Comparison of the Laparoscopic and Open Methods of Gastrostomy at Neonates and Infants Up To Three Months of Age

Abstract

Background:

An open surgical intervention is a common approach for gastrostomy tube placement in neonates and infants. Also available, however less often used, is a laparoscopic technique for low-profile gastrostomy tube (button) placement. In this study we compare the pre-, intra-, and post-procedural outcomes of each technique.

Methods:

We retrospectively evaluated all open and laparoscopically inserted gastrostomies at our department from January 2002 to December 2016 and compared them in terms of operative parameters and outcomes.

Results:

In the study interval, 44 open and 90 laparoscopically placed low-profile (button) gastrostomies were performed. There were no significant differences in gender distribution, mean age (42.54 versus 34.16 days), and mean weight (3311 versus 3476 g). The frequency of concomitant Nissen fundoplication was higher in the laparoscopy group (18% versus 47%; P < .05). The duration of G-tube placement by laparotomy was significantly longer (mean difference 16 minutes), than by laparoscopy, as were time periods between G-tube insertion and the onset of first feeding (mean differences 8.4 and 19.6 hours, respectively). Children in the laparoscopy group spent nearly 15 fewer days in the hospital than those who received a G-tube by laparotomy (29.0 versus 13.9; P < .05). Major complications were observed in 3 (6.82%) patients in the laparotomy group in the form of gastric content leak into the abdominal cavity and resulting peritonitis; complications were lower in the laparoscopy group (68.18% versus 13.33%; P = .03).

Conclusions:

Compared with open gastrostomy, the laparoscopic approach appears to be advantageous with respect to procedural duration, initiation of feedings, hospitalization duration, and rate of complications. Another difference was the frequency of concomitant Nissen fundoplication. Further prospective studies may determine the role of these patient-specific factors regarding who benefits most from the laparoscopic technique.

Introduction

Enteral feeding tube placement by gastrostomy is common in children. According to the European Society for Clinical Nutrition and Metabolism guidelines, gastrostomy placement is indicated in all patients in need of supplementary artificial enteral nutrition for a period exceeding 2 or 3 weeks.¹ Indications for this procedure include conditions that compromise oral feeding, such as neurological disorders, deglutition problems, esophageal obstruction, malnutrition secondary to cardiovascular and metabolic diseases, and tumors.²

Gastrostomy is traditionally performed by the open procedure according to the Stamm–Senn–Kader method. Percutaneous endoscopic gastrostomy (PEG) was first proposed by Gauderer et al. in 1980³ and became widely used. More than three decades of PEG use to facilitate enteral feeding in children have revealed the various complications that can accompany this procedure. Among these, most failures were due to the “blind” puncture of the stomach and possible damage of the colon or small bowel.^4,5 These complications were not reported with the laparoscopic technique, which controls all the intraoperative steps required for its completion.

Consequently, the advantages of laparoscopic gastrostomy compared with PEG are becoming increasingly clear, making the former a real competitor to PEG placement. Moreover, PEG is associated with restrictions regarding age and weight, which accentuates that, at least from this perspective, laparoscopic gastrostomy may be the most flexible option for enteral feeding tube placement in young children.^6,7 In this report, we describe the results of a retrospective comparison between open and laparoscopic gastrostomy in neonates and infants.

Materials and Methods

The standard-of-care evaluations, treatments, and procedures were conducted at the surgery center and neonatal intensive care units of the Pediatric Hospital Irkutsk. The study was approved by the local ethical committees of the Pediatric Hospital Irkutsk and the Irkutsk State Medical University. No protocols were exercised that would have required appropriate informed consent.

This retrospective analysis contains data from 134 pediatric patients up to 3 months of age who required enteral feeding devices due to their inability to feed orally between January 2002 and December 2016.

Forty-four patients underwent Stamm gastrostomy using laparotomy. The remaining 90 patients underwent laparoscopic button gastrostomy using the U-stitch technique proposed by K. Georgeson.

