Complications in Children With Percutaneous Endoscopic Gastrostomy (PEG) Placement
Complications in Children With Percutaneous Endoscopic Gastrostomy (PEG) Placement
https://doi.org/10.1007/s12519-018-0206-y
REVIEW ARTICLE
Received: 24 April 2018 / Accepted: 29 October 2018 / Published online: 19 November 2018
© Children’s Hospital, Zhejiang University School of Medicine 2018
Abstract
Introduction The aim of this study was to analyze the complication rates and mortality in association with different opera-
tive techniques of percutaneous endoscopic gastrostomy (PEG), age, underlying diseases and other risk factors. Moreover,
analysis of the indications of PEG insertion and the underlying comorbidities was also performed.
Methods This study performs a literature analysis of PEG-related complications in children. Literature was searched on
PubMed® (1994–2017) using terms “percutaneous endoscopic gastrostomy”, “complications”, “mortality” and “children”.
Results Eighteen articles with 4631 patients were analyzed. The mean age was 3 years (0–26 years). Operative techniques
were: pull technique in 3507 (75.7%), 1 stage PEG insertion in 449 (9.7%), introducer technique in 435 (9.4%), image-guided
technique in 195 (4.2%) and laparoscopic-assisted PEG in 45 (1.6%). Most frequent indications for PEG insertion were
dysphagia (n = 859, 32.6%), failure to thrive (n = 723, 27.5%) and feeding difficulties (n = 459,17.4%). Minor complications
developed in n1518 patients (33%), including granulation (n = 478, 10.3%), local infection (n = 384, 8.3%) and leakage
(n = 279, 6%). In 464 (10%) patients, major complications occurred; the most common were systemic infection (n = 163, 3.5%)
and cellulitis (n = 47, 1%). Severe complication like perforation occurred in less than 0.3%. Patients with lethal outcomes
(n = 7, 0.15%) had severe comorbidities; and the cause of mortality was sepsis in all cases. Prematurity or young age did not
affect complication rate. Patients with ventriculoperitoneal (VP) shunt had higher risk of major complications. In high-risk
patients, laparoscopic-assisted PEG insertion had less major and severe complication than traditional pull technique.
Conclusions PEG is a safe operative technique; although minor complications are relatively common and occur in up to 1/3 of
patients, there is a fairly low rate of severe complications. Two-thirds of PEG patients have at least one comorbidity. Patients
with VP shunt have higher risk of major complications. In high-risk patients, laparoscopic-assisted PEG is recommended.
Introduction
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of pediatric PEGs varies widely in the literature, ranging Group-3 uses the introducer technique, when gastric
from 4 to 44% [2]. There is no recent study that analyzes the tube is inserted through a percutaneous puncture to avoid
preoperative risk factors for postoperative short- and long- its passage through the mouth. Long curved needles are
term complications. The aim of this study was to analyze the used for two parallel gastropexy stitches under gastro-
complication rates and mortality in association with different scopic assistance. These stitches provide the fixation of
operative techniques of PEG, age, underlying diseases and the anterior wall of the stomach. The metal trocar designed
other risk factors. Moreover, analysis of the indications of for PEG is inserted through a percutaneous incision. The
PEG insertion and the underlying comorbidities was also sheath is removed and the balloon of the gastric tube is
performed. According to the ESPGHAN (European Society inflated. This technique prevents peristomal infections and
for Pediatric Gastroenterology, Hepatology and Nutrition) pharyngoesophageal tumor implantations [5, 6].
guidelines, the complications were divided into early or late, Group-4 had image-guided PEG insertion using biplane
and minor or major [3]. fluoroscopy. Oral barium sulfate suspension is given to the
patient the night before the procedure for localization of
the colon. Ultrasonography is used for visualization of the
liver. A snare is passed orally and a guide wire is inserted
Methods
in the stomach under fluoroscopic guidance and withdrawn
through the mouth. A snare catheter is pulled in a retro-
Literature was searched on PubMed® using terms “percuta-
grade fashion from the abdominal wall to the mouth, and
neous endoscopic gastroscopy”, “children”, “complications”
finally the PEG is pulled down through the esophagus [7].
and “mortality”. Eighteen articles were published between
Laparoscopic assistance is used in Group-5. A scope
1994 and 2017 about the complications of different PEG
is introduced through an umbilical port site. If the stom-
techniques. Altogether, data from 4631 patients were col-
ach is visualized, a 5 mm port is placed in the left upper
lected and analyzed in this study. Surgical techniques were
quadrant. The stomach is grasped with a Babcock forceps
divided into five different groups. Group-1 had the origi-
and pulled up directly to the abdominal wall. A full thick-
nal pull technique, Group-2 had one-stage PEG insertion,
ness gastric traction stitch is performed. After placing two
Group-3 had introducer technique, Group-4 had image-
anchoring fascial sutures and a purse-string suture, the bal-
guided technique and the last group Group-5 had laparo-
loon gastrostomy tube is inserted through a small incision
scopic-assisted PEG insertion.
and the sutures are tied [8, 9].
