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Editor,—We read with interest the article by Cosgrove and Jenkins, describing their experience with percutaneous endoscopic gastrostomy (PEG) in children with Crohn’s disease.1 In the past, we reported improvement in linear growth and overall safety of gastrostomy procedure in 16 children with Crohn’s disease.2
We have since had additional experience with seven children with Crohn’s disease and gastrostomy. The mean age of children was 13.3 years (range 2.5–17 years). Five had PEG and two had surgical gastrostomy tubes placed. The indication for gastrostomy was growth failure and refusal or failure to use nasogastric tube feeding. Follow up after gastrostomy placement was 1–28 months (mean 11 months). Elemental formula (Vivonex, Sandoz Nutrition) was used to provide 50–80% of required energy as continuous nocturnal infusion.
All children showed weight gain and an increased energy level. An increased growth velocity was noted in two children, in one from <1 cm/year before gastrostomy to 6 cm/year and in the other from 3.5 cm/year to 5 cm/year. Three children, two previously on nasogastric tube feeding, maintained their linear growth rate. The duration of enteral nutrition (one and two months) was too short to assess the effect on linear growth in two children. Minor local complications including discomfort, granulation tissue, and local skin infection were observed in four of the seven children. Accidental removal of gastrostomy tubes occurred in two adolescent children. Closure of the gastrostomy tract after removal was complete in four children; three children still have the tube. The procedure and hyperalimentation were tolerated well, even by a 2.5 year old child.
Combining data from two studies1 2 and these seven children, most of the complications of gastrostomy were minor and easily treatable in a total of 33 children with Crohn’s disease. Two complications were noteworthy. Cosgrove and Jenkins reported one patient who developed intestinal obstruction by a leftover gastrostomy flange,1 a complication which is avoidable when PEG removal is done by endoscopy. In one child from our series, surgical closure was required for a persistent failure of gastrostomy tract to close.2 Gastrocutaneous fistula is a recognised complication after the gastrostomy procedure and was reported in 3.6% of patients without Crohn’s disease.3 More studies are required to assess whether the presence of gastric Crohn’s disease increases the risk of this complication.
Out of the 33 children with Crohn’s disease and gastrostomy, 26 (78 %) showed improvement in linear growth and clinical wellbeing was obvious in majority. Although the number of children is still small, it appears that the advantages of gastrostomy outweigh the risks. However, we recommend that nasogastric tube feeding should be the first choice for supplemental nutrition as 25% of our patients with Crohn’s disease and growth failure used this method successfully for long time (mean duration 10.5 months).2 When this method is not possible, gastrostomy is a good and safe option. In case of previous abdominal surgery, surgical gastrostomy tube should be considered rather than PEG.