Procedure

Open gastrostomy by Stamm–Senn–Kader technique involves making an abdominal incision, placement of two purse-string sutures on the anterior wall of the stomach, followed by insertion and placement of the gastrostomy tube toward the anterior abdominal wall.

Alternatively, a laparoscopic gastrostomy was performed using the MIC-KEY gastrostomy tube (G-tube) “button” (Halyard Health, Inc., Alpharetta, GA). The intervention began with insertion of the optical cannula through the umbilicus and placement of a 3.9-mm 30° laparoscope (Karl Storz GmbH, Tuetlingen, Germany) into the abdominal cavity. The size and position of the stomach, and the presence of peritoneal adhesions, were determined by laparoscopy. The gastrostomy site was identified in the left epigastrium by palpation of the anterior abdominal wall. At the palpation site, a small incision of ∼5 mm was made in the skin. A 3-mm atraumatic clamp with a ratchet was inserted through the incision into the peritoneal cavity, which grasped the anterior wall of the stomach in the place of the planned stoma.

On the right and left sides from the clamp, two U-stitch anchor sutures (PDS II 2/0, needle diameter 36–40 mm) were placed through the stomach in a transabdominal fashion. Next, the stomach was insufflated with air through a previously inserted nasogastric tube. The fixation forceps was removed, and the gastric wall was punctured with a 14-gauge needle. The gastric cavity was catheterized by the Seldinger technique using a guidewire, and the tract was dilated with esophageal dilators to accommodate the size of the G-tube. The selection of appropriate MIC-KEY G-tube length was completed after measurement of the stoma tract with the MIC-KEY Stoma Measuring Device (Halyard Health, Inc.). Following G-tube insertion, the G-tube balloon was insufflated with sterile or distilled water. Finally, the capnoperitoneaum was deflated and the U-stitches were tied over the wings of the G-tube.

Follow-up care

Sutures were removed no earlier than 6–7 days after insertion of each G-tube. Follow-up observations of patients occurred 2 weeks, 1 month, and 3 months after tube insertions by the surgeon who performed the procedure.

Patient outcomes

Baseline characteristic parameters that were compared between patients in laparotomy and laparoscopy groups were gender, age, and weight at the time of surgery, and concomitant Nissen fundoplication. In cases of simultaneous Nissen fundoplication, the duration of gastrostomy procedure was evaluated separately by one of the members of the operating team. The duration of G-tube placement took into account two periods of time, which were summed up to obtain the total time of the operation. The first period began from the moment of abdominal puncture with a Veress needle and ended with the installation of optical trocar. The second period began after the end of fundoplication and ended with the closure of laparocentesis holes.

The intra- and postprocedural outcomes compared between the groups included procedure duration, onset of both the start of enteral feeding and the change to full, nutritional (i.e., according to feed volume) enteral feeding, duration of hospitalization, and complications. Major complications considered were leakage of gastric contents into the abdominal cavity and resulting peritonitis, or G-tube migration. Minor complications were local infection (external leakage, growth of granulation, or peristomal dermatitis). Major complications required another procedure, while minor complications were corrected by topical antibacterial ointment or tanning agents. In some cases at the 3-month follow-up, it was determined that the G-tube should be replaced due to the natural growth of the child. The selection of replacement tubes was accomplished using the Stoma Measuring Device.

Data analysis

Categorical data were compared by the Fisher exact and Yates' corrected chi-squared tests. Means and standard deviations were calculated for continuous variables for each patient group and were compared by the Mann–Whitney U test. Significant differences were indicated by P ≤ .05 for each test that was conducted.

Results

The underlying reasons for gastrostomy tube insertion in children were a failure to thrive (FTT) and feeding difficulties resulting from congenital and acquired diseases in the child (Table 1):

Table 1.

