Pediatric Gastrostomy Tube Placement: Avoid the Incision to Avoid the Complications

Abstract

Background:

Tremendous practice variation exists for placing gastrostomy tubes. The objective of this study was to determine if the operative approach is associated with 30-day complication rates.

Methods:

This single-center retrospective cohort study identified pediatric patients who underwent gastrostomy tube placement from June 2019 to April 2022. Gastrostomy approaches included laparoscopic, laparoscopic-assisted (incision at gastrostomy site), modified open (incision at gastrostomy site), and percutaneous endoscopic gastrostomy (PEG). Multivariable logistic regression models were performed to evaluate the association of 30-day complications and operative approach after controlling for prematurity and weight.

Results:

Among 521 gastrostomy patients, the median age was 10 months (interquartile range: 4–33 months), and 181 (34.9%) had a history of prematurity. Weight categories included 217 (41.6%) underweight, 272 (52.2%) normal weight, and 32 (6.1%) overweight. Patients underwent laparoscopic (n = 386, 74.1%), laparoscopic-assisted (n = 73, 14.0%), modified open (n = 33, 6.3%), and PEG (n = 27, 5.2%). Complications included reoperation (n = 17, 3.3%), readmission (n = 12, 2.3%), wound infection (n = 30, 5.8%), wound breakdown (n = 21, 4.0%), tube dislodgement (n = 23, 4.4%), granulation tissue (n = 107, 20.5%), and leakage (n = 33, 6.3%). Following adjustment, laparoscopic-assisted gastrostomy was associated with higher odds of any complication. Laparoscopic-assisted and modified open were associated with higher odds of wound breakdown. Laparoscopic-assisted and modified open were associated with higher odds of leakage. The operative approach was not associated with reoperation, readmission, wound infection, or tube dislodgement.

Conclusions:

Techniques for gastrostomy placement, which include an incision around the tube, were associated with higher rates of complications. To improve complication profiles for patients, surgeons should consider laparoscopic or percutaneous endoscopic gastrostomies.

Introduction

Gastrostomy tube placement in children is a common surgical procedure with rates reported at 18.5 per 100,000.¹ There are a wide variety of indications for gastrostomy placement in the pediatric population including inadequate oral intake (i.e., neurological impairment, severe gastroesophageal reflux, prematurity, trauma, and critical illness), disorders of digestion and absorption (i.e., short gut, cystic fibrosis, and graft-versus-host disease), disorders of gastrointestinal motility, growth failure, and metabolic diseases.^2,3

Historically, gastrostomy tubes were placed with the traditional open Stamm procedure, but, in 1980, Gauderer et al. reported on the percutaneous endoscopic gastrostomy (PEG), which became popular due to its minimally invasive technique, patient tolerance, and speed.^3–5 In the adult population, PEG has become the preferred approach for enteral access.^1,6 However, in the pediatric population, the need for a second anesthetic event to change the PEG to a lower profile tube, and the fact that PEGs are often larger in size and may not be the best option for babies and small children, has led to laparoscopic gastrostomy tube placement being the most common approach in children.^1,7 A single-center, retrospective review comparing open, laparoscopic, and PEG approaches in pediatric patients found a significantly higher rate of early complications with PEG compared with a laparoscopic approach.³ Another pediatric, single-center study showed higher rates of revision with PEG compared with surgically placed gastrostomy.⁸ In contrast, another pediatric study showed no difference in the need for gastrostomy repositioning based on the open, laparoscopic, or PEG approach.⁹

As demonstrated, the current literature has varying rates of complications based on the gastrostomy tube approach. At our center, we employ four operative approaches for placing gastrostomy tubes: laparoscopic, laparoscopic-assisted, modified open, and PEG. The objective of this study was to determine if the operative approach is associated with 30-day complication rates.

Materials and Methods

Operative approach

The four approaches for placing gastrostomy tubes analyzed in this study were laparoscopic (n = 386), laparoscopic-assisted (n = 73), modified open (n = 33), and PEG (n = 27). During the study period, there were 17 surgeons performing these cases, including 10 who performed laparoscopic gastrostomy placement, 3 who performed laparoscopic-assisted, 2 who performed modified open, and 2 who performed PEG. All patients receive preoperative antibiotics. The operative approach for gastrostomy placement is purely based on surgeon preference and comfort.