Surgical techniques
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Complications however, all the patients with lethal outcomes (n = 7) had
severe comorbidities and died due to severe outcomes
Several procedures of PEG insertion techniques exist to of general conditions such as sepsis (n = 6) or cachexia
prevent the higher risk of complications. Among the exam- (n = 1). There was no association between mortality and
ined 4631 patients, 1518 had minor complications. The the operative technique (Suppl. Table 6).
most common minor complications were superficial and of
infectious origin: granulation tissue (n = 478,10.3%), local
infection (n = 384, 8.3%), external leakage (n = 279, 6%) and Laparoscopic versus original pull insertion
skin erosion or erythema (n = 188, 4.1%). Unplanned tube
removal after postoperative period occurred in 65 cases, tube Two studies compared the major complications rate after
migration and obstruction developed in 2%. Less common laparoscopic and original PEG insertion technique in high-
complications are described in Suppl. Table 4. risk patients. All these patients had at least one severe
Major complications developed in 464 (10%) patients. comorbidity; the most important comorbidities were neu-
Almost 50% of the major complications were related to rologic disorders, previous abdominal surgeries, VP shunts
infections. Systemic infections occurred in 163 (3.5%) and PD catheters. There were 541 patients in the original
patients which were treated with intravenous antibiotics. pull technique group and 45 patients in the laparoscopic-
Cellulitis, peritonitis, sepsis or wound dehiscence was assisted group [8]. In the first group, the most common
noticed in 1.5%. Pneumoperitoneum was observed in 34 major complications were buried bumper, granulation,
(0.7%) patients. Asymptomatic pneumoperitoneum can peritonitis and gastrocolic fistula. Altogether, 12.6% of
occur without intestinal perforation as a result of the pro- the high-risk patients had major complications in the first
cedure; however,esophagus or bowel perforations were group. In the laparoscopic group, only 4.4% patients with
noticed in 13 patients (0.3%). Gastrocolic fistulas were severe comorbidities had major complications. One patient
found in 21 patients (0.45%). Buried bumper, intraab- had peritonitis and one child had gastrocutaneous fistula
dominal bleeding and ileus were detected in 1% (Suppl. after the removal of the PEG. According to this report
Table 5). [8], the complication rate is higher in patients with VP
shunt, hepatomegaly, PD catheter, esophageal stenosis,
Mortality coagulopathy and in infants weighing less than 2 kg. Age,
mental retardation, scoliosis, previous abdominal surgery
Literature was also searched for mortality within few and severe constipation are not risk factors for major com-
weeks of insertion in different insertion techniques; plications (Table 1).
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pediatric bone marrow-transplanted children were operated endoscopic gastrostomy in children and adolescents. J Pediatr Gas-
with PEG placement. Four patients were neutropenic during troenterol Nutr. 2015;60:131–41.
4. von Schnakenburg C, Feneberg R, Plank C, Zimmering M, Arbeiter
the procedure and all these patients had severe infection after K, Bald M, et al. Percutaneous endoscopic gastrostomy in children
the procedure. According to this study, significant neutro- on peritoneal dialysis. Perit Dial Int. 2006;26:69–77.
penia may be a contraindication for PEG placement [19]. 5. Evans JS, Thorne M, Taufiq S, George DE. Should single-stage
Several risk factors were analyzed for major complica- PEG buttons become the procedure of choice for PEG placement in
children? Gastrointest Endosc. 2006;64:320–4.
tions on 467 patients with PEG procedure. Only VP shunt 6. Campoli PM, Cardoso DM, Turchi MD, Ejima FH, Mota OM.
was found to be a significant risk factor [8]. Hepatomegaly, Assessment of safety and feasibility of a new technical variant of
coagulopathy, esophageal stenosis and peritoneal dialysis gastropexy for percutaneous endoscopic gastrostomy: an experience
were described as possible risk factors; however, age under with 435 cases. BMC Gastroenterol. 2009;9:48.
7. Nah SA, Narayanaswamy B, Eaton S, Coppi PD, Kiely EM, Curry
1 year, mental retardation, scoliosis, constipation and upper JI, et al. Gastrostomy insertion in children: percutaneous endoscopic
abdominal surgery were not related to complication rate. or percutaneous image-guided? J Pediatr Surg. 2010;45:1153–8.
Thoraco-abdominal deformity had a greater incidence of late 8. Vervloessem D, van Leersum F, Boer D, Hop WC, Escher JC, Mad-
complications such as decubitus or leakage [14]. ern GC, et al. Percutaneous endoscopic gastrostomy (PEG) in chil-
dren is not a minor procedure: risk factors for major complications.
Semin Pediatr Surg. 2009;18:93–7.
