Placement of gastrostomy tubes in infants and children has become increasingly commonplace. A historical emphasis on use of open gastrostomy has been replaced by less invasive methods of placement, including percutaneous endoscopic gastrostomy and laparoscopically assisted gastrostomy procedures. Various complications, ranging from minor to the more severe, have been reported with all methods of placement. Many pediatric patients who undergo gastrostomy tube placement will require long-term enteral therapy. Given the prolonged time pediatric patients may remain enterally dependent, further quality improvement and education initiatives are needed to improve long-term care and outcomes of these patients.
Key points
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Percutaneous endoscopic gastrostomy (PEG) is a common method of establishing an indwelling gastrostomy tube that can support infants and children with a host of complex medical issues.
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PEG placement is generally safe, but can be associated with a range of intraprocedural and postprocedural complications, with most occurring within the first year of placement.
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Laparoscopic gastrostomy is a burgeoning, minimally invasive method for gastrostomy tube placement that may avoid the routine need for exchange to a balloon-based device.
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Regardless of method of placement, a focus on long-term pediatric enteral tube care represents a critical component of improving outcomes of gastrostomy tubes in children.
Background
Placement of gastrostomy tubes were first developed as a method for enteral feeding in children and adults in the late nineteenth and early twentieth century. Initial gastrostomies were established via open surgical approaches, such as the Stamm gastrostomy procedure, which still remains a commonly used method for primary gastrostomy tube placement in the United States and internationally.
With ongoing advances in surgical techniques and the increasing demand for less invasive methods of enteral access, newer gastrostomy techniques have emerged as feasible and safe in children. In 1980, percutaneous endoscopic gastrostomy (also known as the PEG procedure) was codeveloped by a pediatric surgeon, M.W.L. Gauderer, and a gastroenterologist, J.L. Ponsky, as a novel, minimally invasive endoscopic-based technique for primary gastrostomy tube placement. Since its development, the PEG procedure has been adopted by both adult and pediatric surgeons, gastroenterologists, and radiologists, as a method of gastrostomy tube placement that can be performed in a variety of settings. It also has quickly become one of the most common approaches to primary gastrostomy tube placement in infants and children.
Within pediatrics, the PEG procedure has proved effective in a variety of patient populations with complex medical needs. In particular, it has been shown to be safe to perform in small infants, even those weighing less than 6 kg, and in patients with complex neurologic disability, congenital heart disease, cancer, or other complex medical comorbidities. The PEG procedure has also proved beneficial in that helps to minimize exposure to anesthesia, requires a less invasive surgical approach, may occur outside of operating room settings, and is associated with both rapid postoperative recovery times and initiation of enteral feedings. In addition, PEG stomas are considered likely to spontaneously close, when and if a patient elects to remove the gastrostomy tube.
Background
Placement of gastrostomy tubes were first developed as a method for enteral feeding in children and adults in the late nineteenth and early twentieth century. Initial gastrostomies were established via open surgical approaches, such as the Stamm gastrostomy procedure, which still remains a commonly used method for primary gastrostomy tube placement in the United States and internationally.
With ongoing advances in surgical techniques and the increasing demand for less invasive methods of enteral access, newer gastrostomy techniques have emerged as feasible and safe in children. In 1980, percutaneous endoscopic gastrostomy (also known as the PEG procedure) was codeveloped by a pediatric surgeon, M.W.L. Gauderer, and a gastroenterologist, J.L. Ponsky, as a novel, minimally invasive endoscopic-based technique for primary gastrostomy tube placement. Since its development, the PEG procedure has been adopted by both adult and pediatric surgeons, gastroenterologists, and radiologists, as a method of gastrostomy tube placement that can be performed in a variety of settings. It also has quickly become one of the most common approaches to primary gastrostomy tube placement in infants and children.
Within pediatrics, the PEG procedure has proved effective in a variety of patient populations with complex medical needs. In particular, it has been shown to be safe to perform in small infants, even those weighing less than 6 kg, and in patients with complex neurologic disability, congenital heart disease, cancer, or other complex medical comorbidities. The PEG procedure has also proved beneficial in that helps to minimize exposure to anesthesia, requires a less invasive surgical approach, may occur outside of operating room settings, and is associated with both rapid postoperative recovery times and initiation of enteral feedings. In addition, PEG stomas are considered likely to spontaneously close, when and if a patient elects to remove the gastrostomy tube.
