this number is statistically significant, these minor events did not appear clinically significant nor did they requre nonstandard intervention. Conclsion: Our study suggests initating enteral nutrition less than six hours folowing PEG tube placement is as safe as waiting until the first post-operative day in this pediatric cohot. Furthermore, initiating early nutrition following PEG tube placement in children may lead to a decrease length of hospital stay.
Table 1. Patient Demographic Information by Study Group Patient Characteristic Years of Age, median (range) Female Gender, # (%) Primary Diagnosis, # (%) Neurologic Genetic GI Respiratory Other
Early Feeding
Controls
p
3 (.58-16) 13 (48.1%)
4 (.75-17) 13 (48.1%)
0.98 1 0.14
12 (44.4%) 2 (7.4%) 4 (14.8%) 5 (18.5%) 4 (14.8%)
12 (44.4%) 9 (33.3%) 3 (11.1%) 1 (3.7%) 2 (7.4%)
AB286 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
Early Feeing
Controls
p
Time to First Feed, hours, median (range) 3.4 (1.3-5.5) 24.3 (5.5-52.1) 0.001 Length of Stay, hours, median (range) 26.4 (22-49.1) 50.5 (27.7-144.4) 0.001 Febrile Occurrence, # (%) 4 (14.81%) 9 (33.33%) 0.20 Minor Event, # (%) 0.009 Vomiting 3 (11.11%) 2 (7.41%) Leakage around stoma 7 (25.93%) 0 (0%) Other 0 (0%) 1 (3.7%) Major Event, # (%) 1 Peritonitis, Aspiration 0 (0%) 0 (0%) Other 1 (3.7%) 1 (3.7%) Medication Doses, mean (SD) Non-Narcotic 2.40 (1.88) 2.33 (1.59) 0.87 Narcotic 1.70 (1.63) 2.03 (1.65) 0.46
Sa2077 Esophageal Strictures in Pediatric Patients With Eosinophilic Esophagitis (EOE); Short Segment Stricture vs. Narrow Caliber Esophagus Vijayalakshmi Kory1, Vimal Gunasekaran1, Alan Schwartz3, James Berman1,3, Thirumazhisai S. Gunasekaran*1,2 1 Pediatric Gastroenterology, Advocate Children’s Park Ridge, Park Ridge, IL; 2Pediatrics, Ronald McDonald Children’s Hospital, Maywood, IL; 3Pediatrics, University of Illinois, Chicago, IL
Patients with EoE are classified as inflammatory and fibrostenotic and stricture may be an end result in the latter group. We describe EoE pediatric patients with esophageal strictures; segmental (SS) and tubular or narrow caliber esophagus (NCE). Aim: compare clinical features,endoscopy+Bx,treatment including dilation,and outcomes of patients with SS and NCE. Methods: In this retrospective study,children with EoE seen between 1/2001 and 9/2016 were stratified based on main symptom into groups for further analysis as;Dysphagia (EoE-D), abdominal pain without dysphagia, reflux without dysphagia and FTT/Feeding difficulty. From the EoE-D group,patients with strictures defined as;not able to pass regular endoscope OD 9mm or when passed had a mucosal tear,were included. Then were subclassified as;Short segment strictures- SS.(narrowing < 2 cm length) and Narrow caliber esophagus- NCE(narrowing more than 1/3 length of the esophagus). Physical findings,CBC,esophagram,EGD and biopsy of the duodenum,antrum,distal and mid esophagus were captured. Diagnosis of EoE made as per the 2011 consensus. Treatments included topical steroids,dietary modification, +/-PPIs. Strictures were dilated,after initiation of treatment,either with bougies or through the scope balloons. Symptom score for dysphagia, nausea,vomiting,regurgitation,early satiety and heartburn were scored:absent -0, mild -1,and severe-2 except dysphagia had a score up to 3 if they had food impaction. Esophageal EGD findings were scored at diagnosis and follow up. Results: Total EoE patients;373,and EoE-D -101 and 13 had strictures. Stricture incidence 3.4% within the entire group and 12.9% within EoED.Gr –SS:10 and Gr –-NCE:3,mean age 13.04 and 8.7 yrs. (pZ.09). There were no patients with strictures who did not fall between these two groups. Clinical features, X-ray, EGD + biopsy;see Table 1. Dilation type; dilation by passage of endoscope:8,balloon:3,Maloney: 2. Total dilations for Gr-SS: 24(mean 2.4) and for Gr- NCE 12 (mean 4) (pZ.51). Complications: no perforations, chest pain -2. Follow up: GrSS: mean 1.03 yrs.(range 1-12 months) and in Gr-NCE 2.07yrs (1month-5.06yrs). Medical treatment: fluticasone-2,diet-1 or combination-3 and PPI -7. Symptom improvement; mean dysphagia score: Gr-SS 2.7 to 0.7 and Gr -NCE 2.3 to 0.9;composite score 2.5 to 0.9 and 3.0 to 1 respectively. EGD score improved; Gr -SS from 2.5 to 2 (pZ0.07) and NCE from 2 to 1.7 (pZ 0.42); peak eosinophil count: GrSS 44.3 to 38.6 (pZ0.40), and in Gr- NCE 45.6 to 5.3(pZ0.20). Conclusion: Incidence of esophageal stricture:3.4% within the entire EoE patients and 12.9% within the EoE –D. NCE group required more dilations than the SS group, but was not significant. Both groups had symptomatic improvement. EGD scores showed minimal improvement with dilation and treatment. NEC group had significant improvement in the eosinophils compared to SS group.
