Gastrostomy Tube Placement Outcomes: Comparison of Surgical, Endoscopic, and Laparoscopic Methods 
* Department of Surgery, Temple University
Hospital, Philadelphia, Pennsylvania; Correspondence: Robin Rago Bankhead, CRNP, MS, CNSN, Department of Surgery, Temple University Hospital, Broad and Ontario Streets, Philadelphia, PA 19140. Electronic mail may be sent to robin.bankhead{at}tuhs.temple.edu. Background: Advances in percutaneous endoscopic gastrostomy (PEG) and laparoscopic (LAP) techniques now allow for less invasive placement of gastrostomy tubes. This study compared morbidities and feeding outcomes of these procedures with standard surgical (OPEN) insertion. Methods: Gastrostomy tubes placed in the operating room by the PEG, LAP, and OPEN methods were compared for insertion times, tube insertion and maintenance complications, enteral feeding complications, and feeding start days. Patients with concomitant intra-abdominal procedures were excluded. Patients were followed for 6 days after tube placement. Results: A total of 91 catheters (PEG = 23, LAP = 39, OPEN = 29) were inserted in the operating room for indications of ventilator-dependent respiratory failure (45), dysphagia (30), head and neck cancer (9), and decreased mental status (7). No patients were fed on the day of the procedure. Insertion times were significantly longer (p < .05) in the OPEN technique (68 minutes) vs LAP (48 minutes) and PEG (30 minutes). Insertion complications occurred in the LAP and PEG cohorts (3 failed LAP, 1 failed PEG), and maintenance complications were higher in the LAP group, including 1 episode each of cellulitis, bleeding, and serous drainage. Twenty enteral feeding complications in 17 patients occurred in all groups (9 in LAP vs 6 in PEG and 5 in OPEN), and included emesis (6), high residual (5), diarrhea (3), ileus (3), nausea (2), and pain after feeding (1). Overall complications were significantly lower in the PEG (7) and OPEN (5) groups compared with the LAP group (15). Feeding start day was significantly delayed in the OPEN technique (2.1 days vs 1.7 in PEG and 1.5 in LAP); however, no difference was found in days to goal among groups (4.4–4.8 days). Conclusions: PEG should be the procedure of choice for placement of gastrostomy tubes. If PEG is contraindicated, then OPEN technique may be best due to fewer complications, although insertion time is longer than the LAP technique. Over the past decade, the use of gastrostomies has been extended from a permanent access to the gastrointestinal tract for feedings in chronic conditions to a temporizing measure while recovering from acute conditions such as trauma. Along with this increase in indications, new techniques have been developed that have made gastrostomies simpler and less risky. From the classic Stamm technique (OPEN) done via laparotomy, 2 new alternatives have arisen that do not require a laparotomy: the percutaneous endoscopic gastrostomy (PEG) and the laparoscopic gastrostomy (LAP). Their purported benefit is avoidance of a laparotomy, with less associated postoperative pain, earlier return of gastrointestinal function, and decreased hospital stay. Although there is widespread acceptance of the PEG as the insertion technique of choice due to its simplicity and effectiveness,1 there are patients who are not candidates for an endoscopic approach. Conditions that preclude endoscopic placement of a gastrostomy are obstruction of the upper aerodigestive tract, prior upper abdominal surgery, or inaccessible stomach due to high location, hepatomegaly or coverage by transverse colon. The LAP method also avoids the need for a laparotomy but still requires a general anesthetic. Prior upper abdominal surgery, although not an absolute contraindication, may make the LAP method difficult and risky. The LAP method offers better exposure of the stomach than does the OPEN technique, in which the incision is usually quite small. Thus, each procedure offers particular advantages in terms of feasibility and safety and disadvantages in terms of contraindications and morbidity. Although in some special conditions one type of gastrostomy may be more advantageous than another, in most patients the choice is up to the physician in charge. Aside from medical reasons, the choice of one type of gastrostomy over another is often based on referral patterns within an institution, ability to get the patient on the procedures' schedule, and availability of specific resources. This study was performed at a hospital where patients in need of a gastrostomy were routinely referred to surgery and surgeons had the resources to proceed with any of the 3 techniques. Therefore, we sought to compare the risks and benefits of these 3 techniques for placing gastrostomy tubes.
Patients undergoing gastrostomy tube placement in the operating room at Temple University Hospital between July 1, 2000, and June 30, 2001, were included in the study through concurrent and retrospective chart audits. This study was conducted with the approval of the hospital institutional review board. All patients who had previous gastric surgery or a concomitant intraabdominal procedure at the time of gastrostomy tube placement were not included. Operative risk was assessed in all patients using the American Society of Anesthesiologists Classification of Physical Health (ASA) score. A preoperative dose of prophylactic antibiotics was administered intravenously (IV) to all patients. Under general anesthesia, tubes were placed by the PEG, LAP, or OPEN technique. Insertion techniques were selected largely on surgeon preference. All tubes were placed by a surgical resident placed under direct supervision by the attending surgeon. The additional time required for resident education during the procedure was not measured.