Laparoscopic gastrostomy

The patient is in the supine position under general anesthetic, and the gastrostomy site is marked in the left upper quadrant (LUQ) prior to insufflation. A 3-mm or 5-mm port site is placed at the umbilicus. After insufflation of the abdomen, a 5-mm stab incision is made at the marked site of gastrostomy placement, and a laparoscopic instrument is passed through the abdominal wall to grasp the stomach. With the stomach pulled up to the abdominal wall, either four T-fasteners are deployed through the abdominal wall into the stomach, or 2–0 sutures are passed percutaneously through the stomach to suspend the future gastrostomy site. The laparoscopic grasper is removed, and the gastrostomy tube is placed using the Seldinger technique. If stay sutures were used, they are then either buried subcutaneously or tied extracorporeally based on surgeon preference.

Laparoscopic-assisted gastrostomy

The patient is in the supine position under general anesthetic, and the gastrostomy site is marked in the LUQ prior to insufflation. After insufflation of the abdomen, the stomach is located, the gastrostomy site is incised with an incision that is about 2 cm long, and the subcutaneous tissues are dissected down to the anterior fascia. The anterior fascia is incised, the muscle is spread bluntly, and the posterior sheath is entered bluntly. The stomach is grasped with a laparoscopic grasper to bring it up to the LUQ incision, and the abdomen is desufflated. Four tacking sutures are placed from the stomach to the posterior fascia. A purse-string suture is made, and the gastrostomy is placed in the center of the purse-string.

Modified open gastrostomy

The patient is in the supine position under general anesthetic, and the location of the gastrostomy is identified in the LUQ. One incision, about 2 cm in length, is made in the LUQ through which the abdominal cavity is entered, and the gastrostomy tube is placed, rather than entering the abdomen through a separate incision and bringing the gastrostomy tube through the abdominal wall at another site. After the incision is made in the LUQ, the subcutaneous tissues are dissected down to the anterior fascia, the anterior fascia is incised, the muscle is spread bluntly, and the posterior sheath is entered bluntly. The omentum is followed superiorly until the stomach is identified and pulled up through the incision in the LUQ using a Babcock. Four tacking sutures are placed from the stomach to the posterior fascia, and a purse-string suture is made around the stomach with the gastrostomy placed in the center of the purse-string.

Percutaneous endoscopic gastrostomy

The patient is in the supine position under general anesthetic. An endoscope is passed into the stomach, and the stomach is insufflated. After confirming a light reflex and visualizing the internal indentation with external palpation, a gastric puncture is made transcutaneously in the LUQ, the PEG tube is passed endoscopically into the stomach, and the tube is pulled through the abdominal wall. The position of the tube is confirmed endoscopically, and the bumper is secured to the abdominal wall.

Study population

Our retrospective cohort study used inclusion criteria of undergoing an operation for gastrostomy tube placement from June 2019 to April 2022. Our electronic medical record system was queried for all cases entitled “gastrostomy tube insertion,” “laparoscopic gastrostomy tube insertion,” “laparoscopic assisted gastrostomy tube placement,” and “percutaneous endoscopic gastrostomy tube insertion.” Exclusion criteria included patients who were over the age of 18 years. The Ann and Robert H. Lurie Children’s Hospital of Chicago’s Institutional Review Board (IRB) deemed this study exempt from review (IRB number 2022-5449).

Demographic, surgical, and outcome variables

A retrospective chart review was performed including age, weight percentile at the time of surgery, history of prematurity, operative approach, method of tacking suture (i.e., buried, extracorporeal, and T-fastener), and if the patient was being fed with a nasogastric tube (NGT). Patients were classified as underweight if their weight percentile was less than the 5^th percentile, normal weight if they were between the 5^th and 84^th percentile, and overweight if they were in the 85^th percentile or higher. Primary outcomes of interest were 30-day complications including return to the operating room or readmission for gastrostomy tube-related reasons, wound infection, wound breakdown (requiring daily dressing changes and/or readmission to the hospital for wound care), tube dislodgement, or leakage. Leakage was considered a complication if it required slowing or stopping feeds. Secondary outcomes included granulation tissue formation and stitch abscess.

Statistical analysis

Descriptive statistics were reported as number and percent for categorical variables and median and interquartile range (IQR) for continuous variables. Chi-square tests for categorical variables were performed for univariate analysis. Multivariable logistic regression models were used to evaluate the association of operative approach with any complication, wound breakdown, leakage, or return to the operating room while controlling for history of prematurity and weight category at the time of surgery. The variables included in the logistic regressions were determined a priori based on clinical judgment. All analyses were conducted using STATA version 17.0 (College Station, TX). The level of significance was set to P < .05.