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(UCEIS-max). A global assessment of endoscopic lesion severity for the entire colon (GELS) was also recorded using a visual analogue scale. Inter-rater reliability (IRR) was measured using Intraclass correlation coefficients (ICCs). Correlation between scoring tools was measured using Spearman’s test of correlation (r). Results: There was a broad range of endoscopic severity (median UCEIS 6 (Range 3 – 8). The IRR for each aspect of the UCEIS are displayed in Table 1. The tool performed well throughout the colon, with ‘bleeding’ being the variable demonstrating the most disagreement. When comparing standard UCEIS and UCEIS-max, in 33% of patients the maximally affected segment was proximal to the rectosigmoid. In 10% of these subjects the difference in UCEIS score was greater than 1 point. (p Z <0.001). Correlation with GELS was better for UCEIS-max (r Z 0.79, p <0.001), than for standard UCEIS (r Z 0.68, p <0.001). Conclusions: UCEIS is a valuable tool in the assessment of endoscopic disease severity in paediatric UC. UCEIS, when applied in standard fashion to the recto-sigmoid shows excellent IRR amongst IBD physicians. The tool can be applied across the colon, with only a small decrease in consistency. In this group of patients diagnosed with UC, one third of patients will have the maximally affected area proximal to the rectosigmoid, highlighting the importance of complete colonoscopy in assessing disease activity in UC.
Table 1 – Inter-rater reliability for UCEIS variables across anatomical segments UCEIS Location Standard Rectosigmoid Descending Colon Transverse Colon Ascending Colon
Total
Vascular Pattern
Bleeding
Erosions/Ulcers
0.87 (0.74 – 0.95) p Z <0.001 0.81 (0.73 – 0.96) p Z <0.001 0.79 (-0.60 – 0.85) p Z 0.02 0.74 (0.25 – 0.95) p Z 0.01
0.80 (0.60 – 0.91) p Z <0.001 0.89 (0.77 – 0.95) p Z <0.001 0.90 (0.72 – 0.98) p Z <0.001 0.85 (0.53 – 0.97) p Z <0.001
0.50 (0.11 – 0.77) p Z 0.01 0.61 (0.25 - 0.82) p Z <0.001 0.74 (0.26 – 0.91) p Z 0.01 0.69 (0.25 – 0.88) p Z 0.01
0.88 (0.76 – 0.95) p Z <0.001 0.86 (0.71 – 0.94) p Z <0.001 0.69 (0.2 – 0.77) p Z 0.02 0.77 (0.1 – 0.94) P Z 0.05
Sa2074 Recurrent Abdominal Pain in Children: When Should Colonoscopy Be Performed? Harveen Singh, Looi C. Ee* Lady Cilento Children’s Hospital, Brisbane, Queensland, Australia Introduction: Recurrent abdominal pain in children is common, and may result from a multitude of conditions including functional disorders, celiac disease, constipation and inflammatory bowel disease (IBD). While pain is not considered to be an indication for colonoscopy, many are performed to exclude significant pathology. Several reviews have reported abdominal pain to be the primary indication for colonoscopy in 13-20% of pediatric patients. The utility of colonoscopy in recurrent abdominal pain in children remains unclear. Our aim was to assess the diagnostic yield and role of colonoscopy when assessing children with recurrent abdominal pain. Methods: Retrospective review of all colonoscopies between November 2011 and October 2015 in a tertiary pediatric hospital was performed. All patients in whom abdominal pain was an indication for colonoscopy were included in this study. Patient demographics, reason for procedure, secondary indications, endoscopic findings and histology were noted. Stool calprotectin and serum inflammatory markers, if performed were also recorded. Results: 652 colonoscopies were performed during this period, of which 65 (10%) had abdominal pain as one of the indicators for procedure. Median age of the patients was 12 (2-16) years, and 42/65 (65%) were female. Photographs and/or biopsy were used to confirm the extent of colonoscopy in 99.2% of patients, with cecal intubation rate 96.3% (628/652) and ileal intubation rate 92.5% (602/652). Only 2% (15/652) of procedures were performed for isolated abdominal pain, while the rest had other indications including altered bowel habit (nZ15), weight loss (nZ14), significant family history of IBD or polyps (nZ8), iron deficiency anemia (nZ7), food allergy (nZ3), and rectal bleeding (nZ3). All patients had serum inflammatory markers measured (CRP or ESR) and 52% (34/65) had stool calprotectin performed. 