Is a Laparoscopic Gastrostomy Better Than a Percutaneous Endoscopic Gastrostomy?

ME McSweeney et al. JPGN 2021; 73: 586-591. A Retrospective Review of Primary Percutaneous Endoscopic Gastrostomy and Laparoscopic Gastrostomy Tube Placement

This article is a large retrospective single-center (Boston Children’s) review of laparoscopic gastrostomy (LAP, n=545) compared to percutaneous endoscopic gastrostomy (PEG, n=545) (2010-2015). The authors note a shift in attitude in their institution in favor LAP due to perceived safety advantages (citing references 14-16 -reviewed below).

Key findings:

  • Total complication rate: 33% (146) in PEG group, 36% (197) in LAP group; cellulitis reported in 18% in PEG group compared with 10% of LAP group
  • ED visits: 89% (394) of PEG group had zero ED visits compared with 84% of LAP patients; In PEG group, 9% and 1% had one ED visit and two ED visits respectively compared to 15% and 1% in LAP group
  • In the early postoperative period (first week), patients undergoing PEG placement had more gastrostomy-related complications (PEG 30 [6.7%] vs LAP 13 [2.4%], P = 0.0007) and cellulitis (PEG 23 [5.1%] vs LAP 2 [0.4%], P = 0.03). Complications included postoperative pain, leakage, tube dislodgement, and stoma erythema
  • The authors reported higher total costs and operative time for LAP compared to PEG but note that in their institution, total cost may be higher for PEG due to frequent need for 2nd procedure for placement of a skin level device

In the discussion, the authors acknowledge that in their institution, “no differences in total complication rates within the first 6 months were seen.” My view is that the difference in cellulitis needs to interpreted cautiously in a retrospective study. The swelling and erythema around a PEG site in the first days postoperatively can be difficult to determine conclusively if there is cellulitis. With regard to potential cost advantages of LAP, this is affected in the PEG group by whether changing to a skin level device is done at the time of another procedure and whether the case is done in an outpatient surgery center where costs are lower.

My take: There is likely a lower rate of visceral perforation among children who have LAP placement over PEG placement. However, overall, it is uncertain if the complication rate from LAP placement is lower than PEG placement.

Review of some of the cited studies from this article:

S Miyata et al. J Pediatr Surg 2017; 52: 1416-1420. Comparison of operative outcomes between surgical gastrostomy and percutaneous endoscopic gastrostomy in infants (N=1456, Retrospective Study) “Conclusions: When G-tube and PEG were performed as the only procedure throughout a hospitalization in infants and neonates, the two techniques had comparable risks of postoperative complications and mortalities.”

F Sandberg et al. Pediatr Surg Int. 2018; 34 (12):1321-1327. Comparison of major complications in children after laparoscopy-assisted gastrostomy and percutaneous endoscopic gastrostomy placement: a meta-analysis While this meta-analysis with eight studies (n=1500 patients) found a lower risk of complications with LAP compared to PEG, the authors note that “there were no randomized-controlled trials. Overall, the quality of the included studies was determined to be unsatisfactory.” In addition, the results were heavily influenced by one study which reported 20 major complications (death or reoperation within 30 days) among 134 PEG patients.

L Baker et al. J Pediatr Surg 2015; 50: 718-725. A systematic review and meta-analysis of gastrostomy insertion techniques in children In this study, the authors examined 22 studies with 5438 patients that met inclusion criteria. No differences in major complications were noted in studies comparing open versus laparoscopic approaches or open versus PEG. Then, in a subset 10 studies (n=1599 laparoscopic, n=1161 PEG), the authors state that laparoscopic gastrostomy and PEG revealed a significantly increased risk in major complications with PEG (OR 0.29, 95% CI: 0.17–0.51, p < 0.0001). In this study, the most striking difference were 20 cases of visceral perforation with PEG and one case with LAP. Again, the data are limited by the retrospective nature of all but one study. This “suggest that individual-specific and/or institutional-specific factors likely influence outcomes and diminish the generalizability of the presented results.” Cited advantages of LAP: better visualization of site, ability to transfix stomach to abdominal wall, and ability to place primary button.

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