Variability in the Method of Gastrostomy Placement in Children

Pediatric laparoscopic versus percutaneous gastrostomy tube placement: a single-center review

BACKGROUND

The optimal technique for gastrostomy tube (GT) placement in pediatric patients remains controversial. Percutaneous endoscopic gastrostomy (PEG) was the preferred approach over open gastrostomy. With the advent of laparoscopy, many advocate for laparoscopic (LAP) placement to avoid potential visceral injury. Additionally, PEG patients may undergo an additional procedure for conversion to a low-profile button. We sought to compare outcomes including complications, need for subsequent procedures, and anesthesia exposure in LAP vs. PEG patients.

METHODS

Patients (ages 0-18) who underwent GT placement at our pediatric healthcare system between 2018 and 2021 were retrospectively reviewed. Patients were excluded if they underwent fundoplication, gastro-jejunostomy tube placement, open placement, tube placement in concurrence with other intestinal procedures, or failed primary attempt at gastrostomy placement. Data related to demographics and GT placement were recorded. Our primary outcomes were complications, need for subsequent procedures, discrete anesthesia exposures, and cumulative anesthesia exposure. The Wilcoxon rank sum test, Pearson's Chi-squared test, and Fisher's exact test were used to compare characteristics and clinical measurements between PEG and LAP patients.

RESULTS

Six hundred and eighty-eight (688) patients underwent GT placement during the study period, 234 (34.0%) LAP and 454 (66.0%) PEG. LAP patients were younger and weighed less than PEG patients (p = 0.005 and p = 0.002, respectively). Gender distribution, primary insurance status, and ASA (American Society of Anesthesiologists) classification were similar. Within the group excluded, 5 failed PEG placements, while 0 failed LAP GT attempts (p = 0.173). Major complication rates were comparable (1.3% vs. 2.4%, p = 0.401); however, PEG patients were more likely to have skin erythema/local infection (p = 0.006). PEG patients tended toward undergoing subsequent procedures (10.9% vs. 6.5% for LAP, p = 0.061) such as GT revision or conversion to gastro-jejunostomy tube. Additionally, 60.5% of PEG patients required > 2 anesthesia events, most often due to exchange of PEG to a low-profile button, while 93.6% of LAP patients required only one (p < 0.001). Finally, the median total general anesthesia exposure for the PEG group was 75 min (IQR 53-97) and 79 (IQR 67-98) in the LAP group (p = 0.002).

CONCLUSION

PEG technique is associated with more discrete anesthesia exposures and may also require more subsequent operations related to its placement. However, at our institution, overall major complications are similar in both techniques, while PEG tubes are prone to skin erythema/local infection.

LEVEL OF EVIDENCE

Retrospective Comparative Study, Level III.

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.

Percutaneous Endoscopic Gastrostomy Tubes Can Be Considered Safe in Children: A Single-Center 11-Year Retrospective Analysis

Background and Objectives: When the human body is disabled to naturally ingest food through the mouth, enteral or parenteral nutritional support should be started. Percutaneous gastrostomy (PEG) is a flexible feeding tube that is inserted into the stomach through the abdominal wall in patients who will need long-term enteral nutrient intake. The aim of this study is to analyze clinical characteristic of children at the time of PEG placement as well as to determine indications, complications and outcomes associated with PEG at the Department of Pediatrics of the University Hospital of Split. Materials and Methods: Retrospective analysis of the medical records of patients treated from 2010 to 2020 was performed. The following data were collected from medical records: age, gender, information about nasogastric feeding before PEG placement, indication for PEG insertion, duration of PEG, procedure-related complications and treatment outcomes. Malnutrition was determined according to the z-score range for BMI for age and sex. According to the indication for PEG placement, patients were divided into five categories: central nervous system (CNS) diseases, neuromuscular diseases, genetic disorders, metabolic diseases, and group of children with polytrauma. Results: A total of 40 patients with median age of 110 months were included in study. At the time of PEG placement, most patients had deviations in body weight and height compared to expected values for age and sex. The most common underlying diagnoses were diseases of the central nervous system. Minor complications were found in 13 (35%) of patients. One patient (2.7%) developed major complication (gastrocolic fistula) and consequently underwent reoperation. The median duration of PEG in patients with complications before the need for replacement was 27 months, and in patients without complications, 43 months. Conclusions: Negative deviations of z-score body weight, body height, and body mass index could indicate the need for possible earlier placement of PEG. PEG can be considered as a safe therapeutic option in children since PEG-related complications, mostly in minor forms, were found in a small number of patients.