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Percutaneous endoscopic gastrostomy in children on peritoneal dialysis
Christian von Schnakenburg1, Reinhard Feneberg, Christian Plank
1Department for Pediatrics and Adolescent Medicine, University Hospitals, Mathildenstrasse 1, D-79106 Freiburg, Germany. christian.schnakenburg@uniklinik-freiburg.de
Insights
Percutaneous endoscopic gastrostomy (PEG) insertion in pediatric peritoneal dialysis (PD) patients can lead to complications like fungal peritonitis. However, this study found complication rates lower than expected, with successful PD reinitiation in most cases.
Area of Science:
- Pediatric Nephrology
- Gastroenterology
- Interventional Endoscopy
Background:
- Percutaneous endoscopic gastrostomy (PEG) insertion is often considered contraindicated in pediatric patients undergoing chronic peritoneal dialysis (PD) due to perceived risks.
- Previous reports suggest increased morbidity and mortality, but systematic data are lacking.
Purpose of the Study:
- To systematically evaluate the safety and outcomes of PEG insertion in pediatric patients on chronic PD.
- To compare PEG insertion with open gastrostomy (OG) in this patient population.
Main Methods:
- A retrospective multicenter study involving 23 pediatric dialysis units.
- A questionnaire was used to collect data on PD patients who underwent PEG or OG insertion since 1994.
Main Results:
- 27 pediatric PD patients underwent PEG insertion. Major complications included early peritonitis (37%) and fungal peritonitis (26%).
- Four patients required cessation of PD, and two deaths occurred. However, 67% of patients successfully resumed PD shortly after PEG insertion.
- PEG was the preferred gastrostomy method over OG, with only two OG procedures reported.
Conclusions:
- PEG insertion in PD patients carries risks, particularly fungal peritonitis and potential PD failure, but complication rates in this series were lower than previously reported.
- Recommended precautions include antibiotic/antifungal prophylaxis, temporary PD cessation, and experienced endoscopy teams.
- Careful consideration of risks and benefits is needed when deciding between percutaneous and open gastrostomy placement, especially when not performed concurrently with PD initiation.
Objective:
Insertion of percutaneous endoscopic gastrostomies (PEG) in patients on chronic peritoneal dialysis (PD) has been reported to be contraindicated due to an increased risk of morbidity and mortality. However, no systematic survey on this topic has yet been published.
Design:
Retrospective multicenter study.
Setting:
23 pediatric dialysis units associated with the working group Arbeitsgemeinschaft für Pädiatrische Nephrologie (APN).
Data Source:
A structured questionnaire on clinical details of PD patients who had undergone PEG insertion or open gastrostomy (OG) since 1994 was distributed to all pediatric dialysis units of the APN.
Results:
27 PD patients (20 males) from 12 centers in whom PEG insertion was performed after Tenckhoff catheter introduction were evaluated. Age at intervention ranged from 0.25 to 10.9 years (median 1.3 years). Most patients were malnourished, with standard deviation score (SDS) for body weight between -4.2 and -0.6 (median -2.2). Major complications were early peritonitis < 7 days after PEG in 10/27 (37%) patients, episodes of fungal peritonitis in 7/27 (26%) patients, 4 cessations of PD and change to hemodialysis, and 2 associated deaths. However, in 14 patients, no such problems were encountered and, in 4 patients, early peritonitis effectively treated with intraperitoneal antibiotics was the only major complication. Thus, in 18/27 (67%) patients, PD was successfully reinitiated shortly after PEG insertion. Among all participating centers, only two OG procedures were reported during the study period, illustrating a clear preference for the PEG over the OG procedure among members of the APN.
Conclusion:
PEG insertion following PD initiation carries a high risk for fungal peritonitis and potential PD failure; however, complication rates in this largest reported series were lower than previously described. Antibiotic and antifungal prophylaxis, withholding PD for 2 - 3 days, and gastrostomy placement by an experienced endoscopy team are suggested precautions for lowering the risk of associated complications. When gastrostomy placement does not occur prior to or at the time of initiating PD, the risks and benefits of percutaneous versus open placement must be carefully weighed.
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