Ultrasound-Guided Gastrostomy Tube Placement: An Evaluation of Postoperative Complications in the Pediatric Population

Introduction

Gastrostomy feeding tubes (g-tubes) are used across a wide range of diagnoses in pediatric patients to help maintain adequate nutrition. ¹ The placement of g-tubes is one of the most common procedures performed by pediatric surgeons and a variety of techniques have been implemented: open, laparoscopic, percutaneous endoscopic gastrostomy (PEG), and fluoroscopy-guided placement. Although each approach has been declared relatively safe and effective, there are advantages and disadvantages to each procedure.

Although the PEG is considered less invasive, it does not allow for direct visualization of the abdominal cavity and its contents, thus placing other organs at risk for injury. The laparoscopic and fluoroscopic-guided techniques provide better visualization, but this comes at the expense of time and cost in the former, and the use of radiation in the latter. ² Furthermore, the fluoroscopic technique is disadvantaged in that it requires placement of a standard long g-tube initially, with a low-profile button placed at the first tube change weeks to months after the procedure.

Regardless of the technique, the placement of a g-tube also comes with the risk of common minor complications. These include skin issues such as infection and granulation tissue, dislodgment, and leakage around the tube. Although multiple studies have attempted to delineate various risk factors, these minor complications are well-known sequelae of g-tubes irrespective of which of the three minimally invasive techniques is used. ³

One novel technique that recently emerged is ultrasound-guided gastrostomy tube placement (USGTP). USGTP is a new and unique approach to g-tube placement in the pediatric population. One case series done at this same institution demonstrated it to be safe and efficient. ⁴ Encompassing the individual advantages of the established approaches, it is a minimally invasive and time-efficient procedure that provides visualization of vital abdominal organs without the use of radiation. It has the potential to emerge as a feasible method for g-tube placement but requires more investigation to define its success and compare potential complications to the more commonly used techniques. This study aims to identify and evaluate the complications of ultrasound-guided g-tube placement and demonstrate that its rate of minor postoperative complications is comparable with those of the other widely used techniques.

Methods

After IRB approval was obtained through the University of Michigan Institutional Review Board (HUM00193991 and HUM00170853), we evaluated all USGTPs that took place at Mott Children's Hospital between January 2014 and August 2020. Inclusion criteria included patients who underwent a complete USGTP during this time span. Some patients were scheduled for an USGTP, but at the start of the operation it was decided that it was not feasible to proceed with only ultrasound and they were safely converted to a different method of g-tube placement. In these cases, the patients are noted and discussed in this article, but they were excluded from final USGTP data. They were excluded because they ultimately underwent a different procedure and their postoperative complications, if any, would not give us any information about the postoperative complications of USGTP alone.

A retrospective chart review collected demographic and clinical data from the electronic medical records (EMRs) of patients who underwent USGTP during that time period. For comparison, a retrospective chart review was also carried out for patients who underwent laparoscopic g-tube placement (LGTP) at the same institution. Inclusion criteria included patients who underwent completed LGTP between January 2018 and July 2019, which provided an adequate sampling of the LGTP operation. This time span was chosen because it is a segment of time close to the middle of the USGTP implementation timespan that would have a comparable number of surgeries. Data were collected from their EMRs in the same manner and included basic demographics as well as the details of any g-tube-related postoperative issue as outlined in emergency department (ED) visit records.

Data collection from the USGTP group was supplemented with a phone survey. The primary caregiver of each patient who underwent USGTP was identified from their chart and contacted through telephone. A maximum of three phone call attempts were made. The purpose of the interview was explained, and verbal consent was obtained before continuing. The caregiver was then asked a series of six questions that attempted to identify the occurrence and nature of any complications after USGTP.

All data were collected and analyzed in Microsoft Excel (Microsoft Corporation: Redmond, WA). Bivariate analyses were conducted using t-tests to assess for differences between the two groups, and chi-square test was employed for categorical data. Analyses of significance were conducted with P < .05.

Results

A total of 120 patients underwent LGTP and 44 patients were brought to the operative room for scheduled USGTP between January 2014 and August 2020. The LGTP was performed by a variety of attending providers who work at the institution. The USGTPs were all supervised by the main attending who developed the procedure. In most cases, a fellow or other attending was present and being trained in the procedure. Of the 44 USGTPs that were attempted, 2 were converted to LGTP and were completed successfully, and 1 was converted first to LGTP and then subsequently converted to an open operation due to an enterotomy made during the laparoscopic portion.

The reasons for conversion from USGTP to LGTP included, respectively, difficulty with passing the third of three T-fasteners due to positioning, difficulty positioning the balloon correctly in the stomach after it was inflated in the duodenum and could not be traversed past the pylorus, and small bowel adhesions noted to be anterior to stomach on ultrasound. Because these cases were identified and safely converted away from the USGTP technique with no issues, they were excluded from subsequent analysis in any of the groups. This left a total of 41 USGTPs that were successfully completed. There were no adverse intraoperative events recorded in the case of the 41 USGTPs nor in the LGTP group.