Percutaneous endoscopic gastrostomy procedure
The classic PEG procedure uses a pull technique. At the start of the procedure, after a standardized antiseptic skin preparation is applied to the abdomen and antibiotics are provided to the patient, a gastroscope is inserted through the patient’s mouth and into the stomach. Gastric distension is then performed by air insufflation, which in turn inflates the anterior gastric wall up against the abdominal wall. Transillumination of the abdominal wall by the lighted gastroscope is then visualized externally in the mid-epigastrium to guide placement, and a small stab abdominal incision is performed through which a needle, followed by a guide wire, are passed. This wire is then snared by the gastroscope, pulled out in a retrograde fashion from the stomach, through the esophagus, into the mouth, and released. A PEG tube is then tied to this wire, lubricated, and pulled back down through the mouth, esophagus, and stomach, affixing the gastric and abdominal walls together. The gastroscope is then reintroduced to confirm intragastric position of the PEG tube, and an external bumper is applied to secure the tube against the skin.
As a primary tube, a PEG will typically be left in place for a minimum of 6 weeks to 6 months, after which time it may be permanently removed, or exchanged for a skin-level or other balloon-based gastrostomy if the patient continues to require an indwelling tube. A PEG exchange can be accomplished by 1 of 2 basic methods: (1) performing a percutaneous pull, or (2) performing an endoscopic exchange of the PEG tube via endoscopic snaring and retrograde removal of the PEG inner bolster. The latter generally involves general anesthesia and allows for easy visual confirmation of the new intragastric position of the gastrostomy tube using the endoscope; whereas a percutaneous pull may require minimal or even no sedation, and is most safely immediately followed by fluoroscopy to confirm the intragastric position of the new tube.
Complications of Percutaneous Endoscopic Gastrostomy
Since its original description, the PEG procedure has been widely adopted. In turn, multiple PEG-related complications have been documented ( Box 1 ). Published retrospective rates of complications associated with the PEG procedure have varied, ranging from 4% to almost 50%, and likely reflect varied definitions of PEG-related complications ( Table 1 ). One recent prospective study of 103 patients undergoing PEG placement by surgeons at a single institution reported a total major complication rate of 14%.
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Intraprocedural
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Esophageal injury or perforation
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Other abdominal visceral injury
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Pneumoperitoneum
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Hemoperitoneum
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Gastrocolocutaneous fistula
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Peritonitis
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Postprocedural
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Bowel or gastric volvulus
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Abdominal wall bleeding
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Gastric bleeding or ulceration
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Buried bumper syndrome
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Gastric outlet obstruction
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PEG tract disruption with tube exchange
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PEG tube dislodgement
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PEG tube malfunction (tube clogging, breakage, and so forth)
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Stoma-related
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Abscess
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Cellulitis
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Peristomal leakage
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Peristomal pain
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Granulation tissue
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Stomal gastric herniation
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Patient feeding intolerance
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Ileus
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Gastroparesis
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Exacerbation of gastroesophageal reflux disease
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Aspiration
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Post-PEG placement diarrhea
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| Authors, Ref. Year | No. of PEGs | Complication Rate | Early Complications | Late Complications |
|---|---|---|---|---|
| Lalanne et al, 2014 France | 368 | Early (≤7 d after PEG placement): 43% Late (>7 d after PEG placement): 56% | Sepsis, aspiration pneumonia, failure of PEG placement, gastric bleeding, cellulitis, local erythema, wound infection, transient ileus, pain, leakage, pneumoperitoneum | Surgical closure of stoma, gastric ulcer, cutaneous necrosis, intragastric buried or extruded tube, catheter migration, gastrocolic fistula, cellulitis, granulation tissue, erythema, leakage, wound infection, other |
| Park et al, 2011 Korea | 32 | Overall complication rate: 47% Early (<48 h): 25% Late (>48 h): 22% | Pneumoperitoneum, pneumomediastinum, paralytic ileus, atelectasis | Wound infection, worsening gastroesophageal reflux disease, gastrocolic fistula |
