Laparoscopic-assisted percutaneous endoscopic gastrostomy: insertion of a skin-level device using a tear-away sheath

Push-PEG or Pull-PEG: Does the Technique Matter? A Prospective Study Comparing Outcomes After Gastrostomy Placement

BACKGROUND

Push-PEG (percutaneous endoscopic gastrostomy) with T-fastener fixation (PEG-T) allows one-step insertion of a balloon tube or button, and avoids contamination of the stoma by oral bacteria. However, PEG-T is a technically more demanding procedure with a significant learning curve. The aim of the present study was to compare outcomes after PEG-T and pull-PEG in a setting where both procedures were well established.

MATERIALS AND METHODS

The study is a prospective cohort study including all patients between 0 and 18 year undergoing PEG-T and pull-PEG between 2017 and 2020 at a combined local and tertiary referral center. Complications and parent reported outcomes were recorded during hospital stay, after 14 days and 3 months postoperatively.

RESULTS

82 (93%) of eligible PEG-T and 37 (86%) pull-PEG patients were included. The groups were not significantly different with regard to age or weight. Malignant disorders and heart conditions were more frequent in the pull-PEG group, whilst neurodevelopmental disorders were more frequent in the PEG-T group (p < 0.001). 54% in both groups had a complication within 2 weeks. Late complications (between 2 weeks and 3 months postoperatively) occurred in 63% PEG-T vs 62% pull-PEG patients (p = 0.896). More parents in the pull-PEG group (49%) reported that the gastrostomy tube restricted their child's activity, compared to PEG-T (24%) (p = 0.01). At 3 months follow-up, more pull-PEG patients (43%) reported discomfort from the gastrostomy compared to PEG-T (21%) (p = 0.03).

CONCLUSION

Overall complication rates were approximately similar, but pull-PEG was associated with more discomfort and restriction of activity.

LEVELS OF EVIDENCE

Treatment study level II.

Advances and challenges of gastrostomy insertion in children

When oral feeding cannot provide adequate nutritional support to children, enteral tube feeding becomes a necessity. The overall aim is to ultimately promote appropriate growth, improve the patient's quality of life and increase carer satisfaction. Nasogastric tube feeding is considered appropriate on a short-term basis. Alternatively, gastrostomy feeding offers a more convenient and safer feeding option especially as it does not require frequent replacements, and carries a lower risk of complications. Gastrostomy tube feeding should be considered when nasogastric tube feeding is required for more than 2-3 wk as per the ESPEN guidelines on artificial enteral nutrition. Several techniques can be used to insert gastrostomies in children including endoscopic, image guided and surgical gastrostomy insertion whether open or laparoscopic. Each technique has its own advantages and disadvantages. The timing of gastrostomy insertion, device choice and method of insertion is dependent on the local expertise, patient requirements and family preference, and should be individualized with a multidisciplinary team approach. We aim to review gastrostomy insertion in children including indications, contraindications, history of gastrostomy, insertion techniques and complications.

Outcomes of laparoscopic gastrostomy in children with and without the use of a modified T-fastener technique

BACKGROUND

Laparoscopic gastrostomy is commonly performed for durable enteral access in children. T-fasteners have been used intraoperatively to achieve a secure gastropexy, traditionally using external bolsters. We compare the safety profile of a modified paired T-fastener technique to standard laparoscopic-assisted suture gastropexy.

METHODS

A retrospective matched case-control study was performed of pediatric patients who underwent laparoscopic gastrostomy at a single center from 2015 to 2021. In the paired T-fastener group, pairs of T-fasteners were passed into the stomach in a square configuration, allowing the suture pairs to be tied subcutaneously. This cohort was matched in a 1:2 fashion with age, sex, and body mass index or weight-matched controls who underwent laparoscopic gastrostomy with buried transabdominal gastropexy.

RESULTS

Thirty patients underwent laparoscopic gastrostomy using the paired T-fastener technique and were matched to 60 controls. There was no significant difference in median operative time or 30-day complication rates between the groups, but the paired T-fastener technique significantly reduced the number of trocars required, and it was used for patients with thicker abdominal walls.

CONCLUSION

We demonstrate the modified paired T-fastener technique as a safe, efficient means of gastropexy in pediatric laparoscopic gastrostomy. The paired T-fastener approach eliminates external bolsters, reduces additional trocars, and may be advantageous for thicker abdominal walls while maintaining a similar complication profile to standard laparoscopic gastrostomy.

Complications of Percutaneous and Surgical Gastrostomy Placements in Children: a Single-Centre Series

Gastrostomy placement is a standard procedure for children requiring enteral feeding for more than 3-6 weeks. Various techniques have been described (percutaneous endoscopic, laparoscopy, and laparotomy), and many complications have been reported. In our center, gastrostomy placement is performed either percutaneously by pediatric gastroenterologists, by laparoscopy/laparotomy by the visceral surgery team, or jointly, that is laparoscopic-assisted percutaneous endoscopic gastrostomy. This study aims to report all complications and identify risk factors and ways to prevent them.

