Laparoscopically monitored percutaneous endoscopic gastrostomy (PEG) in children: a safer procedure

Laparoscopic-assisted Stamm-gastrostomy: technical modifications to ease suturing inside the minimal trocar site

Laparoscopic gastrostomy tube placement has been increasingly adopted by pediatric surgeons. We herein report our experience with the performance of a laparoscopic-assisted Stamm-operation inside the minimal trocar site without the extension of the trocar site incision or mini-laparotomy. We present some technical modifications that facilitate suturing inside the minimal trocar site.

METHODS

A retrospective chart review was conducted of cases involving patients who underwent laparoscopic-assisted gastrostomy, using a simple extracorporeal method inside the trocar site from April 1998 to March 2018.

RESULTS

One hundred five gastrostomy tubes were placed in a laparoscopic-assisted operation. All but two of the cases involved patients with neurological impairment. The mean age was 12.5 years; 28 cases were > 16 years of age. Seventy-five cases underwent gastrostomy during laparoscopic fundoplication. All gastrostomy procedures were completed without intraoperative difficulties; however, 8 cases, which involved a thick abdominal wall, required extension of the trocar site. No cases required conversion to open gastrostomy. No major complications were observed. Two patients developed continuous peristomal cellulitis after surgery, due to the mismatch of the site position and an unsuitable button device size.

CONCLUSION

We demonstrated that laparoscopic gastrostomy with fully extracorporeal suturing within the trocar site is feasible and beneficial, especially for the most neurologically impaired pediatric cases. Technical modification, changing the order of the process, and suturing technique in the minimal space, made it easier to perform the procedures inside the minimal trocar hole.

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

BACKGROUND

This study describes our experience with the placement of a skin-level gastrostomy device (MIC-KEY) in a single procedure.

METHODS

We identified infants, children and young adults who underwent laparoscopic-assisted percutaneous endoscopic gastrostomy (LAPEG) tube insertion between October 2009 and June 2013. The steps of this procedure include upper endoscopy, single-port laparoscopy, gastropexy via percutaneous T-fasteners and placement of a skin-level gastrostomy device (MIC-KEY) using a "push" technique with a tear-away sheath.

RESULTS

We included 92 patients in our study. Mean age was 3.7 years (range 3 wk-5 yr), and mean weight was 11.2 (range 2.8-54) kg. Median procedural time was 20 (range 12-76) minutes. Total median duration for the most recent 25 procedures was lower than that of the first 25 (62 v. 79 min, p = 0.004). There were no intraoperative complications or conversions to open surgery. Postoperative complications were observed in 6 (6.5%) patients. Three retained T-fasteners were assessed endoscopically (n = 1) or removed via local excision (n = 2). Two patients experienced early dislodged feeding tubes that were replaced via interventional radiology (n = 1) or repeat LAPEG (n = 1). There was also 1 intra-abdominal fluid collection that was drained percutaneously but ultimately required a laparotomy and washout. There were no major complications in the most recent 50 procedures.

CONCLUSION

Our results suggest that LAPEG is a safe, minimally invasive procedure for infants, children and young adults. This approach allows for immediate use of a skin-level gastrostomy device without the need for postoperative tube exchanges.

Safety of percutaneous endoscopic gastrostomy in high-risk patients

Percutaneous endoscopic gastrostomy (PEG) is a minimally invasive procedure. However, failure to transilluminate the anterior wall of the stomach or visualize the indentation of the physician's finger represents the most frequent obstacles encountered by the endoscopist in safely completing PEG tube placement. We described several methods to safely assess PEG placement in high-risk patients. An abdominal plain film after gastric insufflated with 500 mL of air is obtained before PEG in patients. The body of the stomach near the angularis, equidistant from the greater and lesser curves, was defined as the optimal gastric puncture point. The location of the puncture points varied greatly, being situated over the right upper quadrant in 31% of patients, left upper in 59%, left lower in 5%, and right lower quadrant in 5% of patients. If there is any question of safe puncture site selection, safe track technique can be used to provide the information of depth and angle of the puncture tract. Computed tomography can provide detailed anatomy and orientation along the PEG tube and show detailed anatomical images along the PEG tract. Computed tomography-guided PEG tube placement is used when there is difficulty either insufflating the stomach, or the patients had previous surgery, or anatomical problems. Full assessment of the position of the stomach and adjacent organs prior to gastric puncture may help minimize the risk for potential complications and provide safety for the high-risk patients.