The mean age of the patients who underwent USGTP was 2.8 years (range 0.08–26.27 years) and the mean age of the LGTP patients was 4.1 years (range 0.01–20.42 years), Two-sample t-test revealed no statistically significant difference in age between the two groups (P = .15). In both groups, 54% of the patients were male and 46% female, again with no statistically significant difference (P = .96) between the two groups (Table 1). Two-sample t-test revealed that the USGTP group had a statistically significant lower weight than the LGTP group (means of 10.4 and 14.8 kg, respectively; P = .02). There was no significant distinction between the indications for g-tube placement in each group, with failure to thrive listed as the most common indication, followed by oral aversion, dysphagia, a genetic syndrome resulting in g-tube feeding dependence, gastroparesis, and gastroesophageal reflux disease (P = .22).

The USGTP group demonstrated a statistically significant shorter length of procedure with a mean time of 24 minutes (range 10–111, standard deviation [SD] 18) compared with a mean of 38 minutes for LGTP (range 10–99, SD 14, P = .0003). Both USGTP and LGTP were done under general anesthesia and the procedure time included cut to close for the feeding tube portion of the cases. There were several instances in which the USGTP or LGTP were included as part of multiple procedures and the records did not always indicate the exact length of the feeding tube part of the operation. In such cases, the procedure was excluded from the final calculation, leaving a final n = 31 for the USGTP group and n = 78 for the LGTP group for the presented data on length of procedure.

The patients' charts were evaluated for all ED visits at our institution that occurred any time after the procedure through May 31, 2021. This resulted in a mean follow-up observation time of 33 months for USGTP (range 4 days–88 months, SD 21 months) and 29 months for LGTP (range 2–40 months, SD 7 months). For the USGTP group, a total of 19.5% of the patients (n = 8) had at least one ED visit to address an issue with the g-tube at any point postoperatively, which was similar to the LGTP group that had 18% of the patients (n = 22) requiring at least one ED visit. Both groups were also analyzed for emergency room visits at the specific time marks of 30 days and then 6 months after primary placement. For the USGTP group, 3 of the patients died before 30 days and were thus removed from this calculation.

The rest were all followed for at least 6 months, resulting in a total n = 38. For the LGTP group, 1 patient died 2 months after the operation, resulting in n = 120 for the 30-day calculation and n = 119 for the 6-month calculation. The total patients who presented to the ED within 30 days of the operation was 3 (8%) in the USGTP group and 7 (6%) in the LGTP group. A chi-square test of independence showed there was no significant difference between the groups (P = .65). The total number of patients who presented to the ED within 6 months included 5 in the USGTP group (13%) and 13 in the LGTP group (11%). Chi-square test again showed no statistically significant difference (P = .71).

The primary indications prompting an ED visit were recorded in each group for the patients' first visit. In both groups, the most common indication was g-tube dislodgment (88% of USGTP visits and 68% of LGTP visits). Only 1 person in each group required admission to the hospital for a complication. In the LGTP group, a patient presented 5 days after the operation and was admitted for treatment of cellulitis. In the USGTP group, a patient had their g-tube dislodged and required admission for it to be replaced. Of note, in this situation, the patient's g-tube had already been converted to a gastrojejunostomy feeding tube. This therefore prompted the need for admission and IR-guided replacement because of the conversion to jejunal feeding.

The phone survey gathered additional data from the USGTP group. The purpose was to capture any postoperative USGTP complications that may not have been recorded in the EMR. Of the 41 USGTP patients, 3 were excluded from the phone survey because the patients died from other causes. Of the remaining 38, 26 caregivers completed the survey. The average follow-up time on the day of survey completion was 34.6 months (range 8–87). The survey questions and results are summarized in Table 2.

Of the 26 USGTP's who completed the phone survey, 9 (35%) reported a visit to the ED and 8 (31%) reported an unplanned clinic visit for a g-tube-related issue. Sixteen (62%) caregivers reported that the g-tube fell out unintentionally at some point between placement and the time of the survey. Further results from the survey included 9 (35%) reporting leakage around the g-tube that required a change in clothes or dressing; and 17 (65%) reporting erythema/irritation of the skin around the g-tube. Of these 17 with erythema/irritated skin, more than half (n = 10) were treated with protective barrier cream/ointment alone, 1 was treated with oral antibiotics, and 2 were treated with both ointment and oral antibiotics. Finally, the survey showed that 4 patients in total (15%) sought treatment at some point at a clinic that was not the Pediatric Surgery Clinic at our institution.

Discussion

Gastrostomy tube placement in the pediatric population is a common procedure that continues to increase in frequency both in the United States and abroad.^5,6 There are four main widely accepted techniques that are used and each have advantages and disadvantages. These techniques include open, laparoscopic, PEG, and fluoroscopic-guided placement. Multiple studies have evaluated the outcomes and complications of these different techniques. The very first technique employed historically was the open procedure described by Stamm. ⁷ This technique provides adequate visualization of the anatomy but requires a laparotomy incision that yields the subsequent postoperative pain and healing that could be curtailed with a more minimally invasive technique. Both the PEG and laparoscopic approaches are widely used and less invasive options.