An established protocol for the initiation and advancement of tube
feedings, used for all patients regardless of the procedure, was initiated in
the postoperative period. All feeding tubes were placed to straight drainage
from the time of insertion until the following morning. Isotonic tube feeds
were initiated at 30 mL/h the following day if gastric output was Data collection included patient age, body mass index (BMI), albumin and prealbumin, diagnosis, reason for tube placement, insertion time, postoperative measurement of overnight gastric output, and monitoring of tube site for pain, infection, or malposition. Tube feeding start day, goal feeding rate, goal formula, gastric residuals, episodes of nausea, vomiting, and stool output were also recorded, and complications related to insertion, maintenance, and feeding tolerance. All patients were followed through postoperative day 6. Cost was calculated according to both the fixed and variable costs associated with each procedure.
Statistical Analysis
Insertion Techniques LAP insertion was performed through 2 port sites, one in the umbilicus introduced after induction of pneumoperitoneum via a Verees needle and another in the left upper quadrant of the abdomen. The 10-mm umbilical port allowed for the camera placement and the 5-mm left upper quadrant port for grasping of the stomach and tube placement.2 Using this technique, the stomach was insufflated with air via a nasogastric tube and then grasped and pulled up through the 5-mm port site. The stomach was then held against the anterior abdominal wall by placing "T" fasteners. These "T" fasteners are small metal bars connected to a nylon string that are deployed in the gastric lumen, with each one held by a "bumper." Once the stomach was secured to the abdominal wall, a 5-mm trochar was exchanged for a dilator, which in turn was exchanged for dilators of larger sizes. Once the track was dilated up to 14 Fr, a balloon tube was placed through a peel-away introducer. The OPEN procedure was performed through a laparotomy by way of the Stamm technique. After exposure through a small (<5 cm) upper midline incision, pursestring sutures were placed on the anterior wall of the stomach low in the body and close to the greater curvature. The feeding tube was drawn through a stab wound on the abdominal wall and then inserted into the stomach. The stomach was fixed to the abdominal wall by tacking sutures that traverse the seromuscular layer of the stomach and the peritoneum around the exit site of the catheter.
Patient Demographics and Clinical Characteristics A total of 91 patients (52 men and 39 women) were included into the study. Mean patient age was 58 years (range 18–87). Additional demographics and clinical characteristics are presented in Table 1. Gastrostomy tubes were placed in 23 patients by the PEG, 39 by LAP, and 29 by OPEN methods. In the majority of patients, the indication for gastrostomy tube placement was either ventilator-dependent respiratory failure (45 patients) or dysphagia (30 patients), followed by head and neck cancer (9 patients) and altered mental status (7 patients). The admitting services were neurosurgery (16); medicine (14); pulmonary (11); ENT (10); cardiology and cardiothoracic surgery (9 each); neurology, general surgery, and trauma (7 each); and burns (1). Mean age, serum albumin and prealbumin levels, median ASA scores, and BMI were not statistically different between the groups.
Tube Insertion Times and Complications
Tube Maintenance and Enteral Complications
In 90 patients, feedings were begun via continuous (97%) or intermittent (2%) methods, and the initiation formulas were with isotonic (44%), isotonic with fiber (28%), hypertonic high-calorie and protein (21%), or hypertonic semielemental formula (6%). One patient never received feedings through the gastrostomy tube. Feeding start day and days to goal rate and formula are listed in Table 4. Days to achieve goal rate were similar for all groups. When compared with the PEG and LAP groups (1.7 and 1.5 days, p < .05, respectively), the OPEN group had a significant delay in feeding start day (2.1 days). Despite this delay, the OPEN group showed a trend toward reaching goal formula types sooner than the other 2 groups and was more likely to start on the goal formula rather than a more isotonic formula.
Maintenance and enteral complications are listed in Table 5. Maintenance complications occurred only in the LAP population and included 1 episode each of cellulitis, bleeding, and serous drainage around the tube. Enteral feeding tolerance complications occurred in a total of 17 patients from all insertion groups (PEG = 6, LAP = 9, OPEN = 5) and consisted of emesis, high residuals, diarrhea, ileus, nausea, and pain after bolus feeding.
