Gastrostomy is a surgical procedure in which a feeding tube or a button is placed through the abdominal wall into the stomach in aims of long term nutritional support or administration of medications . A gastrostomy is advised in patients that are unable to eat normally, for which the most common reasons are neurological causes, anatomical causes or obstruction of the esophagus. The determining factor of how long one is unable to eat poses different options for the patient; wherein general enteral feeding using a nasogastric tube is recommended when the patient is unable to eat normally for at least 7–14 days. Moreover, if the patient is unable to eat normally for more than 30 days, a gastrostomy as a recommendation goes higher up in the list .
With the advancement of minimal invasive surgeries, newer modifications and techniques have developed including percutaneous endoscopic gastrostomy, percutaneous radiologic gastrostomy and laparoscopic gastrostomies . While all methods have varying complications, efforts in constantly improving patient outcome are being made.
Gastrostomy has become more common and widely accepted over the years in both infants and children. The surgery is done for children with feeding difficulties, malnourishment and other complex medical conditions in which the patient requires long-term enteral nutrition which has its obvious advantages over parenteral nutrition. Percutaneous endoscopic gastrostomy (PEG) was first introduced in the 1980s and quickly gained popularity . According to the European Society for Clinical Nutrition and Metabolism (ESPEN), gastrostomy tube is indicated in patients who require enteral feeding for more than 2 weeks . The goal of this is to prevent significant weight loss, nutritional deficiencies, assist with growth in children and improve their quality of life.
In addition to PEG and with ongoing advances, LG became more available. It is a minimally invasive procedure where the gastrostomy button can be placed directly (instead of a feeding tube), with shorter hospital stay, quicker recovery and fewer complications . One meta-analysis study proved that the risk of major complications was higher in PEG than in LG with a 95% confidence interval of 1.90–7.81 and a p value < 0.0002, making it the preferred method for gastrostomy tube placement in children . In addition, the risk of accidental gastro-enteric fistula development which occurs in 1.27% of PEG is much lower in LG .
The standard laparoscopy technique allows for easy placement of the gastrostomy with direct viewing and manipulation of the stomach yielding a minimized risk of unintentional visceral injury . Before an LG procedure, the site of the gastrostomy is marked on the left upper quadrant below the costal margin to prevent pressure sores. The peritoneal cavity is opened through a sub-umbilical incision according to Hasson technique. Pneumoperitoneum is achieved by inflating carbon dioxide through the 5-mm umbilical port at a rate of 1-3L/min until an intra-abdominal pressure of 8–10 mmHg is obtained. Abdominal exploration is completed using a 5-mm (30-degree) telescope through the umbilical port. Another 5-mm port is then introduced under direct vision over the designated site for the tube placement. The gastric wall is then grasped with a 5-mm laparoscopic Babcock forceps and brought through the port site while simultaneously removing the trocar and decreasing the pneumoperitoneal pressure to 0 mmHg. Once exteriorized, the gastric wall is fixed to the anterior abdominal fascia with four sutures. The incision is sometimes enlarged up to an additional 1cm for placement of the sutures. A gastrostomy is opened at the center of the sutures by diathermy. A balloon gastrostomy button is then inserted over a probe. Pneumoperitoneum (10 mmHg) is recreated for control of the location of the button and the stomach.
While all methods have varying complications, efforts in constantly improving patient outcomes are being made. In line with the continued regard towards improvement, a novel technique was introduced in our pediatric surgery department with a modified U-stitches laparoscopic gastrostomy. This modification consists of a combination of hidden U-stitches placed under direct vision of laparoscopy to anchor the stomach to the abdominal wall and using Seldinger technique to insert the gastrostomy button.
The aim of this research is to compare the rate of complications of two different laparoscopic techniques of a gastrostomy button placement in a pediatric population: A combination of modified U-stitches and Seldinger technique laparoscopic gastrostomy versus the standard laparoscopic gastrostomy. The modified U-stitches technique applied to laparoscopic gastrostomy is expected to yield a decreased number of complications in comparison to the standard laparoscopic gastrostomy in children.