Advantages of the laparoscopic technique over the PEG include a better direct visualization of the abdominal cavity, as well as the benefits of securing the stomach directly to the anterior abdominal wall. The lack of these benefits in the PEG procedure has been implicated in a documented higher complication rate for PEGs, including the need for reoperation. ² However, the proven benefits of the laparoscopic approach come at the cost of an extra incision and increased operative time of the procedure.^2,8 Fluoroscopic-guided placement has been found to have comparable outcomes to the other minimally invasive techniques. ⁹ However, disadvantages of this technique include the use of radiation in children as well as the inability to place a primary button. Rather, a long feeding tube is often placed first, which has been shown to have an increased risk of dislodgment and leakage. ¹⁰

USGTP is a novel technique that overcomes several of the disadvantages of the three standard minimally invasive techniques described earlier. Similar to the PEG, it has been demonstrated to be a quick procedure that requires only a single incision and evades the excess time needed for laparoscopy, as well as the radiation needed for the fluoroscopic-guided procedure. Furthermore, it overcomes some of the PEG procedure's disadvantages by providing direct visualization of the abdominal cavity, enabling initial placement of a low-profile g-tube, and employing the use of T-fasteners to secure the stomach to the abdominal wall. In the situation of a hostile abdomen, after visual confirmation that there is no bowel between the stomach and the abdominal wall, the USGTP technique could be employed to avoid a tedious lysis of adhesions that would be experienced laparoscopically.

In our study of 44 attempted USGTP cases, 3 were safely converted to laparoscopy and there were no major intraoperative complications in the remaining 41 cases, reinforcing the feasibility and safety of USGTP. The three conversions all occurred early in the implementation of the USGTP experience, and it is deduced that with time, improvement in technique, and increased experience, these risks are decreased. Of note, these patients were often chosen for USGTP because a hostile abdomen precluded the feasible use of laparoscopy. In addition, the discovery of bowel between the stomach and the abdominal wall was identified easily with the ultrasound and subsequent safe conversion avoided a bowel injury that may have still transpired had they been done through PEG.

This study specifically sought to evaluate minor postoperative complications after USGTP. The existence of minor complications after any gastrostomy tube placement is not uncommon and is known to often lead to unplanned ED visits. ¹¹ This has been well documented in the literature for all types of gastrostomy tube placement. For example, one retrospective cohort study evaluated the frequency of g-tube-related ED visits within 30 days postoperatively and found that 8.6% of the entire study population (n = 15,642) visited the ED and 3.9% were readmitted through the ED with g-tube issues during this time period. Of note, 28.7% were placed by PEG and the rest were described as “surgical.” The most common indications were infection, mechanical complication, and need for replacement. ¹² A retrospective review of laparoscopic and open g-tubes placed in children at one institution looked at 6-month postoperative complications and found that 38.1% visited the ED with g-tube-related issues. It was also specified that 40.8% of the total experienced granulation tissue and 22.9% experienced leakage. ¹⁰

This study compared the rate of minor complications after USGTP and LGTP done at the same institution and found no significant difference between the groups. EMR review demonstrated that 19.5% of USGTP patients and 18% of LGTP presented to the ED at some point after the operation, with an average follow-up time of 33 and 29 months, respectively. As reported earlier, there was no statistical difference between the charted ED visits recorded at 30 days and 6 months postoperation between the two groups. The recorded ED visits within 30 days and 6 months of USGTP are also comparable with or less than what is reported in the literature as described earlier.^3,12

Given that some of the minor complications, such as leakage, dislodgment, and skin irritation, do not always result in a visit to the emergency room, the phone survey attempted to allow parents to identify whether these complications existed regardless of their EMR records. The use of the phone survey also recognized that some of the minor issues are completely resolved at an outside office or urgent care visit. By design, its employment was meant to capture all minor complications, including the ones that are not recorded in the EMR. The phone survey found that 35% of patients' caregivers reported a g-tube-related ED visit over an average follow-up time of 34.6 months (range 8–87).

As expected, this was higher than the 19.5% postoperative g-tube ED visits found through EMR chart review, over an average follow-up time of 33 months (range 4 days–88 months). This likely relates to caregivers choosing the ED or urgent care closest to their homes and, therefore, not having documentation in the institution-specific EMR. Regardless, although the 35% of patients who reported ED visits in the survey is an increased number from the chart review, it is still comparable with the 38% of ED visits reported in the literature after laparoscopic and open g-tube placements. ¹⁰

This study is limited by the small patient population at a single institution, with USGTP being performed by one provider. Further studies are needed to evaluate the results in other institutions and with a variety of providers.

Conclusion

USGTP is a feasible minimally invasive alternative to other methods of g-tube placement in children. It is a safe procedure with a comparable risk profile to other standard methods. The technique is minimally invasive, avoids the use of radiation, is fast and time-efficient, and allows real-time visualization of intra-abdominal anatomy. This study demonstrates that it has a postoperative minor complication rate that is statistically similar to that of LGTP and also that is comparable with what is reported in the literature for other g-tube placement methods.