The Paired T-Fastener Technique: A Bolster-Free Gastropexy for Laparoscopic Gastrostomy Tube Placement

Introduction

Gastrostomy tube (GT) placement is a common procedure to allow delivery of enteral nutrition. Children may require long-term enteral access for a variety of conditions, including neurological disorders, failure to thrive, and malnutrition. ¹ GTs can be placed using several different surgical techniques. Percutaneous endoscopic gastrostomy (PEG) and laparoscopic gastrostomy have become the favored approaches in children, with unique advantages and limitations to each approach. PEG placement avoids additional abdominal incisions and is readily performed regardless of patient abdominal wall thickness, although it does require adjunct maneuvers to allow primary low-profile—or button—gastrostomy placement. The laparoscopic approach has been shown to have fewer major complications, including gastrocolic fistula formation, than PEG in pediatric patients.^2,3 In addition, PEG tube exchange can be distressing to children and often requires sedation, whereas balloon-containing button tubes can be easily replaced. ⁴ For these reasons, laparoscopic primary button GT placement has become an increasingly popular approach for long-term enteral access in pediatric patients.

A key step in the placement of a primary button gastrostomy is the creation of a gastropexy, which allows the surgeon to dilate and advance the tube through the abdominal wall with gastric counter-tension. ⁵ In addition, a secure gastropexy affords a degree of safety in the event of early tube dislodgment, reducing the risk of gastrocutaneous fistula disruption. There are various suture techniques available to perform laparoscopic gastropexy to secure the stomach to the anterior abdominal wall to allow for GT placement, including T-fasteners, purse string sutures, and U-stitches. ⁶ Although each technique has potential advantages and disadvantages, the local skin complications associated with T-fastener bolsters has limited their use in pediatric patients. We hypothesized that a modified T-fastener technique in which the external bolsters are not required could eliminate the risk of bolster-related skin complications, whereas providing equivalent gastropexy outcomes when compared with other techniques.

Methods

Pediatric patients requiring enteral access who underwent laparoscopic GT placement using the paired T-fastener technique for gastropexy at a single institution from 06/01/2019 to 01/31/2021 were reviewed after Boston Children's Hospital Institutional Review Board approval. All GT placements were performed by pediatric surgeons. Patient demographics as well as operative details, including operative time, GT size, use of endoscopy, and additional concurrent procedures at the time of GT placement such as central line placement or urological procedures, were recorded. Prior abdominal surgery is defined as any prior procedure that involved laparoscopy or laparotomy. Outcomes included 30-day postoperative complications, including local wound infection, granulation tissue formation, bleeding, and need for tube replacement, were recorded.

A standardized technique was used by all surgeons for the study period. Initial peritoneal access was obtained through a transumbilical trocar (Fig. 1). The stomach was inspected to determine the optimal site for GT placement. Gastropexy was achieved by passing pairs of T-fasteners (Avanos Medical, Inc., Alpharetta, GA) under laparoscopic visualization, with or without endoscopic guidance, through the fascia and stomach wall in a square configuration around the planned site of the GT (Fig. 2). The T-fastener consists of a metal anchor attached to an absorbable monofilament polydioxanone suture. Each pair was passed through a single skin stab incision to allow each pair of absorbable sutures to be tied and buried subcutaneously. An additional incision was made centered between the four T-fasteners to accommodate the GT. The stomach was then accessed through this incision with an introducer needle and the GT was placed through Seldinger technique, using the T-fasteners to provide gastric counter-tension to allow dilation of the tract and advancement of the button GT (Applied Medical Technologies, Inc., Brecksville, OH). Intraluminal placement of the GT was confirmed through laparoscopy in all but one case where endoscopy was used (Fig. 3). The paired absorbable sutures were then tied after removing the external bolsters, burying the knots within the subcutaneous tissue.

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FIG. 1.

Operative images: (A) Orientation of T-fastener insertion and umbilical laparoscope position. (B) Laparoscopic view of sutures with introducer needle entering gastric lumen. (C) Laparoscopic view of final gastropexy. (D) Final position of GT with sutures tied subcutaneously after removal of bolster. GT, gastrostomy tube. Color images are available online.

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FIG. 2.

Schematic of T-fastener and GT configuration. GT, gastrostomy tube. Color images are available online.

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FIG. 3.

(A) T-fastener needle entering gastric lumen. (B) Final arrangement of 4 T-fasteners with metal anchors in gastric lumen. (C) Final position of GT with balloon inside gastric lumen. GT, gastrostomy tube. Color images are available online.

