Laparoscopically assisted percutaneous endoscopic gastrostomy

The percutaneous endoscopic approach is an established method for fashioning a gastrostomy. However, the technique is not without complications. Visualising the peritoneal cavity via a small laparoscope may provide additional safety to percutaneous endoscopic gastrostomy.     

Clinical outcome after percutaneous endoscopic gastrostomy in children with malignancies

Percutaneous endoscopic gastrostomies (PEG) are little-used in pediatric oncology. We evaluated complications and efficacy of PEGs in children with malignancies in a retrospective case series. Outcome measures were infection and weight gain. Sixteen PEGs were inserted in 14 patients (mean age 10.3 years; SD 5.6). Sixteen wound infections occurred in nine children (3.7 episodes/1,000 days). Mean weight-for-age z-score fell from diagnosis to PEG placement (-0.68 (SD 1.2) to -1.32 (SD 1.26); P < 0.001) but stabilized afterward. Two (12%) were removed early. PEG placement reversed early weight loss and infectious complications did not usually lead to early PEG removal.     

Complications of removing percutaneous endoscopic gastrostomy tubes in children

BACKGROUND: Little information has been reported regarding the frequency and type of complications arising from removal of percutaneous endoscopic gastrostomy (PEG) tubes in children. METHODS: The records of 397 patients who had PEG tubes placed from 1993 through 1998 were reviewed for complications after removal. Data collected included length of time the tube was in place, age of the patient at insertion, type of tube removed, and patient diagnosis. RESULTS: Fifty-four children had the PEG tube removed by traction or endoscopy. The only complication was persistent leaking through a gastrocutaneous fistula in 13 patients (24%). Leaking ceased in 6 children coincident with H2-antagonist therapy and silver nitrate cautery, and surgical closure of the fistula was required in 7 patients. Comparison of these 7 children with those who did not require surgery (n = 47) showed a longer duration of tube placement (mean +/- SE of 20.6+/-3.6 months, range 11-31 months vs. 11.1+/-1.3 months, range 1-35 months; P<0.05). Further analysis showed no child with a PEG tube removed before 11 months (n = 23) after insertion required surgery, whereas 7 (23%) of 31 children with a PEG tube removed after 11 or more months required surgery. Age at insertion, type of feeding device removed, and patient diagnoses were not different between the two groups. CONCLUSIONS: These data indicate that persistent leaking necessitating surgical closure of a gastrocutaneous fistula does not occur in children with a PEG tube removed within 11 months of insertion. In contrast, 23% of children with a PEG tube removed 11 or more months after insertion require surgery. In patients identified as candidates for tube removal, this time frame may be important in clinical decision making.     

Laparoscopic fundoplication in neurologically impaired children with percutaneous endoscopic gastrostomy.

TOPIC: Laparoscopic fundoplication is the preferred surgical procedure for children with gastro-oesophageal reflux. Little data exist on the feasibility of laparoscopic fundoplication after placement of a percutaneous endoscopic gastrostomy (PEG). PATIENTS AND METHODS: Thirty-nine children aged 4 months to 18 years (median 3.6 years) presented for an antireflux procedure between November 2000 and July 2003. The surgical technique used was the Thal (270 degrees ) fundoplication. Clinical data, technical aspects of the operation, and the postoperative course were collected prospectively. RESULTS: Twenty-two children (56 %), all of them neurologically impaired, already had a PEG in place due to feeding problems irrespective of gastro-oesophageal reflux symptoms. In all cases, laparoscopic fundoplication was performed immediately after gastroscopic removal of the PEG tube. In two cases, conversion to an open procedure became necessary, due to reasons unrelated to the PEG. In one case conversion was necessary because of adhesions of an intrathoracic stomach and in the other case because of circulatory problems due to congenital cardiomyopathy. In one patient, the gastrostomy was moved at the end of the procedure because it was too close to the antrum. In two further cases, the gastrostomy detached during fundoplication. In this case, the gastrostomy catheter was replaced and secured laparoscopically with a purse-string suture. All other cases were without any complications and a balloon tube or a button was placed into the existing gastrostomy channel at the end of surgery. CONCLUSION: No adverse effects are associated with PEG placement prior to a consecutive laparoscopic antireflux procedure. Possible detachment of the pre-existing gastrostomy must be excluded at the end of the procedure.     

