Fluoroscopy-guided Percutaneous Endoscopic Gastrostomy in Children: A Simple and Safe Technique

Let's (Not) Twist Again: Laparoscopic-Assisted Percutaneous Endoscopic Gastrostomy in Paediatric Gastric Volvulus

INTRODUCTION

In the setting of intermittent abdominal pain accompanied by gastro-intestinal obstruction, gastric volvulus should be suspected.

AREAS COVERED

A 10-year-old girl was admitted to our hospital for intermitted abdominal pain associated with recurrent non-bilious vomiting and acute weight loss. The radiological images performed at the district general hospital were reported as negative. After careful review of the imaging, a gastric volvulus was suspected. Exploratory laparoscopy confirmed the diagnosis; laparoscopic-assisted percutaneous endoscopic gastrostomy was performed. The postoperative upper gastro-intestinal study showed stomach in its normal shape and position.

EXPERT COMMENTARY

Gastric volvulus is a potential life-threatening condition with a good outcome when promptly recognized. Laparoscopic-assisted percutaneous endoscopic gastrostomy is a safe and curative procedure in the case of suspected gastric volvulus, avoiding the need for a secondary procedure. In pediatric patients, it facilitates direct inspection of the stomach and abdominal cavity, reducing the need for a second procedure. This procedure may emerge as a 'gold standard' for gastric volvulus treatment.

Safety and efficacy of laparoscopy-assisted percutaneous endoscopic gastrostomy in infants and small children weighing less than 10 kg: A comparison with larger patients

INTRODUCTION

Laparoscopy-assisted percutaneous endoscopic gastrostomy (LAPEG) can reduce the risk of percutaneous endoscopic gastrostomy-related complications, such as intra-abdominal organ injury, and determine the optimal position for placement of the gastrostomy tube. We first employed LAPEG 10 years ago but limited its application to elderly patients. Indications for LAPEG have now expanded to small children. This retrospective study aimed to determine the feasibility of LAPEG in children weighing <10 kg.

METHODS

Our LAPEG procedure for small children involves three essential techniques: gastric insufflation with CO₂ to prevent intestinal dilation, a T-fastener device to overcome the difficulties of gastropexy, and primary placement of a button gastrostomy to create less torque than tube gastrostomy at the insertion site and to prevent early tube dislodgement. The medical records of 48 patients with physical and mental disabilities who underwent LAPEG between 2010 and 2018 were evaluated. The outcomes of LAPEG in patients weighing <10 kg (group A, n=11) and ≥10 kg (group B, n=37) were compared.

RESULTS

The LAPEG procedure was completed in all cases without intraoperative complications or open conversion. The median bodyweight of group A was 6.3 kg (range, 3.6-8.2 kg). None of the patients in group A developed postoperative complications such as stomal infection or dislodgement. The operative time was significantly shorter in group A than in group B (P < .05).

CONCLUSION

By improving surgical techniques for small children, our LAPEG procedure might be feasible and safe for treating children weighing <10 kg, including those weighing as little as 3.6 kg.

Fluoroscopy-Assisted Percutaneous Endoscopic Gastrostomy (F-PEG)—Single-Center Experience and Outcome

Background Gastrointestinal route is considered for feeding in subjects who are unable to swallow, either as a temporary or permanent option. Percutaneous endoscopic gastrostomy (PEG) is the preferred mode for long-term enteral nutrition. The aim was to study the outcome of protocol-based PEG placement in a tertiary medical center.

Materials and Methods All the patients who underwent PEG placement between January 2017 and December 2019 were included in the retrospective study. Study variables were entered into a uniform structured proforma. The procedure was done by two people using Ponsky-Gauderer pull-technique. Fluoroscopy guidance was considered for placement in special situations. Post-procedure, all the patients were regularly followed as per protocol to evaluate for adverse events.