6% (4/65) of patients with abdominal pain had elevated stool calprotectin or inflammatory markers. Only 11% (7/65) of patients had positive findings at colonoscopy, which included Crohn’s disease (nZ3), polyps (nZ2), and microscopic colitis (nZ2). No patient with isolated abdominal pain had positive findings. Patients with associated altered bowel habit or weight loss were more likely to have positive findings; these patients also had abnormal calprotectin and inflammatory markers. Conclusion: The likelihood of significant findings on colonoscopy in children with abdominal pain is low, 11%, and unlikely in the absence of other symptoms or findings. Colonoscopy is not warranted in children with isolated abdominal pain in the absence of secondary symptoms or abnormal calprotectin or inflammatory markers.
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Sa2075 Use of Peroral Endoscopic Myotomy (POEM) in Pediatric Patients as a Primary or Rescue Therapy for Achalasia Stavros N. Stavropoulos*1, Amanda B. Sosulski2, Rani J. Modayil2, Krishna C. Gurram2, Collin E. Brathwaite2, Charles V. Coren2, Harika Boinpally2, James H. Grendell2 1 Medicine, Winthrop Univ. Hosp.-Columbia Univ., Roslyn, NY; 2Winthrop University Hospital, Mineola, NY Background: Achalasia is rare in children with an incidence of w0.1 per 100,000 (approximately one tenth of that seen in the adult population). Historically, achalasia in children has been successfully treated with laparoscopic Heller myotomy (LHM) or pneumatic dilatation (PD). Per Oral Endoscopic Myotomy (POEM) is a minimally invasive Natural Orifice Transluminal Endoscopic Surgery (NOTES) approach to myotomy first performed in 2008, with two publications appearing in 2010 including a case report from our center. With over 5,000 procedures now having been performed there is a growing body of evidence demonstrating excellent safety and high efficacy rivaling that of LHM at mid-term follow-up of 2-3 years. Based on these promising results in adults, POEM is now gradually being introduced to the pediatric population. Five pediatric POEM series (cohorts ranging from 5 to 26 patients) have appeared in the literature over the past year from China (3), Italy (1) and India (1) (Table 1) reporting excellent outcomes that appear superior to pneumatic dilation and at least equivalent to LHM. We report herein the first US series of pediatric POEMs consisting of 10 POEMs (third largest series to date worldwide) including 2 patients in whom POEM was used as rescue therapy after prior failed LHM (only one other series from India reported also 2 such patients). Methods: From a prospectively maintained database of all POEMs performed at our center from 10/2009 to 10/2016 we extracted all POEMs performed on pediatric patients ( <18 years). Out of 318 consecutive POEMs performed during this period by a single operator, 10 pediatric POEMs were identified (3%). We analyzed procedural and patient characteristics, efficacy metrics including LES pressure, Eckardt score and timed barium emptying (TBE), adverse events (AEs), length of stay (LOS) and GERD assessments. Results: See Table 2. 10 patients, mean age 14.7 (10-17) underwent POEM from 2013 to 2016 with the first being patient #99 in our POEM series (i.e. well beyond our initial learning curve for the procedure). Mean duration of symptoms was 21 months (3-84) and 4 patients had previous treatments (2 LHM, 2 dilation). Mean POEM duration was 55 minutes (33-111) and mean LOS 1 day (12). There were no significant AEs. At mean follow-up of 15 months (1- 30) clinical success (Eckardt score 3) was 100% with marked improvements in mean Eckardt score (7.9 to 0.4), mean LES pressure (6 pts, 50 mmHg to 19 mmHg) and TBE(5 pts, 4/5 with 100% emptying at 5 min, 1/5 with 90% emptying at 5 min). pH study+ in 2/5 (40%) with mild erosive esophagitis in the same 2/5 patients (40%). GERD controlled with once a day PPI. Conclusion: POEM provides a safe and effective minimally invasive alternative to LHM in children and may be also used as rescue therapy after prior LHM or dilation.