Cost Analysis
Access to the gastrointestinal tract via PEG, LAP, or OPEN techniques for the purpose of long-term enteral nutrition is a common practice for patients who are unable to partake of oral nutrition. Once a patient is identified as requiring a long-term feeding tube, the decision of which technique to use for tube placement is dependent on several factors. These factors are outlined in Table 7 and are based on the personal experiences of the authors. Indications for enteral tube feeding are neurologic and anatomic dysfunction of the head, neck, and esophagus and altered mental status. The majority of patients in our study required enteral tube feedings due to ventilator-dependent respiratory failure and dysphagia.
The insertion times for gastrostomy tube placement in our study are comparable to other studies from teaching hospitals. Although we did not specifically measure the time attributable to resident education during the insertion of the tubes, our times are within the range of other teaching institutions. For example, Lowe et al3 reported mean insertion times for PEG and OPEN procedures of 36 and 72 minutes, respectively, which are remarkably similar to our respective times. Peitgen et al4 reported an insertion time of 40 minutes in a series of 121 patients undergoing LAP gastrostomy. In their study, insertion time was not dependent on laparoscopic experience of the surgeon but rather whether the patient had prior abdominal surgery (39 minutes without prior abdominal surgery vs 52 minutes with prior abdominal surgery). Our mean LAP gastrostomy insertion times in the absence of prior abdominal surgery were also similar. Insertion complications noted in our study surrounded inability to apply the planned technique, which was the result of either technical issues or anatomical variances that made the "blind" techniques riskier. As a result, 1 failed PEG and 3 failed LAP procedures were converted to the OPEN technique. There is a lack of data to substantiate the most appropriate time to initiate feedings through a newly inserted catheter and what type of formula to instill. In our study, the major variable(s) used to assess readiness to begin feeding was the amount of overnight gastric output or the return of bowel sounds/flatus. The majority of patients in our study, regardless of technique used, started feedings with an isotonic solution, either water or formula. The remainder of the patients received a hypertonic high-calorie and protein formula or a hypertonic semielemental formula. Regardless of gastric output, patients in the OPEN group were delayed in the start of feeding. This phenomenon may be due to the perception that patients undergoing an OPEN procedure need a longer recovery time. Although feedings were significantly delayed in the OPEN cohort, these patients were more likely to start on goal formula rather than isotonic formula. Nevertheless, the goal rates were similar to those of the LAP and PEG groups. During our 6-day postoperative follow-up, maintenance gastrostomy tube complications were noted only in the LAP group and were a result of peristomal cellulitis, bleeding, and serous drainage. This is perhaps due to the use of "T" fasteners and bolsters, which seemed to apply pressure to the stoma site. Light et al5 investigated predictive factors for early morbidity after PEG placement and found that they related to tube complications, wound infection, and premature catheter removal, and were most commonly observed at 1 week. Cosentini et al6 concluded that when comparing procedure-related complications, there was no difference in the OPEN, PEG, and interventional radiology placement. However, tube function of the interventional catheter was inferior as compared with the OPEN and PEG catheters due to its small lumen size. In a comparison study of LAP vs OPEN in head and neck cancer patients, Lydiatt et al7 assessed length of operation, morbidity, mortality, and cost. Their findings were similar to ours. Mean insertion times were significantly shorter in the LAP group (40 minutes) vs the OPEN group (56 minutes), and the costs were similar in these 2 groups. Insertion complications in the LAP group consisted of 2 failed procedures (which resulted in conversions to OPEN placement), 1 wound infection, and 1 with bleeding from a gastric ulcer. In the OPEN group there was 1 episode of wound infection. The observed decrease in cost for PEG placement in our study reflects a shorter insertion time with fewer fixed costs. Although the total costs were similar for LAP and OPEN procedures, the cost components were different. The savings in fixed cost, gained by the shorter insertion time of LAP, were nearly offset by the larger variable cost. The cost analysis was limited to hospital cost for use of the operating room because all other costs, including length of stay, were dependent on variables other than gastrostomy method. Although the professional fees charged by surgeons for each procedure are different, the actual collections were low and essentially similar for all surgeons, regardless of the technique used.
In this study, the results show that LAP has the highest morbidity of all 3 techniques. The OPEN procedure significantly delays feeding start day, which may impact hospital length of stay. Because PEG technique is associated with shorter insertion times, reduced overall complications, and decreased costs, it should be considered the procedure of choice. If PEG is contraindicated, then the OPEN technique may be the best method due to fewer complications.
Nutrition in Clinical Practice, Vol. 20, No. 6,
607-612 (2005) This article has been cited by other articles:
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Material and Methods
Results
200 mL
per 8-hour shift or upon return of bowel sounds/flatus. Tube feedings were
advanced as tolerated every 6–8 hours until goal rate was achieved, at
which time the formula was changed to goal formula. 
2 analysis. 
