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Alternative techniques of feeding gastrostomy in children: a critical analysis
M F Goretsky1, N Johnson, M Farrell
1Division of Pediatric Surgery, Children's Hospital Medical Center, Cincinnati, OH 45229-3039 USA.
Insights
This study found no significant differences in cost-effectiveness, indications, or morbidity rates among three pediatric feeding gastrostomy techniques: Stamm, percutaneous endoscopic gastrostomy (PEG), and percutaneous fluoroscopically guided gastrostomy (PFGG). Individualized patient factors should guide technique selection.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Medical Device Technology
Background:
- Managed care necessitates individualized operative procedures based on patient status, specialist expertise, and cost-effectiveness.
- Analysis of morbidity, mortality, and cost is crucial for selecting optimal therapeutic alternatives.
Purpose of the Study:
- To critically analyze and compare three distinct techniques for establishing gastric feeding access in pediatric patients.
- Evaluate the Stamm, percutaneous endoscopic gastrostomy (PEG), and percutaneous fluoroscopically guided gastrostomy (PFGG) methods.
Main Methods:
- Retrospective analysis of 98 pediatric patients undergoing primary feeding gastrostomy over 36 months.
- Exclusion of patients with concurrent major procedures.
- Comparison of open Stamm (n=47), pull-out PEG (n=32), and antegrade PFGG (n=19) techniques.
Main Results:
- No statistically significant differences in complication rates (PEG 19%, PFGG 16%, Stamm 11%) or reflux incidence (PFGG 21%, PEG 9%, Stamm 6%).
- Hospital charges were comparable ($1,079-$1,316).
- PFGG showed potential cost-effectiveness when including professional fees, though accounting for radiologist fees requires careful consideration.
Conclusions:
- No significant differences were observed in procedural cost-effectiveness, indications, or morbidity among the three feeding access techniques.
- Individualized selection of the gastrostomy technique is recommended, considering the child's overall health, specialist comfort, and institutional experience.
Background:
In the era of managed care, the operative procedure applied to solve a given problem should vary with the status of the patient, the training and experience of the specialist, an analysis of morbidity and mortality rates, and a cost analysis of therapeutic alternatives. The purpose of this study was to critically analyze three different techniques for gastric feeding access in children.
Study Design:
A retrospective analysis of patients who underwent primary feeding gastrostomy was performed at our institution. Patients who underwent gastrostomy placement concurrently with another major procedure were excluded.
Results:
Over a 36-month period, 98 children underwent placement of a feeding gastrostomy by one of three alternative techniques: an open Stamm gastrostomy (Stamm, n=47), a pull-out percutaneous endoscopic gastrostomy (PEG, n=32), or an antegrade percutaneous fluoroscopically guided gastrostomy (PFGG, n=19). An open gastrostomy was performed more frequently in younger patients (average age, 49.7+/-11.9 months for PFGG). The sex distribution and indication for tube placement were similar in all groups (altered mental status: Stamm 43 percent, PEG 19 percent, and PFGG 38 percent; mechanical feeding difficulty: Stamm 66 percent, PEG 13 percent, and PFGG 21 percent; or failure to thrive Stamm 58 percent, PEG 17 percent, and PFGG 25 percent). Complications were most common in this high-risk patient population with PEG (19 percent), when compared with PFGG (16 percent) and Stamm (11 percent), although these were not statistically significant. Whereas reflux was frequent (Stamm 6 percent, PEG 9 percent, and PFGG 21 percent), only three patients in the entire series required a subsequent antireflux operation during the observation period. The three procedures were similar on hospital charge analysis (Stamm $1,316,29+/-63.33. PEG $1,130.04+/-94.88, and PFGG $1,079.83+/-109.12). When professional fees were included, the PFGG may be more economical than both the PEG and Stamm gastrostomy (Stamm $3,101.29+/-73/33. PEG $3,314.04+/-94.88, and PFGG $1,485.77+/-74.41, p<0.05). However, this may be misleading because the radiologist's fee was absorbed into the hospital charge is some cases, and therefore could not be fully accounted for in the total professional fee.
Conclusions:
The data from our institution demonstrate that there is no significant difference in these three feeding-access techniques when comparing procedural cost-effectiveness, indications for tube placement, or morbidity rates. The choice of procedure should be individualized giving consideration to the overall health of the child, the comfort of the specialist peforming the given procedure, and the institutional experience.