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB285
Abstracts
Patient Characteristic Secondary Diagnosis, # (%) Aspiration Dysphagia Failure to Thrive Feeding Difficulties Feeding Problems Poor Weight Gain
Early Feeding
Controls
4 (14.8%) 6 (22.2%) 9 (33.3%) 13 (48.1%) 3 (11.1%) 2 (7.4%)
4 (14.8%) 13 (48.1%) 10 (37%) 2 (7.4%) 9 (33.3%) 2 (7.4%)
p
Table 2. Patient Outcomes by Study Group Outcome
Sa2076 Safety and Outcomes of Early Nutrition Following Percutaneous Endoscopic Gastrostomy Tube Placement in Children Katie L. Mills1, Racha T. Khalaf2, Michael Wilsey*1, Alexander D. Wilsey3, Emily Swan3 1 Gastroenterology, Hepatology, and Nutrition, Johns Hopkins All Children’s Hospital, St Petersbrg, FL; 2Medical Education, Johns Hopkins All Children’s Hospital, St. Petersburg, FL; 3Florida State University, Tallahassee, FL Background: In pediatric patients it is common practice to wait up to 24 hours to begin enteral feedings using a newly placed percutaneous endoscopic gastrostomy (PEG) tube. This delay in feeding was believed to prevent post-procedural complications. Several studies report the safety and efficacy of initiating nutrition as early as three to six hours after gastrostomy tube placement in adults. However, there are few studies that examine early feeding in the pediatric population. Patients and Methods: An IRB approved, prospective controlled trial beginning November 2015 initiating enteral nutrition less than six hours following PEG tube placement in children six months to 18 years of age. Outcomes measuring the safety and tolerability of early feedings, and hospital length of stay were recorded. Pain medication use and compications such as fever, vomiting, and leakage around the stoma, in addition to adverse events including peritonitis and aspiration were recorded. Results from the early feeing group were compared to data collection from a historical control group whose feedings had not been initiated until he first post-operative day. Results: Hospital length of stay was defind as the time of arrival to the inpatient unit following their procedure to time of hospital discharge. Participants who remained inpatient for reasons related to their primary diagnosis were excluded from the duration of hospital stay data. The Wilcoxon rank sum test was used to compare continuous characteristics and outcomes between the two groups; whereas, the chisquare test was used to compare categorical data. Twenty-seven patients per group were studied. No significant demographic difference between the groups were observed. A decrease in the median hospital length of stay was noted in the early feeing group, but there were more minor adverse events. Although this number is statistically significant, these minor events did not appear clinically significant nor did they requre nonstandard intervention. Conclsion: Our study suggests initating enteral nutrition less than six hours folowing PEG tube placement is as safe as waiting until the first post-operative day in this pediatric cohot. Furthermore, initiating early nutrition following PEG tube placement in children may lead to a decrease length of hospital stay.