Laparoscopy-assisted percutaneous endoscopic gastrostomy using a "Funada-kit II" device

We aimed at assessing the effect of using a "Funada-kit II" device during laparoscopy-assisted percutaneous endoscopic gastrostomy (Lap-PEG), by reviewing 29 cases of Lap-PEG we performed from 2001 to 2011. We started using the "Funada-kit II" (CREATE MEDIC CO., Kanagawa, Japan) device with two parallel needles to puncture the stomach and assist suturing the anterior gastric wall to the anterior abdominal wall during Lap-PEG in 2011 (F-PEG). By introducing a loop through the lumen of one needle which allows placement of a suture introduced through the lumen of the other needle. Once repeated, the stomach can be pexied at two points, approximately 2 cm apart. We compared Lap-PEG (n = 23) with F-PEG (n = 6) where the mean ages and weights at surgery and sex ratios were similar. All cases were uneventful without intraoperative complications, although one postoperative wound infection occurred in a Lap-PEG case. There were no differences in the duration of analgesia, time taken to commence tube feeding, and return to full feeding. However, mean operating time was significantly shorter in F-PEG (28.1 min) versus Lap-PEG (46.1 min) p < 0.05. As per results F-PEG would appear to be as safe as Lap-PEG, but much quicker.

Clinical experience of percutaneous endoscopic gastrostomy in Taiwanese patients--310 cases in 8 years

Although percutaneous endoscopic gastrostomy (PEG) has become a popular method for long-term tube feeding worldwide, there are only a few reports about its application in Taiwan. From May 1997 to May 2005, we performed 302 PEG insertions successfully in 310 attempts (97.4% success rate) using modified Ponsky's pull method with 24-Fr feeding tubes. All the patients received PEG for tube feeding except for two patients with cancerous peritonitis for decompression. The underlying diseases in these 308 patients who received PEG for tube feeding were 161 cerebrovascular accidents (52.3%), 62 head and neck cancers (20.1%), 21 cases of Parkinsonism (6.8%), and others. There were 11 major complications (3.6%) and 57 minor complications (18.9%). Ten patients (3.3%) died within 30 days after PEG insertion. However, no procedure-related mortality occurred. In conclusion, PEG is an effective method for tube feeding and drainage with a high success rate. PEG insertion was often indicated for patients with dysphagia caused by cerebrovascular accident, head and neck cancer, and Parkinsonism in Taiwan. It is a relatively safe procedure, with a 3.6% rate of major complications and 18.9% rate of minor complications.

Positioning a safe gastric puncture point before percutaneous endoscopic gastrostomy

To position a safe gastric puncture point prior to the percutaneous endoscopic gastrostomy (PEG) a technique using an abdominal plain film with a gastric insufflation was assessed. After insufflated with 500 ml of air, an abdominal plain film was obtained before PEG in 84 patients. The body of the stomach near the angularis, equidistant from the greater and lesser curves, was defined as the optimal gastric puncture point. The location of the puncture points varied greatly, being situated over the right upper quadrant in 31% of patients, left upper in 59%, right lower in 5% and left lower quadrant in 5% of patients. The marked puncture points on abdominal film in some patients were shown to be partially covered by colon or small bowel loop, lie high under the costal margin, or low beneath the umbilicus. An abdominal plain film utilising a gastric insufflation technique prior to PEG may help to determine optimal gastric puncture site selection. Use this technique in clinical practice might hasten procedural time, provide better assurance to the clinical doctor, and provide an added margin of safety for the patient.

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

BACKGROUND

Gastrostomy tube placement is among the most common gastrointestinal procedures performed in children. The U-stitch laparoscopic technique allows primary button placement and the advantages of laparoscopy. The purpose of this study was to quantify the completion rate and the occurrence of complications in a large single-institution experience.

MATERIALS AND METHODS

All laparoscopic gastrostomy procedures between April 2000 and May 2005 were reviewed. Complications that required operative treatment or hospital readmission were classified as early (<90 days) or late (> or =90 days).

RESULTS

Laparoscopic gastrostomies were created in 461 patients during the study period with primary buttons being placed in 444 (96%). No procedure-related deaths occurred. Early complications included: reoperation secondary to tube dislodgement in 7 patients (1.5%), herniation of omentum postoperatively in 3 patients (0.6%), and development of granulation tissue or everted gastric mucosa requiring excision in 13 patients (3.2%). Late complications occurred in 8 patients (1.7%), with three (0.7%) requiring revision of the gastrostomy due to local site problems. Five patients (1.1%) had intraperitoneal placement of tubes during attempted replacement after 90 days. Age, infancy, and neurological impairment were not associated with a higher rate of complications.

CONCLUSION

The U-stitch gastrostomy technique is safe and allows primary button placement in infants and children. Its complication rate compares favorably to other reported gastrostomy techniques.