Experience with a hybrid, minimally invasive gastrostomy for children with abnormal epigastric anatomy

Abstract

Purpose: This communication is an analysis of the experience with a new type of gastrostomy. It was developed for patients with pronounced epigastric anatomical abnormalities, such as dense adhesions, in whom the conventional "open" gastrostomy could prove difficult and the percutaneous endoscopic, the imaging-guided, and the laparoscopically assisted methods would be unsafe.

Method: A large, soft rubber catheter is inserted in the child's mouth and advanced into the stomach. A small epigastric incision is made. With the help of the catheter, the anterior gastric wall is identified and the stoma site chosen. One of the curved needles of a double-armed monofilament suture is passed through the gastric wall and through the catheter. The needle is then cut off. The other needle is passed through the abdominal wall, from the inside out at the most suitable skin stoma site. When the catheter (with the embedded suture) is withdrawn from the mouth, a tract is established. The suture is replaced by a guide wire, which allows a percutaneous endoscopic gastrostomy-type catheter to be placed by the percutaneous endoscopic gastrostomy "pull" technique.

Results: This approach was used in 15 patients (14 children-ages 1 month to 7 years and one 19 years old) with: status post (s/p) necrotizing enterocolitis and bowel loss (n = 4); s/p gastroschisis and short-gut syndrome (n = 3); cerebral palsy, s/p ventriculo-peritoneal shunt infections (n = 2); s/p complex omphalocele; dwarfism; morphologic abnormalities; repaired prune-belly syndrome; s/p duodenal atresia with malrotation; severe scoliosis with s/p multiple shunt infections (one each). There were no complications. The technique also proved useful in several other children in whom a laparotomy incision for unrelated conditions was remote from the gastrostomy site.

Conclusion: Using a very small incision, this hybrid method permits safe and precise gastric and abdominal wall site selection and gastrostomy catheter placement. Gastrotomy as well as purse-string and peritoneal fixation sutures are not needed, and the danger of accidental catheter dislodgement is minimized.