9. Zamakhshary M, Jamal M, Blair GK, Murphy JJ, Webber EM,
Skarsgard ED. Laparoscopic vs percutaneous endoscopic gastros-
Conclusions tomy tube insertion: a new pediatric gold standard? J Pediatr Surg.
2005;40:859–62.
At least 60–70% of the children with feeding difficulties 10. Szlagatys-Sidorkiewicz A, Borkowska A, Popińska K, Toporowska-
Kowalska E, Grzybowska-Chlebowczyk U, Wernicka A, et al. Com-
such as dysphagia or failure to thrive that qualify for PEG
plications of PEG are not related to age—the result of 10-year mul-
insertions have at least one comorbidity. Parents/caregivers ticenter survey. Adv Med Sci. 2016;61:1–5.
report that the gastrostomy is a great help for themselves and 11. McSweeney ME, Kerr J, Jiang H, Lightdale JR. Risk factors for
their child [20]. PEG is a safe operative technique for enteral complications in infants and children with percutaneous endoscopic
gastrostomy tubes. J Pediatr. 2015;166:1514–9.
feeding, with frequently observed minor complications and a
12. Lalanne A, Gottrand F, Salleron J, Puybasset-Jonquez AL, Guim-
low rate of major complications [21]. Patients with VP shunt ber D, Turck D, et al. Long-term outcome of children receiving
have higher risk of major complications. In case of high-risk percutaneous endoscopic gastrostomy feeding. J Pediatr Gastro-
patients, laparoscopic-assisted PEG is recommended. enterol Nutr. 2014;59:172–6.
13. Minar P, Garland J, Martinez A, Werlin S. Safety of percutaneous
endoscopic gastrostomy in medically complicated infants. J Pediatr
Author contributions Concept and design: BB, TK, AKS. Acquisition
Gastroenterol Nutr. 2011;53:293–5.
of data, and analysis and interpretation of data: BB. Drafting the article
14. Fascetti-Leon F, Gamba P, Dall’Oglio L, Pane A, dé Angelis GL,
and revising it critically for important intellectual content: BB, TK,
Bizzarri B et al. Complications of percutaneous endoscopic gas-
AKS. Final approval of the version to be published: BB, TK, AKS.
trostomy in children: results of an Italian multicenter observational
study. Dig Liver Dis. 2012;44:655–9.
Funding No financial or nonfinancial benefits have been received or 15. Pattamanuch N, Novak I, Loizides A, Montalvo A, Thompson J,
will be received from any party related directly or indirectly to the Rivas Y, et al. Single-center experience with 1-step low-profile per-
subject of this article. cutaneous endoscopic gastrostomy in children. J Pediatr Gastroen-
terol Nutr. 2014;58:616–20.
Compliance with ethical standards 16. Jacob A, Delesalle D, Coopman S, Bridenne M, Guimber D, Turck
D, et al. Safety of the one-step percutaneous endoscopic gastrostomy
button in children. J Pediatr. 2015;166:1526–8.
Ethical approval This article does not contain any studies with human
17. Landisch RM, Colwell RC, Densmore JC. Infant gastrostomy out-
participants performed by any of the authors.
comes: the cost of complications. J Pediatr Surg. 2016;51:1976–82.
18. Fortunato JE, Troy AL, Cuffari C, Davis JE, Loza MJ, Oliva-
Informed consent For this type of study formal consent is not required.
Hemker M, et al. Outcome after percutaneous endoscopic gastros-
tomy in children and young adults. J Pediatr Gastroenterol Nutr.
2010;50:390–3.
References 19. Kaur S, Ceballos C, Bao R, Pittman N, Benkov K. Percutaneous
endoscopic gastrostomy tubes in pediatric bone marrow transplant
1. Gauderer MW, Ponsky JL, Izant RJ Jr. Gastrostomy without lapa- patients. J Pediatr Gastroenterol Nutr. 2013;56:300–3.
rotomy: a percutaneous endoscopic technique. J Pediatr Surg. 20. Avitsland TL, Kristensen C, Emblem R, Veenstra M, Mala T, Bjørn-
1980;15:872–5. land K. Percutaneous endoscopic gastrostomy in children: a safe
2. McSweeney ME, Jiang H, Deutsch AJ, Atmadja M, Lightdale JR. technique with major symptom relief and high parental satisfaction.
Long-term outcomes of infants and children undergoing percutane- J Pediatr Gastroenterol Nutr. 2006;43:624–8.
ous endoscopy gastrostomy tube placement. J Pediatr Gastroenterol 21. Viktorsdóttir MB, Óskarsson K, Gunnarsdóttir A, Sigurdsson L. Per-
Nutr. 2013;57:663–7. cutaneous endoscopic gastrostomy in children: a population-based
3. Heuschkel RB, Gottrand F, Devarajan K, Poole H, Callan J, Dias study from Iceland, 1999-2010. J Laparoendosc Adv Surg Tech A.
JA, et al. ESPGHAN position paper on management of percutaneous 2015;25:248–51.
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