Pediatric gastrostomy tubes and techniques: making safer and cleaner choices.

BACKGROUND: Gastrostomy tube placement is a common procedure that can be accomplished with a variety of techniques, each with its attendant complications. In an effort to standardize practice at our institution, we retrospectively evaluated complications including early dislodgement requiring operative repair, leaks, and granulation tissue to determine the optimal technique. MATERIALS AND METHODS: A retrospective cohort study (June 2008-July 2014) evaluating children (<18) receiving gastrostomy tubes was completed. We recorded demographic data, placement technique, and postoperative complications within 120 days. The seven techniques in use at our institution were categorized into three groups: standard pull-type techniques for percutaneous endoscopic gastrostomies (PEGs), "push" techniques using transabdominal sutures or T-fasteners for securement of the stomach, and "fascial" techniques using sutures directly from the stomach to the abdominal fascia at the stoma site. Descriptive statistics were analyzed using t test and Kruskal-Wallis tests as appropriate, and outcomes with P < 0.05 were considered significant. RESULTS: Of the 450 patients, 255 (56.7%) were male. Median age and weight at the time of operation were 19.3 months (interquartile range, 6.5-89.6 months) and 9.0 kg (interquartile range, 5.7-17.1 kg) respectively. By technique, 245 patients underwent fascial placement (54.4%), 112 underwent push (24.9 %), and 93 underwent PEG (20.7%). Push and fascial techniques were less likely become dislodged than PEG, with odds ratios (ORs) of 0.14 (confidence interval CI 0.02-0.66) and 0.31 (CI 0.11-0.83), respectively. Fascial techniques had more granulation tissue than either push or PEG pull methods, OR 2.39 (CI 1.20-3.36), and more leakage, OR 2.22 (CI 1.19-4.15). CONCLUSIONS: Dislodgement is most likely with PEG techniques. Granulation and leakage are most likely with fascial suture techniques. Push techniques are associated with the lowest complication rate.

Escherichia coli O127 group 4 capsule proteins assemble at the outer membrane.

Enteropathogenic Escherichia coli O127 is encapsulated by a protective layer of polysaccharide made of the same strain specific O-antigen as the serotype lipopolysaccharide. Seven genes encoding capsule export functions comprise the group 4 capsule (gfc) operon. Genes gfcE, etk and etp encode homologs of the group 1 capsule secretion system but the upstream gfcABCD genes encode unknown functions specific to group 4 capsule export. We have developed an expression system for the large-scale production of the outer membrane protein GfcD. Contrary to annotations, we find that GfcD is a non-acylated integral membrane protein. Circular dichroism spectroscopy, light-scattering data, and the HHomp server suggested that GfcD is a monomeric ß-barrel with 26 ß-strands and an internal globular domain. We identified a set of novel protein-protein interactions between GfcB, GfcC, and GfcD, both in vivo and in vitro, and quantified the binding properties with isothermal calorimetry and biolayer interferometry. GfcC and GfcB form a high-affinity heterodimer with a KD near 100 nM. This heterodimer binds to GfcD (KD = 28 µM) significantly better than either GfcB or GfcC alone. These gfc proteins may form a complex at the outer membrane for group 4 capsule secretion or for a yet unknown function.