Department of General and Thoracic Surgery, Children's Mercy Hospital, Kansas City, Missouri.
Department of General and Thoracic Surgery, Children's Mercy Hospital, Kansas City, Missouri.
J Surg Res. 2019 Dec;244:460-467. doi: 10.1016/j.jss.2019.06.090. Epub 2019 Jul 19.
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, early bacterial peritonitis, and catheter loss when percutaneous endoscopic gastrostomy is performed in children already undergoing CPD. Current International Society for Peritoneal Dialysis guidelines recommend only open GT for these patients. We sought to report the safety of laparoscopic gastrostomy (LG) among children already receiving PD.
We conducted a retrospective chart review of children who had initiated CPD before 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/mm and >50% neutrophils, with or without a positive peritoneal culture.
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 because of no overlap of GT and PD catheter, leaving 11 for analysis. Median age at the time of LG was 1.32 y and median weight-for-age z-score was -1.86 (IQR -2.9, -1.3). Median days to PD catheter and GT use after LG were 2 (range 0-4) and 1 (range 0-2). Median weight z-score change at 90 d was +0.5 (IQR -0.1, +0.9). All patients received antifungal and antibiotic coverage at time of GT placement. No subjects developed fungal peritonitis or early bacterial peritonitis, although one developed bacterial peritonitis within 30 d. The overall rate of peritonitis after laparoscopic gastrostomy tube was 0.35 episodes/patient-year. This was similar to a rate of 0.45 episodes/patient-year during PD but before laparoscopic gastrostomy tube in the same patients (P = 0.679). Four subjects required periods of hemodialysis, two of which were because of PD catheter removal due to infection. One of the latter was due to a relapse of pre-LG peritonitis and the patient later resumed PD. The other was due to remote post-LG peritonitis and the patient continued hemodialysis until renal transplant, both after 6 mo.
We found that, in children already receiving PD, LG is similar in safety profile, efficacy, and technical principle to open gastrostomy. LG is therefore an appropriate and safe alternative to open gastrostomy in this setting.
儿童首选的透析方式是慢性腹膜透析（CPD），这些儿童可能需要延迟胃造口管（GT）的放置。研究人员报告称，在已经接受 CPD 的儿童中进行经皮内镜胃造口术时，真菌性腹膜炎、早期细菌性腹膜炎和导管丢失的风险很高。目前国际腹膜透析学会指南建议仅对这些患者进行开放式 GT。我们旨在报告腹腔镜胃造口术（LG）在已经接受 PD 的儿童中的安全性。
我们对 2010 年至 2017 年期间在我们的儿童医院接受 CPD 治疗前接受 GT 治疗的儿童进行了回顾性图表审查。记录了人口统计学数据、临床细节和腹膜炎发生率。腹膜炎定义为腹膜白细胞计数>100/mm³，且>50%为中性粒细胞，无论是否有阳性腹膜培养。
23 名患者均同时接受了 CPD 和 GT 治疗。其中，有 13 名患者在 CPD 开始后进行了 GT 治疗。其中一个因采用开放技术而被排除，另一个因 GT 和 PD 导管没有重叠而被排除，留下 11 个进行分析。LG 时的中位年龄为 1.32 岁，中位体重年龄 Z 评分为-1.86（IQR-2.9，-1.3）。LG 后 PD 导管和 GT 使用的中位数天数为 2 天（范围 0-4）和 1 天（范围 0-2）。90d 时体重 Z 评分中位数变化为+0.5（IQR-0.1，+0.9）。所有患者在 GT 放置时均接受了抗真菌和抗生素治疗。尽管有一名患者在 30d 内发生了细菌性腹膜炎，但没有患者发生真菌性腹膜炎或早期细菌性腹膜炎。腹腔镜胃造口管后的总体腹膜炎发生率为 0.35 例/患者年。这与同一患者在 PD 但在腹腔镜胃造口管之前的 0.45 例/患者年的发生率相似（P=0.679）。4 名患者需要接受血液透析治疗，其中 2 名是由于 PD 导管因感染而被移除。其中 1 名是由于 LG 前腹膜炎复发，患者后来恢复了 PD。另一名是由于 LG 后腹膜炎，患者在 6 个月后继续接受血液透析，直至肾移植。