Results

Patient demographics

There were 521 patients who had a gastrostomy placed during the study period, with 283 (54.3%) patients being male. The median age was 10 months (IQR: 4–33 months), and 181 (34.9%) had a history of prematurity. There were 217 (41.7%) patients who were underweight at the time of gastrostomy placement. Most patients (n = 402, 77.3%) were fed with an NGT prior to gastrostomy, and the majority of those receiving NGT feeds were bolus-fed (n = 329, 63.1%). Laparoscopic gastrostomy was performed in 386 (74.1%) patients, laparoscopic-assisted in 73 (14.0%) patients, modified open in 33 (6.3%) patients, and PEG in 27 (5.2%) patients (Table 1). On univariate analysis, patients who received a PEG were older in age, more likely to be overweight, and less likely to receive NGT feeds compared with patients who had a gastrostomy placed by another operative approach. Additionally, patients with a history of prematurity were associated with a modified open approach to gastrostomy compared with other operative approaches (Table 2).

Table 1.

Demographics for Overall Cohort of Pediatric Patients Who Underwent Gastrostomy Placement at a Single Institution from June 2019 to April 2022

Variable	n	%
Sex
Male	283	54.3
Female	238	45.7
Age, months (median, IQR)	10	4, 33
Operative approach
Laparoscopic	386	74.1
Laparoscopic-assisted	73	14.0
Open	33	6.3
PEG	27	5.2
Weight
Underweight	217	41.7
Normal	272	52.2
Overweight	32	6.1
History of prematurity	181	35.0
Nasogastric feeds prior to surgery	402	77.3
Bolus	329	63.1
Continuous	73	14.01

IQR, interquartile range; PEG, percutaneous endoscopic gastrostomy.

Table 2.

Patient Demographics for Pediatric Patients Who Underwent Gastrostomy Tube Placement at a Single Institution from June 2019 to April 2022 Based on the Four Operative Approaches Utilized at Our Institution

Variable	Laparoscopic (n = 386)		Laparoscopic-assisted (n = 73)		Modified open (n = 33)		PEG (n = 27)		P value
Variable	n	%	N	%	n	%	n	%	P value
Sex									.52
Male	214	55.2	34	46.6	19	576	16	59.3
Female	174	44.9	39	53.4	14	42.4	11	40.7
Age, months (median, IQR)	9	4, 30.5	8	3, 32	8	5, 17	39	19, 168	<.01
Weight									.02
Underweight	159	41	33	45.2	16	48.5	9	33.3
Normal	207	53.4	38	52.1	15	45.5	12	44.4
Overweight	22	5.7	2	2.7	2	6.1	6	22.2
History of prematurity	129	33.5	25	34.3	19	57.6	8	29.6	.04
Nasogastric feeds prior to surgery	296	76.3	66	90.4	27	81.8	13	48.2	<.01
Bolus	247	83.4	53	80.3	22	81.5	7	53.8
Continuous	49	16.6	13	19.7	5	18.5	6	46.2

IQR, interquartile range; PEG, percutaneous endoscopic gastrostomy.

Gastrostomy complications

Wound breakdown occurred at higher rates in patients who underwent laparoscopic-assisted (n = 9, 12.3%) or modified open (n = 6, 18.2%) gastrostomy compared with laparoscopic (n = 5, 1.3%) or PEG (n = 1, 3.7%). Leakage also occurred more often in patients who underwent laparoscopic-assisted (n = 14, 19.2%) or modified open (n = 5, 15.2%) gastrostomy than laparoscopic (n = 14, 3.6%) or PEG (n = 0, 0%). Granulation tissue was common across all approaches (laparoscopic: n = 77, 19.9%; laparoscopic-assisted: n = 20, 27.4%; modified open: n = 6, 18.2%; PEG: n = 3, 11.1%). All approaches had low rates of return to the operating room, readmission, wound infection, tube dislodgement, and stitch abscess. The rate of overall complications was 32.4% for laparoscopic, 49.3% for laparoscopic-assisted, 45.5% for modified open, and 14.8% for PEG (Table 3).

Table 3

Thirty-Day Postoperative Gastrostomy Tube Complications in Pediatric Patients by the Four Operative Approaches Utilized at a Single Institution from June 2019 to April 2022

	Laparoscopic (n = 386)		Laparoscopic-assisted (n = 73)		Modified open (n = 33)		PEG (n = 27)		P value
	n	%	n	%	n	%	n	%	P value
Return to OR	13	3.4	2	2.7	0	0	2	7.4	.45
Readmission	9	2.3	1	1.4	2	6.1	0	0	.39
Wound infection	21	5.4	4	5.5	2	6.1	2	7.4	.98
Wound breakdown	5	1.3	9	12.3	6	18.2	1	3.7	<.01
Leakage	14	3.6	14	19.2	5	15.2	0	0	<.01
Tube dislodgement	19	4.9	1	1.4	3	9.1	0	0	.19
Granulation tissue	77	19.9	20	27.4	6	18.2	3	11.1	.29
Stitch abscess	3	0.8	0	0	0	0	0	0	.80
Any complication	125	32.4	36	49.3	15	45.5	4	14.8	<.01

OR, operating room; PEG, percutaneous endoscopic gastrostomy.