Distribution of Patients

Type of operations	Total	Laparotomy group (N = 44)	Laparoscopy group (N = 90)
Esophageal atresia	70	34	36
Neurologic disorders	45	3	42
Failure to thrive	10	5	5
Neck tumors	5	1	4
Maxillofacial and laryngeal malformations	4	1	3
Total	134	44	90

Complicated esophageal atresia (long gap, delayed anastomosis, anastomotic leak, respiratory distress syndrome)—70;

Neurologic disorders as a result of congenital anomalies of the brain and acquired perinatal lesions of the central nervous system—45;

FTT—10;

Neck tumors (giant lymphangioma and hemangioma)—5;

Maxillofacial and laryngeal malformations (Pierre Robin syndrome and laryngotracheoesophageal cleft)—4.

Patient groups were not homogeneous in terms of baseline characteristics: patients with esophageal atresia prevailed in the open treatment group, and patients with neurological disorders dominated in the laparoscopy group. This was due to the fact that the open treatment group represented a historical cohort with a dominance of patients with esophageal atresia, most of whom did not need fundoplication. Patients with neurodeficiency dominated in the laparoscopy group. These proportions reflect the changes that have occurred in pediatrics and pediatric surgery over the past few decades—improved strategies in the treatment of esophageal atresia using thoracoscopy and an awakened interest toward patients with neurological disorders that are accompanied by feeding disorders.

Comparison of laparoscopy and open gastrostomy in neonates and infants

Table 2 shows the comparative demographic characteristics between the laparoscopy and laparotomy groups. There were no differences across these parameters. Indeed, there were ∼46%–47% females and 53%–54% males in each study group. The average age of each cohort was ∼42.54 and 34.16 days (P = .054), and the mean weight of patients in each group was about 3476 versus 3311 g. The overall frequency of concomitant Nissen fundoplication was different between the groups, but more frequently occurred in the laparoscopy group (46.67% versus 18.8%; P < .05). A lower prevalence of concomitant fundoplication in the historical open group reflects the changes that have occurred in the past decades in pediatrics and pediatric surgery in the treatment of nutritional problems related to neurodeficiency (creation of alternative ways of eating).

Table 2.

Baseline Characteristics of Patient Groups

Baseline characteristics	Laparotomy group (N = 44)	Laparoscopy group (N = 90)	Confidence level of significance (P value)
Gender
Females	20 (45.5%)^a	42 (46.6%)^a	No (1.000^c)
Males	24 (54.5%)^a	48 (53.4%)^a
Mean age at time of surgery (days)	34.16 (6.9)^b	42.54 (3.7)^b	No (.054^d)
Mean weight at time of surgery (g)	3311 (90.01)^b	3476 (96.76)^b	No (.311^d)
Nissen fundoplication	8 (18.18%)	42 (46.67%)	Yes (.006^c)

Percentage of patient population.

Standard error of the mean.

Yates' corrected chi-squared test.

Mann–Whitney U test.

The average amount of time required for G-tube placement by laparotomy was ∼16 minutes longer than that performed by laparoscopy (21.9 and 37.8 minutes; P < .05) (Table 3). The duration of time between G-tube button insertion and the onset of first feeding was greater for those patients who received enteral feeding by laparotomy (8.4 and 19.6 hours, respectively; P < .05). Mean time to full enteral feeding was different between the groups (18.8 versus 34.4 hours; P < .05). Following their respective procedures, patients in the open group spent nearly 15 more days in the hospital than those who received the G-tube by laparoscopy (29.0 versus 13.9 days; P < .05). The increase in length of hospitalization was due to the underlying disease of the patients. The main differences were observed in the treatment of esophageal atresia and were associated with complications (strictures and anastomotic leak).

Table 3.

Intra- and Postprocedural Outcomes of Patient Groups

Outcome	Laparotomy group (N = 44)	Laparoscopy group (N = 90)	Confidence level of significance (P value)
Mean duration of procedure (minutes)	37.8 (1.2)^a	21.9 (0.6)^a	Yes (.001)^b
Mean duration to onset of first feeding following procedure (hours)	19.6 (0.5)^a	8.4 (0.2)^a	Yes (.001)^b
Mean duration to onset of first nutritional feeding following procedure (hours)	34.3 (0.8)^a	18.8 (0.4)^a	Yes (.001)^b
Mean duration of hospitalization (days)	29.0 (4.1)^a	13.9 (1.7)^a	Yes (.001)^b

Standard error of the mean.