Table 1. Patient Demographic Information by Study Group Patient Characteristic Years of Age, median (range) Female Gender, # (%) Primary Diagnosis, # (%) Neurologic Genetic GI Respiratory Other
Early Feeding
Controls
p
3 (.58-16) 13 (48.1%)
4 (.75-17) 13 (48.1%)
0.98 1 0.14
12 (44.4%) 2 (7.4%) 4 (14.8%) 5 (18.5%) 4 (14.8%)
12 (44.4%) 9 (33.3%) 3 (11.1%) 1 (3.7%) 2 (7.4%)
AB286 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
Early Feeing
Controls
p
Time to First Feed, hours, median (range) 3.4 (1.3-5.5) 24.3 (5.5-52.1) 0.001 Length of Stay, hours, median (range) 26.4 (22-49.1) 50.5 (27.7-144.4) 0.001 Febrile Occurrence, # (%) 4 (14.81%) 9 (33.33%) 0.20 Minor Event, # (%) 0.009 Vomiting 3 (11.11%) 2 (7.41%) Leakage around stoma 7 (25.93%) 0 (0%) Other 0 (0%) 1 (3.7%) Major Event, # (%) 1 Peritonitis, Aspiration 0 (0%) 0 (0%) Other 1 (3.7%) 1 (3.7%) Medication Doses, mean (SD) Non-Narcotic 2.40 (1.88) 2.33 (1.59) 0.87 Narcotic 1.70 (1.63) 2.03 (1.65) 0.46
Sa2077 Esophageal Strictures in Pediatric Patients With Eosinophilic Esophagitis (EOE); Short Segment Stricture vs. Narrow Caliber Esophagus Vijayalakshmi Kory1, Vimal Gunasekaran1, Alan Schwartz3, James Berman1,3, Thirumazhisai S. Gunasekaran*1,2 1 Pediatric Gastroenterology, Advocate Children’s Park Ridge, Park Ridge, IL; 2Pediatrics, Ronald McDonald Children’s Hospital, Maywood, IL; 3Pediatrics, University of Illinois, Chicago, IL
Patients with EoE are classified as inflammatory and fibrostenotic and stricture may be an end result in the latter group. We describe EoE pediatric patients with esophageal strictures; segmental (SS) and tubular or narrow caliber esophagus (NCE). Aim: compare clinical features,endoscopy+Bx,treatment including dilation,and outcomes of patients with SS and NCE. Methods: In this retrospective study,children with EoE seen between 1/2001 and 9/2016 were stratified based on main symptom into groups for further analysis as;Dysphagia (EoE-D), abdominal pain without dysphagia, reflux without dysphagia and FTT/Feeding difficulty. From the EoE-D group,patients with strictures defined as;not able to pass regular endoscope OD 9mm or when passed had a mucosal tear,were included. Then were subclassified as;Short segment strictures- SS.(narrowing < 2 cm length) and Narrow caliber esophagus- NCE(narrowing more than 1/3 length of the esophagus). Physical findings,CBC,esophagram,EGD and biopsy of the duodenum,antrum,distal and mid esophagus were captured. Diagnosis of EoE made as per the 2011 consensus. Treatments included topical steroids,dietary modification, +/-PPIs. Strictures were dilated,after initiation of treatment,either with bougies or through the scope balloons. Symptom score for dysphagia, nausea,vomiting,regurgitation,early satiety and heartburn were scored:absent -0, mild -1,and severe-2 except dysphagia had a score up to 3 if they had food impaction. Esophageal EGD findings were scored at diagnosis and follow up. Results: Total EoE patients;373,and EoE-D -101 and 13 had strictures. Stricture incidence 3.4% within the entire group and 12.9% within EoED.Gr –SS:10 and Gr –-NCE:3,mean age 13.04 and 8.7 yrs. (pZ.09). There were no patients with strictures who did not fall between these two groups. Clinical features, X-ray, EGD + biopsy;see Table 1. Dilation type; dilation by passage of endoscope:8,balloon:3,Maloney: 2. Total dilations for Gr-SS: 24(mean 2.4) and for Gr- NCE 12 (mean 4) (pZ.51). Complications: no perforations, chest pain -2. Follow up: GrSS: mean 1.03 yrs.(range 1-12 months) and in Gr-NCE 2.07yrs (1month-5.06yrs). Medical treatment: fluticasone-2,diet-1 or combination-3 and PPI -7. Symptom improvement; mean dysphagia score: Gr-SS 2.7 to 0.7 and Gr -NCE 2.3 to 0.9;composite score 2.5 to 0.9 and 3.0 to 1 respectively. EGD score improved; Gr -SS from 2.5 to 2 (pZ0.07) and NCE from 2 to 1.7 (pZ 0.42); peak eosinophil count: GrSS 44.3 to 38.6 (pZ0.40), and in Gr- NCE 45.6 to 5.3(pZ0.20). Conclusion: Incidence of esophageal stricture:3.4% within the entire EoE patients and 12.9% within the EoE –D. NCE group required more dilations than the SS group, but was not significant. Both groups had symptomatic improvement. EGD scores showed minimal improvement with dilation and treatment. NEC group had significant improvement in the eosinophils compared to SS group.
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