Primary percutaneous endoscopic button gastrostomy: a modification of the "push" technique

Endoscopic button gastrostomy: Comparing a sutured endoscopic approach to the current techniques

PURPOSE

Button gastrostomy is the preferred feeding device in children and can be placed open or laparoscopically (LBG). Alternatively, a percutaneous endoscopic gastrostomy (PEG) can be placed initially and exchanged for a button. Endoscopic-assisted button gastrostomy (EBG) combines both techniques, using only one incision and suturing the stomach to the abdominal wall. The long-term outcomes and potential costs for EBG were compared to other techniques.

METHODS

Children undergoing EBG, LBG, and PEG (2010-2013) were compared. Patient demographics, procedure duration/complications, and clinic and emergency room (ER) visits for an eight-week follow-up period were compared.

RESULTS

Patient demographics were similar (32 patients/group). Mean procedure time (min) for EBG was 38 ± 9, compared to 58 ± 20 for LBG and 31 ± 10 for PEG (p<0.0001). The most common complications were granulation tissue and infection with a trend toward fewer infections in EBG group. Average number of ER visits was similar, but PEG group had fewer clinic visits. 97% of PEG patients had subsequent visits for exchange to button gastrostomy.

CONCLUSIONS

EBG is safe and comparable to LBG and PEG in terms of complications. It has a shorter procedure time than LBG and does not require laparoscopy, device exchange, or subsequent fluoroscopic confirmation, potentially reducing costs.

Safety of the One-Step Percutaneous Endoscopic Gastrostomy Button in Children

Pediatric experience using the single-stage percutaneous endoscopic gastrostomy button has been reported anecdotally. This 3-year prospective monocentric study, including 183 children, demonstrates that this technique is safe, with a low rate of infection, and compares favorably with the pull technique of percutaneous endoscopic gastrostomy while necessitating only one general anesthesia.

ESPGHAN position paper on management of percutaneous endoscopic gastrostomy in children and adolescents

OBJECTIVES

This European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) position statement provides a comprehensive guide for health care providers to manage percutaneous endoscopic gastrostomy tubes in a safe, effective, and appropriate way.

METHODS

Relevant literature from searches of PubMed, CINAHL, and recent guidelines was reviewed. In the absence of evidence, recommendations reflect the expert opinion of the authors. Final consensus was obtained by multiple e-mail exchange and during 3 face-to-face meetings of the gastroenterology committee of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

RESULTS

Endoscopically placed gastrostomy devices are essential in the management of children with feeding and nutritional problems. The article focuses on practical issues such as indications and contraindications.

CONCLUSIONS

The decision to place an endoscopic gastrostomy has to be made by an appropriate multidisciplinary team, which then provides active follow-up and care for the child and the device.

Effect of the introducer technique compared with the pull technique on the peristomal infection rate in PEG: a meta-analysis

BACKGROUND

Peristomal infection is a main complication of PEG. The pull technique appears to be associated with higher infection rates compared with the introducer technique, although published results are controversial.

OBJECTIVE

To determine which technique is associated with a higher risk of infection.

DESIGN

Systematic review and meta-analysis.

SETTING

Studies reporting rates of peristomal infection after PEG performed by either the pull or introducer technique.

PATIENTS

This study involved 2336 patients from 6 comparative and 10 observational studies.

INTERVENTION

Public MEDLINE (National Library of Medicine journal articles database), Excerpta Medica Database, Cochrane Central Register of Controlled Trials, and Latin American and Caribbean Center on Health Sciences Information databases and proceedings of two meetings, Digestive Disease Week and United European Gastroenterology Week, were searched. Both comparative and observational studies were included and analyzed separately.

MAIN OUTCOME MEASUREMENTS

Effect measures from each comparative study were reported as the odds ratio (OR). The pooled effect was then calculated. The infection rate in each observational study was also calculated, and a summary effect was then determined.

RESULTS

In comparative studies, the risk of infection was significantly higher with the pull technique (OR 13.0; 95% confidence interval [CI], 4.6-36.8; P < .0001). Similarly, observational studies also reported higher infection rates with the pull technique (10.7%; 95% CI, 4.9-21.8 with the pull technique vs 0.9%; 95% CI, 0.2-4.5 with the introducer technique).

LIMITATIONS

Few studies were available for inclusion, and there was a high risk of bias among the comparative studies.

CONCLUSION

The pull technique appears to be associated with a significantly higher risk of infection compared with the introducer technique.

Assessment of safety and feasibility of a new technical variant of gastropexy for percutaneous endoscopic gastrostomy: an experience with 435 cases

BACKGROUND

Percutaneous Endoscopic Gastrostomy (PEG) performed through the Introducer Technique is associated with lower risk of surgical infection when compared to the Pull Technique. Its use is less widespread as the fixation of the stomach to the abdominal wall is a stage of the procedure that is difficult to be performed. We present a new technical variant of gastropexy which is fast and easy to be performed. The aim of this study was to evaluate the safety and feasibility of a new technical variant of gastropexy in patients submitted to gastrostomy performed through the Introducer Technique.

METHODS

All the patients submitted to PEG through the Introducer Technique were evaluated using a new technical variant of gastropexy, which consists of two parallel stitches of trasfixation sutures involving the abdominal wall and the gastric wall, performed with a long curved needle. Prophylactic antibiotics were not used. Demographic aspects, initial diagnosis, indication, sedation doses, morbidity and surgical mortality were all analyzed.

RESULTS

Four hundred and thirty-five consecutive PEGs performed between June 2004 and May 2007 were studied. Nearly all the cases consisted of patients presenting malignant neoplasia, 79.5% of which sited in the head and neck. The main indication of PEG was dysphagia, found in 346 patients (79.5%). There were 12 complications (2.8%) in 11 patients, from which only one patient had peristomal infection (0.2%). There was one death related to the procedure.

CONCLUSION

Gastropexy with the technical variant described here is easy to be performed and was feasible and safe in the present study. PEG performed by the Introducer Technique with this type of gastropexy was associated with low rates of wound infection even without the use of prophylactic antibiotics.

Should single-stage PEG buttons become the procedure of choice for PEG placement in children?

BACKGROUND

Single-stage PEG buttons (PEG-B) allow initial placement of a skin-level gastrostomy device for children who require enteral access. They offer significant advantages over traditionally placed PEG tubes (PEG-T) but have not been widely accepted into practice.

OBJECTIVE

To review our experience with PEG-Bs compared with PEG-Ts.

HYPOTHESIS

PEG-B shares a similar safety profile with PEG-T but delays the need for an initial device change well beyond the change that usually occurs at 6 to 8 weeks after PEG-T placement.

DESIGN

Retrospective chart review.

SETTING

Nemours Children's Clinic, Jacksonville, Florida.

PATIENTS

All children undergoing both PEG procedures and attending our clinic from 1997 to 2002.

MAIN OUTCOME MEASUREMENTS

Age, sex, weight, indications, postoperative complications, interval until first tube change and first tube change complications.

RESULTS

Totals of 145 and 93 patients were identified in the PEG-B and PEG-T groups, respectively. Patient characteristics were similar in the 2 groups with respect to age, weight, indications, and postoperative complications. The interval until first tube change, however, was significantly longer in the PEG-B group (314 days) than in the PEG-T (78 days) (P < .0001). In addition, the PEG-B was found to be as safe as the PEG-T for small infants who weighed less than 5 kg.

CONCLUSIONS

PEG-B placement should be considered as the procedure of choice over PEG-T placement for children. It offers similar safety profiles, even for small patients and a significantly longer interval until first device change.