Mann–Whitney U test.

In the early postoperative period, major complications were recorded in 3 (6.82%) patients in the laparotomy group, in the form of gastric content leak into the abdominal cavity and resulting peritonitis, which required repeated surgery. During the period of this study, we did not register such complications in the laparoscopy group (Table 4). However, the differences due to the small number of observations were not statistically significant (P = .338). Other major complications (death, intra-abdominal bleeding, damage of small or large intestines, colonic gastrointestinal fistula) were not detected in either of the groups.

Table 4.

Postoperative Complications

Baseline characteristics	Laparotomy group (N = 44)	Laparoscopy group (N = 90)	Confidence level of significance (P value)
Total complications
Major	3 (6.82%)^a	0 (0%)^a	No (.338)^b
Minor	30 (68.18%)^a	12 (13.33%)^a	Yes (.03)^c
External leakage	10 (22.73%)^a	7 (7.78%)^a	Yes (.03)^c
Peristomal dermatitis	11 (25%)^a	8 (8.89%)^a	Yes (.025)^c
Growth of granulation	9 (20.45%)^a	6 (6.67%)^a	Yes (.037)^c

Percentage of patient population.

Fisher exact test.

Yates' corrected chi-squared test.

Minor problems appeared after surgery in both groups (Table 4). Our data showed a statistically significant increase in the total number of problems in the open treatment group (68.18% versus 13.33%; P = .03). Minor postoperative complications consisted of a lack of tightness of the channel gastrostomy, peristomal dermatitis, or excessive growth of granulation. Sealing the gastrostomy channel against leakage is a major postoperative problem. It was significantly lower (P = .03) in patients after laparoscopy (7.78%) than after laparotomy (22.73%). Peristomal dermatitis was recorded in 8.89% of the patients after laparoscopy and 25% of patients after open surgery (P = .025). The formation of granulation tissue occurred in 6.67% of patients after laparoscopy and 20.45% of patients after laparotomy (P = .037).

Cosmetic results of gastrostomy differed between the groups. In the laparoscopy group, scars were invisible, hidden in the umbilical fold. On examination, patients in the open surgery group exhibited a vertical scar on the left of the midline on the abdominal wall, indicative of prior laparotomy.

Discussion

A gastrostomy tube provides direct access to the gastrointestinal tract for enteral nutrition, and it is one of the most common surgical procedures in pediatric and general surgery.⁸ Currently, there is no consensus in the selection of gastrostomy technique in children. Patients undergoing open gastrostomy usually represent a historical cohort in retrospective studies. Modern gastrostomy is mainly performed by one of three competing ways: PEG, laparoscopy, or a combination of laparoscopic visualization and PEG (laparoscopic-assisted PEG [LAPEG]).

Several issues should be discussed that are directly related to gastrostomy in children and concerning the distribution of various types of gastrostomy currently used in children, the effect of gastrostomy on the occurrence of gastroesophageal reflux, postoperative complications, and the comparison of various gastrostomy technologies in children.

Currently, there are no data available to support the utility of these methods for the placement of a gastrostomy tube in infants. In the United States, roughly 11,000 PEGs are performed each year in pediatric patients.^9–11 Although data concerning the frequency of laparoscopic gastrostomy are not available, a meta-analysis has been published devoted to the topic “gastrostomy in infants.”¹² In this work, 4331 enteral feeding tube placements in public hospitals were reviewed, with 3304 (76%) and 1027 (24%) procedures adopting PEG and laparoscopic gastrostomy, respectively.

