U-Stitch Laparoscopic Gastrostomy Technique Has a Low Rate of Complications and Allows Primary Button Placement: Experience with 461 Pediatric Procedures

A simple suture-retrieval device for the placement of u-stitches during laparoscopic gastrostomy

BACKGROUND

During minimally invasive operations, it is sometimes necessary to retrieve the end of a suture or a suture needle and bring it out through the abdominal wall.

METHODS

Using a standard needle and a length of suture, we have developed a simple device that allows the retrieval of a suture end during minimally invasive operations that require the placement of U-or stay stitches.

RESULTS

The author has used the device described during more than 100 laparoscopic gastrostomy placement procedures and other operations involving the placement of U- or stay stitches with excellent results and no complications.

CONCLUSIONS

Using a beveled hollow-bore needle and a loop of polypropylene suture, one can construct a simple device that allows the retrieval of a suture from within a body cavity during minimally invasive surgery, making the placement of U- and stay stitches easier and more precise.

Modified approach to laparoscopic gastrostomy tube placement minimizes complications

INTRODUCTION

Complications from previously published techniques for laparoscopic gastrostomy tube placement include skin pressure necrosis and extraluminal migration. We developed a modified technique utilizing subcutaneous stay-sutures in order to minimize such complications. This study aimed to identify, quantify, and characterize complications of the modified procedure.

MATERIALS AND METHODS

Charts were reviewed of all pediatric patients undergoing laparoscopic gastrostomy tube placement over 79 months. Complications requiring reoperation, readmission, or outpatient treatment were identified and classified as major or minor.

RESULTS

Laparoscopic gastrostomy tubes were placed via modified procedure in 82 patients. Two (2.44%) high-risk patients with significant comorbidities were readmitted for wound infections, two (2.44%) received outpatient antibiotics for cellulitis, and three (3.66%) developed stitch abscesses which resolved with local care. None of the patients had initial intraperitoneal placement, intraperitoneal location upon tube replacement, extraluminal migration, tube-related pressure necrosis, or procedure-related death.

CONCLUSION

Subcutaneous placement of absorbable stay-sutures for laparoscopic gastrostomy tubes offers significant benefits. We eliminated complications associated with presence of external sutures, as well as those associated with early suture removal. This modified technique avoids additional visits for suture removal, avoids pressure necrosis from external stay-sutures, and provides improved adherence of stomach to abdominal wall, thereby preventing extraluminal migration and intraperitoneal tube replacement.

Experience with a hybrid, minimally invasive gastrostomy for children with abnormal epigastric anatomy

PURPOSE

This communication is an analysis of the experience with a new type of gastrostomy. It was developed for patients with pronounced epigastric anatomical abnormalities, such as dense adhesions, in whom the conventional "open" gastrostomy could prove difficult and the percutaneous endoscopic, the imaging-guided, and the laparoscopically assisted methods would be unsafe.

METHOD

A large, soft rubber catheter is inserted in the child's mouth and advanced into the stomach. A small epigastric incision is made. With the help of the catheter, the anterior gastric wall is identified and the stoma site chosen. One of the curved needles of a double-armed monofilament suture is passed through the gastric wall and through the catheter. The needle is then cut off. The other needle is passed through the abdominal wall, from the inside out at the most suitable skin stoma site. When the catheter (with the embedded suture) is withdrawn from the mouth, a tract is established. The suture is replaced by a guide wire, which allows a percutaneous endoscopic gastrostomy-type catheter to be placed by the percutaneous endoscopic gastrostomy "pull" technique.

RESULTS

This approach was used in 15 patients (14 children-ages 1 month to 7 years and one 19 years old) with: status post (s/p) necrotizing enterocolitis and bowel loss (n = 4); s/p gastroschisis and short-gut syndrome (n = 3); cerebral palsy, s/p ventriculo-peritoneal shunt infections (n = 2); s/p complex omphalocele; dwarfism; morphologic abnormalities; repaired prune-belly syndrome; s/p duodenal atresia with malrotation; severe scoliosis with s/p multiple shunt infections (one each). There were no complications. The technique also proved useful in several other children in whom a laparotomy incision for unrelated conditions was remote from the gastrostomy site.

CONCLUSION

Using a very small incision, this hybrid method permits safe and precise gastric and abdominal wall site selection and gastrostomy catheter placement. Gastrotomy as well as purse-string and peritoneal fixation sutures are not needed, and the danger of accidental catheter dislodgement is minimized.

Laparoscopic gastrostomy: the preferred method of gastrostomy in children

We present a paediatric institutional experience with laparoscopic gastrostomies (LG) and evaluate its appropriateness as the recommended method for gastrostomy placement. We also sought to evaluate the efficacy of a simple technique for LG and collected information on long-term follow-up after LG. LG was performed in 112 children over a 6-year-period. The procedure involves visualization of the stomach through an umbilical port and a second epigastric gastrostomy site to select and anchor the stomach with sutures prior to the placement of a low profile gastrostomy feeding device (LPGD). The follow-up details of the patients were analysed. A review of literature was done to compare LG with percutaneous endoscopic gastrostomy (PEG). The median operating time for the procedure in 112 patients was 48 min. There was one open conversion. Median postoperative length of stay was 6 days. Other complications were vomiting (11%), peri- gastrostomy leak (26%), granulation tissue (42%), accidental dislodgement of the LPGD (4%), faulty device requiring replacement (10%), gastric mucosal prolapse (2%) and localized infection (2%). Follow-up ranged from 6 to 75 months with a cumulative gastrostomy usage of 2,352 months. The advantages of the described technique are virtual feasibility in all patients, primary placement of a LPGD, simplicity with requirement of minimal laparoscopic expertise and safety. Comparison with reports of PEG in the literature indicates that LG should be the preferred method of gastrostomy placement in children.

Gastrointestinal tract feeding access and the role of fundoplication in combination with gastrostomy

PURPOSE OF REVIEW

Feeding access and associated antireflux procedures continue to be some of the most common operations performed in pediatric patients. This review will discuss the various feeding access procedures available, including minimally invasive techniques, and further elaborate on appropriate indications for a concurrent antireflux procedure as well as alternatives to fundoplication.

RECENT FINDINGS

Gastrostomy and jejunostomy can be successfully placed using endoscopic or laparoscopic techniques with low complication rates. Nissen fundoplication is well described laparoscopically but failure with recurrent gastroesophageal reflux has resulted in the development of other operative alternatives.

SUMMARY

Decisions concerning appropriate long-term feeding access must be individualized, understanding the advantages and disadvantages of gastrostomy and jejunostomy techniques. Laparoscopic Nissen fundoplication is successful for treatment of patients who fail medical therapy of gastroesophageal reflux, but recurrent gastroesophageal reflux is a persistent problem that requires innovative solutions.