The effects and efficacy of (laparoscopic) gastrostomy tube placement in children

Abstract

Gastrostomy placement (GP) is a surgical procedure frequently performed in children with chronic feeding problems. The majority of patients suffer from severe neurologic impairment. This thesis focuses on the efficacy and adverse effects of GP. Currently, GP is performed by minimally invasive techniques, either by laparoscopic GP or percutaneous endoscopic gastrostomy (PEG). In the systematic review and meta-analysis comparing both techniques, analyzing 483 laparoscopic and 550 PEG procedures, PEG was associated with significantly more adjacent bowel injuries, early tube dislodgements and complications that required reintervention under general anesthesia. A large retrospective survey of 300 children who underwent laparoscopic GP was performed, showing that GP was successful in providing a long-lasting route for enteral tube feeding in 96% of patients. Nutritional status also improved after GP, as weight-for-height z-scores significantly increased. Evaluation of adverse events in this study showed that laparoscopic GP was a relatively safe procedure, with no procedure related mortality and a major complication rate of 2.0%. However, minor complications occurred very frequently: in 221 out of 300 patients, a total of 408 minor complications occurred, mainly including hypergranulation, infection and/or leakage at the gastrostomy site and dislodgement of the catheter. A prospective, longitudinal cohort study was presented including 50 patients that investigated the influence of GP on gastric emptying. All patients underwent a “13C-gastric emptying breath test” before and 3 months after laparoscopic GP. Gastric half-emptying time significantly increased from the 57th percentile to the 79th percentile after gastrostomy (p<0.001). Fifty percent of patients with normal preoperative GE developed delayed GE (>95th percentile) after GP (p=0.01). The development of GER is a widely discussed complication of GP, but current evidence has been inconsistent. A prospective, longitudinal cohort study was presented including 50 patients who underwent 24-hour multichannel intraluminal impedance - pH metry before and 3 months after operation. Total acid exposure in the esophagus did not change significantly after GP: from 6.2% to 6.1%. The number of reflux episodes did not change, neither for liquid and mixed liquid-gas reflux, nor for acid and weakly acid reflux. GER symptoms reported in reflux questionnaires were present in a comparable number of patients before (44%) and after GP (40%; p = 0.73). Antireflux surgery secondary to GP was indicated in only 2 out of the 300 patients in the retrospective study. Additionally, the sensitivity of preoperative 24-hour pH monitoring for predicting GER was only 17.5%. Improving health-related quality of life (HRQoL) is one of the main aims of GP in children. No previous studies had been performed on HRQoL. A cross-sectional study was performed including 126 patients. Caregivers filled out the validated HRQoL questionnaires. HRQoL was mainly influenced by the underlying medical conditions.A prospective, longitudinal cohort study including 50 patients comparing HRQoL before and 3 months after GP, showed that psychosocial HRQoL increased from 55.8 to 61.2 (p=0.03) after operation. In the majority of patients, the benefits of GP outweigh the potential side effects of GP.