Page 35 - Effects and Efficacy of (Laparoscopic) Gastrostomy Placement in Children - Josephine Franken

Finally, a number of issues still need to be considered regarding the conclusions of this systematic review and meta-analysis. First, all of the included studies in this review were retrospective in design, which resulted in limited access to study outcomes and susceptibility to various forms of bias (mainly confounding and selection bias). Second, patient populations, in terms of comorbidities (e.g., neurologically impaired children, children with congenital cardiac disease and children with cystic fibrosis), were heterogeneous, and studies did not report separate data outcomes comparing specific patient groups. In the meta-analysis, however, none of the outcomes demonstrated excessive heterogeneity. To further take possible effects of heterogeneity between studies into account, we used the random-effects model for meta-analysis, as it generates a more conservative estimate than an analysis using the fixed-effects model. 23 Third, none of the studies used standardized questionnaires or investigation techniques to objectively assess outcomes of efficacy. And finally, patients were operated between 1992 and 2008 and not all authors described their specific surgical techniques in detail. Gastrostomy placement techniques, especially PEG, have changed over the years. 46,50,51 However, the main concept of each procedure (e.g. endoscopic versus laparoscopic view) remained similar.
This systematic review and meta-analysis demonstrate that current literature lacks well- designed studies comparing outcomes such as efficacy of feeding, QoL and GER and, therefore, we have to be cautious in making definitive conclusions. However, there are retrospective studies available that compare PEG versus LGP and report actual data suitable for systematic review and meta-analysis. These studies cannot simply be discarded and are needed to provide patients, caregivers and referring physicians with evidence-based information on both procedures. Systematic review and meta-analysis of these data show that the success rates in terms of completion of the procedure were similar for PEG and LGP. However, LGP was associated with significantly less serious adverse events, namely adjacent bowel injury and early tube dislodgement, and a lower rate of reinterventions that required general anaesthesia. Naturally, to make a more informed decision on which procedure of gastrostomy placement is best practice in children, randomized controlled trials comparing LGP to PEG are highly warranted.
Chapter 2
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