Late-onset complications of percutaneous endoscopic gastrostomy in children.

PURPOSE: The aim of this study was to report the late morbidity of percutaneous endoscopic gastrostomy (PEG) in a pediatric population and to identify possible risk factors for complications developing after PEG insertion. METHODS: A PEG was placed in 110 children between 1 May 1990 and 1 January 1997 using the pull technique. A retrospective study of late-onset complications was performed, with a follow-up period ranging from 1 to 8 years. All the complications occurring more than 6 days after PEG insertion were recorded, except for gastrostomy tube obstruction and accidental tube dislodgement. RESULTS: The prevalence of late-onset complications related to PEG in our patients varied from 3.8 to 4.4 per 10 5 days. The overall rate of late-onset complications was 44% (48 complications observed in 29 patients [26%]). Seventy-five percent of the complications appeared during the first 2 years after PEG insertion. Nine different types of complication have been identified: intragastric buried or extruded gastrostomy (n = 24), gastric metaplasia granulation tissue around the site of gastrostomy (n = 8), intragastric pseudotumoral proliferative gastric mucosa (n = 4), intragastric mucosal ulceration (n = 3), cutaneous necrosis (n = 3), cologastric fistula (n = 2), gastrostomy closure delay after tube removal (n = 2), subcostal neuralgia (n = 1), and peritonitis (n = 1). Wilcoxon and chi-square tests were used to compare the clinical characteristics of the patients and the type of material used in the two populations, with and without complications. No clinical risk factor for the development of complications could be identified. Intragastric buried or extruded gastrostomy appeared more frequently with the use of one type of button than with the use of tubes. CONCLUSIONS: The authors' experience suggests that PEG is associated with significant late morbidity, which is mainly observed within the first 2 years after PEG insertion. However, no risk factor for the development of such complications could be identified.     

CT findings in gastrocolic fistula following percutaneous endoscopic gastrostomy

We describe the CT findings in an initially asymptomatic boy aged 2 years 9 months with a gastrocolic fistula following percutaneous endoscopic gastrostomy (PEG) placement. The findings consisted of an unusual configuration of the gastrostomy tubing on an abdominal radiograph and upper gastrointestinal study indicating the possibility of transcolic PEG placement, which was confirmed with limited section CT. This well-known and major complication following a common procedure may be recognized on plain abdominal radiography, but it has not to our knowledge been documented previously on CT in a child.     

Colocutaneous gastric fistula: a complication of percutaneous endoscopic gastrostomy

Gastrocolic fistula is a rare complication of percutaneous endoscopic gastrostomy. It is most frequently discovered after replacement of the gastrostomy tube. The symptoms are severe diarrhea, failure to thrive, recurrent Gram-negative pulmonary infections, and feculent vomiting.     

Comparison of major complications in children after laparoscopy-assisted gastrostomy and percutaneous endoscopic gastrostomy placement: a meta-analysis

Purpose

A meta-analysis was performed to compare the rates of the major complications associated with two gastrostomy tube placement techniques in a pediatric population: laparoscopy-assisted gastrostomy (LAG) and percutaneous endoscopic gastrostomy (PEG).

Methods

The PubMed electronic database was queried for comparative studies of the two insertion techniques. The Newcastle–Ottawa scale (NOS) was used for the assessment of the quality and risk of bias in the included studies. The main outcome measure was the frequency of major complications defined as the need for reoperation within 30 days or death. RevMan 5.3, was used, with a p?<?0.05 indicating statistical significance.

Results

Eight studies including 1550 patients met the inclusion criteria. The risk for major complications was higher in PEG than in LAG 3.86 (95% confidence interval 1.90–7.81; p?<?0.0002). The number needed to treat to reduce one major complication by performing LAG instead of PEG was 23. There were no randomized-controlled trials. Overall, the quality of the included studies was determined to be unsatisfactory.

Conclusions

PEG placement was associated with a significantly higher risk of major complications compared to LAG placement. Therefore, LAG should be the preferred method for gastrostomy tube placement in children.