| Fortunato et al, 2010 Baltimore, MD | 747 | Overall complication rate: 12% Early (during hospitalization for PEG): 3.7% Late (after hospital discharge): 20% | Gastric separation, wound infection, pneumoperitoneum, cutaneous necrosis, failure of PEG placement | Gastrocolic fistula, wound infection, granulation tissue, pressure necrosis, wound infection |
| Sathesh-Kumar et al, 2009 England | 172 | Overall complication rate: 28% | PEG infection, leakage, bowel obstruction due to tube migration, fever of unknown origin, chest infection | PEG infection, buried bumper, worsening gastroesophageal reflux disease, tube migration, gastrocutaneous fistula, gastrocolic fistula, overgrowth of gastric mucosa |
| Avitsland et al, 2006 Norway | 121 | Early (<30 d postop.): 12% Late (>30 d postop.): not reported | Stoma-related infection, pneumonia, tube dislodgment | Stoma infection, tube dislodgment, skin problems, pain, leakage, granulation tissue, gastrocolonic fistula, internal bumper in esophagus (with a tracheoesophageal fistula) |
| Segal et al, 2001 France | 110 | Late complication rate (>6 d after placement): 44% (26% patients had at least one complication) | Not reported | Intragastric buried/extruded button, granulation tissue, pseudotumoral proliferative gastric mucosa, mucosal ulceration, cutaneous necrosis, gastrocolic fistula, delay of stoma closure postremoval, subcostal neuralgia, peritonitis |
| Fox et al, 1997 Boston, MA | 137 | Overall complication rate: 12.4% Early (<2 wk after placement): 7.3% Late (>2 wk after placement): 5.1% | Cellulitis, gastrocolic fistula, duodenal hematoma, pneumoperitoneum | Cellulitis, fasciitis, gastrocolic fistula, gastric perforation, catheter migration |
Various reports of complications have categorized and defined complications according to whether the complication occurs perioperatively or postoperatively. There have also been widely different definitions of early versus late postoperative complications. Table 1 lists reported complication rates according to individual study definitions. Other investigators have categorized complications based on whether the complication was related to the procedure versus the tube, whether it involved a stoma-related issue, or was related to patient feeding intolerance or change in clinical status (eg, worsening gastroesophageal reflux disease, aspiration pneumonia).
PEG complications have also been defined as minor or major ( Table 2 ). Major complications, or those that are severe in nature, are often defined as adverse patient events requiring urgent evaluation, hospitalization, or repeat surgical or other interventional procedures. The authors’ group performed a long-term outcome study of a cohort of patients who received PEGs at Boston Children’s Hospital from April 1999 through December 2000 (n = 138) and followed them up to 10 years. In this retrospective survival analysis, which focused on time from placement to a first major complication; most major PEG-related complications were postprocedural, and tended to occur within the first 6 months to 1 year of placement ( Fig. 1 ). The cumulative incidence rate of patients having a major complication was 9.4% at 6 months (95% confidence interval [CI] 5.3%–16.4%), 10.4% (95% CI 6%–17.6%) at 1 year, and 15% (95% CI 8.9%–24.5%) by 65 months (5.4 years; see Fig. 1 ).
| Authors, Ref. Year | No. of PEGs | Complication Rate | Major Complications | Minor Complications |
|---|---|---|---|---|
| McSweeney et al, 2015 Boston, MA | 591 | Major: 10.5% Minor: 16.5% | Cellulitis requiring hospitalization, tract disruption with PEG exchange, surgical resection of granulation tissue, perforation of colon/viscera, pneumoperitoneum, other | Infection treated with oral antibiotics, PEG dislodgment, other minor complications |
| McSweeney et al, 2013 Boston, MA | 138 | Overall major complication rate: 11% | Cellulitis requiring hospitalization, surgical resection of granulation tissue, tube dislodgment, intraoperative PEG complication | Not reported |
| Vervloessem et al, 2009 Belgium | 448 PEGs and 19 lap-PEGs | Overall major complication rate: 12.6% | Any complication requiring repeat surgery/endoscopy, treatment antibiotics, blood transfusion, leading to death | Not reported |
| Zamakhshary et al, 2005 Canada | 93 PEGs and 26 lap-PEGs | Overall complication rate: 14% (7.7% lap-PEGs) | Transcolonic tube placement, failed PEG tube placement, peritonitis, tract disruption with PEG exchange | Nonspecific complications noted (including aspiration pneumonia, persistent fistula on tube removal, excessive granulation tissue requiring surgical debridement) |
| van der Merwe et al, 2003 South Africa | 70 | Overall complication rate: 6% | Esophageal perforation, significant stomal complication, submucosal bumper migration (buried bumper syndrome), sepsis | Not reported |
| Khattak et al, 1998 England | 130 | Major: 17.5% Minor: 22.5% | Development or exacerbation of gastroesophageal reflux, severe stoma complications, peritonitis (early or later with PEG exchange), failed PEG tube placement, gastrocolocutaneous fistula, intestinal obstruction, major hemorrhage, external migration of inner bolster, sepsis, death | Peristomal leakage, infection, granulation tissue, recurrent chest infections, pain, PEG tube related problems, feeding intolerance, difficulty in teaching parent to use gastrostomy, single-episode hematemesis, retained inner bolster |
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