Laparoscopic Gastrostomy Placement in Children Has Few Major, but Many Minor Early Complications

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.

Over-the-scope clip for closure of persistent gastrocutaneous fistula after gastrostomy tube removal: a multicenter pediatric experience

BACKGROUND

Percutaneous endoscopic gastrostomy is commonly used for enteral nutritional access, but gastrocutaneous fistulae (GCF) may persist after tube removal, posing clinical challenges. The use of endoscopic closure devices, including over-the-scope clips (OTSC), has shown promise in managing non-healing fistulae, although data in the pediatric population are limited.

METHODS

A retrospective multicenter study analyzed pediatric patients who underwent GCF closure following gastrostomy tube removal. Data from seven centers across multiple countries were collected, including patient demographics, procedural details, complications, and outcomes. Closure techniques were compared between OTSC and surgical closure.

RESULTS

Of 67 pediatric patients included, 21 underwent OTSC closure and 46 had surgical closure. Surgical closure demonstrated a higher success rate (100%) compared to OTSC closure (61.9%, P < 0.001). While procedural duration was shorter for OTSC closure (25 vs. 40 min, P = 0.002), complications, and scar quality were comparable between techniques. A subsequent sub-analysis did not reveal differences based on center experience.

CONCLUSION

OTSC closure is feasible and safe in pediatric patients, but surgical closure remains superior in achieving sustained GCF closure, although OTSC offers benefits, such as shorter procedural duration, potentially reducing the duration of general anesthesia exposure. Non-operative approaches, including OTSC, may be a valuable alternative to surgical closure.

Impact of Scoliosis Severity on Gastrostomy-Related Complications in Children

OBJECTIVES

This study aimed to determine the relationship between scoliosis and risk of developing complications in patients who underwent gastrostomy.

METHODS

Patients who underwent percutaneous endoscopic gastrostomy (PEG) or surgical gastrostomy (SG) between 2012 and 2022 were included. Leakage, discharge, granuloma, and hyperemia were considered minor complications, while visceral injury, ileus, and re-do surgery were considered major complications. The degree of scoliosis was calculated using the Cobb angle. The SG and PEG groups were compared by evaluating the complications and their correlation with scoliosis.

RESULTS

A total of 104 patients with a mean age of 5.0 ± 5.3 were included; 58% of patients were treated with SG. Patients in the SG group were younger ( P < 0.001). Minor complications were significantly more common in the PEG group ( P = 0.018). There was no difference between the groups in terms of major complications ( P = 1.000). Scoliosis was observed in 32.7% of the patients (n = 34). In the SG group, no correlation was found between the Cobb angle and the frequency of minor ( P = 0.173) or major complications ( P = 0.305). There was no significant difference between the Cobb angles of patients with and without minor complications in the PEG group ( P = 0.478); the Cobb angles of patients with major complications (75°) were significantly higher than those without (36°) ( P = 0.030).

CONCLUSION

Gastrostomy is important for weight gain and nutritional needs of children. This study showed that the risk of complications in SGs did not correlate with the degree of scoliosis and that the risk of major complications in PEGs increased in patients with a high degree of scoliosis.

Troubleshooting the pediatric gastrostomy

Gastrostomy tubes benefit patients but also introduce hazards and costs. Most of these costs tend to be administratively invisible, but clinically expensive. Nurses, residents, emergency physicians, surgeons, and others routinely manage complaints about gastrostomy tubes or sites, and the time and effort costs are enormous. Despite widespread use of gastrostomy tubes and the large "cost of ownership," scant instruction guides practitioners on troubleshooting the panoply of tube-related problems. Instead, clinical folk-wisdom leaves staff disarmed, resorting to lore or maladaptive work-arounds that are futile or even harmful. But tubes and gastrostomies fail in predictable ways. This guide reviews commonly used gastrostomy tubes and how they are placed. Routine care of these tubes both in the immediate postoperative period and long-term is detailed. Then, specific gastrostomy tube complications and their principle-based countermeasures are described, organized by presenting complaint. Throughout, specific clinical pitfalls are called out along with their remedies. The aim is to demystify these devices and dispel myths that lead to error.

Definition, Documentation, and Classification of Complications in Pediatric Surgical Literature-A Plea for Standardization

Severity grading systems for complications in surgical patients have been used since 1992. An increasing assessment of these instruments in pediatric surgery is also noticed, without their validation in children. To analyze the current practice, we performed a literature review with focus on the assessment and grading of complications. The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Studies reporting on postoperative complications as a primary or secondary endpoint using a severity grading system were included. Definition for simple adverse events, classification systems used, and the time horizon of postoperative documentation were analyzed. A total of 566 articles were screened, of which 36 met the inclusion criteria. About 86.1% of the papers were retrospective and 13.9% prospective analyses. None of the studies were prospective-randomized trials. Twenty (55.6%) studies did not include a definition of adverse events, whereas the remaining 16 (44.4%) showed variations in their definitions. All studies applied the Clavien-Dindo classification, whereas five (13.9%) additionally used the Comprehensive Complication Index. One study compared alternative grading instruments with the Clavien-Dindo classification, without demonstrating the superiority of any classification in pediatric surgery. Twenty-two studies (61.1%) did not report the time horizon of perioperative complication documentation, while 8 studies (22.2%) used 30 days and 6 studies (16.7%) used 3 months of postoperative documentation. Definition and classification of postoperative complications are inconsistent in the pediatric surgical literature. Establishment of a standardized protocol is mandatory to accurately compare outcome data.

Size Matters: Early Gastrostomy Tube Dislodgment in Children

Background: Gastrostomy tube (g-tube) complications are typically minor and site related with major complications related to dislodgment before tract establishment. With the recent adoption of 12F g-tubes; size of tube has not been evaluated. There is limited research on the efficacy and dislodgment rates of 12 and 14F g-tubes within the early dislodgment window (<42 days postsurgery). Materials and Methods: A retrospective study from June 1, 2013 to May 25, 2020 was performed. A total of 888 patient encounters were identified, with a final data set of 835 being used for analysis. A subset of 21 patients was evaluated based on early dislodgment status. Fisher's exact test and Welch's two-sample test analyses were used to test for significance between groups (P < .05). Results: The early dislodgment rate is low at 2.5% (21/835). There was a significant impact of g-tube size on dislodgment rates. When evaluated by g-tube size, 12F g-tubes are nearly four times more likely to dislodge before 6 weeks than 14F g-tubes. In addition, the average age of 12F patients who dislodged early was significantly lower than that of the population for 14F patients. Conclusions: There is a significant difference in early dislodgment rate and age between the 12F g-tube compared with a 14F. These data suggest a trade-off of the smaller balloon in 12F g-tubes and potential for more limited use in our smallest children.