R. M. Dorman1, L. A. Benedict1, J. Sujka1, J. Sobrino1, C. D. Dekonenko1, W. Andrews1,4, B. Warady2,4, T. A. Oyetunji1,4, R. Hendrickson1,4 1Children’s Mercy Kansas City,Department Of General And Thoracic Surgery,Kansas City, MO, USA 2Children’s Mercy Kansas City,Division Of Pediatric Nephrology,Kansas City, MO, USA 4University of Missouri – Kansas City School of Medicine,Department Of Pediatrics,Kansas City, MO, USA
Introduction: The preferred method of dialysis for children is chronic peritoneal dialysis (CPD), and these children may require delayed gastrostomy tube (GT) placement. Investigators have reported a high risk of fungal peritonitis (26%), early bacterial peritonitis (37% at <7 days), and overall post-GT peritonitis rate (1.5 events/patient-year) when percutaneous endoscopic gastrostomy (PEG) is performed children already undergoing CPD. Current ISPD guidelines recommend only open GT for these patients (post-GT peritonitis rate 1.4 events/patient-year). We sought to report the safety of laparoscopic GT (LGT) among children already receiving CPD.
Methods: We conducted a retrospective chart review of children who had initiated CPD prior to GT placement between 2010 and 2017 at our pediatric hospital. Demographic data, clinical details, and peritonitis rates were recorded. Peritonitis was defined as peritoneal WBC count > 100 /mm3, >50% neutrophils, and a positive peritoneal culture.
Results: Twenty-three subjects had both undergone CPD and had a GT placed in the study period. Of these, 13 had a GT placed after CPD had been initiated. One of these was excluded for open technique and another excluded due to no overlap of GT and PD catheter, leaving 11 for analysis. Median age at the time of LGT was 1.32 (range 0.21 – 17.23) years and median weight for age z-score was -1.86 (IQR -2.9, -1.3). Median days to PD catheter and GT use after GT placement were 2 (range 0-12) and 1 (range 0-4). Median weight z-score change at 90 days was +0.5 (IQR 0.0, 0.9). All patients received antifungal and antibiotic coverage at time of GT placement. No subjects developed fungal peritonitis or early bacterial peritonitis, although two developed bacterial peritonitis within 30 days. The overall rate of peritonitis after LGT was 0.41 (95% CI 0.16, 0.85) events/patient-year. This was similar to a rate of 0.34 (95% CI 0.07, 1.00) during CPD prior to LGT in the same patients. Four subjects required periods of HD, two of which were due PDC removal due to infection. One of the latter resumed CPD and the other continued HD until renal transplant, both after 6 months.
Conclusions: We found that, in children already receiving CPD, laparoscopic gastrostomy is similar in safety profile and technical principle to open gastrostomy, and is superior in safety to PEG. Laparoscopic gastrostomy is therefore an appropriate and safe alternative to open gastrostomy in this setting.