Page 129 - Effects and Efficacy of (Laparoscopic) Gastrostomy Placement in Children - Josephine Franken

Chapter 8
Gastrostomy placement (GP) is a surgical procedure frequently performed in children. A wide spectrum of pediatric patients with often severe, chronic feeding problems are referred to undergo GP. The majority of patients have severe neurologic impairment (NI). 1-3 Currently, GP is performed by minimally invasive techniques, either with laparoscopic GP or percutaneous endoscopic gastrostomy (PEG). 4-6 The work presented in this thesis concerns the effects and efficacy of (laparoscopic) GP.
In chapter one a general introduction was written on indications for GP, different surgical procedures, and complications. Possible effects of GP on gastrointestinal function were introduced, in particular the influence of GP on gastric emptying rate and the occurrence of gastroesophageal reflux (GER). Diagnostic possibilities of these gastrointestinal functions were described. Research questions were raised and the outline of this thesis was summarized.
i. Percutaneous endoscopic versus laparoscopic gastrostomy placement
Although both the percutaneous endoscopic gastrostomy (PEG) and laparoscopic GP are nowadays widely used, controversy remains on which procedure is best practice in the pediatric population. 7,8
In the systematic review and meta-analysis comparing both techniques in chapter 2 we found a lack of well-designed studies that were randomized, clearly standardized and/or of a prospective design. Five suitable retrospective studies were identified comparing 550 PEG procedures to 483 laparoscopic procedures. 7,8 Completion rate and time to reach full feedings was similar for both procedures. PEG was associated with significantly more adjacent bowel injuries (risk ratio (RR) 5.55; p=0.047), early tube dislodgements (RR 7.44; p=0.02) and complications that required reintervention under general anesthesia (RR 2.74; p<0.001). In PEG, although the initial placement required less operating time, patients required a second procedure under general anesthesia for routine tube change.
These results are in favour of the laparoscopic approach. However, analysis was based on studies of a retrospective nature with heterogenic patient groups and limited data on patient selection.
ii. efficacy and adverse events
No previous studies clearly described the long-term efficacy of GP, with either weight and height values or records of long-term postoperative method of feeding. Furthermore, reported complication rates varied strongly among different studies. 9
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