Another report by investigators collaborating from two children's hospitals recorded information about gastrostomy over a 9-year period.¹³ During this time-span, interventions were performed in 1534 pediatric patients. Two hundred eighty-two PEG procedures required 695 insertions of devices laparoscopically for nutrition delivery to the stomach. While G-tube insertion by PEG seemingly became the preferred method by gastroenterologists and radiologists in general hospitals, pediatric surgeons rarely performed PEG. Unlike PEG, laparoscopic gastrostomy is a surgical intervention performed primarily in children's hospitals. One of the advantages of laparoscopic gastrostomy compared with PEG is that PEG devices in most cases cannot be performed in neonates. The PEG catheter is a long tube with an internal retention bumper instead of a balloon at its end. The minimum French size (Fr) available in Russia is Fr 14, which limits the application of retrograde insertion in pediatric patients with a body weight <10 kg¹ and with an abdominal wall thickness <2 cm.¹⁴

In contrast, G-tubes used in laparoscopic gastrostomy, such as the MIC-KEY button used in this study, has a different construction that allows it to be set at the skin level. Furthermore, button gastrostomies are available in smaller French sizes (i.e., 12) and thus can be used in children weighing <10 kg, including neonates and preterm babies. Additionally, laparoscopic gastrostomy is not limited by contraindications in infants that compromise the ability to perform PEG. These include previous surgeries on abdominal organs, ascites or inserted ventriculoperitoneal shunt,⁷ and rare conditions such as severe kyphoscoliosis, hepatosplenomegaly, and reverse position of internal organs.

There is an assumption that gastrostomy is associated with a higher rate of postoperative gastroesophageal reflux requiring a subsequent Nissen fundoplication. Gastroesophageal reflux is often described as one of the complications of gastrostomy. A strong argument for G-tube insertion by laparoscopy is the necessity to perform simultaneous fundoplication in some patients. According to Aprahamian et al.,¹⁵ 24% of children require fundoplication after gastrostomy. Moreover, 72%–77% patients^15,16 may require an additional antireflux surgery at a later time. Laparoscopy can be performed without taking down a gastrostomy in these patients.^13,17

The origin of gastroesophageal reflux in patients after a gastrostomy is controversial. Thomson et al.¹⁸ reported an increase in gastroesophageal reflux episodes in neurologically damaged infants after a gastrostomy. However, Plantin et al.¹⁹ suggested that correct placement of the gastrostomy tube is critical, because it will prevent reflux of stomach contents into the esophagus. Thus, visually controlled insertion of the gastrostomy tube into the stomach by laparoscopy may prevent the development of gastroesophageal reflux. The meta-analysis has shown that simultaneous gastrostomy and fundoplication does not reduce the number of complications associated with reflux. The simultaneous antireflux procedure should be performed only with confirmed gastroesophageal reflux that is refractory to drug therapy.²⁰

Patients undergoing tube placement by gastrostomy have a high risk of procedure-related complications. There are divergent views on the complications that follow gastrostomy.

Currently, there is no standardization of the various complications of gastrostomies. However, most of these can be classified into early (<90 days after surgery) and late (>90 days)¹⁵ and as being major or minor in nature.^2,21 Major complications include patient fatality, intra-abdominal bleeding, perforation of the esophagus, gastroesophageal reflux, injury of the small bowel or colon at the time of gastric puncture, liver injuries, peritonitis, and gastrocolonic fistula. A paucity of complications has been reported in association with laparoscopic gastrostomy. Wragg et al.²² noted failure rates of 14% for PEG versus 4% for laparoscopic gastrostomy for enteral feeding tube placement, while Zamakhshary et al.²³ reported 14% versus 7.7% failure rates for these respective techniques.

A frequent reason for similar side effects is a result of blind gastric puncture. The most catastrophic situation occurred in the case of fistula formation between the stomach and colon in 1.2%–12.5% of patients.^4,5,23–26 A possible interposition of abdominal organs between the anterior abdominal wall and the stomach wall during PEG can lead to their injury and the development of peritonitis, bleeding, and formation of gastrointestinal fistula. Laparoscopic gastrostomy is not associated with such complications.^4,5

Among the minor complications, the most common are the formation of granulation tissue around the gastrostomy tube²⁷ and the development of contact dermatitis.²⁸ The process of fixing the stomach during laparoscopic gastrostomy varies. Some authors have used T-shaped anchors, which are recommended by manufacturers of G-tube buttons.^29,30 Other researchers utilized extracorporally performed purse-string sutures.^8,22 However, the dominant method of fixing the G-tube button in infants involves the use of transabdominal anchor U-stitches proposed by Georgeson and colleagues,³¹ and this method is the most attractive for laparoscopic gastrostomy in children. The use of transabdominal anchor sutures securely fixes the stomach and gastric tube and can be performed in preterm infants.