Results One hundred and eighteen patients with placement of PEG were included in the study. The mean age of the patients was 49.6 ± 7 years with 67.8% males. The most common indication of PEG was inability to swallow associated with head injury (43, 36.4%), followed by carcinoma esophagus (35, 29.8%) and stroke (24, 20.3%). Fluoroscopy was useful in 38 (32%) for PEG site identification. Tube dislodgement (16, 13.5%) and aspiration pneumonia (20, 16.9%) were the common adverse events. Age more than 60 years and dysphagia in neurologic disorders accounted for more than 60% of adverse events. Forty-nine (42%) of the PEG patients expired due to either primary illness or due to sepsis after a median time of 139 days (range: 32–288 days). There was no difference in the survival in patients with or without PEG-related complications (p = 0. 74).

Conclusions Fluoroscopy assistance helps in accurate PEG placement in one third. Age > 60 years and dysphagia in neurologic disorders were independent risk factors associated with PEG tube complications.

Evaluating complication rates and outcomes among infants less than 5kg undergoing traditional percutaneous endoscopic gastrostomy insertion: A retrospective chart review

PURPOSE

Percutaneous endoscopic gastrostomy (PEG) enables enteral nutrition for patients with inadequate oral intake. Laparoscopic guidance of PEG insertion is used for high-risk populations, including in infants less than 5kg at insertion. This study aimed to assess complication rates with traditional PEG tube insertion in infants less than 5kg at a single tertiary care center.

METHODS

A retrospective review of patients less than 5kg who underwent PEG insertion was conducted. PEG insertion-related complications, up to four years following insertion, were collected. Outcomes were reported as counts and percentages, or median with minimum and maximum values.

RESULTS

480 pediatric gastrostomy procedures between January 1, 2009 and February 1, 2017, were screened, with 129 included for analysis. Median weight at PEG insertion was 3800g. Superficial surgical site infection (SSI) occurred in 6 (4.7%) patients, and 1 (0.8%) required readmission for intravenous antibiotics. One (0.8%) required endoscopic management for retained foreign body, 1 (0.8%) required operative management for gastrocolic fistula, and 1 (0.8%) for persistent gastrocutaneous fistula. No deep space SSI, procedure-related hemorrhage requiring readmission or transfusion, buried bumper syndrome, or procedure-related mortality occurred.

CONCLUSION

Traditional PEG tube insertion in infants less than 5kg results in complication rates comparable to pediatric literature standards.

LEVEL OF EVIDENCE

Level II, retrospective prognosis study.

Comparison of operative outcomes between surgical gastrostomy and percutaneous endoscopic gastrostomy in infants

PURPOSE

Safety profile of different gastrostomy procedures in small children has not been well studied. This study was conducted to investigate whether complication and mortality rates differ between surgical gastrostomy (G-tube) and percutaneous endoscopic gastrostomy (PEG) in infants and neonates.

METHODS

In this retrospective study utilizing the Kids' Inpatient Database, all infants who underwent either G-tube or PEG as a sole procedure were identified. Variables included age, gender, race, presence of neurological impairment, prematurity, complex chronic condition, and severity of illness/risk of mortality subclasses. Postoperative complication, reoperation, and mortality rates were compared between G-tube and PEG. A subgroup of neonates was also analyzed.

RESULTS

A total of 1456 infants were identified (G-tube n=874, PEG n=582). In univariate analysis, the rates of adverse outcomes were not significantly different (G-tube vs PEG complication rate was 7.3% and 6.7%, p=0.65; mortality rate 1.3% and 0.7%, p=0.29, respectively). Adjusted odds ratios (ORs) for complication were 1.07 (G-tube vs PEG, 95% confidence interval [CI] 0.700-1.620) for overall infants and 1.19 (95% CI 0.601-2.350) for the neonatal subgroup. Similarly, adjusted ORs for mortality did not differ significantly both in infants (OR 1.749, 95% CI 0.532-5.755) and in the neonatal subgroup (OR 2.153, 95% CI 0.566-8.165).

CONCLUSIONS

When G-tube and PEG were performed as the only procedure throughout a hospitalization in infants and neonates, the two techniques had comparable risks of postoperative complications and mortalities.

LEVEL OF EVIDENCE

Retrospective comparative study, Level III.