Results

Discussion

Laparoscopic tube gastrostomy placement remains a common procedure among children. This series describes our experience using T-fasteners without external bolsters to perform gastropexy during minimally invasive tube gastrostomy placement. We find this technique to be an efficient and secure method for gastropexy. There are several technical advantages offered by this method. A single trocar placed in the umbilicus provides adequate access to the peritoneal cavity and produces a good cosmetic result. A direct view of the stomach allows the surgeon to identify the ideal GT location and visualize the gastropexy. The T-fasteners allow excellent counter-tension on the stomach to allow dilation and transabdominal advancement of a primary button gastrostomy. The paired T-fastener technique eliminates the discomfort and pressure associated skin injury that often occurs with bolsters and eliminates the need for bolster or suture removal following the procedure. This is especially important in children, where suture removal or further tube manipulation can be particularly distressing.

A number of techniques for optimal gastropexy during GT placement have been described previously. Although the U stich is a commonly used technique, the use of T-fasteners has been proposed for patients with thick abdominal walls.^6,7 Intracorporeal Stamm sutures have also been described; however, this can be a technically challenging laparoscopically. ⁸ Alternatively, nonabsorbable sutures may be used to create a temporary gastropexy, which are initially tied to the tube or skin and removed following the procedure. Mason et al. have also described a technique in which absorbable sutures are tied in the subcutaneous space. ⁹ Although often more technically challenging to place, subcutaneous sutures can eliminate the risk of pressure necrosis and skin erosion seen with external suture fixation and external bolster devices. ¹⁰ This benefit is also seen with the subcutaneous U-stitch, but we believe the modified T-fastener technique to be technically easier, especially in patients with a thick abdominal wall. In our experience, the transabdominal U-stitch technique becomes increasingly difficult above a thickness of 2 cm without the addition of an additional port, and it is for these patients where we have preferentially used this technique. This is demonstrated by the mean tube length of 2.2 cm, with a range up to 4.0 cm, which suggests patients in our institution in which this novel technique was employed had thicker abdominal walls.

There were no major complications reported among our patient cohort and no patients required hospital readmission due to procedure-related complications. Our rate of tube dislodgment (10%) was similar to rates reported in prior studies. In these studies, dislodgment rates ranged from 1.5% to 27.7%.^2,5,11–13 Among studies using a similar technique to ours, with subcutaneous suture for gastropexy, a 7% rate of dislodgment is reported compared with our rate of 10%. ⁹ Sutherland et al. also performed a comparison of GTs placed by PEG, T-fasteners, and subcutaneous absorbable sutures. They found that T-fasteners had the lowest rates of dislodgment at a rate of 1.8% compared with 3.7% with transfascial subcutaneous sutures and 14% with PEG tubes. ¹¹ Although our T-fasteners dislodgment rate is higher, we found an intact gastropexy among all patients who required tube replacement for dislodgment, which suggests that no case of tube dislodgment was a direct result of T-fastener failure. Thus, we believe our technique offers a secure gastropexy.

The rate of granulation tissue formation (17%) was lower than other studies that have reported granulation tissue rates ranging from 23.5% to 60.8%.^2,6,11–13 Among T-fastener cases, granulation tissue was reported in 47.3% compared with 17% in our study, both of which are less than the reported 60.8% of subcutaneous suture cases. ¹¹ In a previous study comparing the U-stitch technique to T-fasteners, a higher rate of granulation tissue was found in the U-stitch group. ⁷ No patients required surgical excision of granulation tissue in our series.

The infection rate in our series is higher than that reported by Petrosyan et al., who reported an infection rate of 2.5% in subcutaneous suture gastropexies, as well as Mason et al., who reported a 10.3% infection rate in their series of 301 patients who underwent gastropexy with subcutaneous U-stitch.^9,10 Importantly, all patients responded to antibiotics and none required additional procedures such as incision and drainage. Since this technique was preferentially used on patients with thick abdominal walls, it is possible that the obese patients with thick abdominal walls in this patient cohort were more prone to infection. Three patients (10%) required elective tube exchange for upsizing. This may reflect the challenge of accurately measuring the stem length for primary button GTs in patients with thick abdominal walls, especially while in supine position.

There are several limitations to this study. It is a single-center study and thus the results of this cohort may not be generalizable to other institutions. The number of patients (30) represents a relatively small cohort and thus precludes subgroup analysis. The decision to use this technique was left to the individual surgeon, potentially contributing to selection bias. A prospective study with a larger patient population and randomization may help to better determine the efficacy of the paired T-fastener technique for gastropexy when compared with other commonly used techniques.

In conclusion, the paired T-fastener technique allows for simple and secure gastropexy during minimally invasive GT insertion and may be particularly useful in patients with thick abdominal walls.