Despite the widespread use of laparoscopic gastrostomy, there is a lack of evidence concerning the efficiency of this technique. Studies comparing laparoscopic gastrostomy with other methods (open surgery, PEG, LAPEG, fluoroscopic-assisted gastrostomy) in the pediatric population are limited. However, none of them provide a direct comparison of laparoscopy and open gastrostomy. Many studies have presented the results of comparison of laparoscopic placement of G-tube and PEG. The analysis of postoperative data^4,5,22 suggested advantages in laparoscopic gastrostomy compared with PEG, as indicated by anesthesia required for the former as well a shorter time-period until the beginning of enteral feeding.

Other advantages include shorter hospital stays and fewer postoperative complications associated with laparoscopic gastrostomy. One study examined open gastrostomy and PEG and found that the open technique was associated with a higher rate of postprocedural gastroesophageal reflux.³² Another pediatric study by Wragg et al. compared PEG and LAPEG and displayed comparable overall complications between PEG and LAPEG (52% versus 59%).²² In contrast, one study collected and collated the results of five different techniques of gastrostomy in children—open, PEG, laparoscopy, LAPEG, and fluoroscopic-guided gastrostomy.³³ Compared with other procedures, laparoscopic gastrostomy demonstrated zero returning to operating room within 30 days after the procedure (P < .0004).

Another study compared the outcomes and complications of three competing techniques of gastrostomy—PEG, LAPEG, and open surgery.³⁴ In this work, it was found that both PEG and LAPEG were significantly superior over open gastrostomy in terms of overall complications rates. PEG had higher early complications than LAPEG.

The current study demonstrated that laparoscopy is a useful and safe method for the initiation and delivery of enteral nutrition in infants compared with open gastrostomy. It should be noted that the minimal trauma of the anterior abdominal wall by endoscopic ports during laparoscopy is not an indicator of minimal invasiveness of the operation as a whole, since the main aim of the procedures on abdominal organs is the resumption of intestinal transit and absorption. Improving the results of laparoscopic gastrostomy is based on providing better-quality surgical manipulations through excellent visualization of the anatomy of the stomach, minimally invasive access, and the use of optimal methods for the fixation of gastrostomy tubes using transparietal U-shaped stitches.

Our study demonstrated a significant reduction in the time to start of enteral feeding and time of transition to full enteral nutrition in patients who underwent minimally invasive procedures. The use of U-shaped sutures during laparoscopic gastrostomy improves the tightness of the gastrostomy canal than the purse-string sutures during open gastrostomy. It leads to a smaller number of complications from this procedure. Thus, these data suggest that laparoscopic placement of G-tube buttons can be recommended for wider use in pediatric practice.

Conclusion

Gastrostomy in newborns and infants is an important topic in pediatric surgery. Until now, there is no consensus on the methods of placement of gastrostomy tube, types of gastrostomy devices, and methods of gastropexy. This study demonstrated that laparoscopy can improve the results of operations designed to provide enteric delivery in newborns and infants with diseases associated with eating disorders. The advantages of laparoscopy are the reduction in the duration of the procedure, rapid postoperative recovery of patients, absence of major complications, and reduction in the incidence of minor complications.

The conclusions of this study are limited by significant differences in the baseline characteristics of patients undergoing each procedure related to the composition of patients in each group and the use of Nissen fundoplication. However, further investigations may determine if these differences in outcomes are related to the technique of placement of G-tubes or patient-specific factors.

Footnotes

Disclosure Statement

No competing financial interests exist.

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