Methods

This is a monocentric retrospective study including children younger than 18 years who underwent gastrostomy placement (percutaneous or surgical) between January 2012 and December 2020. Complications that occurred up to 1 year after placement were collected and classified according to their time of onset, degree of severity, and management. A univariate analysis was conducted to compare the groups and the occurrence of complications.

Results

We established a cohort of 124 children. Sixty-three (50.8%) presented a concomitant neurological disease. Fifty-nine patients (47.6%) underwent endoscopic placement, 59 (47.6%) surgical placement, and 6 (4.8%) laparoscopic-assisted percutaneous endoscopic gastrostomy. Two hundred and two complications were described, including 29 (14.4%) major and 173 (85.6%) minor. Abdominal wall abscess and cellulitis were reported 13 times. Patients who underwent surgical placement presented more complications (major and minor combined) with a statistically significant difference compared with the endoscopic technique. Patients with a concomitant neurological disease had significantly more early complications in the percutaneous group. Patients with malnutrition had significantly more major complications requiring endoscopic or surgical management.

Conclusion

This study highlights a significant number of major complications or complications requiring additional management under general anesthesia. Children with a concomitant neurological disease or malnutrition are at greater risk of severe and early complications. Infections remain a frequent complication, and prevention strategies should be reviewed.

Reduced complication rate after implementation of a detailed treatment protocol for percutaneous endoscopic gastrostomy with T-fastener fixation in pediatric patients: A prospective study

BACKGROUND/AIMS

Percutaneous endoscopic gastrostomy with push technique (PEG-T) is increasingly used in pediatric patients. In a retrospective study of PEG-T (cohort 1) we reported frequent complications related to T-fasteners and tube dislodgment. The aim of this study was to assess complications after implementation of a strict treatment protocol, and to compare these with the previous retrospective study.

MATERIALS AND METHODS

The study is a prospective study of PEG-T placement performed between 2017 and 2020 (cohort 2) in pediatric patients (0-18 years). Complications were recorded during hospital stay, fourteen days and three months postoperatively, graded according to the Clavien-Dindo classification and categorized as early (<30 days) or late (>30 days).

RESULTS

In total 82 patients were included, of which 52 (60%) had neurologic impairments. Median age and weight were 2.0 years [6 months-18.1 years] and 13.4 kg [3.5-51.5 kg], respectively. There was a significant reduction in median operating time from 28 min [10-65 min] in cohort 1 to 15 min [6-35 min] in cohort 2 (p<0.001), number of patients with early tube dislodgement (cohort 1: 9 (10%) vs cohort 2: 1 (1%), p = 0.012), and number of patients with late migrated T-fasteners (cohort 1: 11 (13%) vs cohort 2: 1 (1%), p = 0.004).

CONCLUSION

We experienced less migrated T-fasteners and tube dislodgment after implementation of strict treatment protocol.

LEVEL OF EVIDENCE

Treatment study level III.

Is endoscopy beneficial in pediatric laparoscopic gastrostomy insertion; A 9-year comparative study

Objectives

Advancements in pediatric percutaneous endoscopic gastrostomy placement (PEG), laparoscopic-assisted gastrostomy (LAG) technique, and laparoscopic-assisted percutaneous endoscopic gastrostomy (LAPEG) procedure have opened up new options for gastrostomy tube placement. LAPEG utilizes endoscopy and laparoscopy for gastrostomy insertion. This review compares the outcomes and complications of LAG and LAPEG techniques in children.

Methods

All LAG and LAPEG gastrostomy tube placements in children from September 2010 to September 2019 were reviewed retrospectively. Patient demographic, along with procedural and 1-year complication data, were collected.

Results

In total, 92/181 of gastrostomies were LAG and 89/181 were LAPEG. The mean age, weight and patient characteristics were comparable. Conversion rate was 1% in both groups (p = 0.74), there was no peritoneal leak in either group, a minor serosal injury to the stomach was seen in 1 patient in LAG with no bowel injury in LAPEG cohort (p = 0.51), need for re-operation was 1 and 2% in LAG and LAPEG, respectively (p = 0.49), early tube dislodgement was in 8 (9%) patients in LAG and 7 (6%) in LAPEG (p = 0.53) and wound infection was 13/92 in LAG and 11/89 in LAPEG (p = 0.8). The median operative time for LAPEG was less than LAG (p < 0.001) by 11 min but the median length of hospital stay was not significantly different (p < 0.096).

Conclusion

Both LAG and LAPEG techniques in children are safe with comparable complication rates and length of hospital stay, the addition of endoscopy to LAG allowed for shorter operative time in the LAPEG technique.

