Laparoscopic-assisted percutaneous endoscopic gastrostomy: insertion of a skin-level device using a tear-away sheath

Abstract

Background: This study describes our experience with the placement of a skin-level gastrostomy device (MIC-KEY) in a single procedure. Methods:We identified infants, children and young adults who underwent laparoscopicassisted percutaneous endoscopic gastrostomy (LAPEG) tube insertion between October 2009 and June 2013. The steps of this procedure include upper endoscopy, single-port laparoscopy, gastropexy via percutaneous T-fasteners and placement of a skin-level gastrostomy device (MIC-KEY) using a "push" technique with a tearaway sheath. Results:We included 92 patients in our study. Mean age was 3.7 years (range 3 wk-5 yr), and mean weight was 11.2 (range 2.8-54) kg. Median procedural time was 20 (range 12-76) minutes. Total median duration for the most recent 25 procedures was lower than that of the first 25 (62 v. 79 min, p = 0.004). There were no intraoperative complications or conversions to open surgery. Postoperative complications were observed in 6 (6.5%) patients. Three retained T-fasteners were assessed endoscopically (n = 1) or removed via local excision (n = 2). Two patients experienced early dislodged feeding tubes that were replaced via interventional radiology (n = 1) or repeat LAPEG (n = 1). There was also 1 intra-abdominal fluid collection that was drained percutaneously but ultimately required a laparotomy and washout. There were no major complications in the most recent 50 procedures. Conclusion:Our results suggest that LAPEG is a safe, minimally invasive procedure for infants, children and young adults. This approach allows for immediate use of a skin-level gastrostomy device without the need for postoperative tube exchanges.Contexte : Cette étude décrit notre expérience avec la pose d'un dispositif de gastrostomie au niveau de la peau (MIC-KEY) en une seule intervention.

Initial experience with percutaneous endoscopic gastrostomy with T-fastener fixation in pediatric patients

“…In the large Swedish series of 201 patients getting PEG-T, median time for PEG-T placement was 20 minutes 6 . We did not see a decrease in operating time or in the frequency of patients experiencing early complications in our study as reported in other series 7 8 , but this may partly be explained by the relatively high number of physicians involved. Jacob et al found the PEG-T procedure to be technically challenging, and they experienced a significant learning curve with regard to both complications and operating time 7 .…”

“…Compared to other reported series of PEG-P, this is a high number 13 14 . In 2 series of PEG-T 6 7 , there was no report of any early dislodgment, while Livingston et al reported this in 2 of 92 patients 8 . We have no apparent explanation for the high frequency of early dislodgment.…”

“…Livingston et al changed from cutting the T-fastener sutures 3 – 4 weeks postoperatively to 5 days after PEG insertion. After this change of practice, they did not report any T-fastener related complications 8 . Göthberg and Björnsson cut all sutures after 2 – 3 weeks, and they have not experienced any T-fastener related complications 6 .…”

“…Although the use of T-fasteners is becoming increasingly popular in pediatric patients needing a gastrostomy, very few studies have addressed problems with T-fasteners in this population. In 1 retrospective study of 92 pediatric patients undergoing laparoscopic assisted PEG-T, only 3 patients (3 %) experienced problems with the T-fasteners; 1 needed an endoscopic evaluation, and 2 had migrated T-fasteners removed under local anesthesia 8 . In contrast, 2 other studies including 201 6 and 186 7 children reported no T-fastener related complications.…”

“…Recently, PEG placement with the push technique and T-fastener gastropexy (PEG-T) has been introduced in pediatric patients 6 , and this particular method has gained popularity. So far, there are only a few studies that have evaluated the PEG-T technique in pediatric patients 6 7 8 , therefore, we wanted to report our initial experience with the PEG-T with particular emphasis on peri- and postoperative complications.…”