A subgroup analysis was performed looking at patients who had an operative approach with an incision around the gastrostomy tube (laparoscopic-assisted and modified open) compared with those without an incision around the gastrostomy tube (laparoscopic and PEG). Wound breakdown was significantly higher in the incision group (n = 15, 14.2%) compared with the no incision group (n = 6, 1.5%; P < .01). Leakage was also significantly higher in the incision group (n = 19, 17.9%) compared with the no incision group (n = 14, 3.4%; P < .01, Table 4). A multivariable logistic regression after controlling for history of prematurity and weight category at the time of surgery showed 10.8 times higher odds (IQR: 4.1–28.8) of wound breakdown and 6.5 times higher odds (IQR: 3.1–13.6) of leakage in patients who had an incision around the gastrostomy tube compared with those who did not have an incision. After controlling for prematurity and weight, laparoscopic-assisted gastrostomy was found to have 10.7 times higher odds (IQR: 3.5–32.9) of wound breakdown and 6.5 times higher odds (IQR: 2.9–14.5) of leakage compared with laparoscopic gastrostomy. Modified open gastrostomy was found to have 15.5 times higher odds (IQR: 4.4–55.0) of wound breakdown and 5.0 times higher odds (IQR: 1.6–15.2) of leakage compared with laparoscopic gastrostomy (Table 5).

Table 4.

Subgroup Analysis Comparing 30-Day Postoperative Complications in Pediatric Patients at a Single Institution Based on the Operative Approach Having an Incision Around the Gastrostomy Tube

	Incision (laparoscopic-assisted and modified open)n = 106		No incision (laparoscopic and PEG)n = 415		P value
	n	%	n	%	P value
Return to OR	2	1.9	15	3.6	.37
Readmission	3	2.8	9	2.2	.69
Wound infection	6	5.7	24	5.8	.96
Wound breakdown	15	14.2	6	1.5	<.01
Leakage	19	17.9	14	3.4	<.01
Tube dislodgement	4	3.8	19	4.6	.72
Granulation	26	24.5	81	19.5	.25
Any complication	51	48.1	130	31.3	<.01

OR, operating room; PEG, percutaneous endoscopic gastrostomy.

Table 5.

Multivariable Logistic Regressions Evaluating the Association of Operative Approach with Rates of Any Complication, Wound Breakdown, Leakage, and Return to the OR After Controlling for Prematurity and Weight Category in Pediatric Patients

	Any complication Odds ratio (95% confidence interval)	Wound breakdown Odds ratio (95% confidence interval)	Leakage Odds ratio (95% confidence interval)	Return to OR Odds ratio (95% confidence interval)
Operative Approach
Laparoscopic	Reference	Reference	Reference	Reference
Laparoscopic-assisted	2.1 (1.2–3.4)	10.7 (3.5–32.9)	6.5 (2.9–14.5)	0.9 (0.2–4.0)
Modified open	1.8 (0.9–3.8)	15.5 (4.4–55.0)	5.0 (1.6–15.2)	No cases
PEG	0.4 (0.1–1.0)	3.0 (0.3–27.0)	No cases	2.6 (0.5–13.0)

OR, operating room; PEG, percutaneous endoscopic gastrostomy.

Techniques for laparoscopic gastrostomy

For patients who underwent laparoscopic gastrostomy, 198 (51.3%) had buried stay sutures, 164 (42.5%) had extracorporeal stay sutures, and 24 (6.2%) had T-fasteners to secure the stomach to the abdominal wall. The rates for stitch abscess and granulation tissue formation were not significantly different between these groups. After controlling for prematurity and weight on logistic regression, there was a nonsignificant trend toward a higher likelihood of granulation tissue formation for patients with extracorporeal stay sutures (odds ratio: 1.7, IQR: 1.0–2.8).