Optimization and assessment of a novel gastric electrode anchoring system designed to be implanted by minimally invasive surgery

A novel electrode anchoring design and its implantation procedure, aiming for a minimally invasive solution for gastric electrical stimulation, are presented. The system comprises an anchor made of a flexible body embedding two needle-shaped electrodes. The electrodes can easily switch from a parallel position - to pierce the stomach - to a diverging position - enabling them to remain firmly anchored into the muscular layer of the stomach. Key device parameters governing anchoring stability were assessed on a traction test bench, and optimal values were derived. The device was then implanted in six dogs by open surgery to assess its anchoring durability in vivo. Computed tomography images showed that the electrodes remained well placed within the dogs' gastric wall over the entire assessment period (more than one year). Finally, a prototype of a surgical tool for the minimally invasive device placement was manufactured, and the anchoring procedure was tested on a dog cadaver, providing the proof of concept of the minimally invasive implantation procedure. The use of our electrode anchoring system in long-term gastric electrical stimulation is promising in terms of implantation stability (the anchor withstands a force up to 0.81 N), durability (the anchor remains onto the stomach over one year) and minimal invasiveness of the procedure (the diameter of the percutaneous access is smaller than 12 mm). Moreover, the proposed design could have clinical applications in other hollow organs, such as the urinary bladder.

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.

The Effectiveness of Laparoscopic-assisted Percutaneous Endoscopic Gastrostomy in Patients with Unfavorable Anatomy: A Single-center Retrospective Cohort Study

Percutaneous endoscopic gastrostomy (PEG) is an easy means to provide enteral access in patients unable to maintain adequate nutrition via the oral route. In patients with morbid obesity, altered intra-abdominal anatomy due to prior abdominal surgery, the interposition of the colon or other factors precluding endoscopy, feeding tube placement by laparoscopic means (LAPEG) can provide a potentially safe alternative. The objective of this study was to examine the efficacy and outcomes of laparoscopic-assisted placement of PEG in adult patients. This is a retrospective cohort analysis of adult patients, who underwent PEG and/or laparoscopic-assisted percutaneous endoscopic gastrostomy placement (LAPEG) by two surgeons at a single institution. A total of 36 patients underwent PEG and/or LAPEG. No significant differences were found in the total and postoperative length of stay and mortality. There were no procedure-related complications in the LAPEG group versus two in the PEG group (8.7%), but this did not reach statistical significance. LAPEG was 100% successful in gaining enteral feeding access in patients that had failed PEG. The most common reason for PEG placement failure was colonic interposition (39%), followed by intra-abdominal adhesions and gastric displacement by hiatal hernia (each 23%). 38.5% of LAPG procedures could be done via 5-mm single port access, 38.5% required two-port and 23% required three-port access. In conclusion, LAPEG is a feasible minimally invasive alternative to gain enteral feeding access in patients that have failed PEG that does not increase the length of stay, morbidity or mortality.

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.

Initial experience with percutaneous endoscopic gastrostomy with T-fastener fixation in pediatric patients

BACKGROUND AND STUDY AIMS

 Insertion of a percutaneous endoscopic gastrostomy (PEG) with push-through technique and T-fastener fixation (PEG-T) has recently been introduced in pediatric patients. The T-fasteners allow a primary insertion of a balloon gastrostomy. Due to limited data on the results of this technique in children, we have investigated peri- and postoperative outcomes after implementation of PEG-T in our department.

PATIENTS AND METHODS

 This retrospective chart review included all patients below 18 years who underwent PEG-T placement from 2010 to 2014. Main outcomes were 30-day postoperative complications and late gastrostomy-related complications.

RESULTS

 In total, 87 patients were included, and median follow-up time was 2.4 years (1 month - 4.9 years). Median age and weight at PEG-T insertion were 1.9 years (9.4 months - 16.4 years) and 10.4 kg (5.4 - 33.0 kg), respectively. Median operation time was 28 minutes (10 - 65 minutes), and 6 surgeons and 3 endoscopists performed the procedures. During the first 30 days, 54 complications occurred in 41 patients (47 %). Most common were peristomal infections treated with either local antibiotics in 11 patients (13 %) or systemic antibiotics in 11 other patients (13 %). 9 patients (10 %) experienced tube dislodgment. Late gastrostomy-related complications occurred in 33 patients (38 %). The T-fasteners caused early and late complications in 9 (10 %) and 11 patients (13 %), respectively. Of these, 4 patients (5 %) had subcutaneously migrated T-fasteners which were removed under general anesthesia.

CONCLUSION

 We found a high rate of complications after PEG-T. In particular, problems with the T-fasteners and tube dislodgment occurred frequently after PEG-T insertion.

Laparoscopic-Assisted Percutaneous Endoscopic Gastrostomy

There are a variety of techniques for gastrostomy tube placement. Endoscopic and radiologic approaches have almost entirely superseded surgical placement. However, an aging population and significant advancements in modern healthcare have resulted in patients with increasingly complex medical issues or postsurgical anatomy. The rising prevalence of obesity has also created technical challenges for proceduralists of many specialties. When patients with these comorbidities develop the need for long-term enteral nutrition and feeding tube placement, standard approaches such as percutaneous endoscopic gastrostomy (PEG) by endoscopists and percutaneous image-guided gastrostomy (PIG) by interventional radiologists may be technically difficult or impossible. For these challenging situations, laparoscopic-assisted PEG (LAPEG) is an alternative option. LAPEG combines the advantages of PEG with direct intraperitoneal visualization, helping ensure a safe tube placement tract free of intervening organs or structures. In this review, we highlight some of the important factors of first-line gastrostomy techniques, with an emphasis on the utility and procedural technique of LAPEG when they are not feasible.