Discussion

Our study evaluated 30-day complication rates after the four operative approaches used to place gastrostomy tubes in pediatric patients. We found that laparoscopic-assisted and modified open operative approaches, which have incisions around the gastrostomy site, have higher rates of complications, particularly wound breakdown and leakage. The lowest wound complications were observed for laparoscopic gastrostomy tube and PEG placement, where the skin incision is minimal and closely approximates the gastrostomy device. This finding remained significant after adjusting for prematurity and patient weight.

Similarly, Liu et al. found lower rates of leakage in laparoscopic gastrostomies and PEGs compared with open gastrostomies.³ In contrast, Naiditch et al. found no differences in leakage or peristomal skin maceration based on open, laparoscopic, or laparoscopic-assisted operative approach.¹⁰ While a recent systematic review and meta-analysis found no statistically significant difference in complication rates for open compared with laparoscopic gastrostomy tube placement (3.2% versus 0.9%, P = .08), the authors felt the magnitude of complications was clinically significant with an open approach.¹¹ Therefore, laparoscopic gastrostomy tube placement was recommended, which is in agreement with the findings of this study.

The same systematic review and meta-analysis recommended laparoscopic gastrostomy over PEG as well.¹¹ Multiple studies found higher complication rates with PEG compared with laparoscopic gastrostomy, mostly driven by tube dislodgement.^12–16 Studies have shown that PEG typically takes less time than placing a laparoscopic gastrostomy tube^12,15 but that should be balanced with the need for a second operation for tube exchange. Our study found a low rate of overall complications in the PEG group, and there was no difference in rates of tube dislodgement based on an operative approach, but this was the least common operative approach at our institution. While we did not evaluate surgeons’ decision-making in choosing an operative approach, some common reasons PEG may be avoided in children are the desire to avoid a second procedure for tube exchange, family desire for a low-profile gastrostomy tube, or anatomical considerations (i.e., aberrant rotation, scoliosis, and prior abdominal surgery). At our institution, the smallest PEG tube is an 8 French, which may be too large for smaller children.

Overall, the most common complication in our study was granulation tissue formation, with 20% of patients experiencing this complication. This rate is in line with prior literature reporting up to a rate of 58% of patients developing granulation tissue.^10,17

Moving forward, the division of pediatric surgery at our institution is now working on clinical care guidelines for gastrostomy tubes. The objective is to develop a standardized postoperative feeding and wound care regimen for all pediatric patients undergoing gastrostomy tube placement regardless of operative approach or the surgeon performing the case. A consideration regarding wound care is placing a stabilizing dressing around the gastrostomy tube at the end of the case. Comparing complications, particularly wound breakdown and leakage, in children with a stabilizing dressing compared with those without has been discussed as a possible future study. We hypothesize that having a dressing that would decrease movement of the gastrostomy tube may be associated with improved wound healing and fewer complications. Finally, based on the results of this study, we have had surgeons change their practice from placing gastrostomy tubes with a laparoscopic-assisted approach to a laparoscopic approach in an effort to decrease complications.

Our study is not without limitations. First, this is a single-center retrospective study, which does not allow us to evaluate clinical decision-making when it comes to the operative approach. However, the operative approach is typically based on surgeon preference at our institution. Second, the operative techniques performed at our institution may not be standard practice elsewhere, which may limit generalizability. Third, complications may be underestimated if patients were seen at a different institution after their gastrostomy tube placement. However, this should be limited because we have a gastrostomy care team who sees the children in clinic for follow-up. The team has a standardized note template documenting any complications and if the patient was seen at any emergency department related to gastrostomy tube complications. Finally, our results may be confounded because we do not have a standardized method for postoperative gastrostomy tube dressings or feeding regimens. Moving forward, we are developing a clinical care guideline to standardize postoperative gastrostomy tube care. Nevertheless, feeding regimens may not dramatically impact local wound-related outcomes.

Conclusions

Techniques for gastrostomy placement, which include an incision around the tube, were associated with higher rates of 30-day postoperative complications, specifically leakage and wound breakdown. To improve complication profiles for patients, surgeons should consider techniques that avoid an incision around the gastrostomy tube.

Footnotes

Authors’ Contributions

A.J.R., T.B.L., and M.V.R. completed the conceptualization, formal analysis, drafting, approval, and accountability. A.J.R., F.L., and B.L.T. performed data collection. M.M.C., C.J.H., C.J., and G.A.S. contributed to critical review, approval, and accountability.

Disclosure Statement

The authors have no relevant financial disclosures.

Funding Information

The authors received no funding for this work. Of note, A.J.R. was supported on a training grant by the National Cancer Institute, Surgical Multispecialty Access to Research in Residency Training (SMART) training grant [R38 CA245095].

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